Eldar S, Sabo E, Nash E, Abrahamson J, Matter I
Department of Surgery, Bnai Zion Medical Center, Haifa, Israel.
Surg Laparosc Endosc. 1997 Oct;7(5):407-14.
Elective laparoscopic cholecystectomy is established as the treatment of choice for symptomatic cholecystolithiasis and is now proposed for the treatment of acute cholecystitis. We initiated the present study in order to clarify the question of safety of the procedure in the presence of an inflamed gallbladder, and to compare the results with those of a traditionally treated group with acute cholecystitis. We compared the preoperative, operative, and postoperative courses of 146 patients with acute cholecystitis, managed laparoscopically between 1994 and 1996, with those of 97 patients, treated traditionally by open cholecystectomy for the same diagnosis between 1992 and 1993. In the acute cholecystitis cases, when laparoscopic cholecystectomy was successfully performed, the operative and postoperative courses were superior to those of open cholecystectomy. The use of drains and NG tubes, the need for antibiotics and analgesia, the associated morbidity, and the hospital stay were significantly reduced. Following conversion, the postoperative course was similar to that of open cholecystectomy. Of the group of acute cholecystitis cases laparoscopically approached 39 (27%) needed conversion. Twenty-five complications occurred in 24 (16.5%) patients of the laparoscopic group, whereas 30 complications occurred in 25 (26%) patients of the traditionally operated group. Male sex, older patients, and larger bile stones were found to be associated with a higher conversion rate as well as a higher complication rate. A nonpalpable gallbladder and gangrenous cholecystitis were associated with conversion while fever was associated with complications. Laparoscopic cholecystectomy can be performed safely in selected cases of acute cholecystitis, with acceptable conversion and low complication rates. When laparoscopic cholecystectomy is successfully performed, the operative and postoperative courses are superior to those of open cholecystectomy. Following conversion, the postoperative course is similar to that of open cholecystectomy. According to this study, male sex, older age, large bile stones, a nonpalpable gallbladder, and gangrenous cholecystitis may be regarded as predictors of conversion, while male sex, older age, large bile stones, and fever may be regarded as predictors of complications. The timing of laparoscopic cholecystectomy should be within 96 h from onset of the inflammation.
择期腹腔镜胆囊切除术已被确立为有症状胆囊结石的首选治疗方法，目前也被提议用于治疗急性胆囊炎。我们开展本研究是为了阐明在胆囊发炎情况下该手术的安全性问题，并将结果与传统治疗的急性胆囊炎患者组进行比较。我们比较了1994年至1996年间接受腹腔镜治疗的146例急性胆囊炎患者与1992年至1993年间因相同诊断接受传统开腹胆囊切除术治疗的97例患者的术前、术中及术后病程。在急性胆囊炎病例中，成功实施腹腔镜胆囊切除术时，术中及术后病程优于开腹胆囊切除术。引流管和鼻胃管的使用、抗生素和镇痛的需求、相关发病率及住院时间均显著减少。中转开腹后，术后病程与开腹胆囊切除术相似。在腹腔镜治疗的急性胆囊炎病例组中，39例（27%）需要中转开腹。腹腔镜组24例（16.5%）患者发生了25例并发症，而传统手术组25例（26%）患者发生了30例并发症。发现男性、老年患者及较大的胆结石与较高的中转率以及较高的并发症发生率相关。无法触及的胆囊和坏疽性胆囊炎与中转开腹相关，而发热与并发症相关。在选定的急性胆囊炎病例中，腹腔镜胆囊切除术可以安全进行，中转率和并发症发生率均可接受。成功实施腹腔镜胆囊切除术时，术中及术后病程优于开腹胆囊切除术。中转开腹后，术后病程与开腹胆囊切除术相似。根据本研究，男性、高龄、较大的胆结石、无法触及的胆囊及坏疽性胆囊炎可被视为中转开腹的预测因素，而男性、高龄、较大的胆结石及发热可被视为并发症的预测因素。腹腔镜胆囊切除术的时机应在炎症发作后96小时内。
