急性胆囊炎合并胆囊结石行腹腔镜胆囊切除术的困难因素分析

目的:分析急性胆囊炎合并胆囊结石患者行腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)的困难因素,以提高手术安全性,减少术后并发症的发生。方法:随机选取219例急性胆囊炎合并胆囊结石行LC的患者,观察术前发作次数、伴随疾病、术前住院时间、手术时间、术后住院时间等指标。应用ANOVA单因素分析与多重线性回归分析统计结果。结果:胆囊大小、患者性别与手术操作难度相关,胆囊壁厚度、胆囊炎发作次数与手术时间、出血量、术后住院时间的关系较小,同时非上腹部大手术不会影响手术时间、出血量及术后住院时间。结论:胆囊大小、患者性别与手术操作难度存在一定联系,而胆囊壁厚度、胆囊炎发作次数可能并不是影响LC手术难度的主要因素,同时下腹部手术、上腹部微创手术都不会影响手术的操作难度。     

急性结石性胆囊炎行LC术难易程度的相关因素分析

目的：探讨急性结石性胆囊炎行LC(Laparoscopic Cholecystectomy,LC)手术难易程度的相关因素。方法：将245例急性结石性胆囊炎患者根据手术时间和有无中转分成容易组（123例）和困难组（122例）（含中转开腹组33例 open cholecystectomy, OC）,分别比较各组术前一般资料、术前影像学差异和腹腔镜下所见,筛选出有统计学差异的指标。结果：术前资料中,容易组和困难组在体温、白细胞计数,手术时机、胆囊壁厚度、胆囊体积、胆总管直径各指标间差异有统计学意义（均P<0.05）;术中镜下所见,两组在胆囊壁厚度、大小、颈部结石嵌顿、胆总管直径、胆囊三角各指标间差异均有统计学意义（均P<0.01）。结论：急性结石性胆囊炎体温升高,白细胞计数增加,胆囊壁增厚、胆囊体积增大、胆总管直径大于8 mm、颈部结石嵌顿、Calot三角不清是行LC困难的因素。     

彩色多普勒超声对急性胆囊炎LC难度的预测价值

目的 探讨彩色多普勒超声(color Doppler flow imaging, CDFI)检查对急性胆囊炎LC难度的预测价值.方法 99例因急性胆囊炎行LC的患者,根据术前CDFI检查的指标(胆囊容积、胆囊壁厚度及血流信号、胆囊腔、胆囊床和肝内外胆管的情况)评分分为容易组和困难组;根据术中难度评分分为手术容易组和手术困难组,评估其对手术难度的预测价值.结果 术前CDFI预测容易组和困难组分别为67例和32例;根据术中难度评分,手术容易组和手术困难组分别为61例和38例.术前CDFI预测困难组与容易组比较,胆囊容积增大[(39.5±13.2)cm3 vs(32.6±10.4)cm3],胆囊壁增厚[(10.1±4.0)mm vs(3.8±0.9)mm],胆囊颈结石嵌顿、胆囊壁血流信号丰富和胆囊粘连的患者多于容易组,差异有统计学意义(t=-2.820,-12.318,-3.952,x2=33.548,19.461,P<0.05).以胆囊容积、胆囊壁厚度、胆囊颈结石嵌顿、胆囊周围粘连情况为预测指标,急性胆囊炎术前CDFI预测LC难度准确率为94%(93/99).结论 术前CDFI检查有助于掌握急性胆囊炎LC适应证,对手术难度预测具有指导价值.     

36例腹腔镜胆囊切除术中转开腹原因分析

分析腹腔镜胆囊切除术(LC)中转开腹的原因。回顾性分析2011年10月—2015年1月1128例急症LC术和中转开腹36例患者临床资料,对中转开腹的因素进行单因素和Logistic多因素回归分析。结果显示,年龄、胆囊炎发作时间、上腹部手术史、合并糖尿病、BMI、胆囊壁厚度、手术出血量、手术时间、急性发病次数、并发症、术前白细胞计数、总胆红素水平、谷丙转氨酶水平均为LC术中转开腹的危险因素,Logistic回归分析年龄、胆囊壁厚度、合并糖尿病、胆囊炎发作时间为中转开腹的独立危险因素。结果表明,导致腹腔镜胆囊切除术中转开腹的危险因素包括年龄、胆囊壁厚度、胆囊炎发作时间、合并糖尿病等。     

急性胆囊炎LC术中转开腹的危险因素及预后分析

目的探讨急性胆囊炎LC术中转开腹的危险因素及预后情况。 方法回顾性分析2014年3月至2017年7月231例急性胆囊炎行LC术的患者的临床资料,根据患者LC术中是否转开腹,分为LC术组(205例)和转开腹组(26例)对比分析两组患者性别、年龄、BMI指数、病程、胆囊壁厚及生化检查等情况,本研究采用Stata 14.1统计软件对数据处理。计量资料单因素分析采用t检验,计数资料单因素分析采用卡方检验。采用Logistic回归模型分析LC术中转开腹危险因素,并拟合ROC曲线评价模型价值,P<0.05为差异具有统计学意义。 结果单因素分析显示,BMI指数、病程、胆囊壁厚度、白细胞计数、碱性磷酸酶5个因素与LC术中转开腹有关;多因素Logistic回归分析显示,BMI指数(OR＝1.407, P＝0.000)、白细胞计数(OR＝1.600, P＝0.003)、碱性磷酸酶(OR＝1.042, P＝0.000)是LC术中转开腹的独立危险因素。26例转开腹患者术后观察无严重的并发症发生。 结论手术医师在LC术前应对患者体质状况,白细胞水平、碱性磷酸酶等情况进行合理的评估,以降低LC术中转开腹率。     

急性胆囊炎腹腔镜胆囊切除术中转开腹危险因素分析

目的:探讨急性胆囊炎行腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)的危险因素。方法:回顾分析我科401例急性胆囊炎患者行LC的临床指标,并进行多因素分析。结果:391例成功完成LC,10例中转开腹。结论:急性胆囊炎LC失败的危险因素有上腹部手术史,白细胞、总胆红素、碱性磷酸酶增高,胆囊管结石嵌顿,发病超过72h。急性胆囊炎患者行LC的危险因素有助于外科医师在术前对患者进行全面评估,以提高LC的成功率,减少并发症的发生。     

腹腔镜联合胆道镜治疗胆囊及胆总管结石中转开腹列线图模型的建立

目的探讨腹腔镜胆囊切除术(LC)联合腹腔镜胆总管探查术(LCBDE)治疗胆囊结石合并胆总管结石的术前危险因素,建立预测中转开腹的列线图模型。方法回顾性分析沧州市人民医院2015年1月1日—2019年12月31日309例行LC联合LCBDE患者的临床资料,根据是否中转开腹分为未开腹组290例,开腹组19例。通过单因素及多因素Logistic回归分析得到中转开腹的独立预测因素,应用RStudio建立列线图模型并对其进行验证。结果单因素分析结果表明腹部手术史、BMI、白细胞、中性粒细胞比率、碱性磷酸酶、血清总胆红素、胆囊壁厚度、胆总管直径及胆总管下段结石嵌顿是LC联合LCBDE发生中转开腹的相对危险因素(OR=0.195,0.369,0.287,0.241,0.237,0.082,0.166,0.198,0.190;95%CI:0.073~0.517,0.114~1.195,0.096~0.859,0.085~0.682,0.092~0.613,0.023~0.287,0.058~0.475,0.073~0.537,0.056~0.649);多因素Logistic回归分析显示,白细胞>10×10^9/L、碱性磷酸酶>150 U/L、血清总胆红素>17.1 umol/L、胆囊壁厚度>4 mm、胆总管直径>12 mm、胆总管下段结石嵌顿是LC联合LCBDE中转开腹的独立预测因素(OR=6.498,3.656,22.160,5.762,4.849,7.916;95%CI:1.434~29.442,1.095~12.203,4.485~109.496,1.491~22.262,1.384~16.988,1.366~45.884)。基于独立预测因素建立列线图模型,随后采用Bootstrap重复抽样对预测模型进行内部验证,校正曲线发现预测模型一致性良好,C-index为0.924(95%CI:0.857~0.990),受试者工作特征(ROC)曲线下面积为0.924(95%CI:0.855~0.992),说明预测模型准确性高。结论基于胆总管下段结石嵌顿、胆囊壁厚度、胆总管直径、白细胞、碱性磷酸酶及血清总胆红素因素建立的列线图模型预测LC联合LCBDE中转开腹能力较好,临床应用价值高。     

术前超声预测腹腔镜胆囊切除术手术难度的分析

目的:根据术前超声资料建立预测腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)手术难度的评分表,并评价其科学性。方法:连续选择1 078例接受LC的患者,随机分为两组,训练样本960例,验证样本118例。采用自身前后对照试验方案,术前应用超声检测胆囊大小、胆囊壁厚度、胆囊颈结石嵌顿情况、胆囊结石数量与最大长径,以及脐孔、胆囊颈、胆囊底有无粘连;观察手术时间、术中出血量、中转开腹、引流管放置情况、并发症及术后住院时间、切口疼痛、胃肠道反应、肛门排气等指标。根据960例训练样本LC的实际难度分为容易与困难两组,应用t检验、χ2检验筛选有统计学意义的超声检测指标,建立术前超声预测LC手术难度的评分表。进行受试者工作特征曲线(receiver operating characteristic curve,ROC)分析。结果:胆囊大小、胆囊壁厚度、单枚胆囊结石最大径、胆囊颈结石嵌顿、胆囊颈粘连、胆囊底粘连6项检测指标在LC容易与困难两组间差异有统计学意义(P<0.05)。应用6项指标建立术前超声预测LC难度评分表。经ROC分析,曲线下面积为0.948,与完全随机情况下获得的曲线下面积(0.5)相比,差异有统计学意义(P<0.05)。经118例检验样本前瞻性误判概率评估,结果显示术前超声预测LC难度误判率约4.2%。结论:术前超声预测LC手术难度的评分表可正确预测手术难度,对手术适应证的选择具有重要意义。     

腹腔镜胆囊切除术中转开腹的原因分析及时机选择

目的:研究腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)中转开腹的原因及时机。方法:将成功施行LC的胆囊炎合并胆囊结石患者归入LC组,中转行开腹胆囊切除术(open cholecystectomy,OC)的患者归入OC组,进一步根据中转开腹的时机分为主动中转组与被动中转组,以观察LC中转开腹的危险因素及术中、术后各项指标。结果:OC组上腹部手术史例数、急性胆囊炎发作例数、白细胞计数、胆囊壁厚度均大于LC组;主动中转组手术时间、术中出血量、输血例数、术后引流量、排气时间、下床时间、术后住院时间均明显优于被动中转组。结论:上腹部手术史、急性胆囊炎发作、白细胞计数偏高及胆囊壁厚度增加均是中转开腹的危险因素,根据术中探查情况选择合适的中转开腹时机具有积极的临床意义。     

急症腹腔镜胆囊切除术中转开腹危险因素的分析

目的:分析术前预测急症腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)中转开腹的可能性,以期找到客观、实用、准确率高的预测LC手术难易度的方法,并选择适当的手术方式.方法:回顾分析2005～2009年120例急症LC中38例中转开腹患者的临床资料.从胆囊炎、胆囊结石疾病病理方面提取胆囊...     

Acute cholecystitis and laparoscopic cholecystectomy.

OBJECTIVE: To determine whether laparoscopic cholecystectomy (LC) should be the procedure of choice in treating acute cholecystitis. METHOD: A prospective study was conducted over a 4 1/2-year period. There were 187 patients with acute cholecystitis out of 1020 patients with gallbladder disease who required cholecystectomy. These patients were divided into three groups based on the time interval between the onset of pain and the time patients sought medical attention: Group 1, < 3 days; Group 2, 3 to 7 days; Group 3, > 7 days. All the patients underwent LC after a comprehensive preoperative workup. The parameters analyzed included operating time, hospital stay, and conversion rate. The comparison was made among the various groups and with those who had elective LC. RESULTS: One hundred twenty patients (64.17%) presented for treatment within 3 to 7 days of the onset of an attack. Empyema of the gallbladder was seen in 106 (56.68%) patients and phlegmon of the gallbladder in 42 (22.46%) patients. Group 3 patients had an operative time of 56.2 min as opposed to 18.5 min in Group 1 and 17.5 min in the elective LC group. The conversion rate in Group 3 was 19.5% versus 3.8% in Group 1 and 3.48% in the elective LC group. The complication rate was 7.3% in Group 3, 3.8% in Group 1, and 3.7% in the elective LC group. CONCLUSION: Acute cholecystitis is better managed by laparoscopic cholecystectomy, except in the patients presenting with a gallbladder phlegmon later than 7 days after the onset of the attack.     

Preoperative evaluation to predict technical difficulties of laparoscopic cholecystectomy on the basis of histological inflammation findings on resected gallbladder

BACKGROUND: No papers have heretofore documented histological studies of cases involving the inflammation of resected gallbladder or examined surgical difficulties on the basis of pathological findings. METHODS: On the basis of the histological inflammation findings on the resected gallbladders of 437 patients who underwent laparoscopic cholecystectomy (LC), the factors affecting the technical difficulty of the operation were examined through preoperative clinical findings (13 items), diagnostic imaging (22 items), and blood test findings (6 items), using multivariate analysis. RESULTS: In accordance with the four-stage classification of inflammation findings for the resected gallbladder, the inflammation findings on the resected gallbladder indicated a higher correlation with the time required for gallbladder dissection (30.2 +/- 16.3 minutes) than with the operation time (77.6 +/- 32.7 minutes). Thus, the technical difficulty of the operation was judged according to the time required for gallbladder dissection. For the preoperative findings on 418 patients who underwent successful LC, the most influential factors on the time required for gallbladder dissection were the presence of abnormal findings on computed tomography, the degree of fever, obesity index, nonvisualized gallbladder cholangiography, and cystic duct length. According to the multiple regression equation of these five factors, the gallbladder dissection for the 19 patients who underwent conversion to open cholecystectomy (OC) due to extreme inflammation was calculated to require 61.9 +/- 12.3 minutes, and the patients who showed a gallbladder dissection time longer than 49.6 minutes were judged to have high technical difficulty predicted from the preoperative evaluation. In the preoperative evaluation, sensitivity was 79.6%, specificity was 97.6%, accuracy was 95.0%, positive predictive value was 85.0%, and negative predictive value was 96.6%. Next, each finding was scored on the basis of a multiple regression equation of five factors, and the technical difficulty of the operation was quantified using these scores. The score of the patients who underwent conversion to OC was 8.0 +/- 2.0, and the patients who showed a score higher than 6 were judged to have high technical difficulty. Almost the same results as in the aforementioned preoperative evaluation were obtained using these scores. CONCLUSION: The judgment using the scores was satisfactory in terms of the simplicity of evaluating the technical difficulties associated with each patient and the ease of obtaining information for each factor. The quantification of technical difficulty using the scores is useful for preoperative prediction of which patients will have difficulties in gallbladder dissection and the conversion to OC in LC. Our results suggest that the consideration of technical difficulties is important for conducting safe operations with avoiding intraoperative complications.     

Male gender: risk factor for severe symptomatic cholelithiasis

The aim of this study was to determine the effect of male gender on the clinical presentation of symptomatic cholelithiasis. Laparoscopic cholecystectomy (LC) has been accepted as standard procedure for the management of symptomatic cholelithiasis even when the gallbladder is acutely inflamed. With the accumulated experience in the management of acute cholecystitis, some factors including male gender were recognized to influence the clinical presentation of symptomatic cholelithiasis and increase the conversion rate during LC. This retrospective study tried to clarify the correlation between male gender and the clinical presentation of symptomatic cholelithiasis. The medical records of all patients presenting with symptomatic cholelithiasis from January 1994 to August 1999 were evaluated. These cases were divided into four groups as follows: (1) elective LC group: patients with a history of biliary colic or acute attack of cholecystitis but whose LC was performed electively without any inflammatory change in the gallbladder during operation; (2) acute LC group: patients presenting with acute cholecystitis, and LC was performed successfully without conversion; (3) acute conversion group: patients who underwent LC during the course of acute cholecystitis but the procedure were disturbed by severe inflammatory change so they were converted to open surgery; (4) acute open group: patients whose acute cholecystitis was managed by direct open surgery due to the preoperative prediction that LC would not succeed. The correlation of gender, age, and operating time were assessed among these four groups. We found that: (1) the male/female ratio increased (in the patient group sequence of simple LC, acute LC, acute open, and acute conversion group); (2) in the acute LC group male patients had significantly (p = 0.04, t-test) longer operating time than females; (3) although there was no significant difference between the mean age of male (55.7 +/- 13.4) and female (56.3 +/- 15.7) patients in the acute cholecystitis groups (i.e., all patients in the acute LC, acute conversion, and acute open groups), the distribution curve by age in male patients showed a significantly shift to a younger age compared with female patients (p = 0.009, Fisher's exact test).     

老年急性胆囊炎患者PTGBD后LC手术实施时机及其影响因素

目的 探讨老年急性胆囊炎患者经皮经肝胆囊穿刺引流（PTGBD）后安全的LC手术时机和影响因素。方法 选取2020年6月至2022年7月间在新疆维吾尔自治区第三人民医院接受PTGBD+择期LC手术治疗的老年急性胆囊炎患者120例进行前瞻性研究,按照PTGBD后不同时期实施LC手术,将患者随机分为4组：4周组（n=30）、6周组（n=30）、8周组（n=30）和10周组（n=30）。对术前资料、术中困难程度评分、手术相关指标、手术损伤和手术并发症进行组间对比,并分析手术时机的影响因素。结果 4组术前资料的比较,差异无统计学意义（P>0.05）;针对胆囊周围表现、胆囊三角表现、胆囊床表现等单项困难程度评分和术中困难程度总评分,4周组均显著高于6周组、8周组和10周组;针对术中胆囊及其周围其他表现评分,4周组高于8周组和10周组;差异均具有统计学意义（P<0.05）;针对手术时间、术中出血量和腹腔引流量,4周组均显著高于6周组、8周组和10周组;差异均具有统计学意义（P<0.05）。4组胆囊部分切除率、术后排气时间和术后住院时间的比较,差异无统计学意义（P>0.05）;...     

超声检查对腹腔镜胆囊切除术难度的预测价值

目的:评价术前超声检查对预测慢性胆囊炎患者行腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)难度的应用价值.方法:793例患者因慢性胆囊炎行LC,术前超声检查对胆囊轮廓、胆囊颈部、囊壁厚度、囊壁回声、囊内回声情况进行综合分析,评估胆囊周围、Calot三角区的粘连程度,并与手术病理进行对...     

How to predict difficult laparoscopic cholecystectomy? Proposal for a simple preoperative scoring system

Background

Few studies have used operative time as a reflection of the surgical difficulty to create a preoperative score of operative difficulty in laparoscopic cholecystectomies (DiLCs score).

Methods

Patients who benefited from cholecystectomy between 2010 and 2015 were reviewed. Difficult procedures were identified using the deviations from the operative time for simple cholecystectomies. Logistic regression analyses were carried out to build risk-assessment models and derive the DiLC score.

Results

Overall, 644 patients were identified. Multivariate analyses identified male sex, previous cholecystitis attack, fibrinogen, neutrophil, and alkaline phosphatase count to be predictive of operative difficulties. Risk-assessment model was generated with an area under the receiver-operator curve of .80. Internal validation was performed using the bootstrap method.

Conclusions

The DiLC score is a simple and reliable tool which could be used to improve patient counseling, optimize surgical planning, detect procedures at risk, identify patients eligible for outpatient care, and enhance resident training.     

Predictive Factors for Conversion of Laparoscopic Cholecystectomy

Reliable predictive factors for conversion of laparoscopic cholecystectomy (LC) would be extremely useful in the preparation and planning of admission for patients with symptomatic cholelithiasis. Data from 783 patients in whom LC was attempted in a university clinic from June 1990 to December 1995 were retrospectively analyzed. The aim of this study was to determine preoperative indicators that can be useful for predicting conversion to open cholecystectomy (OC). Conversion was required in 58 (7.4%) patients, of which 48 (83%) were elective and 10 (17%) emergency. Factors evaluated were age, sex, obesity, duration of gallstone disease, co-morbid factors, indication for surgery, previous abdominal surgery, fever, physical examination findings, white blood cell (WBC) count, liver function tests, ultrasound findings, and the experience of the surgeon. Acute cholecystitis, rigidity in the right upper abdomen, fever, thickened gallbladder wall on ultrasonography, elevated alkaline phosphatase (ALP), liver transaminases and the WBC count were significant predictors of conversion in the univariate analysis. Multivariate logistic regression analysis on these significant predictors showed that acute cholecystitis [odds ratio (OR) = 3.12], thickened gallbladder wall on ultrasonography (OR = 3.75), elevated ALP (OR = 2.23), and WBC count (OR = 3.69) were jointly significant.