胆源性SAP病人经皮经肝胆囊穿刺引流后腹腔镜胆囊切除的手术时机选择及中转开腹的影响因素分析

张太哲; 徐志鹏; 郑传明; 宋琦; 邵志林; 李磊; 邱兆磊; 王振杰

doi:10.13898/j.cnki.issn.2097-5252.2025.01.017

胆源性SAP病人经皮经肝胆囊穿刺引流后腹腔镜胆囊切除的手术时机选择及中转开腹的影响因素分析

Operative timing selection of laparoscopic cholecystectomy in patients with biliary SAP after percutaneous transhepatic gallbladder drainage and analysis of the influencing factors of conversion to laparotomy

摘要

摘要:
目的： 探讨胆源性重症急性胰腺炎（SAP）病人经皮经肝胆囊穿刺引流术（PTGD）后腹腔镜胆囊切除术（LC）的手术时机选择及中转开腹的影响因素。
方法： 回顾性收集132例胆源性SAP病人为研究对象。根据PTGD后病人行LC时间不同分为A组（1 ~ 2个月）、B组（2 ~ 3个月）和C组（＞3个月），各44例；并根据是否中转开腹分为中转开腹组28例和未中转开腹组104例。比较病人入院时基础资料及围手术期相关指标，分析A、B、C组病人LC术中及术后指标（手术时间、术中出血量、术后引流量、中转开腹、术后并发症、住院时间），分析病人LC中转开腹的影响因素（术前胆囊壁厚度、AP发作史、PTGD治疗时间）。
结果： A、B组病人引流管并发症发生率均低于C组（P ＜ 0.05）；B、C组胆囊壁厚度均小于A组（P ＜ 0.05）。3组病人LC术后并发症发生率差异无统计学意义（P ＞ 0.05）；B、C组病人手术时间、术中出血量、术后引流量及住院时间均少于A组（P ＜ 0.05），B组病人手术时间、住院时间亦均少于C组（P ＜ 0.05）；B组中转开腹率均小于A、C组（P ＜ 0.05）。中转开腹组和未中转开腹组病人在术前胆囊壁厚度、AP发作史和PTGD治疗时间方面差异均有统计学意义（P ＜ 0.05 ~ P ＜ 0.01）；logistic回归分析显示，术前胆囊壁厚度≥5 mm是中转开腹的独立危险因素（P ＜ 0.01），PTGD治疗2 ~ 3个月、AP发作史≤1次均为其独立保护因素（P ＜ 0.05）。
结论： 胆源性SAP病人PTGD治疗2 ~ 3个月后行LC安全性较好，术前胆囊壁厚度≥5 mm是LC中转开腹的危险因素，PTGD治疗2 ~ 3个月及AP发作史≤1次是中转开腹的保护因素。

Abstract:
Objective To explore the operative timing selection of laparoscopic cholecystectomy (LC) in patients with biliary severe acute pancreatitis (SAP) after percutaneous transhepatic gallbladder drainage (PTGD), and analyze the influencing factors of conversion to laparotomy.
Methods The clinical data of 132 patients with biliary SAP were retrospectively analyzed. According to the time of LC after PTGD, the patients were divided into the group A (1–2 months), group B (2–3 months) and group C (＞3 months) (44 cases in each group). The patients were divided into the conversion to laparotomy group (28 cases) and non-conversion to laparotomy group (104 cases) according to whether conversion to laparotomy. The basic data at admission and perioperative indexes were compared, and the intraoperative and postoperative indexes (operation time, intraoperative blood loss, postoperative drainage volume, conversion to laparotomy, postoperative complications and length of hospital stay) and influencing factors of conversion to laparotomy (preoperative gallbladder wall thickness, AP attack history and PTGD treatment time) in the three groups were analyzed.
Results The incidence rates of complications of drainage tube in group A and group B were lower than that in group C (P ＜ 0.05). The thickness of gallbladder wall in the group B and group C were lower than that in group A (P ＜ 0.05). There was no statistical significance in the incidence of complications after LC among 3 groups (P ＞ 0.05). The operative time, intraoperative blood loss, postoperative drainage volume and hospital stay in the group B and group C were lower than those in group A (P ＜ 0.05), and the operative time and hospital stay in the group B were also lower than those in group C (P ＜ 0.05). The conversion rate of laparotomy in the group B was lower than that in groups A and C (P ＜ 0.05). The differences of preoperative gallbladder wall thickness, AP history and PTGD treatment time between the conversion to laparotomy group and non-conversion to laparotomy group were statistically significant (P ＜ 0.05 to P ＜ 0.01). The results of logistic regression analysis showed that the preoperative gallbladder wall thickness ≥5 mm was an independent risk factor of conversion to laparotomy (P ＜ 0.01), and the PTGD treatment for 2–3 months and AP attack history ≤1 time were the independent protective factors (P ＜ 0.05).
Conclusions The safety of LC in patients with biliary SAP after 2–3 months of PTGD treatment is good. The preoperative gallbladder wall thickness ≥5 mm is a risk factor of LC conversion to laparotomy, and the PTGD treatment for 2–3 months and AP attack history ≤1 time are the protective factors of conversion to laparotomy.

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