急性胆囊炎经皮经肝胆囊穿刺引流术后择期腔镜胆囊切除术最佳时间的选择

Selection for optimal timing of elective laparoscopic cholecystectomy following percutaneous transhepatic gallbladder drainage for acute cholecystitis

摘要:

背景与目的 经皮经肝胆囊穿刺引流术（PTGD）联合择期腔镜胆囊切除术（LC）是治疗急性胆囊炎（AC）常用方法，临床工作中发现，PTGD与LC之间的时间间隔（PTGD-LC间隔）会影响LC手术操作难易程度，但对于两者的最佳时间间隔尚无定论。因此，本研究探讨AC患者急诊行PTGD术后行择期LC的最佳时机，为临床提供参考。方法 收集中国医科大学附属盛京医院2013—2019年间先行PTGD后择期行LC的AC患者的临床资料，根据LC手术难度将患者分为非困难组和困难组，比较两组患者PTGD-LC间隔及其他相关临床因素的差异；绘制PTGD-LC间隔预测困难LC的ROC曲线并得出临界值，绘制以PTGD-LC间隔为自变量，困难LC比例为应变量的拟合曲线分析PTGD-LC间隔与LC难度的关系。结果 共纳入98例患者，其中非困难组56例，困难组42例，非困难组的PTGD-LC间隔明显长于困难组（69.0 d vs. 39.5 d，P=0.043）；非困难组的手术时间明显短于困难组、转氨酶水平明显低于困难组（均P<0.05）。PTGD-LC间隔预测手术难度的ROC曲线的AUC=0.6，临界值为40.5 d，当PTGD-LC间隔>40.5 d时，困难LC例数明显降低（30.8% vs. 66.7%，P=0.001）；胆囊周围粘连严重的比例、术后住院时间减少（均P<0.05）。拟合曲线分析显示，在PTGD-LC间隔15.1 d时手术治疗困难LC比例最高，随后逐渐降低，PTGD-LC间隔61.7 d时手术的困难LC比例最低，随后困难LC比例又有所上升。结论 PTGD-LC间隔与择期LC手术的难度密切相关，将手术难度与患者生活质量综合考虑，PTGD后择期行LC的最佳时间间隔的范围在40.5~61.7 d。

Abstract:

Background and Aims Percutaneous transhepatic gallbladder drainage (PTGD) followed by elective laparoscopic cholecystectomy (LC) is a commonly used modality for the treatment of acute cholecystitis (AC). It is found in clinical practice that the time interval between PTGD and LC (PTGD-LC interval) would affect the degree of difficulty in performing LC, but the optimal time interval between the two procedures is still an unresolved question. Therefore, this study was performed to investigate the optimal timing of LC after emergency PTGD for AC patients, so as to provide guidance for clinical practice.Methods The clinical data of AC patients undergoing PTGD followed by elective LC in Shengjing Hospital of China Medical University from 2013 to 2019 were collected. According to the degree of difficulty of LC, the patients were classified into non-difficult group and difficult group, and the differences in PTGD-LC interval and other clinical variables between the two groups were compared. The ROC curve for PTGD-LC interval predicting difficult LC was drawn to obtain the cut-off value, and the fitted curve analysis with the PTGD-LC interval as independent variable and the proportion of cases of difficult LC as dependent variable was created to analyze the relationship between PTGD-LC interval and the difficulty of LC.Results A total of 98 patients were enrolled, with 56 cases in non-difficult group and 42 cases in difficult group. The PTGD-LC interval in non-difficult group was significantly longer than that in difficult group (69.0 d vs. 39.5 d, P=0.043), and in addition, the operative time for LC was significantly shorter and the aminotransferase levels were significantly lower in non-difficult group than those in difficult group (all P<0.05). The AUC of the ROC curve for PTGD-LC interval predicting difficult LC was 0.6, and the cut-off value was 40.5 d. The proportion of cases of difficult LC was significantly decreased when the interval was more than 40.5 d (30.8% vs. 66.7%, P=0.001), and meanwhile, the proportion of cases with severe pericholecystic adhesions and length of postoperative hospital stay were significantly reduced (both P<0.05). The fitted curve analysis showed that the proportion of cases of difficult LC reached the highest level at 15.1 d of PTGD-LC interval, followed by a continuous decrease, and then reached the lowest level at 61.7 d of PTGD-LC interval, followed by an increasing trend in later period.Conclusion The PTGD-LC interval is closely associated with the degree of difficulty of the elective LC. Taking both surgical difficulty and patients' quality of life into account, the optimal time interval of the elective LC after PTGD ranges from 40.5 to 61.7 d.