糖尿病患者胆囊切除术的比较研究

目的探讨糖尿病患者胆囊切除术的选择. 方法比较我院1998年10月～2002年4月46例糖尿病行腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)和开腹胆囊切除术(open cholecystectony,OC)的术中出血量、手术时间、住院时间及并发症发生率. 结果 LC组和OC组的术中出血量分别是(80±23)ml和(120±40)ml(t=-4.518,P=0.000);手术时间为(45±20)min和(69±28)min(t=-3.345,P=0.002);住院时间为(6±2)d和(11±3)d(t=-6.651,P=0.000).两组术后并发症发生率无统计学差异(P＞0.05). 结论糖尿病患者选择LC是安全的,具有出血少,手术时间短和住院时间短的优点.     

老年患者腹腔镜胆囊切除术320例临床分析

目的:评价老年人行腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)的安全性及可行性,探讨防范风险的应对措施。方法:比较、分析60岁以上老年人LC组(n=320)、开腹胆囊切除术(open cholecystectomy,OC)组(n=112)及非老年LC组(n=1 923)的临床资料。结果:老年人LC及OC组并存病显著高于非老年LC组(P<0.001)。LC组患者术后恢复良好,未发生严重并发症;老年LC与非老年LC在平均手术时间、平均术后住院天数及中转开腹率方面差异无统计学意义(P>0.05);而OC组平均手术时间、平均术后住院天数均较LC组显著延长(P<0.001),且并发症多(P<0.05)。结论:只要高度重视围手术期的处理,正确评估麻醉与手术的风险,把握手术时机及技巧,对老年患者施行LC不仅安全可行,而且更能凸显微创手术的优越性。     

腹腔镜胆囊切除术对机体炎症免疫反应的影响

目的对比研究腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)和开腹胆囊切除术(open cholecystectomy,OC)对机体炎症免疫反应的影响. 方法监测胆囊结石或胆囊息肉样病变患者(LC、OC各30例)术前、术后1 h、1 d、2 d的外周血T淋巴细胞亚群、WBC计数、C反应蛋白(C-reactive protein,CRP)及白细胞介素-6(IL-6)的变化并进行比较.酶联免疫吸附法(ELISA)检测IL-6,流式细胞仪检测T细胞亚群. 结果 OC组术后2 d,成熟T淋巴细胞(CD3)(q=5.822,P<0.05)、辅助性T淋巴细胞(CD4)(q=10.636,P<0.05)较术前显著下降,2组CD4/CD8在术后1、2 d无统计学差别(P＞0.05).OC组术后2 d, WBC计数(t=4.904,P=0.000)、CRP(t=9.409,P=0.000)、IL-6(t=6.471,P=0.000)均明显高于LC组. 结论 LC对机体炎症免疫反应影响小,有利于术后恢复.     

腹腔镜胆囊切除术对老年患者肝肾功能影响的临床研究

目的:探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)与传统开腹手术对老年患者肝肾功能的影响。方法:回顾分析2009年6月至2013年6月为118例70岁以上老年患者行胆囊切除术的临床资料,其中65例行LC(LC组),53例行开腹胆囊切除术(open cholecystectomy,OC组)。对比两组患者手术时间、术中出血量、术后住院时间、术后并发症及手术前后肝肾功能指标的变化情况。结果:118例患者均成功完成手术,LC组在术后住院时间、术后进食时间及术后并发症方面优于OC组(P<0.05);与术前相比,两组患者术后第1天肝功能指标AST、ALT、ALP、TBIL及肾功能指标BUN、SCr均有所升高,差异有统计学意义(P<0.05);术后第5天,LC组上述指标基本下降至术前水平,而OC组仍高于术前水平(P<0.05)。两组间相比,术后第1天、第5天,OC组患者AST、ALT、ALP、TBIL、BUN、SCr均高于同时点LC组(P<0.05)。结论:LC患者创伤小,术后康复快,对肝肾功能影响较小;在严格把握手术适应证的前提下,实施个体化治疗原则,为老年患者行LC是安全、可行的。     

腹腔镜胆囊切除术与开腹胆囊切除术的效果比较

目的 比较腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)与传统开腹胆囊切除术(open chole-cystectomy,OC)的手术效果.方法 128例患者中,64例施行LC,64例施行OC,比较两组手术的手术时间、术中出血量、术后排气等7项指标.结果 LC组手术时间、术中出血量、术后排气时间、术后镇痛药物应用、术后胃肠功能恢复时间、切口感染情况及住院时间明显优于OC组(P<0.01).结论 LC具有有创伤小、痛苦轻、恢复快等优越性.     

腹腔镜与开腹胆囊切除术医疗效率和费用的比较分析

目的比较腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)与开腹胆囊切除术(open cholecystectomy,OC)医疗效率指标和费用. 方法回顾分析97例胆囊切除术临床资料,其中腹腔镜组41例,开腹组56例.比较两组住院日、术前住院日、术后住院日、并发症、住院费用等. 结果腹腔镜组和开腹组住院日、术后住院日分别为(11.4±3.0) d和(15.1±4.2) d(t＝-4.811,P=0.000)、(6.1±0.9) d和(10.7±2.4) d(t＝-11.673,P=0.000);腹腔镜组、开腹组住院费用分别为(8 723.8±1 077.2)元、(6 423.4±1 398.4)元(t＝8.791,P=0.000);腹腔镜组、开腹组医疗收入分别为(6 236.4±591.0)元、(3 426.6±683.2)元(t=21.162,P=0.000).两组术前住院日、并发症发生率无明显差异(t=1.684,P=0.095;χ2=0.434,P=0.510). 结论 LC卫生资源利用率较高,但费用也较高.     

腹腔镜胆囊次全切除术临床应用分析

目的探讨腹腔镜胆囊次全切除术（laparoscopic subtotal cholecystectomy，LPC）在胆囊疾病中的应用价值。方法将我院2004年1月～2008年3月收治的特殊类型胆囊病变94例随机分为LPC组和腹腔镜胆囊切除术（laparoscopic cholecystectomy，LC）组各47例。观测两组病人术中出血量、手术时间、LC中转开腹胆囊切除（operative cholecystectomy，OC）情况、术后引流情况、胆囊窝积液和并发症等指标。结果LC组术中出血量、手术时间和每天腹腔引流量均显著高于LPC组。LC组术后并发症及术后1个月复查时胆囊窝积液发生率也高于LPC组。结论LPC可简化手术，降低手术风险；减少术中并发症的发生率，降低LC的中转开腹手术比例，没有明显增加术后并发症的发生率，是一种安全、有效的手术方法.     

剖腹胆囊切除术与腹腔镜胆囊切除术胰岛素抵抗的差异

目的对比剖腹胆囊切除术(OC)和腹腔镜胆囊切除术(LC)的胰岛素抵抗程度和持续时间,以确定LC有更小的组织创伤。方法将53例择期手术病例分为OC组(28例)和LC组(25例),对比两组的生理学评分、住院时间及在术前、手术结束、术后24h、72h的胰岛素敏感性(IS)改变。结果LC组IS下降最多仅为8%,而OC组IS下降可达20%。两者有统计学差异(P<0.01)。结论LC术后IS改变较OC术后少,对机体的损伤小,有利于病人的康复。     

老年人行腹腔镜胆囊切除术的特点

目的:探讨老年人腹腔镜胆囊切除术的特点。方法:分析266例老年人(≥65岁)行腹腔镜胆囊切除术(LC)的手术时间、中转剖腹手术例数、住院天数、手术并发症、围手术期肺功能和血气分析变化,分别与中青年患者LC及老年患者剖腹胆囊切除术(OC)比较。结果:老年人LC平均手术时间为39min,手术中转率为5.6％,手术并发症占5.3％,均高于中青年LC患者,但明显低于OC的老年患者,且比较轻。但老年患者LC后的肺功能减退(10.2％)和高碳酸血症(20.3％)明显多于OC,多数可在术后短时间内恢复。结论:与OC比较,老年人LC仍是一种损伤小、安全可靠和恢复快的理想手术方法,但要针对老年患者的特点以及LC可能引起的肺功能下降和高碳酸血症,做好术前处理、术中及术后监测和并发症的预防。     

老年人腹腔镜胆囊切除术的特点

目的 探索老年人LC的特点及围手术期处理。方法 回顾性分析了266例老年人(≥65岁)行腹腔镜胆囊切除术(LC)的手术时间、中转剖腹手术例数、住院天、手术并发症、围手术期肺功能和血气分析变化,分别与中青年病人LC及老年病人剖腹胆囊切除术(OC)比较。结果 老年人LC平均手术时间(39分)、手术中转率(5.6％)、手术并发症(5.3％)均高于中青年LC患者,而明显低于OC的老年病人,且并发症较轻。但老年人LC后的肺功能减退(10.2％)和高碳酸血症(20.3％)明显多于OC,多数可在术后短时间内恢复。结论 老年人LC仍不失为一种损伤小、安全可靠和恢复快的理想手术方法,但要针对老年病人的特点以及LC可能引起的肺功能下降和高碳酸血症,做好术前处理、术中及术后监测和并发症的预防。     

腹腔镜与开腹胆囊切除术对比分析

我院于1994年8月～1996年6月完成腹腔镜胆囊切除术(LC)70例,为了客观地评价LC的优越性及不足之处,本文随机将1993年7月～     

腹腔镜胆囊大部分切除术在复杂胆囊手术中的应用

目的　探讨胆囊大部分切除在复杂腹腔镜胆囊切除术中应用的可行性及安全性。　方法　对 1999～ 2 0 0 1年施行的 2 6例腹腔镜胆囊大部分切除术的方法、手术疗效及并发症进行了回顾分析。手术指征为化脓性胆囊炎、Mirris综合征Ⅰ型、Calot三角“冰冻样”改变、萎缩性胆囊炎、胆囊床与肝脏瘢痕样致密粘连等。　结果　手术时间为 (5 1± 16 5 )分钟 ,开始下床活动时间 (11± 4 3)小时 ,开始进食时间 (2 2± 8 5 )小时 ,住院时间 (4 5± 1 5 )天 ,术后胆漏 2例 ,均经保守治疗治愈。随访 6月～ 2 5月 ,未见与手术有关的并发症。　结论　在困难胆囊手术中 ,腹腔镜胆囊部分切除术可简化手术 ,降低手术风险 ,可收到胆囊造瘘与标准胆囊切除相结合的疗效。     

Two-port versus four-port laparoscopic cholecystectomy

Background: Two-port laparoscopic cholecystectomy has been reported to be safe and feasible. However, whether it offers any additional advantages remains controversial. This study reports a randomized trial that compared the clinical outcomes of two-port laparoscopic cholecystectomy versus conventional four-port laparoscopic cholecystectomy. Methods: One hundred and twenty consecutive patients who underwent elective laparoscopic cholecystectomy were randomized to receive either the two-port or the four-port technique. All patients were blinded to the type of operation they underwent. Four surgical tapes were applied to standard four-port sites in both groups at the end of the operation. All dressings were kept intact until the first follow-up 1 week after surgery. Postoperative pain at the four sites was assessed on the first day after surgery using a 10-cm unscaled visual analog scale (VAS). Other outcome measures included analgesia requirements, length and difficulty of the operation, postoperative stay, and patient satisfaction score on surgery and scars. Results: Demographic data were comparable for both groups. Patients in the two-port group had shorter mean operative time (54.6 ± 24.7 min vs 66.9 ± 33.1 min for the four-post group; p = 0.03) and less pain at individual subcostal port sites [mean score using 10-cm unscaled VAS: 1.5 vs 2.8 (p = 0.01) at the midsubcostal port site and 1.3 vs 2.3 (p = 0.02) at the lateral subcostal port site]. Overall pain score, analgesia requirements, hospital stay, and patient satisfaction score on surgery and scars were similar between the two groups. Conclusion: Two-port laparoscopic cholecystectomy resulted in less individual port-site pain and similar clinical outcomes but fewer surgical scars compared to four-port laparoscopic cholecystectomy. Thus, it can be recommended as a routine procedure in elective laparoscopic cholecystectomy. Paper presented at the Fifth World Congress of the International Hepato-pancreato-biliary Association, Tokyo, Japan, April 2002     

困难腹腔镜胆囊切除应对策略

困难胆囊包括Mirrizi综合征、胆囊十二指肠内瘘、萎缩性胆囊炎、门静脉高压症胆囊等。困难腹腔镜胆囊切除是导致术中胆管与血管损伤的主要原因,确保手术安全是实施困难腹腔镜胆囊切除的重要原则。为此,术前应完善磁共振胰胆管造影（MRCP）与增强CT检查,排除胆道血管变异,根据局部炎症与术者经验选择适宜的手术时机。术中应选择适宜的解剖路径与解剖技巧,离断胆囊动脉与胆囊管均应在清晰解剖Calot三角的前提下。术后应注意创面的检查与引流,及时发现并处理各种并发症如胆管损伤、血管损伤、胆漏、胆囊管残余结石、胆囊床积液、胃肠道损伤等。     

腹腔镜胆囊次全切除术的临床应用

目的：探讨腹腔镜胆囊次全切除术的可行性,总结困难型腹腔镜胆囊切除术的经验,尤其是腹腔镜胆囊次全切除理念在困难型腹腔镜胆囊切除术中的体现及应用。方法回顾分析我院2008年1月至2013年10月所行腹腔镜胆囊次全切除病例,并以2011年5月为时间节点分为 A 组（节点前时段）、B 组（节点后时段）,分别比较前后两组的（胆囊切除实行专病专治）,手术时间、术后住院时间、术中出血量。结果 B 组手术时间（78.1±6.6）min 少于 A 组（97.5±7.3）min,B 组术后住院时间（3.5±0.4）d 少于 A 组（5.6±0.5）d,出血量 B 组（68.9±7.2）ml 多于 A 组（56.7±7.7）ml。差异均有统计学意义。结论腹腔镜胆囊次全切除应成为腹腔镜术者的常规理念;熟练掌握腹腔镜技术、积累一定经验后,腹腔镜胆囊次全切除可作为常规手术操作应用于临床。     

Racial variation in the use of laparoscopic cholecystectomy in the Department of Veterans Affairs Medical System

Background: While studies have found racial differences in the rates of use of established invasive cardiac and cerebrovascular procedures, no study has evaluated racial variation in the rates of adoption of new surgical procedures. For patients undergoing laparoscopic cholecystectomy, the procedure represents a new and safe option that shortens the duration of postoperative hospitalization by almost one week. In this study, we evaluated whether, in the equal access Veterans Affairs (VA) medical system, the rate of adoption of this procedure and improvements in the duration of postoperative hospitalization differed between African-American and Caucasian patients.

Study Design: Data were obtained from two sources—administrative claims files and prospectively compiled clinical data from medical records and patient interviews. In both data sets, frequency of use, length of stay, and outcomes for African-American and Caucasian patients undergoing minimally invasive and open gallbladder surgery were analyzed for the first four years of use of the procedure in the VA system (1992 to 1995).

Results: Analyses based on claims files indicated that, after adjustment for potentially confounding variables, African-American patients who underwent cholecystectomy in VA medical centers were 25% less likely to undergo a minimally invasive cholecystectomy during the first 4 years of use of the new procedure (adjusted odds ratio, 0.74; 95% confidence interval, 0.66–0.83). Shortening of the average postoperative length of stay from 9 days or more in the prelaparoscopic era to less than 4.5 days for patients undergoing the laparoscopic procedure occurred in the first year for Caucasian patients, but did not occur until the fourth year for African-American patients (p < 0.001). The overall difference in postoperative length of stay between African-American and Caucasian patients more than doubled from 1.7 days before introduction of laparoscopic cholecystectomy to 3.8 days in the fourth year. In comparison, analyses based on nurse-compiled clinical data indicated that, after adjustment for relevant clinical factors, racial variations in the rate of laparoscopic surgery were even larger (adjusted odds ratio for laparoscopic versus open cholecystectomy for African-American versus Caucasian veterans, 0.68; 95% confidence interval, 0.55–0.84).

Conclusions: Compared to Caucasian patients, African-American patients who underwent cholecystectomy in VA medical centers had an approximately 25% to 32% lower likelihood of undergoing minimally invasive cholecystectomy procedures. The differences in rates of adoption of laparoscopic surgery did not appear to be from more comorbid illnesses among African-American patients. African-American and Caucasian veterans may differ in their preference for new surgical procedures like laparoscopic cholecystectomy. Conversely, VA physicians may have been less likely to recommend laparoscopic cholecystectomies to African-American patients.     

Laparoscopic cholecystectomy in the elderly

Background Few studies have examined the results of laparoscopic cholecystectomy (LC) in the elderly. We reviewed our experience with the procedure in 194 patients age 65 and older. Methods A chart review was performed on patients who underwent attempted LC over a 4-year period. Age, conversion rate to open cholecystectomy (OC), length of stay, and morbidity and mortality rates were compared between elective and inpatients as well as between patients age 65–75 and patients over age 75. Results Conversion rate to OC was 10.6%. Mean length of hospital stay was 2.7 days. Morbidity and mortality rates were 18% and 1%. Elective patients experienced significantly fewer medical complications. There were no differences in complication rates between patients age 65–75 and patients over 75 years, but younger patients had a significantly shorter mean length of hospitalization. Conclusions Elderly patients experience more complications and longer lengths of stay than the general population. However, our results compare favorably with OC series in elderly patients. Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Orlando, Florida, USA, 11–14 March 1995     

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。     

胆囊切除术后创伤反应的前瞻性临床研究

目的 探讨ＬＣ、ＭＣ、ＣＣ对机体的创伤反应程度。方法 对择期胆囊切除的１５９例良性胆囊疾病者随机分组，ＬＣ５３列、ＭＣ５３例、ＣＣ５３例，全麻下手术，术关、术毕、术后第１日至３日每晨作白细胞计数、血糖、体温监测，记录切口长度，术中失血量，治愈。手术时间、失血量、切口长度、未毕血糖升高ＬＣ组小于ＭＣ组（Ｐ〈０．０１）、ＭＣ组小ＣＣ组（Ｐ〈０．０１），白细胞增加从术毕至术后３日ＬＣ组小于ＭＣ（Ｐ〉０．     

A financial analysis of laparoscopic and open cholecystectomy

Laparoscopic cholecystectomy (LC) is now the method of choice in treatment of symptomatic gallstone disease. Despite its rapidly growing popularity, comparative costs of this new method and open cholecystectomy (OC) remain unclear. The most outstanding feature of laparoscopic cholecystectomy is the period of short recovery. In Sweden the social insurance office documents sick leave period, sickness allowance, as well as diagnosis and therefore provides a reliable basis for an economic analysis. The purpose of this study was to estimate the hospital cost and costs due to sick leave in a series of patients operated on with elective cholecystectomy using the two methods. In each group 50 consecutive patients were studied retrospectively. The total hospital cost was 10% lower in the laparoscopy group—$1,864 as compared to $2,030 per patient in the OC group. Median number of days off work was 14 after LC and 35 days after open surgery, which corresponds to a median sickness allowance of $516 per patient (LC) compared to $1,424 (OC). Laparoscopic cholecystectomy is more cost-effective than open cholecystectomy mainly due to a reduced sick leave period.