Morse Bryan C, Smith J Brandon, Lawdahl Richard B, Roettger Richard H
Academic Department of Surgery, Greenville Hospital System/University Medical Center, Greenville, South Carolina 29605, USA.
Am Surg. 2010 Jul;76(7):708-12. doi: 10.1177/000313481007600724.
The diagnosis of acute cholecystitis in critically ill patients carries a high mortality rate. Although decompression and drainage of the gallbladder through a cholecystostomy tube may be used as a temporary treatment of acute cholecystitis in this population, there is still some debate about the management of the tube and the subsequent need for a cholecystectomy. This series evaluates the clinical course and outcomes of critically ill patients who underwent the insertion of cholecystostomy tubes for the initial treatment of acute cholecystitis. This is a retrospective review of critically ill patients admitted to the hospital intensive care unit who were diagnosed with acute cholecystitis and underwent a cholecystostomy tube as a temporary treatment for the disease. Patients were identified through the Greenville Hospital System electronic medical records coding database. Medical records were reviewed for demographic data, diagnoses, imaging, complications, and outcomes. From January 2002 through June 2008, 50 patients were identified for the study. The mean age was 72 +/- 11 years, and the majority (66%) were men. The following comorbidities were found: severe cardiovascular disease (40 patients), respiratory failure (30 patients), and multisystem organ dysfunction (30 patients). The mean intensive care unit length of stay (LOS) was 16 +/- 9 days, and the mean hospital LOS was 28 +/- 27 days. At 30 days, the morbidity associated with the cholecystostomy tube itself was 4 per cent, but overall in-hospital morbidity and mortality rates were 62 and 50 per cent, respectively. Of the 25 patients who survived longer than 30 days, 12 retained their cholecystostomy tubes until they underwent cholecystectomy (four open, seven laparoscopic). All of the remaining 13 patients had their cholecystostomy tubes removed, and eight developed recurrent cholecystitis. Of these patients with recurrent of cholecystitis, five had cholecystectomy or repeat cholecystostomy, but the remaining three patients died. Although this is a small patient population, these data suggest that, in critically ill patients, cholecystostomy tubes should remain in place until the patient is deemed medically suitable to undergo cholecystectomy. Removal of the cholecystostomy tube without subsequent cholecystectomy is associated with a high incidence of recurrent cholecystitis and devastating consequences.
危重症患者急性胆囊炎的诊断死亡率很高。尽管通过胆囊造瘘管进行胆囊减压和引流可作为该人群急性胆囊炎的临时治疗方法，但对于造瘘管的管理以及后续是否需要进行胆囊切除术仍存在一些争议。本系列研究评估了因急性胆囊炎初始治疗而接受胆囊造瘘管置入术的危重症患者的临床病程和结局。这是一项对入住医院重症监护病房、被诊断为急性胆囊炎并接受胆囊造瘘管作为该病临时治疗的危重症患者的回顾性研究。通过格林维尔医院系统电子病历编码数据库识别患者。查阅病历以获取人口统计学数据、诊断、影像学检查、并发症和结局信息。从2002年1月至2008年6月，共识别出50例患者用于该研究。平均年龄为72±11岁，大多数（66%）为男性。发现有以下合并症：严重心血管疾病（40例）、呼吸衰竭（30例）和多系统器官功能障碍（30例）。重症监护病房平均住院时间（LOS）为16±9天，医院平均住院时间为28±27天。30天时，与胆囊造瘘管本身相关的发病率为4%，但总体住院发病率和死亡率分别为62%和50%。在存活超过30天的25例患者中，12例保留胆囊造瘘管直至接受胆囊切除术（4例开腹，7例腹腔镜手术）。其余13例患者均拔除了胆囊造瘘管，其中8例发生复发性胆囊炎。在这些复发性胆囊炎患者中，5例接受了胆囊切除术或再次胆囊造瘘术，但其余3例患者死亡。尽管这是一个较小的患者群体，但这些数据表明，在危重症患者中，胆囊造瘘管应保留至患者被认为在医学上适合接受胆囊切除术。在未进行后续胆囊切除术的情况下拔除胆囊造瘘管与复发性胆囊炎的高发生率及严重后果相关。
