Mou Danny, Tesfasilassie Tomas, Hirji Sameer, Ashley Stanley W
Harvard Medical School CRICO Scholar in Quality and Safety Brigham and Women's Hospital Boston Massachusetts.
Department of Surgery Harvard Medical School Brigham and Women's Hospital Boston Massachusetts.
Ann Gastroenterol Surg. 2019 Feb 19;3(3):247-253. doi: 10.1002/ags3.12240. eCollection 2019 May.
The diagnosis and management of acute cholecystitis (AC) continues to evolve. Among the most common surgically treated conditions in the USA, appropriate diagnosis and management of AC require astute clinical judgment and operative skill. Useful diagnostic and grading systems have been developed, most notably the Tokyo guidelines, but some recent clinical validation studies have questioned their generalizability to the US population. The timing of surgical intervention is another area that requires further investigation. US surgeons traditionally pursue laparoscopic cholecystectomy (LC) for AC patients with symptoms onset <72 hours, but for patients with symptoms over 72 hours, surgeons often elect to treat the patients with antibiotics and delay LC for 4-6 weeks to permit the inflammation to subside. This practice has recently been called into question, as there are data suggesting that LC even for AC patients with over 72 hours of symptoms confers decreased morbidity, shorter length of stay, and reduced overall healthcare costs. Finally, the role of percutaneous cholecystostomy (PC) needs to be better defined. Traditional role of PC is a temporizing measure for patients who are poor surgical candidates. However, there are data suggesting that in AC patients with organ failure, PC patients suffered higher mortality and readmission rates when compared with a propensity-matched LC cohort. Beyond diagnosis, the surgical management of AC can be remarkably challenging. All surgeons need to be familiar with best-practice surgical techniques, adjunct intra-operative imaging, and bail-out options when performing LC.
急性胆囊炎（AC）的诊断和管理仍在不断发展。在美国最常见的外科治疗疾病中，AC的恰当诊断和管理需要敏锐的临床判断力和手术技巧。有用的诊断和分级系统已经制定出来，最著名的是东京指南，但最近的一些临床验证研究对其在美国人群中的通用性提出了质疑。手术干预的时机是另一个需要进一步研究的领域。美国外科医生传统上对症状出现<72小时的AC患者采用腹腔镜胆囊切除术（LC），但对于症状超过72小时的患者，外科医生通常选择用抗生素治疗并将LC推迟4 - 6周，以使炎症消退。这种做法最近受到了质疑，因为有数据表明，即使对于症状超过72小时的AC患者，LC也能降低发病率、缩短住院时间并降低总体医疗成本。最后，经皮胆囊造瘘术（PC）的作用需要更明确地界定。PC的传统作用是作为手术条件较差患者的一种临时措施。然而，有数据表明，在伴有器官衰竭的AC患者中，与倾向匹配的LC队列相比，PC患者的死亡率和再入院率更高。除了诊断之外，AC的手术管理可能极具挑战性。所有外科医生在进行LC时都需要熟悉最佳实践手术技术、术中辅助成像以及补救措施。
