趙紅光， 劉 凱， 劉亞輝

(吉林大學(xué)第一醫(yī)院 肝膽胰外科， 長春 130021)

論著/膽道疾病

經(jīng)皮經(jīng)肝膽囊穿刺引流術(shù)后擇期行腹腔鏡膽囊切除術(shù)治療60歲以上急性重癥膽囊炎患者的最佳時(shí)機(jī)探討

趙紅光， 劉 凱， 劉亞輝

(吉林大學(xué)第一醫(yī)院 肝膽胰外科， 長春 130021)

目的 觀察經(jīng)皮經(jīng)肝膽囊穿刺引流術(shù)(PTGD)后擇期行腹腔鏡膽囊切除術(shù)(LC)治療老年急性重癥膽囊炎的效果，探究擇期手術(shù)的最佳時(shí)機(jī)。方法 選取吉林大學(xué)第一醫(yī)院肝膽胰外科2015年1月-2016年6月收治的行PTGD的60歲以上急性重癥膽囊炎患者90例，根據(jù)擇期LC時(shí)間將其分為3組：PTGD術(shù)后2個(gè)月內(nèi)行LC(A組)、2～4個(gè)月行LC(B組)、4個(gè)月后行LC(C組)，每組30例，觀察PTGD的治療效果及擇期LC效果。計(jì)量資料2組間比較采用t檢驗(yàn)，多組間比較采用方差分析，進(jìn)一步兩兩比較采用LSD-t檢驗(yàn)。計(jì)數(shù)資料組間比較采用χ2檢驗(yàn)。結(jié)果 90例患者均成功完成PTGD，腹痛緩解時(shí)間(2.52±0.76)h；術(shù)后24～72 h內(nèi)體溫恢復(fù)正常，實(shí)驗(yàn)室指標(biāo)(白細(xì)胞、中性粒細(xì)胞、ALT、AST、TBil)較術(shù)前均明顯改善(t值分別為8.339、8.386、15.194、17.340、12.761，P值均<0.05)，無1例患者出現(xiàn)因穿刺所致的膽漏、膽道出血、氣胸、結(jié)腸穿孔等并發(fā)癥；無1例脫管再次行PTGD。3組患者的術(shù)前膽囊壁厚度、手術(shù)時(shí)間、術(shù)中出血量、住院時(shí)間、中轉(zhuǎn)開腹率、并發(fā)癥發(fā)生率差異均有統(tǒng)計(jì)學(xué)意義(F值分別為8.029、24.674、12.864、22.844；χ2值分別為12.345、8.750，P值分別為<0.001、<0.001、<0.001、<0.001、0.002、0.013)，其中B、C組患者的術(shù)前膽囊壁厚度、手術(shù)時(shí)間、術(shù)中出血量、住院時(shí)間、中轉(zhuǎn)開腹率、并發(fā)癥發(fā)生率均低于A組，差異均有統(tǒng)計(jì)學(xué)意義(P值均<0.05)，B組手術(shù)時(shí)間、術(shù)中輸血量、住院時(shí)間明顯小于C組(P值均<0.05)。結(jié)論 PTGD術(shù)后2～4個(gè)月內(nèi)擇期行LC治療老年急性重癥膽囊炎效果顯著，且安全性高。

膽囊炎， 急性； 引流術(shù)； 膽囊切除術(shù)， 腹腔鏡； 老年人

急性膽囊炎常伴惡心、嘔吐、寒戰(zhàn)、發(fā)熱等癥狀，病情嚴(yán)重者可并發(fā)全身性黃疸，嚴(yán)重影響患者的身心健康，甚至危及生命安全[1-2]。故早期行積極有效的診療，對(duì)改善患者預(yù)后有著重要意義。

老年膽囊炎患者早期功能和生理儲(chǔ)備系統(tǒng)能力明顯降低，動(dòng)脈硬化造成膽囊動(dòng)脈閉塞，膽囊壞死及穿孔，免疫功能降低，極易發(fā)生中毒癥狀，甚至休克。另外，老年患者常伴多種基礎(chǔ)內(nèi)科疾病，因此增加了治療難度[3]。老年急性重癥膽囊炎手術(shù)風(fēng)險(xiǎn)高，不僅要考慮徹底性，還需注重安全性，以降低術(shù)后并發(fā)癥[4]。急診經(jīng)皮經(jīng)肝膽囊穿刺引流術(shù)(percutaneous transhepatic gallbladder drainage，PTGD)可避免高危患者腹腔鏡膽囊切除術(shù)(LC)的創(chuàng)傷，減少并發(fā)癥的發(fā)生，通過穿刺置管引流感染膽汁，降低膽囊腔內(nèi)壓力，減少毒素的吸收，減輕中毒癥狀，同時(shí)結(jié)合抗感染、營養(yǎng)支持等對(duì)癥綜合治療可有效控制癥狀，為擇期行LC贏得時(shí)間[5]。目前，研究者一致認(rèn)為若急性重癥膽囊炎患者經(jīng)保守治療未見好轉(zhuǎn)，則行PTGD術(shù)后擇期LC治療，但術(shù)后擇期的時(shí)機(jī)選擇尚無統(tǒng)一的標(biāo)準(zhǔn)和意見[6]。為進(jìn)一步探討PTGD術(shù)后擇期行LC的最佳手術(shù)時(shí)機(jī)，筆者對(duì)老年急性重癥膽囊炎患者PTGD術(shù)后不同時(shí)期行LC治療，取得了顯著的療效，現(xiàn)報(bào)道如下。

1 資料與方法

1.1 研究對(duì)象 選取本院肝膽胰外科2015年1月-2016年6月收治的老年急性重癥膽囊炎患者。納入標(biāo)準(zhǔn)：(1)年齡60～90歲，性別不限；(2)急性重癥膽囊炎患者，診斷符合《急性膽道系統(tǒng)感染的診斷和治療指南(2011版)》[7]，并根據(jù)急性膽囊炎東京指南[8]分級(jí)為Ⅲ級(jí)，伴有器官功能障礙；(3)發(fā)病時(shí)間<72 h；(4)疑有膽囊化膿或壞疽，但未穿孔；(5)合并轉(zhuǎn)氨酶、膽紅素水平升高或者胰腺炎表現(xiàn)，但彩超和CT等檢查未證實(shí)膽管結(jié)石；(6)經(jīng)科室會(huì)診確定不宜行急診外科手術(shù)治療者；(7)符合PTGD適應(yīng)證且完成手術(shù)者；(8)PTGD術(shù)后行LC治療者。排除標(biāo)準(zhǔn)：(1)合并出血性疾病及凝血功能障礙者；(2)確診為膽囊息肉、膽總管結(jié)石、膽道惡性腫瘤者；(3)行急診開腹膽囊切除術(shù)或LC者；(4)因各種因素導(dǎo)致PTGD術(shù)后多次穿刺治療者；(5)臨床資料不全，影響療效和安全性評(píng)估準(zhǔn)確性的患者。研究經(jīng)本院倫理委員會(huì)審核批準(zhǔn)，患者及家屬均簽署知情同意書。

1.2 治療和分組方法 患者入院后給予常規(guī)禁食、胃腸減壓、補(bǔ)液、抗菌藥物等治療，完善各項(xiàng)實(shí)驗(yàn)室和影像學(xué)檢查。PTGD操作前肌注50 mg哌替啶注射液，取左側(cè)臥位，反復(fù)B超檢查確定穿刺部位，常規(guī)消毒、鋪巾后使用2%利多卡因?qū)Υ┐厅c(diǎn)進(jìn)行局部麻醉。麻醉成功后，切開皮膚0.2 cm，B超引導(dǎo)下用7-8 F豬尾形穿刺引流套管沿著針道經(jīng)肝穿入膽囊，B超復(fù)查確定位于膽囊后拔出針芯，接注射器抽取部分膽汁，穿刺針拔出過程中間套管尾部推入并盤曲在膽囊內(nèi)，固定引流管，連接引流裝置，無菌敷料包扎并妥善固定引流管。將抽取的膽汁立即送檢，進(jìn)行細(xì)菌培養(yǎng)和藥敏試驗(yàn)。術(shù)后嚴(yán)密監(jiān)測患者生命體征、腹部體征和引流情況，同時(shí)給予抗感染、抑酸、保肝、止血、營養(yǎng)補(bǔ)液等綜合治療。另外，根據(jù)細(xì)菌培養(yǎng)和藥敏試驗(yàn)結(jié)果調(diào)整抗菌藥物，待患者癥狀和體征緩解后，可逐漸進(jìn)食少許清淡食物，無不適者則可間斷夾閉引流管，繼而持續(xù)夾閉；若腹部癥狀、發(fā)熱、疼痛等仍存在，則繼續(xù)引流。

PTGD術(shù)后定期復(fù)查B超，根據(jù)恢復(fù)情況拔管和行LC。將納入患者按LC時(shí)間分為3組：A組于PTGD術(shù)后2個(gè)月內(nèi)行LC，B組于2～4個(gè)月行LC，C組于4個(gè)月后行LC。術(shù)前完善各項(xiàng)檢查和準(zhǔn)備，全身麻醉后采用3孔或者4孔法完成，對(duì)于仍攜帶PTGD引流管者拔除后建立氣腹，于臍上、劍突下、右肋緣下建立10 mm和5 mm手術(shù)通道，按常規(guī)LC切除膽囊，自劍突下切口取出膽囊并送檢。檢查穿刺竇道是否有出血、膽漏等，根據(jù)術(shù)中情況決定是否留置腹腔引流管。對(duì)于術(shù)中出現(xiàn)不可控出血、膽道和周圍臟器損傷、膽囊分離極為困難等導(dǎo)致無法完成LC者則轉(zhuǎn)開腹膽囊切除術(shù)。

1.3 觀察指標(biāo) PTGD術(shù)后觀察患者臨床癥狀和體征改善情況、體溫恢復(fù)情況、實(shí)驗(yàn)室指標(biāo)(白細(xì)胞、中性粒細(xì)胞、肝功能指標(biāo))改善情況以及并發(fā)癥發(fā)生情況。同時(shí)，觀察LC手術(shù)情況，主要包括術(shù)前膽囊壁厚度、手術(shù)時(shí)間、術(shù)中出血量、中轉(zhuǎn)開腹、并發(fā)癥、住院時(shí)間等。1.4 PTGD拔管指征 置管時(shí)間>7 d；無腹痛、發(fā)熱、黃疸；膽汁顏色清澈透明，呈黃色或黃綠色，無膿液及絮狀物；膽汁細(xì)菌培養(yǎng)陰性；膽囊壁厚度<5 mm，膽囊橫徑較前減??；實(shí)驗(yàn)室檢查外周血白細(xì)胞、中性粒細(xì)胞、血清ALT、TBil水平恢復(fù)正常[9]。對(duì)于年齡>70歲、全身營養(yǎng)不良、嚴(yán)重低蛋白血癥、重度貧血、長期服用類固醇藥物者可適當(dāng)延長帶管時(shí)間，必要時(shí)行膽囊造影，確保竇道已形成。

2 結(jié)果

2.1 一般資料 共納入老年急性重癥膽囊炎患者90例，每組30例。3組患者性別構(gòu)成比、年齡、病程、并發(fā)癥等基線資料比較，差異均無統(tǒng)計(jì)學(xué)意義(P值均>0.05)(表1)。

2.2 患者行PTGD前后體溫及實(shí)驗(yàn)室指標(biāo)比較 所有患者均成功完成PTGD，穿刺時(shí)間20～50 min，平均(32.58±7.36)min；術(shù)中膽汁引流量5～60 ml，平均(29.56±11.52)ml；腹痛緩解時(shí)間0.5 h～8 d，平均(2.52±0.76)h；進(jìn)食時(shí)間1～4 d，平均(2.35±0.58)d。術(shù)后24～72 h內(nèi)患者體溫恢復(fù)正常，實(shí)驗(yàn)室指標(biāo)(白細(xì)胞、中性粒細(xì)胞、肝功能)較術(shù)前均明顯改善(P值均<0.05)(表2)，無1例患者出現(xiàn)因穿刺所致的膽漏、膽道出血、氣胸、結(jié)腸穿孔等并發(fā)癥。置管時(shí)間7～49 d，平均(22.58±10.36)d，無1例脫管再次行PTGD。

2.3 3組患者LC觀察指標(biāo)比較 3組患者均無1例死亡。3組患者的術(shù)前膽囊壁厚度、手術(shù)時(shí)間、術(shù)中出血量、住院時(shí)間、中轉(zhuǎn)開腹率、并發(fā)癥發(fā)生率差異均有統(tǒng)計(jì)學(xué)意義(P值均<0.05)。B、C組術(shù)前膽囊壁厚度、手術(shù)時(shí)間、術(shù)中出血量、住院時(shí)間、中轉(zhuǎn)開腹率、并發(fā)癥發(fā)生率均低于A組(P值均<0.05)；B組手術(shù)時(shí)間、術(shù)中輸血量、住院時(shí)間均明顯低于C組(P值均<0.05)(表3)。

表1 3組患者一般資料

表2 PTGD術(shù)前和術(shù)后24～72 h體溫及實(shí)驗(yàn)室指標(biāo)比較

表3 3組患者LC手術(shù)相關(guān)指標(biāo)比較

注：與A組比較，1)P<0.05；與B組比較，2)P<0.05

3 討論

急性重癥膽囊炎是臨床常見的急腹癥之一，老年重癥膽囊炎起病急驟、病情進(jìn)展快、急診手術(shù)困難，可導(dǎo)致肝功能嚴(yán)重?fù)p傷甚至衰竭、膽囊壞疽穿孔、彌漫性腹膜炎以及敗血癥等多種嚴(yán)重并發(fā)癥，未經(jīng)及時(shí)處理可致患者死亡，故臨床一旦確診則需急診處理[10]。急性膽囊炎患者明確診斷后立即給予禁食、營養(yǎng)支持、抗感染、補(bǔ)充維生素、糾正水電解質(zhì)和酸堿平衡等綜合保守治療，多數(shù)患者病情可得到控制，為擇期手術(shù)創(chuàng)造機(jī)會(huì)[11-12]；對(duì)于病情無好轉(zhuǎn)且逐漸加重者應(yīng)行急診手術(shù)[13]。目前臨床常用的手術(shù)方式為傳統(tǒng)開腹術(shù)、膽囊造瘺術(shù)、PTGD、LC等，長期實(shí)踐發(fā)現(xiàn)急性膽囊炎最徹底的治療方案為膽囊切除術(shù)。隨著腹腔鏡技術(shù)的逐漸發(fā)展，LC成為急性膽囊炎較常用的手術(shù)方式，其療效確切且安全性高[14-16]，但目前對(duì)于行LC時(shí)機(jī)的選擇仍有眾多爭議[17]，有待進(jìn)一步的深入研究。

研究[18-19]報(bào)道急性膽囊炎癥狀出現(xiàn)的24～72 h內(nèi)最宜行膽囊切除術(shù)，若發(fā)病時(shí)間超過72 h，膽囊和周圍組織炎癥較重，局部組織充血、水腫甚至壞死，與周圍組織黏連嚴(yán)重進(jìn)而明顯增加手術(shù)難度，中轉(zhuǎn)開腹率高，尤其是對(duì)于老年重癥膽囊炎患者；麻醉和氣腹亦會(huì)增加LC的手術(shù)風(fēng)險(xiǎn)[20]。此外，因老年重癥膽囊炎患者癥狀重、膽囊三角結(jié)構(gòu)模糊難以分離、極易出血和損傷膽總管，中轉(zhuǎn)開腹率、術(shù)后并發(fā)癥發(fā)生率及病死率高[21]，故需要一種可快速緩解臨床癥狀的干預(yù)方法即膽囊減壓引流術(shù)。PTGD是臨床常用的一種微創(chuàng)、操作簡單、療效確切的膽道持續(xù)引流減壓治療方法，不受年齡、病情的影響[22]，在B超、CT、X線引導(dǎo)下穿刺，避免盲目穿刺，增加了穿刺的精準(zhǔn)性，可在床邊完成，廣泛應(yīng)用于急性膽囊炎患者膽囊減壓治療，已替代了開腹膽囊引流術(shù)[23]。同期配合全身抗感染等支持治療迅速緩解臨床癥狀和體征，阻止病情進(jìn)一步惡化，為并發(fā)癥的治療及擇期行LC贏得充足時(shí)間[24]。本研究納入患者均成功完成PTGD，且無穿刺所致并發(fā)癥發(fā)生，腹痛緩解和炎癥消退快，再次證實(shí)上述觀點(diǎn)。故常采用PTGD引流炎性膽汁，待炎癥完全消退和體質(zhì)狀況恢復(fù)后再行LC，可明顯降低手術(shù)難度及風(fēng)險(xiǎn)，提高臨床療效并改善患者預(yù)后[25]。

關(guān)于PTGD術(shù)后行LC時(shí)機(jī)的選擇存在眾多爭議，術(shù)后1周行LC中轉(zhuǎn)開腹率較高；術(shù)后3周左右行LC操作困難，且術(shù)后并發(fā)癥發(fā)生率高，影響患者術(shù)后早期恢復(fù)，不符合目前外科快速康復(fù)理念；術(shù)后4～5周行LC可能存在膽囊三角嚴(yán)重黏連情況，手術(shù)操作較為困難。故目前多建議PTGD術(shù)后2～4個(gè)月行LC，可明顯縮短手術(shù)時(shí)間，減少術(shù)中出血量，降低中轉(zhuǎn)開腹率，且術(shù)后并發(fā)癥明顯減少，有利于患者術(shù)后早期康復(fù)。但目前PTGD術(shù)后行LC的最佳時(shí)機(jī)尚無定論，主要取決于膽囊炎癥消退情況及其他基本條件、醫(yī)院設(shè)備、術(shù)者臨床經(jīng)驗(yàn)等，故筆者為進(jìn)一步探究最佳的手術(shù)時(shí)機(jī)，對(duì)比分析了PTGD術(shù)后3個(gè)不同時(shí)期行LC患者的術(shù)中和術(shù)后情況，結(jié)果發(fā)現(xiàn)PTGD術(shù)后2個(gè)月行LC操作更為簡單，術(shù)中出血量、中轉(zhuǎn)開腹率較2個(gè)月內(nèi)行LC患者明顯降低(P值均<0.05)；患者術(shù)后康復(fù)情況顯示2個(gè)月后行LC較2個(gè)月內(nèi)行LC，患者術(shù)后并發(fā)癥明顯減少，住院時(shí)間明顯縮短(P值均<0.05)；此外，2個(gè)月后膽囊壁厚度明顯降低(P<0.05)，提示PTGD術(shù)后2個(gè)月內(nèi)膽囊內(nèi)壓力降低，但炎癥尚未完全消退，膽囊壁水腫嚴(yán)重，膽囊周圍黏連嚴(yán)重，局部解剖結(jié)構(gòu)不清，膽囊三角分離難度大；2個(gè)月后膽囊炎癥明顯改善，局部黏連減輕，手術(shù)操作相對(duì)較容易，故筆者認(rèn)為2個(gè)月后行LC較2個(gè)月內(nèi)行LC效果更為顯著。此外，2～4個(gè)月內(nèi)行LC的手術(shù)時(shí)間、術(shù)中出血量、中轉(zhuǎn)開腹率、住院時(shí)間均明顯低于4個(gè)月后行LC者，結(jié)果與邱明[26]和姜慶賀等[27]報(bào)道一致，故認(rèn)為2～4個(gè)月內(nèi)行LC患者并發(fā)癥少、恢復(fù)較快，可極大程度減輕患者的痛苦，完全符合快速康復(fù)理念。此外，筆者認(rèn)為PTGD術(shù)后應(yīng)動(dòng)態(tài)復(fù)查膽囊壁厚，若2～4個(gè)月內(nèi)膽囊壁厚≤4.2 mm則可視為LC最佳的手術(shù)時(shí)機(jī)，但尚需后期大樣本、多中心系統(tǒng)性研究證實(shí)。

綜上所述，PTGD術(shù)后2～4個(gè)月內(nèi)擇期行LC治療老年急性重癥膽囊炎可明顯縮短手術(shù)時(shí)間、減少術(shù)中出血量，降低中轉(zhuǎn)開腹率和并發(fā)癥發(fā)生率，術(shù)后恢復(fù)較快，具有極其重要的臨床意義和價(jià)值。

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引證本文：ZHAO HG, LIU K, LIU YH. The most appropriate timing for selective laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage in patients with acute severe cholecystitis aged above 60 years[J]. J Clin Hepatol, 2017, 33(4): 705-710. (in Chinese) 趙紅光, 劉凱, 劉亞輝. 經(jīng)皮經(jīng)肝膽囊穿刺引流術(shù)后擇期行腹腔鏡膽囊切除術(shù)治療60歲以上急性重癥膽囊炎患者的最佳時(shí)機(jī)探討[J]. 臨床肝膽病雜志, 2017, 33(4): 705-710.

(本文編輯：葛 俊)

The most appropriate timing for selective laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage in patients with acute severe cholecystitis aged above 60 years

ZHAOHongguang,LIUKai,LIUYahui.

(DepartmentofHepatopancreatobiliarySurgery,TheFirstHospitalofJilinUniversity,Changchun130021,China)

Objective To investigate the clinical effect of selective laparoscopic cholecystectomy (LC) after percutaneous transhepatic gallbladder drainage (PTGD) in the treatment of elderly patients with acute severe cholecystitis, as well as the most appropriate timing for selective operation. Methods A total of 90 patients with acute severe cholecystitis aged above 60 years who were admitted to Department of Hepatobiliary Surgery in The First Hospital of Jilin University from January 2015 to June 2016 were enrolled, and according to the time of selective LC, they were divided into group A (with 2 months), group B (2-4 months), and group C (>4 months), with 30 patients in each group. The clinical effects of PTGD and selective LC were observed. Thet-test was used for comparison of continuous data between two groups, an analysis of variance was used for comparison between three groups, and LSD-ttest was used for comparison between any two groups; the chi-square test was used for comparison of categorical data between groups. Results All the patients underwent successful PTGD, and the time to abdominal pain remission was 2.52±0.76 hours. Body temperature returned to normal with 24-72 hours after surgery, and there were significant improvements in laboratory markers (white blood cell count, neutrophil count, and liver function) (allP<0.05). No patient experienced complications such as bile leakage, hematobilia, pneumothorax, and colon perforation caused by puncture, and there was no case of PTGD after the tube was detached. There were significant differences between the three groups in gallbladder wall thickness before LC(F=8.029,P<0.001), time of operation (F=24.674,P<0.001), intraoperative blood loss (F=12.864,P<0.001), length of hospital stay (F=22.844,P<0.001), rate of conversion to laparotomy (χ2=12.345,P=0.002), and incidence rate of complications (χ2=8.750,P=0.013). Compared with group A, groups B and C had significantly lower gallbladder wall thickness before LC, intraoperative blood loss, length of hospital stay, rate of conversion to laparotomy, and incidence rate of complications (allP<0.05), and group B had significantly lower time of operation, intraoperative blood loss, and length of hospital stay than group C (allP<0.05). Conclusion Selective LC with 2-4 months after PTGD has a marked clinical effect and high safety in the treatment of elderly patients with acute severe cholecystitis.

cholecystitis, acute; drainage; cholecystectomy, laparoscopic; aged

10.3969/j.issn.1001-5256.2017.04.021

2016-10-12；

2016-12-12。

趙紅光(1991-)，男，主要從事肝膽胰疾病方面的研究。

劉亞輝，電子信箱：liuyahui2008@yeah.net。

R657.41

A

1001-5256(2017)04-0705-06