急性胆囊炎的诊断和治疗：一项针对指南遵循情况和患者结局的单中心审计。
Diagnosis and management of acute cholecystitis: a single-centre audit of guideline adherence and patient outcomes.
机构信息
From the Department of Surgery, McMaster University, Hamilton, Ont. (Giles, Godzisz, Nenshi, Forbes, Farrokhyar, Lee, Eskicioglu); the Department of Surgery, St. Joseph's Healthcare Hamilton, Hamilton, Ont. (Nenshi, Eskicioglu); and the Department of Surgery, Hamilton Health Sciences, Hamilton, Ont. (Forbes).
出版信息
Can J Surg. 2020 May 8;63(3):E241-E249. doi: 10.1503/cjs.002719.
BACKGROUND
The Tokyo Guidelines were published in 2007 and updated in 2013 and 2018, with recommendations for the diagnosis and management of acute cholecystitis. We assessed guideline adherence at our academic centre and its impact on patient outcomes.
METHODS
This is a retrospective chart review of patients with acute calculous cholecystitis who underwent cholecystectomy at our institution between November 2013 and March 2015. Severity of cholecystitis was graded retrospectively if it had not been documented preoperatively. Compliance with the Tokyo Guidelines' recommendations on antibiotic use and time to operation was recorded. Cholecystitis severity groups were compared statistically, and logistic regression was used to determine predictors of complications.
RESULTS
One hundred and fifty patients were included in the study. Of these, 104 patients were graded as having mild cholecystitis, 45 as having moderate cholecystitis, and 1 as having severe cholecystitis. Severity was not documented preoperatively for any patient. Compliance with antibiotic recommendations was poor (18.0%) and did not differ by cholecystitis severity (p = 0.90). Compliance with the recommendation on time to operation was 86.0%, with no between-group differences (p = 0.63); it improved when an acute care surgery team was involved (91.0% v. 76.0%, p = 0.025). On multivariable analysis, comorbidities (odds ratio [OR] 1.47, 95% confidence interval [CI] 1.19-1.85, p < 0.001) and conversion to laparotomy (OR 13.45, 95% CI 2.16-125.49, p = 0.01) predicted postoperative complications, while severity of cholecystitis, antibiotic compliance and time to operation had no effect.
CONCLUSION
In this study, compliance with the Tokyo Guidelines was acceptable only for time to operation. Although the poor compliance with recommendations relating to documentation of severity grading and antibiotic use did not have a negative affect on patient outcomes, these recommendations are important because they facilitate appropriate antibiotic use and patient risk stratification.
背景
《东京指南》于 2007 年发布，分别于 2013 年和 2018 年更新，为急性胆囊炎的诊断和治疗提供了建议。我们评估了我院的指南遵循情况及其对患者结局的影响。
方法
这是一项回顾性图表研究，纳入 2013 年 11 月至 2015 年 3 月在我院接受胆囊切除术的急性结石性胆囊炎患者。如果术前未记录胆囊炎严重程度，则进行回顾性分级。记录抗生素使用和手术时间方面对《东京指南》建议的遵守情况。对胆囊炎严重程度组进行统计学比较，并使用逻辑回归确定并发症的预测因素。
结果
研究纳入 150 例患者。其中 104 例患者被评为轻度胆囊炎，45 例患者为中度胆囊炎，1 例患者为重度胆囊炎。没有患者术前记录胆囊炎严重程度。抗生素建议的遵守情况较差（18.0%），且胆囊炎严重程度之间无差异（p=0.90）。遵守手术时间建议的比例为 86.0%，组间无差异（p=0.63）；当涉及急性护理手术团队时，该比例提高（91.0%比 76.0%，p=0.025）。多变量分析显示，合并症（比值比 [OR] 1.47，95%置信区间 [CI] 1.19-1.85，p<0.001）和转为剖腹手术（OR 13.45，95%CI 2.16-125.49，p=0.01）预测术后并发症，而胆囊炎严重程度、抗生素使用依从性和手术时间无影响。
结论
在这项研究中，仅在手术时间方面对《东京指南》的遵循情况是可以接受的。尽管在记录严重程度分级和抗生素使用方面的建议遵守情况不佳对患者结局没有负面影响，但这些建议很重要，因为它们有助于合理使用抗生素和对患者进行风险分层。
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