Department of General Surgery, Tan Tock Seng Hospital, 308433, Singapore.
Department of General Surgery, Tan Tock Seng Hospital, 308433, Singapore.
Hepatobiliary Pancreat Dis Int. 2022 Jun;21(3):273-278. doi: 10.1016/j.hbpd.2022.03.008. Epub 2022 Mar 21.
Cholecystectomy is considered a general surgical operation. However, general surgeons are not trained to manage severe complications such as bile duct injury (BDI) and should refer to hepatopancreatobiliary (HPB) surgeons when difficulty arises. This study aimed to investigate the outcomes of patients who had on-table HPB consults during cholecystectomy.
This is an audit of 50 patients who required on-table HPB consult during cholecystectomy from 2011 to 2017. Consultations were classified as "proactive" and "reactive", where consults were made before or after surgical incision, respectively. Patient demographics and perioperative details were collected.
The median age of the patients was 62.5 years [interquartile range (IQR) 50.8-71.3 years]. Eight (16%) patients had underlying HPB co-morbidity. Gallbladder wall was thickened in all patients (median 5 mm, IQR 4-7 mm), and common bile duct was of normal caliber in all patients (median 5 mm, IQR 4-6 mm). Median length of operation and length of stay were 165 min (IQR 124-209 min) and five days (IQR 3-7 days), respectively. Subtotal cholecystectomy was performed in 18 (36%) patients. Forty-eight patients were initially managed by laparoscopic approach, 15 (31%) required open conversion; majority (9/15, 60%) were initiated before on-table consult. Majority of referrals (98%) were reactive. Common reasons for referral included unclear anatomy or anatomical variations (30%), presence of dense adhesions and/or contracted gallbladder (18%) and impacted stones in Hartmann's pouch (16%). Three (6%) patients were referred for BDI (2 Strasberg D and 1 Strasberg E1), and two (4%) were referred for torrential bleeding from arterial injury (1 cystic artery and 1 right hepatic artery). Any morbidity and 30-day readmission were 22% and 6%, respectively. There was no 90-day mortality.
Calling for help in BDI is obligatory, but in other instances is a personal choice. Calling for help prior to open conversion is lacking and this awareness should be raised. Whether surgical outcomes could be improved by early HPB consult needs to be determined by larger multicenter reports.
胆囊切除术被认为是一种普通外科手术。然而，普通外科医生并未接受过处理严重并发症（如胆管损伤）的培训，因此在遇到困难时应向肝胆胰外科医生寻求帮助。本研究旨在探讨在胆囊切除术中进行台上肝胆胰会诊患者的结局。
这是一项对 2011 年至 2017 年期间在胆囊切除术中需要台上肝胆胰会诊的 50 例患者的回顾性研究。会诊分为“主动”和“被动”，分别是指在手术切口之前或之后进行的会诊。收集患者的人口统计学和围手术期资料。
患者的中位年龄为 62.5 岁（四分位距 [IQR] 50.8-71.3 岁）。8 例（16%）患者存在合并肝胆胰疾病。所有患者的胆囊壁均增厚（中位数 5mm，IQR 4-7mm），所有患者的胆总管均正常（中位数 5mm，IQR 4-6mm）。手术时间和住院时间的中位数分别为 165 分钟（IQR 124-209 分钟）和 5 天（IQR 3-7 天）。18 例（36%）患者行次全胆囊切除术。48 例患者最初采用腹腔镜入路，15 例（31%）需要转为开腹手术；其中大多数（9/15，60%）是在台上会诊之前开始转为开腹的。大多数会诊（98%）为被动会诊。会诊的主要原因包括解剖结构不清或解剖结构变异（30%）、致密粘连和/或收缩胆囊（18%）以及 Hartmann 袋内嵌顿结石（16%）。3 例（6%）患者因胆管损伤（2 例 Strasberg D 型和 1 例 Strasberg E1 型）被转科，2 例（4%）因动脉损伤所致大出血（1 例胆囊动脉和 1 例右肝动脉）被转科。任何并发症和 30 天再入院率分别为 22%和 6%，无 90 天死亡病例。
在胆管损伤时寻求帮助是强制性的，但在其他情况下则是个人选择。在转为开腹手术之前寻求帮助的情况较少，应提高这方面的意识。早期肝胆胰会诊是否能改善手术结局，需要更大规模的多中心研究来确定。
