背景:急性胆囊炎(AC)的早期腹腔镜胆囊切除术(ELC)提出了多重挑战。2018年东京指南(TG18)取消了时间限制(<72h),并将手术指征扩大到严重AC。本研究旨在评估在单个高容量中心的TG18后ELC对AC的临床结果。
方法:从2019年到2021年,我们用TG18流程图管理所有AC患者,并前瞻性招募在症状发作后7天内接受ELC的患者。主要结果是总体发病率,与轻度(I级)和中度/重度(II级/III级)AC之间的比较。
结果:在研究期间,201例患者行ELC为I级(56.2%),II(40.3%),和III(3.5%)AC。平均年龄为69±15.2岁,从症状发作到手术的时间为0(12.9%),1-3(66.7%),和4-7天(20.4%)。平均手术时间和出血量分别为118.9±42.7min和57.8±99.4mL,分别。76.1%的患者获得了严格的安全观(CVS),接受救助程序的比例为21.4%。没有开放转换或胆管损伤。在5.5%的病例中观察到重大发病率(Clavien-Dindo分类≥IIIa),死亡率为0.5%。将II/III级与I级进行比较,手术时间较长(112.3vs.127.3分钟,p=0.014),失血量较高(40.3vs.80.1毫升,p=0.005),CVS率较低(83.2vs.67.0%,p=0.012),主要发病率较高(1.8vs.10.2%,p=0.012)。在II/III级的亚组分析中,两组之间的主要发病率没有显着差异(p=0.288)(0-3vs.4-7天)。
结论:ELC治疗TG18后AC是可行的,发病率低。然而,II/III级AC的ELC仍然具有挑战性,手术前,外科医生必须仔细评估术中困难和手术风险。
Early laparoscopic cholecystectomy (ELC) for acute cholecystitis (AC) poses multiple challenges. The
Tokyo Guidelines 2018 (TG18) eliminated the time limit (< 72 h) and expanded the surgical indication to severe AC. This study aimed to evaluate the clinical outcomes of ELC for AC following the TG18 in a single high-volume center.
From 2019 to 2021, we managed all AC patients with a TG18 flowchart and prospectively enrolled those who underwent ELC within 7 days of symptom onset. The primary outcome was overall morbidity, with a comparison between mild (Grade I) and moderate/severe (Grade II/III) AC.
During the study period, 201 patients underwent ELC was for Grade I (56.2%), II (40.3%), and III (3.5%) ACs. Mean age was 69 ± 15.2 years and time to surgery from symptom onset was 0 (12.9%), 1-3 (66.7%), and 4-7 days (20.4%). Mean operative time and blood loss were 118.9 ± 42.7 min and 57.8 ± 99.4 mL, respectively. The critical view of safety (CVS) was achieved in 76.1% of patients, and bailout procedures were performed in 21.4%. There were no open conversions or bile duct injuries. Major morbidities (Clavien-Dindo classification ≥ IIIa) were observed in 5.5% of cases and mortality in 0.5%. Comparing Grades II/III to Grade I, operative time was longer (112.3 vs. 127.3 min, p = 0.014), blood loss was higher (40.3 vs. 80.1 mL, p = 0.005), the CVS rate was lower (83.2 vs. 67.0%, p = 0.012), and the major morbidity rate was higher (1.8 vs. 10.2%, p = 0.012). In the subgroup analysis of Grade II/III, there were no significant differences in major morbidities (p = 0.288) between the two groups (0-3 vs. 4-7 days).
ELC for AC following TG18 is feasible with low morbidity rates. However, ELC for Grade II/III ACs remains challenging, and surgeons must carefully assess intraoperative difficulties and surgical risks before proceeding.