Ke Chang-Wei, Wu Shuo-Dong
The Second General Surgey of Shengjing Hospital of China Medical University, Shengyang, China .
J Laparoendosc Adv Surg Tech A. 2018 Jun;28(6):705-712. doi: 10.1089/lap.2017.0502. Epub 2018 Apr 16.
Patients with moderate (grade II) acute cholecystitis patients, as defined by the 2013 Tokyo Guidelines, were retrospectively compared with respect to emergency cholecystectomy (EC) and delayed cholecystectomy (DC) after percutaneous transhepatic gallbladder drainage (PTGBD) to determine the better treatment strategy.
Forty-nine of 103 patients with PTGBD and 47 of 54 patients with EC were assessed for eligibility from January 2013 to January 2017. Patients with the following conditions were included: (i) moderate (grade II) acute cholecystitis diagnosed by the 2013 Tokyo Guidelines; (ii) no common bile duct stones; (iii) no atrophic cholecystitis; (iv) no decompensated liver cirrhosis and massive ascites; (v) no diffuse peritonitis; (vi) surgeons are professors or associate professors; and (vii) PTGBD is not the only procedure for the patient defined by clinicians. The preoperative characteristics and postoperative outcomes were analyzed. PTGBD was performed by experienced interventional radiologists and cholecystectomy was performed by professors or associate professors.
Patients in the EC and PTGBD + DC groups had similar demographic, clinical, preoperative laboratory, and imaging characteristics. Both PTGBD and EC resolved the cholecystitis quickly. Compared to the PTGBD + DC group, EC patients had more intraoperative bleeding (101 ± 125 mL versus 33 ± 37 mL, P = .003), longer duration of postoperative abdominal drainage (9.0 ± 12.9 days versus 3.4 ± 2.1 days, P = .041), more patients converted to open cholecystectomy (OC; 19.1% versus 4.1%, P = .021), more OC patients (14.9% versus 0%, P = .005), more patients with gangrenous cholecystitis (40.4% versus 8.2%, P < .001), more cholecystitis patients with perforation (12.8% versus 0%, P = .012), a higher incidence of respiratory failure (14.8% versus 2.0%, P = .029), more admissions to the intensive care unit (ICU) (21.3% versus 2.0%, P = .003), and longer postoperative hospital stays (8.2 ± 3.2 days versus 11.6 ± 4.6 days, P < .001) in the PTGBD + DC group. In addition, there were statistically more OC patients (63.2% versus 14.3%, P = .001) in the nonbiliary surgeon group than the biliary surgeon group.
CONCLUSION(S): In patients with moderate (grade II) acute cholecystitis, PTGBD and EC were highly efficient in resolving cholecystitis. DC patients after PTGBD had better outcomes with a lower rate of OC, less intraoperative bleeding, shorter duration of postoperative abdominal drainage, shorter hospital stays after cholecystectomy, a lower incidence of respiratory failure, fewer admissions to the ICU than EC, and reversed the pathologic process affecting the gallbladder. The total postoperative hospital stay was longer in the PTGBD + DC group.
回顾性比较2013年东京指南定义的中度（II级）急性胆囊炎患者行急诊胆囊切除术（EC）和经皮经肝胆囊引流术（PTGBD）后延迟胆囊切除术（DC）的情况，以确定更佳治疗策略。
2013年1月至2017年1月期间，对103例行PTGBD患者中的49例和54例行EC患者中的47例进行资格评估。纳入符合以下条件的患者：（i）根据2013年东京指南诊断为中度（II级）急性胆囊炎；（ii）无胆总管结石；（iii）无萎缩性胆囊炎；（iv）无失代偿期肝硬化和大量腹水；（v）无弥漫性腹膜炎；（vi）外科医生为教授或副教授；（vii）PTGBD不是临床医生为患者确定的唯一手术方式。分析术前特征和术后结果。PTGBD由经验丰富的介入放射科医生实施，胆囊切除术由教授或副教授实施。
EC组和PTGBD + DC组患者在人口统计学、临床、术前实验室和影像学特征方面相似。PTGBD和EC均能迅速缓解胆囊炎。与PTGBD + DC组相比，EC组患者术中出血更多（101±125 mL对33±37 mL，P = 0.003），术后腹腔引流时间更长（9.0±12.9天对3.4±2.1天，P = 0.041），转为开腹胆囊切除术（OC）的患者更多（19.1%对四.1%，P = 0.021），OC患者更多（14.9%对0%，P = 0.005），坏疽性胆囊炎患者更多（40.4%对8.2%，P < 0.001），胆囊炎穿孔患者更多（12.8%对0%，P = 0.012），呼吸衰竭发生率更高（14.8%对2.0%，P = 0.029），入住重症监护病房（ICU）的患者更多（21.3%对四.0%，P = 0.003），PTGBD + DC组术后住院时间更长（8.2±3.2天对11.6±4.6天，P < 0.001）。此外，非胆道外科医生组的OC患者在统计学上比胆道外科医生组更多（63.2%对14.3%，P = 0.00四.
在中度（II级）急性胆囊炎患者中，PTGBD和EC在缓解胆囊炎方面效率很高。PTGBD后行DC的患者预后更好，OC率更低，术中出血更少，术后腹腔引流时间更短，胆囊切除术后住院时间更短，呼吸衰竭发生率更低，入住ICU的患者更少，并逆转了影响胆囊的病理过程。PTGBD + DC组术后总住院时间更长。
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