腹腔镜手术治疗胆囊结石伴肝硬化的疗效观察
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摘要
目的探讨胆囊结石伴肝硬化患者行腹腔镜胆囊切除术(LC)的可行性及临床疗效。方法回顾性分析收治的105例胆囊结石伴肝硬化患者的临床资料。患者分成LC组(54例)和开腹胆囊切除术(OC)组(51例),比较并分析两组间的手术时间、术中出血量、术后住院时间、总费用、术后并发症,肝功能的术前术后变化等指标;统计术后并发症的发生率,分析其发生的相关危险因素。结果与OC组比较,LC组的手术时间[52.5(35~150)min vs 70(45~150)min]少、住院时间[(3.9±2.9)d vs(9.5±4.8)d]更短,术中出血量[50(20~280)ml vs 75(30~500)ml]更少,肝功能、肝功能Child-Pugh评分术前术后的变化更小,差异均有统计学意义(P<0.05)。术后并发症(11%vs18%)、肝功能Child-Pugh分级术前术后的改变,两组间差异无统计学意义(P>0.05)。肝功能ChildPugh分级、术前腹腔积液与胆囊结石伴肝硬化患者行胆囊切除术后并发症的发生有关(P<0.05),术前腹腔积液(OR=10.258,95%CI 1.364-77.146,P=0.024)是术后发生并发症的独立危险因素。结论胆囊结石伴肝硬化患者(肝功能Child-Pugh A、B级)行LC是安全可行的;与OC相比,其具有术中手术时间短、术中出血少、术后住院时间短、对肝功能影响小的优势;此类患者行胆囊切除术后并发症的出现与术前腹腔积液密切相关。
Objective To investigate the feasibility and benefits of laparoscopic cholecystectomy( LC) in cirrhotic patients with cholecystolithiasis. Methods The clinical data of 105 cases of cholecystolithiasis associated with liver cirrhosis were retrospectively analyzed. All patients were divided into laparoscopic cholecystectomy group( n = 54) and open cholecystectomy group( n = 51). The two groups were compared regarding operative time,blood loss,surgical complications,postoperative liver function,postoperative hospital stay and hospital costs. The incidence rate of the complications and the risk factors for the complications were also analyzed. Results As compared with open cholecystectomy group,the operative time [52. 5( 35-150) min vs 70( 45-150) min] and postoperative hospital stay [( 3. 9 ± 2. 9) days vs( 9. 5 ±4. 8) days] were shorter,blood loss was less [50( 20-280) ml vs 75( 30-500) ml],and the changes of liver function and Child-Pugh score were milder in laparoscopic cholecystectomy group. The differences were statistically significant( P < 0. 05). But the differences in postoperative complications and the change of ChildPugh class between two groups were not significant( P > 0. 05). According to the univariate analysis,the Child-Pugh class and preoperative ascites were risks factors for the postoperative complications( P < 0. 05).Further analysis using multiple logistic regression illustrated that preoperative ascites was independent risk factor for the postoperative complications( OR = 10. 258,95% CI 1. 364-77. 146,P = 0. 024). Conclusions Laparoscopic cholecystectomy is an effective and safe treatment for symptomatic gallstone disease in patients with Child-Pugh A and B cirrhosis. The advantages over open cholecystectomy are the shorter operative time and postoperative hospital stay,the less blood less and the milder effect on liver function. The occurrence of the complications for the cirrhotic patients with cholecystolithiasis undergoing cholecystectomy is closely associated with the preoperative ascites.
Objective To investigate the feasibility and benefits of laparoscopic cholecystectomy( LC) in cirrhotic patients with cholecystolithiasis. Methods The clinical data of 105 cases of cholecystolithiasis associated with liver cirrhosis were retrospectively analyzed. All patients were divided into laparoscopic cholecystectomy group( n = 54) and open cholecystectomy group( n = 51). The two groups were compared regarding operative time,blood loss,surgical complications,postoperative liver function,postoperative hospital stay and hospital costs. The incidence rate of the complications and the risk factors for the complications were also analyzed. Results As compared with open cholecystectomy group,the operative time [52. 5( 35-150) min vs 70( 45-150) min] and postoperative hospital stay [( 3. 9 ± 2. 9) days vs( 9. 5 ±4. 8) days] were shorter,blood loss was less [50( 20-280) ml vs 75( 30-500) ml],and the changes of liver function and Child-Pugh score were milder in laparoscopic cholecystectomy group. The differences were statistically significant( P < 0. 05). But the differences in postoperative complications and the change of ChildPugh class between two groups were not significant( P > 0. 05). According to the univariate analysis,the Child-Pugh class and preoperative ascites were risks factors for the postoperative complications( P < 0. 05).Further analysis using multiple logistic regression illustrated that preoperative ascites was independent risk factor for the postoperative complications( OR = 10. 258,95% CI 1. 364-77. 146,P = 0. 024). Conclusions Laparoscopic cholecystectomy is an effective and safe treatment for symptomatic gallstone disease in patients with Child-Pugh A and B cirrhosis. The advantages over open cholecystectomy are the shorter operative time and postoperative hospital stay,the less blood less and the milder effect on liver function. The occurrence of the complications for the cirrhotic patients with cholecystolithiasis undergoing cholecystectomy is closely associated with the preoperative ascites.
引文
1 Kim KO,Kim TN,Lee SH.Endoscopic papillary large balloon dilation for the treatment of recurrent bile duct stones in patients with prior sphincterotomy[J].J Gastroenterol,2010,45(12):1283-1288.
2 Debray D,Rainteau D,Barbu V,et al.Defects in gallbladder emptying and bile Acid homeostasis in mice with cystic fibrosis transmembrane conductance regulator deficiencies[J].Gastroenterology,2012,142(7):1581-1591.
3 王子晨,张宁,陈卫刚,等.肝硬化合并胆囊结石临床特点分析105 例[J].世界华人消化杂志,2015,23(8):1308-1313.
4 Morino M,Cavuoti G,Miglietta C,et al.Laparoscopic cholecystectomy in cirrhosis:contraindication or privileged in dication[J].Su rg Laparosc Endosc Percut an Tech,2000,10(6):360-363.
5 Nguyen KT,Kitisin K,Steel J,et al.Cirrhosis is not a contraindication to laparoscopic cholecystectomy:results and practical recommendations[J].HPB,2011,13(3):192-197.
6 Quillin RC,Burns JM,Pineda JA,et al.Laparoscopic cholecystectomy in the cirrhotic patient:predictors of outcome[J].Surgery,2013,153(5):634-640.
7 辛建,陶凯雄,夏泽锋,等.腹腔镜手术治疗合并肝硬化胆囊结石的临床分析[J].华中科技大学学报(医学版),2010,39(4):532-535.
8 冯龙,冯泽国,蔡守旺,等.控制性低中心静脉压技术在精准肝切除术中的应用[J].军医进修学院学报,2012,33(5):482-484.
9 Bessa SS,Abdel-Razek AH,Sharaan MA,et al.Laparoscopic cholecystectomy in cirrhotics:a prospective randomized study comparing the conventional diathermy and the harmonic scalpel for gallbladder dissection[J].Journal of Laparoendoscopic&Advanced Surgical Techniques,2011,21(1):1-5.
10 徐庆,顾磊,吴志勇.胆石症合并肝硬化门静脉高压症术中和术后出血的处理[J].中华肝胆外科杂志,2006,12(12):814-816.
11 Machado NO.Laparoscopic cholecystectomy in cirrhotics[J].JSLS:Journal of the Society of Laparoendoscopic Surgeons,2012,16(3):392-400.
12 Hamad MA,Thabet M,Badawy A,et al.Laparoscopic versus open cholecystectomy in patients with liver cirrhosis:a prospective,randomized study[J].J Laparoendosc Adv Surg Tech A,2010,20(5):405-409.
13 Shaikh AR,Muneer A.Laparoscopic cholecystectomy in cirrhotic patients[J].JSLS:Journal of the Society of Laparoendoscopic Surgeons,2009,13(4):592-596.
14 Leandros E,Albanopoulos K,Tsigris C,et al.Laparoscopic cholecystectomy in cirrhotic patients with symptomatic gallstone disease[J].ANZ J Surg,2008,78(5):363-365.
15 Palanivela C,Rajan PS,Jani K,et al.Laparoscopic cholecystectomy in cirrhotic patients:Role of subtotal cholecystectomy and its variants[J].J Am Coll Surg,2006,203(2):145-151.
16 Giger U,Ouaissi M,Schmitz SFH,et al.Bile duct injury and use of cholangiography during laparoscopic cholecystectomy[J].Br J Surg,2011,98(3):391-396.
17 倪怀坤.结石性萎缩性胆囊炎腔镜手术并发症分析[J/CD].中华腔镜外科杂志:电子版,2015,8(5):325-327.
18 Laurence JM,Tran PD,Richardson AJ,et al.Laparoscopic or open cholecystectomy in cirrhosis:a systematic review of outcomes and meta-analysis of randomized trials[J].HPB,2012,14(3):153-161.
19 Nguyen KT,Kitisin K,Steel J,et al.Cirrhosis is not a contraindication to laparoscopic cholecystectomy:results and practical recommendations[J].HPB,2011,13(3):192-197.
20 王小平,赖远辉,甄宇洋.胆囊切除术在肝硬化大量腹水合并症状性胆囊结石治疗中的作用[J].现代医院,2009,9(11):13-15.
21 Mancero JM,D'Albuquerque LA,Gonzalez AM,et al.Laparoscopic cholecystectomy in cirrhotic patients with symptomatic cholelithiasis:a case control study[J].World J Surg,2008,32(2):267-270.
2 Debray D,Rainteau D,Barbu V,et al.Defects in gallbladder emptying and bile Acid homeostasis in mice with cystic fibrosis transmembrane conductance regulator deficiencies[J].Gastroenterology,2012,142(7):1581-1591.
3 王子晨,张宁,陈卫刚,等.肝硬化合并胆囊结石临床特点分析105 例[J].世界华人消化杂志,2015,23(8):1308-1313.
4 Morino M,Cavuoti G,Miglietta C,et al.Laparoscopic cholecystectomy in cirrhosis:contraindication or privileged in dication[J].Su rg Laparosc Endosc Percut an Tech,2000,10(6):360-363.
5 Nguyen KT,Kitisin K,Steel J,et al.Cirrhosis is not a contraindication to laparoscopic cholecystectomy:results and practical recommendations[J].HPB,2011,13(3):192-197.
6 Quillin RC,Burns JM,Pineda JA,et al.Laparoscopic cholecystectomy in the cirrhotic patient:predictors of outcome[J].Surgery,2013,153(5):634-640.
7 辛建,陶凯雄,夏泽锋,等.腹腔镜手术治疗合并肝硬化胆囊结石的临床分析[J].华中科技大学学报(医学版),2010,39(4):532-535.
8 冯龙,冯泽国,蔡守旺,等.控制性低中心静脉压技术在精准肝切除术中的应用[J].军医进修学院学报,2012,33(5):482-484.
9 Bessa SS,Abdel-Razek AH,Sharaan MA,et al.Laparoscopic cholecystectomy in cirrhotics:a prospective randomized study comparing the conventional diathermy and the harmonic scalpel for gallbladder dissection[J].Journal of Laparoendoscopic&Advanced Surgical Techniques,2011,21(1):1-5.
10 徐庆,顾磊,吴志勇.胆石症合并肝硬化门静脉高压症术中和术后出血的处理[J].中华肝胆外科杂志,2006,12(12):814-816.
11 Machado NO.Laparoscopic cholecystectomy in cirrhotics[J].JSLS:Journal of the Society of Laparoendoscopic Surgeons,2012,16(3):392-400.
12 Hamad MA,Thabet M,Badawy A,et al.Laparoscopic versus open cholecystectomy in patients with liver cirrhosis:a prospective,randomized study[J].J Laparoendosc Adv Surg Tech A,2010,20(5):405-409.
13 Shaikh AR,Muneer A.Laparoscopic cholecystectomy in cirrhotic patients[J].JSLS:Journal of the Society of Laparoendoscopic Surgeons,2009,13(4):592-596.
14 Leandros E,Albanopoulos K,Tsigris C,et al.Laparoscopic cholecystectomy in cirrhotic patients with symptomatic gallstone disease[J].ANZ J Surg,2008,78(5):363-365.
15 Palanivela C,Rajan PS,Jani K,et al.Laparoscopic cholecystectomy in cirrhotic patients:Role of subtotal cholecystectomy and its variants[J].J Am Coll Surg,2006,203(2):145-151.
16 Giger U,Ouaissi M,Schmitz SFH,et al.Bile duct injury and use of cholangiography during laparoscopic cholecystectomy[J].Br J Surg,2011,98(3):391-396.
17 倪怀坤.结石性萎缩性胆囊炎腔镜手术并发症分析[J/CD].中华腔镜外科杂志:电子版,2015,8(5):325-327.
18 Laurence JM,Tran PD,Richardson AJ,et al.Laparoscopic or open cholecystectomy in cirrhosis:a systematic review of outcomes and meta-analysis of randomized trials[J].HPB,2012,14(3):153-161.
19 Nguyen KT,Kitisin K,Steel J,et al.Cirrhosis is not a contraindication to laparoscopic cholecystectomy:results and practical recommendations[J].HPB,2011,13(3):192-197.
20 王小平,赖远辉,甄宇洋.胆囊切除术在肝硬化大量腹水合并症状性胆囊结石治疗中的作用[J].现代医院,2009,9(11):13-15.
21 Mancero JM,D'Albuquerque LA,Gonzalez AM,et al.Laparoscopic cholecystectomy in cirrhotic patients with symptomatic cholelithiasis:a case control study[J].World J Surg,2008,32(2):267-270.