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。

     

急性炎症期腹腔镜胆囊切除术的中转开腹原因分析

目的：探讨急性炎症期腹腔镜胆囊切除术中转开腹的原因与防治。方法：回顾分析651例急性炎症期胆囊炎患者行腹腔镜胆囊切除术的临床资料。结果：腹腔镜胆囊切除术成功935例（97.54%）,中转开腹16例（2.46%）。其中因胆囊三角解剖不清、胆囊与周围组织紧密粘连,主动中转开腹11例（1.69%）,被动中转开腹的5例（0.77%）中胆管损伤2例,出血3例。结论：急性炎症期腹腔镜胆囊切除术是安全可行的,正确处理胆囊三角是降低LC并发症及中转开腹率的有效措施。     

急性结石性胆囊炎腹腔镜手术时机及中转开腹影响因素的探讨

目的探讨腹腔镜手术治疗急性结石性胆囊炎的最佳时机以及影响中转开腹的因素。方法对468例行腹腔镜胆囊切除术的急性结石性胆囊炎病人的临床资料进行回顾性分析。将468例病人分为A（症状发作48h内手术）、B（48～72h内手术）、C（72h后手术）、D（保守治疗后再择期手术）4组。结果A、B、C、D4组的术后并发症发生率分别为3．48％（5／146）、3．69％（5／137）、5．88％（6／102）和3．17％（2／63），各组间术后并发症发生率并无显著性差异（P均〉0．05）；C组的手术时间较其他3组明显延长（P〈0．05），且手术中转率也显著高于其他各组（P〈0．05）；A组的手术时间较其他组短，开腹中转率也较其他组低（P〈0．05）；单因素分析结果显示体温、右上腹肌紧张、胆囊肿大、白细胞计数、胆囊壁厚度、胆囊颈部结石嵌顿、手术时机7个因素与中转开腹率显著相关（P〈0．05）。多因素回归分析显示白细胞计数和手术时机是影响腹腔镜中转开腹率的独立危险因素。结论急性结石性胆囊炎症状发作后48h内是腹腔镜手术的最佳时机，白细胞计数和手术时机是影响腹腔镜中转开腹率的独立危险因素。     

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.     

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。     

腹腔镜胆囊切除术中转开腹手术105例临床分析

目的探讨腹腔镜胆囊切除术(LC)中转开腹的原因及防治措施。方法回顾性分析2003年1月至2012年12月我科收治3047例LC中105例中转开腹的临床资料,分析其中转开腹的原因并总结。结果本组患者的中转开腹率为3.45%,分析原因主要为胆囊三角严重粘连、解剖困难、胆囊管结石嵌顿、胆管损伤、大出血、意外胆囊癌等,105例患者经中转开腹后无严重并发症,均痊愈出院。结论准确严格把握LC手术适应证,术中规范、精细操作可有效降低中转开腹率,而当操作困难或对手术没把握时,应及时中转开腹以确保手术安全性。     

腹腔镜胆囊切除术转开腹手术的危险因素分析

目的研究多个临床因素对腹腔镜胆囊切除术(LC)转开腹手术的影响。方法对浙江大学医学院附属邵逸夫医院1994年4月至2001年6月的7134例LC的临床资料进行单因素分析,再进行多元逻辑回归分析(逐步排除法),得出影响LC转开腹手术的独立的危险因素。结果男性、高龄(≥65岁)、上腹部手术史、糖尿病、总胆红素升高(≥20.5μmol/L)、胆囊壁增厚(≥4mm)、胆总管直径增宽(≥8mm)、急性胆囊炎是转开腹手术的危险因素。结论可以根据转开腹手术的危险因素指导临床工作。     

Laparoscopic cholecystectomy in acute cholecystitis: predictors of conversion to open cholecystectomy and preliminar results

Inspite of increased technical difficulties and high incidence of conversion to open procedures and complications, laparoscopic cholecystectomy is a well established treatment for acute cholecystitis. In this study we reported our results in patients with acute cholecystitis undergoing laparoscopic cholecystecomy from 1998 to 2003. We found out that laparoscopic cholecystectomy was safe and was carried out with acceptable conversion rate and low morbidity. Predictors of complications were delay of surgery more than 48 hours following the onset of symptoms, leucocytosis > 15.000 U/microl and gallbladder wall ultrasonography thickness > 7mm.     

腹腔镜胆囊切除术中转开腹危险因素的分析

目的分析腹腔镜胆囊切除术(LC)中转开腹的危险因素,为在保证安全前提下,降低中转开腹率提供参考。方法回顾分析328例LC患者的临床资料,采用Logistic回归分析方法,分析LC中转开腹的危险因素。结果 328例LC患者中转开腹26例,占7.93%,主要原因是Calot三角解剖不清(12/26,46.12%),腹腔粘连(9/26,34.62%)。墨菲氏征阳性、胆囊壁厚≥3mm、近6个月发作频数≥2次和黄疸为中转开腹的危险因素。结论对存在危险因素的患者,应术前做好中转开腹和适时选择开腹手术的准备。     

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。     

Preoperative findings predict conversion from laparoscopic to open cholecystectomy

BACKGROUND: Previous studies evaluating predictive factors for conversion from laparoscopic to open cholecystectomy have drawn conflicting conclusions. We evaluated objective preoperative variables to create an accurate, accessible risk score to predict conversion. METHODS: A retrospective review was performed of laparoscopic cholecystectomy patients at an urban tertiary care center. Seventy characteristics were subjected to bivariate and multivariate logistic regression analysis to identify parameters that independently predict conversion to open cholecystectomy. A model was created based on this analysis. RESULTS: Laparoscopic cholecystectomy was performed on 1377 patients for benign gallbladder disease over a 71-month period. There were 112 (8.1%) conversions to open cholecystectomy. The correlation between the preoperative clinical diagnosis and pathologic diagnosis for acute and chronic cholecystitis was 48.6% and 94.6%, respectively. Multivariate analysis identified male gender, elevated white blood cell count, low serum albumin, ultrasound finding of pericholecystic fluid, diabetes mellitus, and elevated total bilirubin as independent predictors of conversion. These 6 factors were also associated with the pathologic diagnosis of acute cholecystitis. A model to calculate the risk for conversion was created with an area under the receiver operator curve of 0.83. The risk for conversion also can be estimated based on the number of factors identified present and ranged from 2% when 1 factor was present to 89% with 6 factors. CONCLUSIONS: These results demonstrate that conversion to open cholecystectomy can be predicted based on parameters available preoperatively. Conversion is more likely in patients who have acute cholecystitis; however, the correlation between its clinical and pathologic diagnosis is poor. Improvements in the ability to determine the risk for conversion have important implications for surgical care.     

腹腔镜胆囊切除术转开腹可能性评分系统建立和运用

目的　根据术前临床资料建立预测腹腔镜胆囊切除术转开腹可能性的评分系统。方法　对邵逸夫医院 1994年 4月 4日至 2 0 0 1年 6月 30日的 7134例LC的术前临床资料进行单因素分析 ,筛选出中转开腹的危险因素 ,再进行logistic多元回归分析。男性、高龄 (≥ 6 5岁 )、上腹部手术史、糖尿病、总胆红素升高 (≥ 1 2mg/dl)、胆囊壁增厚 (≥ 4cm )、胆总管直径增宽 (≥ 8cm)、急性胆囊炎是转开腹的危险因素并被分别赋值 ,建立预测转开腹可能性的评分系统。计算 7134例LC的综合得分 ,比较不同得分组转开腹率。用ROC曲线评价该评分系统的效能。 2 0 0 1年 7月 1日至 2 0 0 1年 12月 31日 938例LC运用该评分系统 ,比较各得分组转开腹率的差异。结果　 7134例LC中各组得分越高 ,转开腹率越高 ,且多数相邻两组的转开腹率有显著性差异 (P <0 0 1)。ROC曲线以下面积为0 81,标准误为 0 0 1。 938例LC中的各组也是得分越高 ,转开腹率越高 ,且多数相邻两组的转开腹率有显著性差异 (P <0 0 5 )。结论　根据危险因素预测LC转开腹可能性 ,以指导临床工作。     

A nationwide study of conversion from laparoscopic to open cholecystectomy

PURPOSE: To determine the national incidence and risk factors for conversion from laparoscopic to open cholecystectomy. BACKGROUND: Most series reporting the rates at which laparoscopic cholecystectomies are performed, relative to the open procedure, have come from centers specializing in laparoscopic surgery. The rates at which conversions occur from these centers may not reflect those in community practice. We sought to determine the actual, and therefore acceptable, conversion rate by examining nationally representative discharge data. METHODS: The National Hospital Discharge database for 1998 to 2001 was acquired from the Centers for Disease Control. All gallbladder disease related admissions were extracted, and the cholecystectomies (ICD-9-CM codes 51.2X) were analyzed using the SAS package. Stepwise logistic regression was used to determine what factors were associated with the risk of conversion from laparoscopic to open cholecystectomy. RESULTS: Approximately 25% of all cholecystectomies are performed by the open technique. Of the remaining 75%, there is an approximately 5% to 10% conversion rate. The major risk factors for conversion included male sex, obesity, and cholecystitis. Concurrent choledocholithiasis, cholelithiasis, and cholecystitis were associated with a conversion rate of 25%. Length of stay (LOS) was reduced for laparoscopic operations and although conversion added 2 to 3 days to the LOS, for most cases the LOS was still less than for primary open operations. CONCLUSIONS: Three quarters of all cholecystectomies are performed laparoscopically, and the national conversion rate is 5% to 10%. Cholecystitis, choledocholithiasis, male sex, and obesity are major predictors for conversion. The data presented in terms of conversion rates and LOS were derived from population-adjusted hospital discharge data and represent the current U.S. experience for cholecystectomy. From these data the community experience for conversion rates, risk factors, and LOS can be derived.     

Risk factors for conversion of laparoscopic cholecystectomy to open cholecystectomy

Background Conversion to open cholecystectomy is still required in some patients. The aim of this study was to evaluate preoperative factors associated with conversion to open cholecystectomy in elective cholecystectomy and acute cholecystitis.Methods The records of 1,804 patients who underwent cholecystectomy from May 1992 to January 2004 were reviewed retrospectively. The demographics and preoperative data of patients who required conversion to laparotomy were compared to those with successful laparoscopic cholecystectomy.Results Conversion to open cholecystectomy was needed in 94 patients (5.2%),of which 44 (2.8%) had no inflammation and 50 (18.4%) had acute inflammation of the gallbladder. Male gender, age older than 60 years, previous upper abdominal surgery, diabetes, and severity of inflammation were all significantly correlated with an increased conversion rate to laparotomy. Also, the conversion from laparoscopic to open cholecystectomy in acute cholecystitis patients was associated with greater white blood cell count, fever, elevated total bilirubin, aspartate transaminase, and alanine transaminase levels, and the various types of inflammation.Conclusions None of these risk factors were contraindications to laparoscopic cholecystectomy. This may help predict the difficulty of the procedure and permit the surgeon to better inform patients about the risk of conversion from laparoscopic to open cholecystectomy.     

腹腔镜胆囊切除术中转开腹的影响因素

目的：分析腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）中转开腹的影响因素并探讨其防治措施。方法：对2000年1月至2006年1月1 170例LC术中97例（8.29%）中转开腹情况进行回顾性分析。结果：急性炎症期胆囊炎51例,占中转开腹的52.6%;术中出血25例（25.8%）;怀疑胆总管结石12例（12.4%）;胆囊癌5例（5.15%）;过度肥胖患者4例（4.12%）,开腹手术均获成功,均痊愈出院。结论：熟悉胆道系统解剖及变异、熟练的腹腔镜操作技术是减少LC中转开腹的关键,但适时中转开腹是防止LC严重并发症的最佳选择。     

A risk score for conversion from laparoscopic to open cholecystectomy

BACKGROUND: Laparoscopic cholecystectomy has become the standard operative procedure for cholelithiasis, but there are still some patients requiring conversion to open cholecystectomy mainly because of technical difficulty. Our aim was to develop a risk score for prediction of conversion from laparoscopic to open cholecystectomy. METHODS: Preoperative clinical, laboratory, and radiologic parameters of 1,000 patients who underwent laparoscopic cholecystectomy were analyzed for their effect on conversion rates. Six parameters (male sex, abdominal tenderness, previous upper abdominal operation, sonographically thickened gallbladder wall, age over 60 years, preoperative diagnosis of acute cholecystitis) were found to have significant effect in multivariate analysis. A constant and coefficients for these variables were calculated and formed the risk score. RESULTS: Overall 48 patients required conversion to open cholecystectomy (4.8%). These patients had significantly higher scores (mean 6.9 versus -7.2, P <0.001). Increasing scores resulted with significant increases in conversion rates and probabilities (P <0.001). Ideal cut-off point for this score was -3; conversion rate was 1.6% under -3, but 11.4% over this value (P <0.001). CONCLUSIONS: Conversion risk can be predicted easily by this score. Patients having high risk may be informed and scheduled appropriately. An experienced surgeon has to operate on these patients, and he or she has to make an early decision to convert in case of difficulty.     

急性结石性胆囊炎腹腔镜胆囊切除术的体会

目的:总结急性结石性胆囊炎患者行腹腔镜胆囊切除术的临床应用价值。方法:回顾性分析2005年3月至2008年11月我院收治的122例急性结石性胆囊炎患者行腹腔镜胆囊切除术的临床资料。结果:122例患者均用腹腔镜完成了手术,未发生严重并发症。结论:急性结石性胆囊炎患者行腹腔镜胆囊切除术安全可行。     

The treatment of laparoscopic cholecystectomy for acute cholecystitis

The aim of the study is to evaluate the results of early laparoscopic cholecystectomy for acute cholecystitis and to analyse the problems related to patients' selection and surgical timing. The authors report their personal experience of 45 laparoscopic cholecystectomies for acute cholecystitis. The diagnosis was based on clinical, blood test and US scan analyse findings. Technical surgical details were decompression of the gallbladder, use of endobag and abdominal dranage. We didn't perform and intraoperative cholangiography in absence of predictive factor for common bile duct stones. The mean time required for surgery was 120 minutes, conversion rate was 15% in early operations and 23.8% in operations delaied more than 72 h. Dissection difficulty is the main cause of conversion. Four patients underwent postoperative complications: one subphrenic abscess, one bile leakage (both recovered with nonsurgical therapy and two wound infections). In conclusion laparoscopic cholecystectomy is safe and effective as early treatment of acute cholecystitis in the first 72 hours due to easier dissection of the inflammed and oedematous tissue. This approach allows a reduction of the operative risk and the conversion rate with medical and economic advantages. Presence of bile duct stones is still now indication to conversion in open surgery.