Eldar S, Sabo E, Nash E, Abrahamson J, Matter I
Department of Surgery, Bnai Zion Medical Center, Haifa, Israel.
Surg Laparosc Endosc. 1998 Jun;8(3):200-7.
Laparoscopic cholecystectomy (LC), the procedure of choice for elective cholelithiasis, is now also used in the management of acute cholecystitis. In the various types of gallbladder disease, favorable and unfavorable conditions may influence the conversion and complication rates. Information about these conditions may help elucidate the optimal circumstances for LC or indicate when the procedure is best avoided. We attempted to perform emergency LC on 215 patients with acute cholecystitis. The procedure was successful in 171 patients (79.5%), and conversion to open cholecystectomy (OC) was needed in 44 (20.5%). Complications occurred in 37 patients (17%). Uncomplicated acute cholecystitis was associated with age <50 years, duration of complaint <48 h, temperature <38.5 degrees C, a nonpalpable gallbladder, and an alkaline phosphatase >100 U/L. Acute gangrenous cholecystitis was associated with a negative gallbladder history, other associated diseases, temperature >38.5 degrees C, a palpable gallbladder, and serum bilirubin levels <1 mg/dl. Hydrops was associated with a temperature <38 degrees C and a leukocyte count of >12,000/cc3, and empyema of the gallbladder was associated with duration of complaint >48 h and a palpable gallbladder. The conversion rate of acute gangrenous cholecystitis (40%) was significantly higher than that of uncomplicated acute cholecystitis (8%) (p < 0.00001, odds ratio=7.7), as well as that of empyema of the gallbladder (12.5%) (p=0.005, odds ratio=4.7). The conversion from LC to OC in uncomplicated acute cholecystitis was associated with male sex and with duration of complaint >24 h, and in gangrenous cholecystitis with age >60 years, a nonpalpable gallbladder, and a leukocyte count of >15,000/cc3. The complication rates of acute cholecystitis, hydrops, empyema of the gallbladder, and gangrenous cholecystitis were 16%, 7%, 22%, and 21%, respectively (p = NS). The total complication rate in acute cholecystitis tended to be associated with a duration of complaint >48 h and in gangrenous cholecystitis with male sex, age >60 years, other associated disease, larger bile stones, and elevated serum bilirubin levels. Generally, LC is safe in all forms of cholecystitis, with acceptably low conversion and complication rates, excluding gangrenous cholecystitis. In gangrenous cholecystitis, a conversion rate of approximately 40% is expected. Predictors of conversion and complications may be particularly helpful in planning the laparoscopic approach to acute gangrenous cholecystitis. Patients >60 years of age, with a nonpalpable gallbladder and with a leukocyte count >15,000/cc3, frequently need conversion. In men >60 years old, with other associated disease, with larger bile stones, and with elevated serum bilirubin levels, complications are frequently expected. Under these conditions, laparoscopic approach should be undertaken by especially experienced teams, or OC should be considered.
腹腔镜胆囊切除术（LC）是择期胆石症的首选术式，目前也用于急性胆囊炎的治疗。在各类胆囊疾病中，有利和不利条件可能会影响中转开腹率和并发症发生率。了解这些情况有助于明确LC的最佳适用情形，或提示何时最好避免实施该手术。我们尝试对215例急性胆囊炎患者进行急诊LC。手术成功171例（79.5%），44例（20.5%）需要中转开腹胆囊切除术（OC）。37例（17%）发生并发症。单纯性急性胆囊炎与年龄<50岁、症状持续时间<48小时、体温<38.5℃、胆囊不可触及以及碱性磷酸酶>100 U/L相关。急性坏疽性胆囊炎与无胆囊病史、其他相关疾病、体温>38.5℃、胆囊可触及以及血清胆红素水平<1 mg/dl相关。胆囊积水与体温<38℃和白细胞计数>12,000/cc3相关，胆囊积脓与症状持续时间>48小时和胆囊可触及相关。急性坏疽性胆囊炎的中转开腹率（40%）显著高于单纯性急性胆囊炎（8%）（p<0.00001，优势比=7.7），也高于胆囊积脓的中转开腹率（12.5%）（p=0.005，优势比=4.7）。单纯性急性胆囊炎中转开腹与男性以及症状持续时间>24小时有关，坏疽性胆囊炎中转开腹与年龄>60岁、胆囊不可触及以及白细胞计数>15,000/cc3有关。急性胆囊炎、胆囊积水、胆囊积脓和坏疽性胆囊炎的并发症发生率分别为16%、7%、22%和21%（p无统计学意义）。急性胆囊炎的总并发症发生率往往与症状持续时间>48小时有关，坏疽性胆囊炎的总并发症发生率与男性、年龄>60岁、其他相关疾病、较大胆石以及血清胆红素水平升高有关。一般来说，除坏疽性胆囊炎外，LC在所有类型的胆囊炎中都是安全的，中转开腹率和并发症发生率均可接受且较低。在坏疽性胆囊炎中，预计中转开腹率约为40%。中转开腹和并发症的预测因素对于规划急性坏疽性胆囊炎的腹腔镜手术方法可能特别有帮助。年龄>60岁、胆囊不可触及且白细胞计数>15,000/cc3的患者经常需要中转开腹。60岁以上男性、有其他相关疾病、有较大胆石且血清胆红素水平升高的患者，经常会发生并发症。在这些情况下，应由经验特别丰富的团队进行腹腔镜手术，或考虑行OC。
