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Lingnan Modern Clinics in Surgery ›› 2020, Vol. 20 ›› Issue (02): 184-187.DOI: 10.3969/j.issn.1009-976X.2020.02.011

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Efficacy and safety of selective transumbilical single-port laparoscopic cholecystectomy for elderly patients with acute cholecystitis after percutaneous hepatic and gallbladder puncture and drainage

  

  1. Department of Hepatobiliary Surgery, Huizhou Central People??s Hospital, Huizhou, Guangdong 516002, China

经皮肝胆囊穿刺引流术后择期经脐单孔腹腔镜胆囊切除术治疗老年急性胆囊炎患者的疗效及安全性分析

  

  1. 惠州市中心人民医院肝胆外科,广东惠州 516002
  • 通讯作者: 艾志国

Abstract: [Abstract] Objective To explore the effect of transumbilical single-port laparoscopic cholecystectomy (TUSLC) in elderly patients with acute cholecystitis (AC) after percutaneous transhepatic gallbladder drainage (PTGD). Methods Eighty elderly patients with AC in our hospital (from December 2017 to December 2018) were divided into control group (n=40) and experimental group (n=40) according to the operation plan. PTGD+traditional laparoscopic cholecystectomy (LC) and PTGD+TUSLC were performed respectively. The bleeding volume, operation time, recovery time of white blood cells, recovery time of gastrointestinal function, hospitalization time and complications of the two groups were observed, and the pain degree (VAS) of 1, 3 and 7 days after operation was compared. Results Compared with the control group, the recovery time of white blood cells, hospital stay and gastrointestinal function in the experimental group were shorter, and the amount of bleeding during operation was less (P<0.05)|compared with the control group, the VAS score of the experimental group was lower on the 1st, 3rd and 7th day after operation (P<0.05)|compared with the control group, the incidence of complications in the experimental group was lower (P<0.05). Conclusion Selective TUSLC after PTGD is helpful to reduce the blood loss, relieve the pain, reduce the risk of complications and shorten the rehabilitation process of elderly AC patients.

Key words: PTGD, old age, acute cholecystitis, TUSLC, LC

摘要: 经皮肝胆囊穿刺引流术后择期经脐单孔腹腔镜胆囊切除术治疗老年急性胆囊炎患者的疗效及安全性分析

经皮肝胆囊穿刺引流术后择期经脐单孔腹腔镜胆囊切除术治疗老年急性胆囊炎患者的疗效及安全性分析

艾志国, 程玉, 张旭

[摘要] 目的 探究经皮肝胆囊穿刺引流(PTGD)术后择期经脐单孔腹腔镜胆囊切除术(TUSLC)在老年急性胆囊炎(AC)中的应用效果。方法 选取我院80例老年AC患者(2017年12月~2018年12月),根据手术方案分为对照组(n=40)和观察组(n=40),分别施行PTGD+传统腹腔镜胆囊切除术(LC)、PTGD+TUSLC。观察2组术中出血量、手术时间、白细胞恢复时间、胃肠功能恢复时间、住院时间、并发症,对比术后1 d、3 d、7 d疼痛程度(VAS)。结果 与对照组比较,观察组白细胞恢复时间、住院时间、胃肠功能恢复时间较短,术中出血量较少(P<0.05);与对照组比较,术后1 d、3 d、7 d观察组VAS评分较低(P<0.05);与对照组比较,观察组并发症发生率较低(P<0.05)。结论 PTGD术后择期行TUSLC,有助于减少老年AC患者术中出血量,缓解术后疼痛,降低并发症发生风险,缩短康复进程。

[关键词] 急性胆囊炎;老年;PTGD;TUSLC;LC

老年急性胆囊炎(AC)具有起病急、急诊手术困难、病情进展快等特点,稍有不慎,即可损伤肝功能,引起弥漫性腹膜炎、胆囊坏疽穿孔等严重并发症,甚至死亡[1]。既往文献显示,针对轻中度AC患者,推荐施行早期腹腔镜胆囊切除术(LC),重度AC患者,推荐先行胃肠减压、经皮肝胆囊穿刺引流(PTGD)等保守治疗,后进行延期手术[2]。LC治疗AC效果已得到临床证实,但随微创技术发展与完善,经脐单孔腹腔镜胆囊切除术(TUSLC)受到临床重视,与传统LC比较,更加微创及美观,但勉强施行TUSLC可增加手术风险,引起胆道损伤、出血等一系列并发症,中转开腹手术概率较高[3]。PTGD有效解决胆囊胆汁引流问题,待炎症消退后施行TUSLC,可减少并发症,提高手术安全性[4]。在此背景下,本研究将PTGD术后择期TUSLC应用于老年AC患者,取得满意效果。

1 资料与方法

1.1 研究对象

选取我院80例老年AC患者(2017年12月~2018年12月),根据手术方案分为对照组(n=40)和观察组(n=40)。2组性别、年龄、体质量指数(BMI)、腹痛持续时间、基础疾病、白细胞计数(WBC)、谷氨酸氨基转移酶(ALT)、天门冬氨酸氨基转移酶(AST)资料均衡可比(P>0.05),且研究征得我院伦理委员会审核批准。见表1。

表1 两组临床资料对比

临床资料性别(男/女)年龄/岁BMI/kg·m-2腹痛持续时间/h基础疾病/例糖尿病高血压心肺疾病WBC(×109/L)ALT/U·L-1 AST/U·L-1观察组(n=40)25/15 60~82(71.03±3.08)18~25(21.37±1.31)10~50(30.51±9.15)对照组(n=40)23/17 60~81(70.78±3.32)18~24(21.06±1.37)12~50(31.22±8.69)t/χ2 0.208 0.346 1.034 0.359 P 0.648 0.717 0.304 0.723 12(30.00)10(25.00)9(22.50)8~20(13.60±2.52)65~280(169.33±50.80)95~400(244.74±73.41)14(35.00)13(32.50)11(27.50)9~19(14.02±1.89)68~297(174.48±52.34)90~400(238.87±71.66)0.228 0.550 0.267 0.843 0.447 0.362 0.633 0.459 0.607 0.402 0.656 0.718

入组标准符合AC诊断标准[5];B超、CT等影像学检查确诊;发病至入院时间≤3 d;年龄≥60岁;患者及家属知晓并签署同意书。排除标准包括手术禁忌证者;严重心脑血管疾病者;凝血障碍者;腹部手术史者;出血倾向者;其他胆囊疾病者;临床资料不完整,无法完成研究者。

1.2 方法

2组接受补液、胃肠减压、禁食等治疗。观察组施行PTGD,术前肌肉注射哌替啶50 mg,左侧卧位,根据B超检查结果确定穿刺点、方向、深度,利多卡因(浓度为2%)局麻,自右侧腋前线取一切口,长度约0.2 cm,B超引导下,8 F猪尾形穿刺引流管插入胆囊,拔出针芯,固定引流管,接通引流装置,无菌敷料包扎。术后密切观察患者腹部体征、生命体征,并予以营养支持、抑酸、抗感染等对症治疗。PTGD术后2~4个月内行TUSLC,气管插管全麻,拔除PTGD引流管,自脐上缘正中处作一纵向切口,长度约1.5 cm,逐级分离皮肤,直至进入腹腔,置放单孔三通道装置,开放人工气腹,压力维持在14 mmHg,于三通道装置放入操作器械、腹腔镜,腹腔镜引导下,分离胆囊三角区,游离胆囊管、胆囊动脉并切断,切除胆囊,彻底止血,退镜取胆囊,闭合切口。对照组施行PTGD+传统腹腔镜胆囊切除术(LC),PTGD操作步骤如观察组,LC操作步骤为,气管插管全麻,平卧位,气腹针穿刺进入腹腔,建立人工通道,常规三孔法放入操作器械、腹腔镜,观察胆囊壁和局部组织有无粘连,出现粘连者,先行分离,游离胆囊三角,离断胆囊管、胆囊动脉,剥离胆囊,电凝止血,生理盐水反复冲洗,取出胆囊,缝合切口。

1.3 观察指标

2组手术时间、胃肠功能恢复时间、术中出血量、白细胞恢复时间、住院时间;2组术后1 d、3 d、7 d疼痛程度。应用视觉模拟评分法(VAS)评估,最高分10分,分值越低疼痛程度越轻。2组并发症。

1.4 统计学计算

通过SPSS 23.0处理,计量资料以x±s表示,两组间计量资料使用t检验,计数资料以n(%)表示,行χ2检验,P<0.05为差异有统计学意义。

2 结果

2.1 围术期指标

观察组白细胞恢复时间、住院时间、胃肠功能恢复时间短于对照组,术中出血量少于对照组(P<0.05),2组手术时间比较,差异无统计学意义(P>0.05)。见表2。

2.2 VAS评分

术后1 d、3 d、7 d观察组VAS评分较对照组低(P<0.05)。见表3。

2.3 并发症

观察组并发症发生率5.00%较对照组22.50%低(P<0.05)。见表4。

表2 围术期指标(x±s)

组别观察组对照组n 40 40 t P白细胞恢复时间/d 1.02±0.45 4.31±0.59 28.042<0.001手术时间/min 66.71±8.72 67.58±9.04 0.438 0.663胃肠功能恢复时间/h 21.31±4.22 26.84±5.23 5.204<0.001术中出血量/mL 40.31±10.65 55.35±8.94 6.841<0.001住院时间/d 10.85±2.33 19.01±3.14 13.198<0.001

表3 VAS评分(x±s,分)

组别观察组对照组n 40 40 t P术前6.68±0.47 6.40±0.64 0.452 0.511术后1 d 4.04±0.51 5.65±0.62 12.684<0.001术后3 d 2.81±0.42 3.78±0.44 10.085<0.001术后7 d 1.65±0.33 2.30±0.35 8.546<0.001

表4 并发症[n(%)]

组别观察组对照组n 40 40肝脏损伤0(0.00)1(2.50)气胸1(2.50)3(7.50)胆漏0(0.00)2(5.00)肠穿孔1(2.50)3(7.50)χ2 P总发生率2(5.00)9(22.50)5.165 0.023

3 讨论

随社会老龄化趋势日益明显,老年急性胆囊炎(acute cholecystitis,AC)发病率呈逐渐升高趋势,据统计,AC在年龄≥70岁人群中发病率达50%,若未及时治疗,可在短期内出现严重并发症,危及其生命安全[6]。因此,老年AC患者的早期治疗显得十分重要。

PTGD可通过穿刺置管引流脓性胆汁,缓解胆囊管梗阻,降低胆囊压力,抑制毒素吸收,缓解炎性症状,为择期手术治疗提供良好基础[7]。LC是临床治疗老年AC重要手段,能有效清除胆囊病变,控制患者临床症状及体征,但其存在切口大且多、美观性不足等问题。TUSLC是在LC基础上改良而来,由于脐为机体自然瘢痕,自脐上缘入路,手术切口更为隐蔽,能满足患者对美观需求[8]。研究显示,PTGD联合TUSLC可改善AC患者围术期指标,降低中转其他手术风险[9]。Lin等[9]总结752例老年急性结石性胆囊炎实施经皮胆囊造口置管引流术(PC)+腹腔镜胆囊切除术(DLC),结果显示出PC+DLC较单纯LC具有术中出血少、胆管损伤率低、残余结石和胃肠器官损伤率低的优势;同时DLC组患者ICU入院和死亡的发生率较低,重复手术的发生率明显较低。然而,PC+DLC总住院时间明显延长,治疗成本明显高与LC组患者。Ke等[10]总结急性胆囊炎患者经皮经肝胆囊引流术(PTGBD)后的紧急胆囊切除术(EC)和延迟胆囊切除术(DC)的效果,结果为在中度(Ⅱ级)急性胆囊炎患者中,PTGBD和EC对胆囊炎有很高的疗效;PTGBD后DC患者预后较好,OC发生率较低,术中出血少,术后腹腔引流时间短,胆囊切除术后住院时间短,呼吸衰竭发生率较低,ICU入院次数较EC少,胆囊病理过程逆转。PTGBD+DC组术后住院时间较长。

本研究数据显示,观察组白细胞恢复时间、住院时间、胃肠功能恢复时间、术中出血量优于对照组(P<0.05),与上述研究观点相符。分析原因与以下2方面有关,一方面是TUSLC手术创伤小,另一方面是PTGD术后2~4个月内施行TUSLC,此时胆囊炎症明显缓解,局部粘连减轻,手术操作相对容易,围术期指标改善更为明显[11,12]。进一步研究发现,术后1 d、3 d、7 d观察组VAS评分低于对照组(P<0.05),分析原因可能与TUSLC手术切口小有关,可减轻周围组织损伤,缓解术后疼痛,加快术后恢复。但TUSLC存在问题,即操作器械及腹腔镜置入位置集中,空间狭小,操作时存在相互干扰情况,对术者及操作者要求较高,需默契配合才能很好完成手术。

综上,PTGD术后择期行TUSLC,有助于减少老年AC患者术中出血量,缓解术后疼痛,降低并发症发生风险,缩短康复进程。

参考文献

[1] Loozen CS,Oor JE,van Ramshorst B,et al.Conservative treatment of acute cholecystitis:a systematic review and pooled analysis[J].Surg Endosc,2017,31(2):504-515.

[2] 陈春华,杨林华,王坚,等.B超引导经皮经肝胆囊穿刺引流术在高危患者中的应用价值[J].肝胆胰外科杂志,2015,27(3):228-230.

[3] 林泽伟,刘晓平,刘吉奎,熊沛.腹腔镜胆囊切除术所致胆管损伤的诊治体会[J]. 岭南现代临床外科,2012,12(6):421-423.

[4] Ni QQ,Chen DB,Xu R,Shang D.The efficacy of percutaneous transhepatic gallbladder drainage on acute cholecystitis in high-risk elderly patients based on the tokyo guidelines:a retrospective case-control study[J].Medicine(Baltimore),2015,94(34):e1442.

[5] Pisano M,Ceresoli M,Cimbanassi S,et al.2017 WSES and SICG guidelines on acute calcolous cholecystitis in elderly population[J].World J Emerg Surg,2019,14:10.

[6] Escartín A,González M,Cuello E,et al.Acute Cholecystitis in Very Elderly Patients:Disease Management,Outcomes,and Risk Factors for Complications[J].Surg Res Pract,2019,2019:9709242.

[7] Hu YR,Pan JH,Tong XC,et al.Efficacy and safety of B-mode ultrasound-guided percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy for acute cholecystitis in elderly and high-risk patients[J].BMC Gastroenterol,2015,15:81.

[8] Vaccari S,Lauro A,Cervellera M,et al.Cholecystectomy for acute cholecystitis in octogenarians:impact of advanced age on postoperative outcome[J].Minerva Chir,2019,74(4):289-296.

[9] Lin D,Wu S,Fan Y,Ke C.Comparison of laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy in aged acute calculous cholecystitis:a cohort study[J].Surg Endosc,2019.doi:10.1007/s00464-019-07091-4.[Epub ahead of print]

[10] Ke CW,Wu SD.Comparison of emergency cholecystectomy with delayed cholecystectomy after percutaneous transhepatic gallbladder drainage in patients with moderate acute cholecystitis[J].J Laparoendosc Adv Surg Tech A,2018,28(6):705-712.

[12] 尹飞飞,李学民,段希斌,等.日间经脐单孔腹腔镜胆囊切除术65例单中心临床疗效分析[J].中国普通外科杂志,2019,34(8):712-713.

Efficacy and safety of selective transumbilical single-port laparoscopic cholecystectomy for elderly patients with acute cholecystitis after percutaneous hepatic and gallbladder puncture and drainage

AI Zhi-guo,CHEN Yu,ZHANG Xu
Department of Hepatobiliary Surgery,Huizhou Central People"s Hospital,Huizhou,Guangdong 516002,China

[Abstract] Objective To explore the effect of transumbilical single-port laparoscopic cholecystectomy(TUSLC)in elderly patients with acute cholecystitis(AC)after percutaneous transhepatic gallbladder drainage(PTGD).Methods Eighty elderly patients with AC in our hospital(from December 2017 to December 2018)were divided into control group(n=40)and experimental group(n=40)according to the operation plan.PTGD+traditional laparoscopic cholecystectomy(LC)and PTGD+TUSLC were performed respectively.The bleeding volume,operation time,recovery time of white blood cells,recovery time of gastrointestinal function,hospitalization time and complications of the two groups were observed,and the pain degree(VAS)of 1,3 and 7 days after operation was compared.Results Compared with the control group,the recovery time of white blood cells,hospital stay and gastrointestinal function in the experimental group were shorter,and the amount of bleeding during operation was less(P<0.05);compared with the control group,the VAS score of the experimental group was lower on the 1st,3rd and 7th day after operation(P<0.05);compared with the control group,the incidence of complications in the experimental group was lower(P<0.05).Conclusion Selective TUSLC after PTGD is helpful to reduce the blood loss,relieve the pain,reduce the risk of complications and shorten the rehabilitation process of elderly AC patients.

[Key words] acute cholecystitis;old age;PTGD;TUSLC;LC

doi: 10.3969/j.issn.1009-976X.2020.02.011

中图分类号:R657.4

文献标识码:A

作者单位:惠州市中心人民医院肝胆外科,广东惠州516002

通讯作者:艾志国,Email:aizhiguo_2019@qq.com

(收稿日期:2019-11-13)

关键词: 急性胆囊炎, TUSLC, PTGD, LC, 老年

CLC Number: