Bradshaw Luke, Lau Lawrence, Knowles Brett, Fox Adrian, Banting Simon W
Hepatobiliary and Upper Gastrointestinal Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia.
HPB Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.
ANZ J Surg. 2020 Nov;90(11):2264-2268. doi: 10.1111/ans.15986. Epub 2020 Jun 3.
Subtotal cholecystectomy is utilized in conditions of high risk to critical structures, like the common bile duct. However, the remnant gall bladder may become symptomatic and require a completion cholecystectomy for treatment. This second procedure can itself be a risk to critical structures. To establish the incidence of redo-cholecystectomy and identify risk factors that lead to subtotal cholecystectomy and repeat operation in a review of state-based practices for cholecystectomy.
A search of state coding records relating to cholecystectomy from 1998 to 2016. Patients who were coded for cholecystectomy-related procedures on different dates were identified. Patients who underwent the procedures within 6 months were excluded to avoid acute post-operative complications and gall bladder malignancy.
210 719 cholecystectomies were performed. 1133 required repeat procedure. 616 were excluded, leaving 516 (0.25%) cholecystectomy patients requiring a second cholecystectomy. The subsequent operation was more likely to be an emergency procedure; involve transcystic bile duct exploration, adhesiolysis and require intensive care unit admission post-operatively. A repeat cholecystectomy was more likely to occur after having the primary procedure at a public hospital and when an intra-operative cholangiogram was not performed. Over the study period, the rate of repeat cholecystectomy increased from 0.02% to 0.6%. Incidentally, the rate of intra-operative cholangiogram during a primary cholecystectomy increased from 43% to 73%.
Repeat cholecystectomy is an uncommon procedure. A second cholecystectomy is a more complex and likely to require intensive care unit support. Referral to a tertiary hepatobiliary unit is recommended.
在存在损伤关键结构（如胆总管）高风险的情况下，会采用胆囊次全切除术。然而，残留胆囊可能出现症状，需要行二期胆囊切除术进行治疗。而这第二次手术本身对关键结构也存在风险。在一项基于全州胆囊切除术实践的回顾中，确定再次胆囊切除术的发生率，并识别导致胆囊次全切除术和再次手术的风险因素。
检索1998年至2016年与胆囊切除术相关的州编码记录。确定在不同日期进行胆囊切除术相关手术编码的患者。排除在6个月内接受手术的患者，以避免急性术后并发症和胆囊恶性肿瘤。
共进行了210719例胆囊切除术。1133例需要再次手术。排除616例，剩下516例（0.25%）胆囊切除术患者需要二次胆囊切除术。后续手术更可能是急诊手术；涉及经胆囊胆管探查、粘连松解，且术后需要入住重症监护病房。在公立医院进行初次手术后以及未进行术中胆管造影时，更有可能进行再次胆囊切除术。在研究期间，再次胆囊切除术的发生率从0.02%升至0.6%。顺便提一下，初次胆囊切除术中术中胆管造影的发生率从43%升至73%。
再次胆囊切除术是一种不常见的手术。二次胆囊切除术更为复杂，可能需要重症监护病房的支持。建议转诊至三级肝胆科单位。
