Spira Ram M, Nissan Aviran, Zamir Oded, Cohen Tzeela, Fields Scott I, Freund Herbert R
Department of Surgery, Hadassah University Hospital, Mount Scopus and Hebrew University-Hadassah Medical School, P.O. Box 24035, Jerusalem, il-91240, Israel.
Am J Surg. 2002 Jan;183(1):62-6. doi: 10.1016/s0002-9610(01)00849-2.
The ultimate therapy for acute cholecystitis is cholecystectomy. However, in critically ill elderly patients the mortality of emergency cholecystectomy may reach up to 30%. Open cholecystostomy performed under local anesthesia was considered to be the procedure of choice for treatment of acute cholecystitis in high-risk patients. In recent years, ultrasound- or computed tomography (CT)-guided percutaneous transhepatic cholecystostomy (PTHC) replaced open cholecystostomy for the treatment of acute cholecystitis in critically ill patients.
The aim of the present study was to evaluate the results of a 5-year protocol using PTHC followed by delayed laparoscopic cholecystectomy for the treatment of acute cholecystitis in critically ill patients. We reviewed the charts of 55 patients who underwent PTHC at the Hadassah University Hospital Mount Scopus during the years 1994 to 1999.
The main indications for PTHC among this group of severely sick and high-risk patients was biliary sepsis and septic shock in 23 patients (42%); and severe comorbidities in 32 patients (58%). The median age was 74 (32 to 98) years, 33 were female and 22 male. Successful biliary drainage by PTHC was achieved in 54 of 55 (98%) of the patients. The majority of the patients (31 of 55) were drained transhepaticlly under CT guidance. The rest, (24 of 55) were drained using ultrasound guidance followed by cholecystography for verification. Complications included hepatic bleeding that required surgical intervention in 1 patient and dislodgment of the catheter in 9 patients that was reinserted in 2 patients. Three patients died of multisystem organ failure 12 to 50 days following the procedure. The remaining 52 patients recovered well with a mean hospital stay of 15.5 plus minus 11.4 days. Thirty-one patients were able to undergo delayed surgery: 28 underwent laparoscopic cholecystectomy of whom 4 (14%) were converted to open cholecystectomy. This was compared with a 1.9% conversion rate in 1,498 elective laparoscopic cholecystectomies performed at the same time period (P = 0.012). Another 3 patients underwent planned open cholecystectomy, 1 urgent and 2 combined with other abdominal procedures. There was no surgery associated mortality, severe morbidity, or bile duct injury.
The use of PTHC in critically ill patients with acute cholecystitis is both safe and effective.
急性胆囊炎的最终治疗方法是胆囊切除术。然而，在重症老年患者中，急诊胆囊切除术的死亡率可能高达30%。在局部麻醉下进行的开放性胆囊造口术曾被认为是治疗高危患者急性胆囊炎的首选方法。近年来，超声或计算机断层扫描（CT）引导下的经皮经肝胆囊造口术（PTHC）已取代开放性胆囊造口术，用于治疗重症患者的急性胆囊炎。
本研究的目的是评估一项为期5年的方案的结果，该方案采用PTHC，随后进行延迟腹腔镜胆囊切除术，用于治疗重症患者的急性胆囊炎。我们回顾了1994年至1999年期间在哈达萨大学医院斯科普斯山接受PTHC的55例患者的病历。
在这组病情严重且高危的患者中，PTHC的主要适应证为胆源性败血症和感染性休克23例（42%）；以及严重合并症32例（58%）。中位年龄为74（32至98）岁，女性33例，男性22例。55例患者中有54例（98%）通过PTHC成功实现了胆道引流。大多数患者（55例中的31例）在CT引导下经肝引流。其余患者（55例中的24例）在超声引导下引流，随后进行胆囊造影以进行验证。并发症包括1例需要手术干预的肝出血和9例导管移位，其中2例重新插入。3例患者在术后12至50天死于多系统器官衰竭。其余52例患者恢复良好，平均住院时间为15.5加减11.4天。31例患者能够接受延迟手术：28例行腹腔镜胆囊切除术，其中4例（14%）转为开放性胆囊切除术。同期进行的1498例择期腹腔镜胆囊切除术中的转换率为1.9%，两者相比（P = 0.012）。另外3例患者接受了计划性开放性胆囊切除术，1例急诊手术，2例与其他腹部手术联合进行。没有手术相关的死亡率、严重发病率或胆管损伤。
在重症急性胆囊炎患者中使用PTHC既安全又有效。
