To explore the effect of laparoscopic surgery for gallstones with acute cholecystitis for more than 72 hours
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摘要: 目的 探讨对大于72 h胆囊结石伴急性胆囊炎患者行腹腔镜胆囊切除术的安全性及有效性。方法 选取2022年1月—2022年6月在北京丰台右安门医院普通外科行腹腔镜胆囊切除术的351例患者，按照病程的不同将患者分为两组：观察组(即大于72 h组)159例，对照组(即小于72 h组)192例，比较两组患者相关临床指标的差异。结果 与对照组相比，观察组在手术时间、术中出血量、胆囊坏疽发生率方面均较高，两组差异有统计学意义(P＜0.05)。而两组在中转开腹率、术后48 h白细胞水平、引流管拔除时间、术后并发症(如胆漏、出血等)的发生率、术后住院天数及住院总费用方面均差异无统计学意义(P＞0.05)。结论 对于胆囊结石伴急性胆囊炎患者应及早进行腹腔镜胆囊切除手术，对于病程大于72 h的胆囊结石伴急性胆囊炎患者，腹腔镜胆囊切除手术仍是安全、有效的手术方式，在具有经验的普外科中心或急腹症中心值得推广。Abstract: Objective To explore the safety and effectiveness of laparoscopic cholecystectomy in patients with gallstones and acute cholecystitis for more than 72 hours.Methods Patients who underwent laparoscopic cholecystectomy in the general surgery of Beijing Fengtai Youanmen Hospital from January 2022 to June 2022 were selected. The patients were divided into two groups according to the course of disease. The observation group was greater than 72 hours group, and the control group was less than 72 hours group. The differences of relevant clinical indicators between the two groups were compared.Results A total of 351 patients participated in this study, including 159 in the observation group and 192 in the control group. Compared with the control group, the observation group had statistically significant differences in operation time, intraoperative bleeding and the incidence of gallbladder gangrene(P < 0.05). However, there was no significant difference between the two groups in the conversion rate to laparotomy, the level of leukocytes in 48 hours after operation, the time of drainage tube extraction, the incidence of postoperative complications such as bile leakage and bleeding, the number of days in hospital and the total cost of hospitalization(P > 0.05).Conclusion Laparoscopic cholecystectomy should be performed as soon as possible in patients with gallstones and acute cholecystitis. For patients with gallstones and acute cholecystitis with a course of more than 72 hours, laparoscopic cholecystectomy is still a safe and effective surgical method, which is worth promoting in experienced general surgery centers or acute abdomen centers.
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Key words:
- gallstones /
- acute cholecystitis /
- laparoscopic cholecystectomy
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表 1 两组患者一般资料比较
例 临床资料 观察组(159例) 对照组(192例) P 性别 男 86 104 0.531 女 73 88 0.412 年龄/岁 57.5±6.1 60.2±5.3 0.689 糖尿病 34 40 0.570 高血压 42 49 0.692 冠状动脉粥样硬化性心脏病 11 20 0.685 慢性阻塞性肺疾病 7 14 0.898 术前检查 白细胞/(×109·L-1) 14.6±3.5 15.0±4.3 0.329 白蛋白/(g·L-1) 39.2±1.7 38.4±2.5 0.446 胆囊炎程度分级 轻度 101 122 0.156 中度 58 70 0.249 起病至手术时间/h 42.6±10.2 100.3±20.7 0.039 入院至手术时间/h 13.6±2.3 13.9±2.7 0.732 
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表 2 急性胆囊炎程度分级
疾病程度 分级标准 轻度急性胆囊炎 急性胆囊炎不伴随中度及重度急性胆囊炎局部或全身炎症表现 中度急性胆囊炎 急性胆囊炎合并以下中的2项可诊断：①白细胞计数＞8×109/L；②右上腹触及压痛的肿块；③明显的局部炎症(坏疽性胆囊炎、胆囊周围脓肿、肝脓肿、胆汁性腹膜炎、气肿性胆囊炎) 重度急性胆囊炎 急性胆囊炎合并以下≥1个器官功能不全。①心血管功能障碍：低血压需要多巴胺≥5 μg/(kg·min)；②神经系统功能障碍：意识障碍；③呼吸功能障碍：氧合指数＜300 mmHg(1 mmHg=0.133 kPa)；④肾功能衰竭：少尿，血肌酐>176.8 μmol/L；⑤肝功能不全：PT-INR＞1.5；⑥凝血功能障碍：血小板计数＜100×109/L
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表 3 两组术后观察指标比较
指标 观察组(159例) 对照组(192例) P 手术时间/min 76.4±14.2 45.3±11.5 0.037 术中出血量/mL 30.6±6.1 15.7±3.6 0.029 胆囊坏疽发生率/例(%) 29(18.2) 10(5.2) 0.024 中转开腹率/例(%) 10(6.3) 9(4.9) 0.211 引流管拔除时间/d 4.3±1.3 3.1±1.5 0.464 术后48h白细胞水平/(×109·L-1) 9.8±2.4 7.7±1.6 0.513 住院总费用/元 13634.2± 1148.6 12285.3± 988.2 0.598 术后住院天数/d 4.8±1.2 3.8±1.4 0.423 术后胆漏/例(%) 1(0.6) 1(0.5) 0.736 术后出血/例(%) 5(2.6) 3(1.6) 0.257
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