Thapar Pinky, Salvi Prashant, Killedar Madhura, Roji Philip, Rokade Muktachand
Department of Minimal Invasive Surgery, Jupiter Hospital, Off Eastern Express Highway, Thane, Maharashtra, 400 601, India.
Department of Radiology, Jupiter Hospital, Off Eastern Express Highway, Thane, Maharashtra, 400 601, India.
Surg Endosc. 2021 Aug;35(8):4231-4240. doi: 10.1007/s00464-020-07905-w. Epub 2020 Sep 1.
Laparoscopic cholecystectomy (LC) in complicated acute calculus cholecystitis (ACC) poses multiple challenges. This prospective, observational study assessed the utility and safety of a set protocol and intraoperative steps in LC for complex ACC.
All cases of ACC from 2008 to 2018 were graded as per Tokyo guidelines; moderate and severe ACC were termed as 'complex ACC (CACC).' Patients were subjected to upfront LC or percutaneous drainage (PCD) followed by LC. Seven intraoperative safety steps were used to achieve critical view of safety (CVS). Use of safety steps, duration of surgery, and length of hospital stay were compared between moderate and severe ACC; complications were classified using Clavien-Dindo classification.
We analyzed 145 patients with moderate (74.5%) and severe (25.5%) ACC. There were significantly more male (p = 0.0059) and older (p = 0.0006) patients with severe ACC. Upfront LC was performed in 81.4%; PCD required in 6.9%. Timing of LC from symptom onset was < 1 week (53.1%), 2-5 weeks (28.3%), and ≥ 6 weeks (18.6%). CVS was achieved in 97.2%, subtotal cholecystectomy performed in 2.8%, conversion rate was 1.4%, major postoperative complications (Clavien-Dindo Grade IIIa and IIIb) were seen in 4.1%, no bile duct injury, and mortality was 0.7%. The outcomes were similar irrespective of timing of intervention.
The study concludes that preoperative assessment by Tokyo guidelines, algorithmic plan of treatment and use of intraoperative safety steps results in favorable outcome of LC in ACC.
复杂急性结石性胆囊炎（ACC）的腹腔镜胆囊切除术（LC）面临多重挑战。这项前瞻性观察性研究评估了一套既定方案及LC术中步骤在复杂ACC中的效用和安全性。
将2008年至2018年所有ACC病例按照东京指南分级；中度和重度ACC被称为“复杂ACC（CACC）”。患者接受直接LC或经皮引流（PCD）后再行LC。采用七个术中安全步骤以实现安全关键视野（CVS）。比较中度和重度ACC在安全步骤使用、手术时长及住院时间方面的差异；并发症按照Clavien-Dindo分类法进行分类。
我们分析了145例中度（74.5%）和重度（25.5%）ACC患者。重度ACC患者中男性（p = 0.0059）及年龄较大者（p = 0.0006）明显更多。81.4%的患者接受了直接LC；6.9%的患者需要PCD。从症状出现到行LC的时间为<1周（53.1%）、2 - 5周（28.3%）及≥6周（18.6%）。97.2%的患者实现了CVS，2.8%的患者进行了次全胆囊切除术，中转率为1.4%，4.1%的患者出现了主要术后并发症（Clavien-Dindo IIIa级和IIIb级），无胆管损伤，死亡率为0.7%。无论干预时机如何，结果相似。
该研究得出结论，按照东京指南进行术前评估、采用程序化治疗方案及术中安全步骤可使ACC患者LC获得良好结局。
