Department of General Surgery, Okinawa Chubu Hospital, 281 Miyazato, Uruma, Okinawa, Japan.
BMC Surg. 2021 Oct 30;21(1):386. doi: 10.1186/s12893-021-01387-w.
Severe adhesions and fibrosis between the posterior wall of the gallbladder and liver bed often render total cholecystectomy after percutaneous transhepatic gallbladder drainage (PTGBD) difficult, leading to high open conversion rates. Since the publication of Tokyo Guidelines 2018 (TG18), our policy has shifted from open conversion to subtotal cholecystectomy (SC) when total laparoscopic cholecystectomy for difficult cases of cholecystitis is not feasible. Recently, SC has been frequently applied as bailout surgery for complicated cholecystitis. Nonetheless, the efficacy and validity of laparoscopic SC after PTGBD remain unclear. This study aimed to evaluate the safety and feasibility of laparoscopic SC after PTGBD for grade II or III acute cholecystitis (AC) by comparing two periods of altered surgical strategies.
This retrospective cohort study was conducted between January 2013 and December 2020. A total of 44 eligible patients with grade II or III AC were divided according to the time of cholecystitis onset into the pre-TG18 group (2013-2017, n = 17) and post-TG18 group (2018-2020, n = 27). Patients' background demographics, surgical method, surgical results, and postoperative complications were compared.
The interval between PTGBD and surgery was significantly longer in the post-TG18 group than in the pre-TG18 group (15 [interquartile range: 9-42] days vs. 8 [4-11] days; P = 0.010). The frequency of laparoscopic cholecystectomy significantly increased from 52.9% in the pre-TG18 group to 88.9% in the post-TG18 group (P = 0.007), whereas the frequency of SC was 23.5% and 40.7%, respectively, which showed no statistically significant difference (P = 0.241). However, the rate of laparoscopic SC significantly increased from 0 to 90.9% among 15 SC cases, whereas the rate of open SC significantly plummeted from 100 to 9.1% (P = 0.001). Significant differences in the operative time, amount of intraoperative bleeding, and incidence of postoperative complications (wound infection and subhepatic abscess) were not observed. Mortality, bile leakage, and bile duct injury did not occur in either group.
For grade II or III AC after PTGBD, aggressive adoption of SC increased the completion rate of laparoscopic surgery. Laparoscopic SC is a safe and feasible treatment option.
经皮经肝胆囊引流（PTGBD）后，胆囊后壁与肝床之间严重粘连和纤维化，常使全胆囊切除术难以进行，导致开放转化率高。自 2018 年东京指南（TG18）发布以来，我们的策略已从开放转为困难型胆囊炎的腹腔镜胆囊次全切除术（SC）。最近，SC 已被频繁应用于复杂胆囊炎的抢救性手术。然而，PTGBD 后腹腔镜 SC 的疗效和有效性尚不清楚。本研究旨在通过比较两种改变手术策略的时期，评估 PTGBD 后 II 级或 III 级急性胆囊炎（AC）行腹腔镜 SC 的安全性和可行性。
这是一项回顾性队列研究，于 2013 年 1 月至 2020 年 12 月进行。根据胆囊炎发病时间将 44 例符合条件的 II 级或 III 级 AC 患者分为 TG18 前组（2013-2017 年，n=17）和 TG18 后组（2018-2020 年，n=27）。比较两组患者的背景人口统计学、手术方法、手术结果和术后并发症。
TG18 后组 PTGBD 与手术之间的间隔时间明显长于 TG18 前组（15[四分位距：9-42]天比 8[4-11]天；P=0.010）。腹腔镜胆囊切除术的频率从 TG18 前组的 52.9%显著增加到 TG18 后组的 88.9%（P=0.007），而 SC 的频率分别为 23.5%和 40.7%，差异无统计学意义（P=0.241）。然而，15 例 SC 中腹腔镜 SC 的比例从 0 显著增加到 90.9%，而开腹 SC 的比例从 100 显著下降到 9.1%（P=0.001）。手术时间、术中出血量和术后并发症（伤口感染和肝下脓肿）发生率无显著差异。两组均未发生死亡、胆漏和胆管损伤。
对于 PTGBD 后 II 级或 III 级 AC，积极采用 SC 可提高腹腔镜手术的完成率。腹腔镜 SC 是一种安全可行的治疗方法。
