Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania.
Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, Pennsylvania.
Ann Surg. 2020 Sep 1;272(3):449-456. doi: 10.1097/SLA.0000000000004210.
To compare cholecystectomy (CCY) and nonoperative treatment (no-CCY) for acute cholecystitis in pregnancy.
Current Society of Gastrointestinal and Endoscopic Surgery guidelines recommend CCY over nonoperative management of acute cholecystitis during pregnancy, and the American College of Obstetricians and Gynecologists recommend medically necessary surgery regardless of trimester. This approach has been recently questioned.
Pregnant women admitted with acute cholecystitis were identified using the Nationwide Readmission Database 2010-2015. Propensity-score adjusted logistic regression models were used to compare CCY and no-CCY. The primary outcome was a composite measure of adverse maternal-fetal outcomes (intrauterine death/stillbirth, poor fetal growth, abortion, preterm delivery, C-section, obstetric bleeding, infection of the amniotic fluid, venous thromboembolism).
There were 6390 pregnant women with acute cholecystitis: 38.2% underwent CCY, of which 5.1% were open. Patients were more likely to be managed operatively in their second trimester (First 43.9%, Second 59.1%, Third 34.2%; P < 0.01). Patients managed with CCY did not differ in age, insurance, income, Charlson Comorbidity Index, diabetes or obesity when compared to no-CCY (all P > 0.05), but were less likely to have a previous C-section, gestational diabetes, preeclampsia/eclampsia or be in the third trimester (P ≤ 0.01). Risk-adjusted analyses showed that no-CCY was associated with significantly increased maternal-fetal complications during the index admission [odds ratio 3.0 (95% confidence interval 2.08-4.34), P < 0.01] and 30-day readmissions [odds ratio 1.61 (confidence interval % CI 1.12-2.32), P < 0.01].
Contrary to current guidelines, most pregnant women admitted in the US with acute cholecystitis are managed nonoperatively. This is associated with over twice the odds of maternal-fetal complications in addition to increased readmissions.
比较胆囊切除术（CCY）和非手术治疗（无 CCY）在妊娠急性胆囊炎中的应用。
目前，胃肠内镜外科学会的指南建议在妊娠期间，CCY 优于急性胆囊炎的非手术治疗，美国妇产科医师学会建议无论孕期如何，只要有手术指征就应进行手术。这种方法最近受到了质疑。
利用 2010 年至 2015 年国家再入院数据库，确定因急性胆囊炎入院的孕妇。采用倾向评分调整后的逻辑回归模型比较 CCY 和无 CCY。主要结局是母婴不良结局（宫内死产/死胎、胎儿生长不良、流产、早产、剖宫产、产科出血、羊水感染、静脉血栓栓塞）的综合指标。
共有 6390 例孕妇患有急性胆囊炎：38.2%行 CCY，其中 5.1%为开放性手术。患者在孕中期更倾向于接受手术治疗（第一孕期为 43.9%，第二孕期为 59.1%，第三孕期为 34.2%；P＜0.01）。与无 CCY 相比，行 CCY 的患者在年龄、保险、收入、Charlson 合并症指数、糖尿病或肥胖方面无差异（均 P＞0.05），但行 CCY 的患者行剖宫产术、妊娠期糖尿病、子痫前期/子痫的可能性较低，且处于第三孕期的可能性较小（P≤0.01）。风险调整分析显示，无 CCY 与指数入院时母婴并发症显著增加相关[比值比 3.0（95%置信区间 2.08-4.34），P＜0.01]和 30 天再入院[比值比 1.61（置信区间%CI 1.12-2.32），P＜0.01]。
与当前指南相反，美国大多数因急性胆囊炎入院的孕妇采用非手术治疗。这与母婴并发症的发生几率增加两倍以上有关，此外，还会增加再入院的几率。
