Angrisani L, Lorenzo M, Corcione F, Vincenti R
Universita' Degli Studi di Napoli Federico II, Facolta' di Medicina e Chirurgia, I Chirurgia Generale, Italy.
J Laparoendosc Adv Surg Tech A. 1997 Aug;7(4):213-20. doi: 10.1089/lap.1997.7.213.
Surgical literature around 1980 has emphasized the technical challenge and the risks of cholecystectomy in cirrhotic patients reporting discouraging results. The aim of this study is the retrospective analysis of laparoscopic cholecystectomy in cirrhotics. The collected laparoscopic experience of 3 surgical groups for the last 5 years is reported. Cirrhotics were classified according to Child-Pugh criteria. Postoperative complications were classified using Clavien's rules. Forty patients were recruited; 31 received successful laparoscopic cholecystectomy. Liver cirrhosis was preoperatively diagnosed in all Child-Pugh B (n = 11) and in 11/20 Child-Pugh A patients. Compared with 989 noncirrhotics undergoing laparoscopic cholecystectomy, cirrhotics were similar in terms of age (59.9+/-10.3 vs. 58.1+/-10.9) and sex (male: 51.6% vs. 50.1%). Acute cholecystitis has a similar frequence in cirrhotics and noncirrhotics (3.2% vs. 4.1%, respectively). Bile duct stones and acute pancreatitis were significantly more frequent in cirrhotic patients (6.4% vs. 3.7%, p < 0.001; and 6.4% vs. 0.3%, p < 0.001, respectively). Endoscopic papillotomy and stone extraction combined with laparoscopic cholecystectomy was performed in 2 patients. Intraoperatively, technical problems occurred in 5 (16.1%) patients: liver bed bleeding (n = 4) was significatively more frequent in cirrhotics vs. noncirrhotics (p < 0.001). Mean operative time was 90 min, range 50-180, and it was not significantly longer than in noncirrhotics (85 min, range 30-200). Conversion rate was also similar (3%). Seven patients presented 8 postoperative complications (Class II): right side lung effusion (n = 2), ascites (n = 2), temporary worsening of Child-Pugh status (n = 2), hyperosmotic coma (n = 1), and umbilical hernia (n = 1). Mean hospital stay in noncomplicated cases was the same for noncirrhotics (3+/-1). The authors suggest a more liberal use of laparoscopic cholecystectomy for symptomatic gallstones in selected Child-Pugh A and B patients.
1980年左右的外科文献强调了肝硬化患者胆囊切除术的技术挑战和风险，报告的结果令人沮丧。本研究的目的是对肝硬化患者的腹腔镜胆囊切除术进行回顾性分析。报告了3个手术组过去5年积累的腹腔镜手术经验。根据Child-Pugh标准对肝硬化患者进行分类。使用Clavien规则对术后并发症进行分类。招募了40例患者；31例成功接受了腹腔镜胆囊切除术。所有Child-Pugh B级（n = 11）和20例Child-Pugh A级患者中的11例术前被诊断为肝硬化。与989例接受腹腔镜胆囊切除术的非肝硬化患者相比，肝硬化患者在年龄（59.9±10.3岁 vs. 58.1±10.9岁）和性别（男性：51.6% vs. 50.1%）方面相似。肝硬化患者和非肝硬化患者急性胆囊炎的发生率相似（分别为3.2%和4.1%）。胆管结石和急性胰腺炎在肝硬化患者中明显更常见（分别为6.4% vs. 3.7%，p < 0.001；6.4% vs. 0.3%，p < 0.001）。2例患者进行了内镜乳头切开取石术并联合腹腔镜胆囊切除术。术中，5例（16.1%）患者出现技术问题：肝硬化患者肝床出血（n = 4）明显多于非肝硬化患者（p < 0.001）。平均手术时间为90分钟，范围为50 - 180分钟，并不显著长于非肝硬化患者（85分钟，范围为30 - 200分钟）。中转率也相似（3%）。7例患者出现8例术后并发症（II级）：右侧胸腔积液（n = 2）、腹水（n = 2）、Child-Pugh状态暂时恶化（n = 2）、高渗性昏迷（n = 1）和脐疝（n = 1）。非并发症病例的平均住院时间在非肝硬化患者中相同（3±1天）。作者建议对于选定的Child-Pugh A级和B级有症状胆结石患者更广泛地使用腹腔镜胆囊切除术。
