急性胆囊炎早期腹腔镜治疗术后并发症的高危因素分析

目的:探讨急性胆囊炎早期行腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)术后并发症的相关因素。方法:回顾分析2009年1月至2013年12月737例早期行LC的急性胆囊炎患者的临床资料,应用Logistic多因素回归分析术后并发症的相关危险因素。结果:LC术后15例(2.04%)早期出现并发症,6例再次手术治疗,9例保守治疗,均治愈。单因素分析显示早期LC术后并发症的发生与既往病程、是否为结石性胆囊炎、胆囊三角解剖变异、术者经验及出血量有关(P0.05),与性别、年龄、肥胖、合并内科疾病、胆囊颈结石嵌顿、胆囊萎缩及放置腹腔引流管无关(P0.05)。多因素分析显示既往病程、术者经验是早期LC术后并发症的独立危险因素(P0.05)。结论:急性胆囊炎患者LC术后早期容易发生并发症与既往病程较长、术者经验少相关,术者应加强训练,严格把握手术适应证及中转开腹指征。     

基于东京指南(2018)下中度(Ⅱ级)急性胆囊炎行腹腔镜胆囊切除中转开腹危险因素分析

目的探讨中度(Ⅱ级)急性胆囊炎行腹腔镜胆囊切除(LC)中转开腹的危险因素。 方法回顾性分析2014年1月至2016年1月137例急性胆囊炎患者资料,57例患者行LC,80例患者行LC中转开腹,依据手术方式不同分成LC组和中转开腹组。所有数据采用SPSS13.0统计软件进行处理。计量资料以( ±s)表示,对各变量进行正态性检验,各变量未通过正态性检验(P<0.05),以连续性变量以中位数(四分位间距)表示并做秩和检验。多因素分析采用Logistic回归分析,P<0.05为差异有统计学意义。 结果(1)单因素分析结果显示：患者年龄、急性胆囊炎发生次数、患者本次发病最高白细胞计数、患者最高体温、彩超诊断下胆囊厚度、胆囊大小中转开腹组均显著高于LC组(P<0.05),LC医师年资中转开腹组均显著低于LC组(P<0.05)。(2)多因素分析结果显示：急性胆囊炎发生次数,患者本次发病最高体温是中转开腹的独立危险因素,LC医师年资是中转开腹的独立保护因素。 结论急性胆囊炎发生次数、患者体温是中度(Ⅱ级)急性胆囊炎行LC中转开腹独立危险因素,有经验的手术医师可以减少该类疾病中转开腹的概率。     

急性胆囊炎腹腔镜胆囊切除术中转开腹相关风险因素的分析

目的:探讨致急性胆囊炎患者腹腔镜胆囊切除术(LC)中转开腹的影响因素。方法:回顾分析2011年1月—2015年6温州医科大学附属浙江省台州市中心医院及台州医院1 161例急性胆囊炎行LC患者的临床资料,选择中转开腹的56例患者为研究组,随机选取78例顺利完成LC术患者为对照组,分析中转开腹的相关风险因素。结果:单因素分析表明,纤维蛋白原、白蛋白、糖尿病、胆囊壁厚度、是否胆囊坏疽、术中出血量均与LC中转开腹有关(均P0.05)。Logistic回归分析结果表明,低白蛋白(OR=1.258)、术中出血量(OR=0.988)是LC中转开腹独立危险因素(均P0.05)。结论:低白蛋白、纤维蛋白原、糖尿病、胆囊坏疽及胆囊壁增厚及术中出血量是LC中转开腹的危险因素。     

影响急性胆囊炎手术难易度的因素分析

目的:探讨急性胆囊炎行腹腔镜胆囊切除术(LC)时影响手术难易度的相关因素。方法:回顾性分析我院急性胆囊炎患者行LC治疗的临床指标,运用多因素线性回归分析方法分析影响手术难易度的相关因素。结果:急性胆囊炎行LC 53例,中转开腹3例。多元线性回归分析结果显示,年龄及术前最高体温是影响手术难易度的相关因素。结论:急性胆囊炎行手术治疗时可根据年龄及术前最高体温预测手术难易度。     

急性胆囊炎术前超声征象与腹腔镜胆囊切除术转开腹的关系

目的：探讨急性胆囊炎术前腹部超声检查征象与腹腔镜胆囊切除术（laparoscopic cholecystectomy, LC）中转开腹的关系。
方法：对226例急性胆囊炎LC患者术前行腹部超声检查,记录胆囊容积,胆囊壁厚度,胆囊窝有无积液,胆囊颈管是否有结石嵌顿,胆囊与周围粘连,胆囊三角粘连情况。分析超声显像与LC转开腹的关系。
结果：208例成功完成LC,18例中转开腹。单因素分析显示超声检查胆囊容积增大,胆囊壁增厚,胆囊颈管结石嵌顿,胆囊颈粘连是中转开腹的危险因素（P＜0.05）。多因素回归分析显示胆囊壁增厚和胆囊颈粘连是影响腹腔镜中转开腹率的独立危险因素。
结论：术前超声检查预测急性胆囊炎LC转开腹简便易行,对急性胆囊炎行腹腔镜手术适应证的选择有重要指导意义。

     

腹腔镜胆囊切除中转开腹手术的危险因素分析

目的：分析腹腔镜胆囊切除术中转开腹手术的危险因素。方法：回顾分析我院5年间2 850例LC临床资料,采用单因素分析至Logistic多元回归分析推算出LC中转开腹的危险因素。结果：LC中转开腹手术115例,中转率为4.03%。LC中转开腹的危险因素有近半年胆囊炎急性发作≥2次,胆囊炎病史>2年,伴有右上腹体征（右上腹压痛、肝区叩痛、Murphy′s征阳性）,胆囊壁厚度≥3 mm和胆囊积液。结论：中转开腹的危险因素有近期胆囊炎发作频数、胆囊炎病史、右上腹体征、胆囊壁厚度和胆囊积液。术前仔细询问病史和完善检查,选择适合的LC患者和提高术者手术技术是降低LC中转开腹率的有效措施。对于存在危险因素的患者应适时的选择开腹手术。     

腹腔镜胆囊切除术治疗急性结石性胆囊炎

目的:探讨急性结石性胆囊炎行腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)的术中处理及并发症的防治。方法:回顾分析2004年11月至2009年11月为63例急性结石性胆囊炎患者行LC的临床资料。结果:53例成功行胆囊切除术,3例胆囊大部切除+胆囊粘膜电灼术,7例中转开腹,无死亡、大出血及胆管损伤。结论:急性结石性胆囊炎行LC是安全可行的,提高腹腔镜技术、适时中转开腹是防治并发症发生的关键。     

腹腔镜胆囊切除术治疗急性胆囊炎的疗效分析(附103例报告)

目的:探讨急性胆囊炎患者行腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)的可行性及临床价值。方法:回顾分析2006年1月至2008年6月我院为103例急性胆囊炎患者行LC的临床资料。结果:100例成功完成LC;3例中转开腹(2.91%),均为发病72h后行LC,其中1例Calot三角区严重水肿、粘连致密,无法辨清胆管关系,Mirizzi综合征及胆囊十二指肠瘘各1例。手术时间30～140min,平均80min。均痊愈出院,随访6～60个月,平均28.5个月,无并发症发生及死亡病例。结论:急性胆囊炎行LC,难度大,但只要合理选择患者,把握手术时机并注重手术技巧,急性胆囊炎患者行LC是安全可靠的。     

急性胆囊炎行腹腔镜胆囊切除术的体会(附275例报告)

目的:探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)治疗急性胆囊炎的手术时机和手术技巧。方法:回顾分析2004年8月至2009年12月为275例急性胆囊炎患者施行LC的临床资料,总结成功为急性胆囊炎患者行LC的经验。结果:本组242例成功完成LC,33例中转开腹,全组无死亡病例及大出血等严重并发症发生,仅1例胆管损伤。结论:急性胆囊炎在发病早期(72h内)应用适当的手术技巧,多数急性胆囊炎患者行LC是安全可靠的。     

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...     

急性坏疽性胆囊炎69例的腹腔镜治疗

目的 探讨腹腔镜治疗急性坏疽性胆囊炎中转开腹的危险因素及影响预后的指标。方法 总结69例急性坏疽性胆囊炎腹腔镜手术的临床资料，包含术前临床指标和预后相关因素。计量资料采用x^-±s表示，行t检验；计数资料行χ^2检验。结果 腹腔镜手术成功完成45例，中转开腹24例；中转开腹的危险因素为年龄（χ^2=2．234，P=0．034）和合并心血管疾病（χ^2=4．983，P=0．027）；早期行腹腔镜手术和术中及时中转开腹的病例预后较好。结论 急性坏疽性胆囊炎应早行腹腔镜探查，若操作困难，应早期及时中转开腹手术；对于高龄和合并有心血管疾病的患者，应行开腹胆囊切除术。     

Prophylactic cholecystectomy with gastric bypass operation: incidence of gallbladder disease

Background: Morbid obesity is one of the major risk factors for gallbladder disease, and this risk is even greater following rapid weight loss. Because of this, prophylactic cholecystectomy has been offered to our patients undergoing the transected silastic ring vertical Roux-en-Y gastric bypass (TSRVRYGBP). A study was undertaken to determine the incidence of pathologic gallbladders in patients undergoing this prophylactic cholecystectomy. Method: The records of all patients who underwent TSRVRYGBP from June 1999 through December 2000 were reviewed. Pathologic findings of the gallbladder were documented as cholelithiasis, cholecystitis, cholesterolosis, polyps or normal. Results: 761 patients underwent the operation. 178 patients (23%) had cholecystectomy before the surgery. 154 (20%) had gallstones documented by ultrasound and had cholecystectomy at the time of the surgery. 324 of the 429 patients with negative preoperative findings by ultrasound had pathologic evidence of gallbladder disease. Conclusion: Because of the high incidence of gallbladder disease even with negative preoperative findings in morbidly obese patients and the lack of significant morbidity with cholecystectomy in experienced hands, routine cholecystectomy at the time of the weight loss operation is justified.     

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。     

急性胆囊炎腹腔镜胆囊切除术中转手术的相关因素评估

目的 探讨急性胆囊炎腹腔镜胆囊切除术中转手术的相关因素.方法 回顾性分析我院2005年1月～2010年11月间,332例急性胆囊炎患者行腹腔镜胆囊切除术的病例资料;其中,中转手术51例.通过比较腹腔镜手术组和中转手术组患者的年龄,性别,体重指数,术前全血白细胞计数、碱性磷酸酶、总胆红素、血清谷丙转氨酶水平、谷草转氨酶、...     

Predictive factors for conversion of laparoscopic cholecystectomy

BACKGROUND: Laparoscopic cholecystectomy has replaced open cholecystectomy for the treatment of gallbladder disease. However, certain cases still require conversion to open procedures. Identifying these patients at risk for conversion remains difficult. This study identifies risk factors that may predict conversion from a laparoscopic to an open procedure. METHODS: From January 1996 to January 2000, a total of 1,347 laparoscopic cholecystectomies were performed at the Cleveland Clinic Foundation (CCF). A retrospective analysis of 34 parameters including patient demographics, clinical history, laboratory data, ultrasound results, and intraoperative details was performed. Stepwise, multivariate logistic regression was used to determine those variables predicting conversion of laparoscopic cholecystectomy. RESULTS: Seventy-one (5.3%) laparoscopic cholecystectomies required conversion. Multivariate analysis revealed that for all cases, a white blood cell count >9 (2.9 greater odds ratio [OR] of conversion P = 0.006) and a gallbladder wall thickness >0.4 cm (7.2 OR, P <0.001) predicted conversion to open cholecystectomy. However, when patients with acute cholecystitis were evaluated only a body mass index >30 kg/m(2) (5.6 OR, P = 0.02) predicted conversion. For patients undergoing elective cholecystectomy, a body mass index >40 kg/m(2) (33.1 OR, P = 0.01) and a wall thickness >0.4 cm (24.7 OR, P <0.004) predicted conversion. Finally, an ASA >2 (5.3 OR, P = 0.01) predicted conversion in patients undergoing nonelective cholecystectomies. CONCLUSIONS: Obese patients with acute cholecystitis undergoing laparoscopic cholecystectomy have an increased chance of conversion. Likewise, patients with multiple comorbid diseases undergoing nonelective laparoscopic cholecystectomy are more likely to require conversion. Finally, in an elective laparoscopic cholecystectomy, morbidly obese patients with chronic cholecystitis and a thickened gallbladder wall are more likely to require conversion. These factors can help counsel patients undergoing laparoscopic cholecystectomy with regards to the probability of conversion to an open procedure.     

What are the contraindications for laparoscopic cholecystectomy?

Acute cholecystitis, morbid obesity, and previous upper abdominal surgery have been reported as relative contraindications to laparoscopic cholecystectomy. An analysis of 706 laparoscopic cholecystectomies performed at our institution was undertaken to determine if these relative contraindications led to increased morbidity, an increased rate of conversion to the open technique, or longer operating time. One hundred ninety-seven patients demonstrated one or more relative contraindications to laparoscopic cholecystectomy. Morbidity was not increased in patients with these risk factors, but conversion to open cholecystectomy was required in a greater percentage of patients with acute cholecystitis. We favor an attempt at laparoscopic cholecystectomy in patients with these risk factors; however, they should be counseled as to the increased risk of conversion to open cholecystectomy in the presence of acute cholecystitis.     

Gangrenous cholecystitis in the decade before and after the introduction of laparoscopic cholecystectomy.

BACKGROUND: Gangrenous cholecystitis is a severe form of acute cholecystitis with high morbidity. This study investigate the outcomes for patients undergoing cholecystectomy for gangrenous cholecystitis in the decade before and after the introduction of laparoscopic technology at our institution. METHODS: From 1982 to 2002, all patients undergoing cholecystectomy for gangrenous cholecystitis were prospectively entered into a database. Demographic data, method of surgery, and outcome variables were assessed and compared over time. RESULTS: Cholecystectomy was performed to treat gangrenous cholecystitis in 238 patients (mean age, 54 years). From 1982 to 1992, 98 patients underwent cholecystectomy for gangrenous cholecystitis, and from 1992 to 2002, 140 patients underwent the procedure. Ninety-seven patients underwent laparoscopic cholecystectomy, and 33 patients (34%) required conversion. The open and laparoscopic cholecystectomy group differed in the number of intensive care unit admissions (13% vs. 5%, P < 0.05), overall length of hospital stay (10 vs. 5.7 days, P < 0.001) and rate of intraabdominal abscesses (8% vs. 0.7%). CONCLUSION: Gangrenous cholecystitis remains a disease with high morbidity. Laparoscopic cholecystectomy shortened hospital stay and can be offered without increasing morbidity. Methods to decrease intraabdominal abscess formation in patients undergoing laparoscopic cholecystectomy for gangrenous cholecystitis are needed.     

Is Prophylactic Cholecystectomy Useful in Obese Patients Undergoing Gastric Bypass?

Background: Obesity constitutes a clear risk factor for cholelithiasis, especially if it is associated with a rapid weight loss, as is the case of patients following bariatric surgery. Prophylactic cholecystectomy is indicated in biliopancreatic diversions due to the high incidence of postoperative cholelithiasis. However, there is no agreement on gastric bypass. This study was conducted to establish the incidence of cholecystopathy demonstrated by histology and to assess the indication for prophylactic cholecystectomy in a systematic way on patients undergoing gastric bypass. Methods: The evaluation is based on 100 consecutive morbidly obese patients undergoing open gastric bypass surgery with concomitant prophylactic cholecystectomy. Variables studied were: age, gender, body mass index, preoperative ultrasound and the anatomopathologic analysis of the gallbladder that was removed. Results: Of the 100 patients who took part in the trial, 11 had had a previous cholecystectomy. Among the 89 patients remaining, preoperative ultrasound diagnosis of cholelithiasis was 16.8%, and the actual postoperative incidence was 24.7%. Other histologic alterations were: cholesterolosis 46.1%, chronic unspecified cholecystitis 22.5%, and granulomatous cholecystitis 1.1%. The total incidence of cholecystopathy was 93.3%. The morbi-mortality related to cholecystectomy was 0%. Conclusions: Based on these results and given the absence of morbidity, we believe that prophylactic cholecystectomy is suitable during open gastric bypass.     

Predicting conversion of laparoscopic cholecystectomy for acute cholecystitis.

BACKGROUND AND OBJECTIVES: Laparoscopic cholecystectomy can be safely performed in patients with acute cholecystitis. However, the rate of conversion to open cholecystectomy remains higher when compared with patients with chronic cholecystitis. Preoperative clinical or laboratory parameters that could predict the need for conversion may assist the surgeon in preoperative or intraoperative decision making. This could have cost-saving implications. METHODS: A retrospective review of 46 patients undergoing laparoscopic cholecystectomy for acute cholecystitis was performed. Records were assessed for preoperative clinical, laboratory and radiographic parameters on admission. Temperature and laboratory parameters were also recorded prior to surgery after an initial period of hospitalization that included intravenous antibiotics. The effect of admission and preoperative parameters as well as the trend in these parameters prior to surgery upon the rate of conversion to open cholecystectomy was assessed. RESULTS: Ten patients (22%) required conversion to open cholecystectomy. Conversion was required more often in males (43%) when compared with females (4%) (p=0.003). Conversion rate was 30% in patients with increased wall thickness by ultrasound compared with 12% for patients without wall thickening (p=ns). No admission or preoperative laboratory values predicted conversion. The trend in the patient's temperature (p=0.0003) and serum LDH value (p=0.043) predicted the need for conversion to open surgery. CONCLUSIONS: Preoperative prediction of the need for open cholecystectomy remains elusive. Male patients and patients with rising temperature and LDH levels while on intravenous antibiotics require conversion at increased frequency. However, the benefits of laparoscopic cholecystectomy warrant an attempt at laparoscopic removal in most patients with acute cholecystitis.