Morley Timothy J, Fridling Jeremy, Brewer Jennifer M, Gross Ronald, Montgomery Stephanie, Miller Corrine, Posillico Sarah, Jeremitsky Elan, Jayaraman Vijay, Roberts Kurt E, Hill Thomas Russell, Moutinho Manuel, Doben Andrew R, Greig Chasen J
Department of Surgery, St Francis Hospital, Hartford, CT. (Drs. Morley, Gross, Montgomery, Miller, Posillico, Jeremitsky, Jayaraman, Roberts, Hill, Moutinho, Doben, and Greig).
Department of General Surgery, University of Connecticut, Farmington, CT. (Drs. Fridling and Brewer).
JSLS. 2025 Jan-Mar;29(1). doi: 10.4293/JSLS.2024.00060. Epub 2025 Mar 25.
Acute cholecystitis (AC) is among the most frequently encountered surgical problems. Current management typically includes laparoscopic cholecystectomy (LC). Suboptimal outcomes of LC can include bile duct injury, open conversion (OC), and/or subtotal cholecystectomy (SC). Percutaneous cholecystostomy tube (PCT) drainage with interval cholecystectomy has emerged as an alternative in high-risk patients but outcomes vary widely. We describe an evidence-based algorithm for managing AC in high-risk patients via PCT followed by minimally invasive cholecystectomy (MIS-C). We hypothesized that our algorithm would prove safe, effective, and decrease OC and SC rates.
Retrospective chart review of patients undergoing PCT and MIS-C according to our algorithm from January 2020 to June 2023. The primary outcome was OC or SC. Secondary outcomes included bile leak, bile duct injury, and perioperative complications. Demographic, clinical, and operative data were collected. Statistical analysis was performed using Minitab Software.
Twenty-nine patients met criteria and were treated according to our algorithm during the study period. One patient (3.4%) required conversion to SC. Other complications included 3 postoperative bile leaks (10.4%). There were no bile duct injuries and no deaths. None were lost to follow up. When stratified by LC or robotic-assisted cholecystectomy (RC), complications occurred more frequently in the LC group, including the lone conversion to SC.
Our management protocol of high-grade AC in high-risk patients appears safe, feasible, and may reduce adverse events. Additionally, our data suggest a potential benefit of RC in this setting which may be an underutilized tool in acute care surgery. Prospective data are needed to validate and further refine this algorithm.
急性胆囊炎（AC）是最常见的外科问题之一。目前的治疗通常包括腹腔镜胆囊切除术（LC）。LC的不理想结果可能包括胆管损伤、中转开腹（OC）和/或次全胆囊切除术（SC）。经皮胆囊造瘘管（PCT）引流并择期行胆囊切除术已成为高危患者的一种替代治疗方法，但结果差异很大。我们描述了一种基于循证的算法，用于通过PCT然后行微创胆囊切除术（MIS-C）来管理高危患者的AC。我们假设我们的算法将被证明是安全、有效的，并能降低OC和SC的发生率。
对2020年1月至2023年6月期间按照我们的算法接受PCT和MIS-C治疗的患者进行回顾性病历审查。主要结局是OC或SC。次要结局包括胆漏、胆管损伤和围手术期并发症。收集人口统计学、临床和手术数据。使用Minitab软件进行统计分析。
在研究期间，29例患者符合标准并按照我们的算法进行治疗。1例患者（3.4%）需要转为SC。其他并发症包括3例术后胆漏（10.4%）。没有胆管损伤，也没有死亡病例。无一例失访。按LC或机器人辅助胆囊切除术（RC）分层时，LC组并发症发生率更高，包括唯一1例转为SC的病例。
我们针对高危患者的高级别AC管理方案似乎是安全、可行的，并且可能减少不良事件。此外，我们的数据表明RC在这种情况下可能具有潜在益处，这可能是急性护理手术中一种未充分利用的工具。需要前瞻性数据来验证和进一步完善该算法。
