Surgical tactics in acute cholecystitis in old patients]

Based on some characteristic features of the clinical course of acute cholecystitis and large number of its destructive forms in aged persons, it is recommended to operate patients of this group during 24-28 hours after their admission. 216 aged and senile patients with acute cholecystitis were operated upon, the postoperative mortality being 9.7%. Cholecystectomy is considered to be the operation of choice. In the appropriate indications this operation was associated with drainage of the common bile duct. Cholecystostomy was performed in 10.6%.     

腹腔镜治疗老年人急性胆囊炎的体会

目的探讨老年人急性胆囊炎的腹腔镜治疗特点。方法将我院2001年4月～2006年4月收治的164例LC老年病例分为早期组(85例,急性发作48h内)与延期组(79例,急性发作48h后)进行比较分析。同时,将老年人组(164例)与非老年人组(164例)进行比较分析。结果延期组较早期组LC手术时间和平均住院时间明显延长;老年人组较非老年人组LC手术时间延长,术中出血量及术后并发症明显增多。结论老年急性胆囊炎病人宜早期施行LC。老年女性常因妇科炎症且腹腔内粘连,使LC难度增加,术中、术后并发症的发生率增高。     

Determination of surgical risk in patients with acute cholecystitis

On the basis of rich clinical experience and analysis of the case records of 445 patients who underwent operation in 1982-1988, the author calculates the risk of the operation in patients with acute cholecystitis according to the severity of their condition, the concomitant diseases and complications, the complex nature of the intervention which will be undertaken, the surgeon's rating, and other factors. The high efficacy of the calculations shown.     

老年人急性胆囊炎的腹腔镜手术治疗

目的探讨老年人急性胆囊炎采用腹腔镜手术治疗的临床效果与应用价值。方法回顾性分析105例因急性胆囊炎实施胆囊切除术的老年患者的临床资料,按手术方式分为腹腔镜组(LC组)和剖腹胆囊切除术组(OC组)。结果两组患者手术时间、肠功能恢复时间及住院天数差异均有统计学意义(P<0.01),LC组优于OC组;术中出血、腹腔引流量和术后并发症两组差异无统计学意义(P>0.05)。结论老年急性胆囊炎患者行腹腔镜治疗是安全可行的。     

老年急性化脓性胆囊炎的外科治疗

目的:探讨老年急性化脓性胆囊炎的合理治疗方法。方法:回顾性分析36例老年急性化脓性胆囊炎的临床资料。结果:36例均有发热(体温37.5～39 ℃)，右上腹疼痛，腹胀；局限性腹膜炎25例（69.4 %），黄疸6例16.7 %），休克5例（13.8 %），胆囊坏疽5例（13.8 %）；合并胆囊结石31例（86.1 %），胆总管结石6例（16.7 %）；合并心脑血管疾病15例，慢性支气管炎11例，糖尿病9例。急诊手术19例，其中腹腔镜胆囊切除(LC)3例，开腹胆囊切除手术(OC)15例，开腹大部切除胆囊1例，同时行胆总管切开探查6例；经皮胆囊穿刺置管引流待急性症状控制后手术切除胆囊11例，单纯经皮胆囊穿刺置管引流6例。35例治愈出院，治愈率为97.2 %。手术切口感染5例，肺部感染2例。急诊手术后死亡1例，急诊手术病死率为5.3 %。结论:对老年急性化脓性胆囊炎应采取稳妥的个体化治疗原则，反对一味冒险急诊手术。B超引导下经皮胆囊穿刺置管引流是一种安全有效的应急治疗措施。     

68例老年急性胆囊炎的手术治疗分析

回顾性分析68例老年急性胆囊炎的临床资料。其中急性结石性胆囊炎63例，非结石性急性胆囊炎5例。行单纯胆囊切除44例，胆囊切除加胆道探查17例，胆总管十二指肠吻合术2例，胆囊部分切除4例，胆囊造瘘1例。术后并发肺部感染8例，双侧胸腔积液1例，胃穿孔上消化道出血1例，切口感染2例。68例中67例痊愈，1例死亡。笔者体会，老年急性胆囊炎确诊后若无手术禁忌证当及早手术治疗。     

Predicting surgical risk in acute cholecystitis

From mathematical treatment of the results of operative treatment of 163 patients with acute cholecystitis on a computer with the use of program complexes on the basis of the mathematical theory of image recognition the authors obtained a decisive rule which allowed calculation of the prognostic index reflecting the severity of the patient's condition and the prognosis of the surgical treatment according to the initial values of total protein, leucocytosis, AlAT, and the patient's age. Besides, the efficacy of the preoperative management can be judged from the dynamics of changes of the index. Development of the tactics of treatment of patients with acute cholecystitis on the basis of the prognostic index improved the results of operative treatment considerably.     

Comprehensive therapy of acute cholecystitis in elderly and very old patients]

A high effectiveness of the use of target transport of antibiotics in the autological erythrocytic shadows in the complex of surgical treatment of acute cholecystitis in 65 elderly and senile patients when compared with that in use of the existing methods of conservative treatment was revealed. The method developed permits to create in the bile a high and prolonged antibiotic concentration, and as well to reduce 4.5-fold the time for cupping off acute cholecystitis, to increase the quality of examination, preoperative preparation and elective operative treatment of the patients.     

Early surgical treatment of acute cholecystitis

Correlations between anatomic and clinical findings were absent in a series of 214 cases of acute cholecystitis, and there was a high percentage of severe forms (58 p. 100). Early operation (between 48 and 72 hours) is therefore the most logical treatment and demonstrates comparable morbidity and mortality, if not lower figures, than with delayed surgery. Diagnosis can usually be made on clinical grounds and results of ultra-sound imaging and allows surgery to be performed after intensive care and preoperative antibiotic therapy. Total surgery with perioperative cholangiography is usually possible (95 p. 100 cases).     

The surgical treatment of acute cholecystitis

We are in accord with Smith in the belief that operation within forty-eight hours of onset carries too high a mortality to warrant much consideration, especially in the wards of a public charitable hospital whose patients are not infrequently poor surgical risks. Furthermore, these patients often do not come to the hospital within forty-eight hours of the acute onset. Our opportunities have been limited as regards statistics for this group. Our entire Group 1 series has little positive value since it is too small in numbers.We are inclined to the view of Cutler and Whipple that any early operation, preferably cholecystectomy, should be done within six to twelve hours of onset. So far as we have been able to determine, apparently the peak of the disease is reached in from one to four days.In Group 2, after forty-eight hours, seven acute, ten subacute, five ulcerative, four gangrenous, two empyemas and one hydrops were present; in other words, considerable acute pathology remained. The chronic cases, almost a third, showed subsidence of the pathology. Nevertheless the mortality for this group had dropped by 60 per cent, from the 19 per cent of Group 1 to 7.8 in Group 2.In Group 3, in which operation occurred after six days (most of them about the fourteenth day), we still find evidence of acute gall-bladder pathology. There was evidence of an active pathology in 130 cases out of 427 supposedly subsided cases. In all of these we waited, and in the majority of instances they showed minimal clinical manifestations when operated upon. Yet acute lesions were present in 31 per cent of cases. The mortality, however, dropped from 19 per cent in Group 1 and 7.8 per cent in Group 2 to 5.4 per cent in Group 3.There were nine deaths in Group 3 due to accidental injuries of ducts and blood vessels. These deaths represented almost 40 per cent of the total mortality of this group; if these nine deaths were eliminated the mortality would be 3.5 per cent.     

Variants of surgical treatment of acute cholecystitis in high operative risk patients

Results of surgical treatment of acute cholecystitis were analyzed in 105 patients. Immediate results of laparoscopic cholecystectomy and immediate and long-term results of puncture treatment were estimated. It was shown that in patients with extremely high degree of the operation risk (IV-V degree by ASA) the puncture treatment of acute cholecystitis judged by immediate results proved to be effective in 75% of the patients, and the effect judged by long-term results was 92.5%.