李嘉
[摘要] 目的 探討分析急性結(jié)石梗阻性膽囊炎患者行經(jīng)皮膽囊穿刺引流聯(lián)合腹腔鏡膽囊切除術(shù)的治療效果。 方法 選取該院自2011年12月—2013年1月期間,住院部收治的急性結(jié)石梗阻性膽囊炎患者共計(jì)50例作為研究對(duì)象,按照計(jì)算機(jī)隨機(jī)方法分組為對(duì)照組,研究組,每組患者各計(jì)25例。對(duì)照組患者直接給予腹腔鏡膽囊切除術(shù)進(jìn)行治療,研究組患者在行經(jīng)皮膽囊穿刺引流術(shù)后再給予腹腔鏡膽囊切除術(shù)進(jìn)行治療。對(duì)兩組患者的腹腔鏡手術(shù)成功率、平均住院時(shí)間、術(shù)后并發(fā)癥發(fā)生率進(jìn)行綜合對(duì)比與分析。 結(jié)果 對(duì)照組25例患者中,20例患者腹腔鏡手術(shù)取得成功,手術(shù)成功率為80.00%,研究組25例患者中,25例患者腹腔鏡手術(shù)取得成功,手術(shù)成功率為100.00%,研究組腹腔鏡手術(shù)成功率明顯高于對(duì)照組;研究組患者住院時(shí)間明顯短于對(duì)照組;研究組患者平均術(shù)中出血量明顯低于對(duì)照組;研究組術(shù)后并發(fā)癥發(fā)生率明顯低于對(duì)照組;以上數(shù)據(jù)對(duì)比存差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。 結(jié)論 急性結(jié)石梗阻性膽囊炎患者應(yīng)用經(jīng)皮膽囊穿刺引流聯(lián)合腹腔鏡膽囊切除術(shù)進(jìn)行干預(yù)具有安全、有效的優(yōu)勢(shì),可早期控制膽道炎癥,降低膽道壓力,提高腹腔鏡手術(shù)的成功率、降低術(shù)后并發(fā)癥發(fā)生率,提高患者預(yù)后水平,值得臨床應(yīng)用。
[關(guān)鍵詞] 經(jīng)皮膽囊穿刺引流;腹腔鏡膽囊切除術(shù);急性結(jié)石梗阻性膽囊炎
[中圖分類號(hào)] R657.4 [文獻(xiàn)標(biāo)識(shí)碼] A [文章編號(hào)] 1674-0742(2014)05(a)-0030-02
[Abstract] Objective To investigate the treatment effect of percutaneous drainage of gallbladder combined with laparoscopic cholecystectomy in the treatment of acute calculous obstructive cholecystitis. Methods 50 cases of patients with acute calculous obstructive cholecystitis admitted in our hospital from December, 2011 to January, 2013 were selected as the subjects, and they were divided into the control group and the study group according to the computer random method with 25 cases in each. Patients in the control group were given laparoscopic cholecystectomy, and patients in the study group were given laparoscopic cholecystectomy after percutaneous drainage of gallbladder. The success rate of laparoscopic operation, the average length of stay, the incidence of postoperative complications of two groups were compared and analyzed. Results Of the 25 patients in the control group, the laparoscopic operation of 20 patients were successful, the success rate of operation was 80%. Of the 25 patients in the study group, the laparoscopic operation of the 25 patients were successful, the success rate of operation was 100.00%. The laparoscopic operation success rate of the study group was significantly higher than that of the control group; the hospitalization time was much shorter than that of the control group; the average amount of bleeding during operation of the study group was significantly less than that of the control group; the incidence of postoperative complications was obviously lower than that of the control group; there were statistically significant differences in the above data(P<0.05). Conclusion Percutaneous drainage of gallbladder combined with laparoscopic cholecystectomy for acute calculous obstructive cholecystitis has the advantages of safety and effectiveness, which can control the inflammation of biliary tract, reduce the biliary tract pressure, improve the success rate of laparoscopic cholecystectomy, reduce the incidence of postoperative complications and improve the prognosis, and is worthy of clinical application.
[Key words] Percutaneous drainage of gallbladder; Laparoscopic cholecystectomy; Acute calculous obstructive cholecystiti
為進(jìn)一步研究經(jīng)皮膽囊穿刺引流聯(lián)合腹腔鏡膽囊切除術(shù)對(duì)于急性結(jié)石梗阻性膽囊炎患者的治療效果,該研究以該院2011年12月—2013年1月間所收治的50例急性結(jié)石梗阻性膽囊炎患者為研究對(duì)象,其中25例行經(jīng)皮膽囊穿刺引流聯(lián)合腹腔鏡膽囊切除術(shù),取得了確切的治療效果,現(xiàn)報(bào)道如下。
1 資料與方法
1.1 一般資料
選取該院自住院部收治的急性結(jié)石梗阻性膽囊炎患者共計(jì)50例作為研究對(duì)象。50例患者中,男21例,女29例。患者年齡在52~75周歲范圍之內(nèi),平均年齡為(62.5±3.1)歲?;颊甙l(fā)病時(shí)間在1~7 d范圍之內(nèi),平均發(fā)病時(shí)間為(2.8±0.3) d?;颊吲R床指征為:患者右上腹痛、嘔吐;溫度>38.0 ℃,有右上腹壓痛、反跳痛、Murphy征陽(yáng)性,白細(xì)胞計(jì)數(shù)>15.0×109/L。入院后即予補(bǔ)液、抗感染等治療。按照計(jì)算機(jī)隨機(jī)方法分組為對(duì)照組,研究組,每組患者各計(jì)25例。研究組中男11例,女14例,平均年齡為(61.8±2.7)歲,平均發(fā)病時(shí)間為(2.5±0.2) d;對(duì)照組中男性共計(jì)10例,女性共計(jì)15例,平均年齡為(63.7±2.4)歲,平均發(fā)病時(shí)間為(2.9±0.4) d。
1.2 方法
1.2.1 對(duì)照組 急診行腹腔鏡膽囊切除術(shù)治療。術(shù)中應(yīng)用三孔或四孔法操作。根據(jù)患者手術(shù)情況,7例患者因有膽漏風(fēng)險(xiǎn)術(shù)中放置引流管引流。
1.2.2 研究組 患者急診行經(jīng)皮膽囊穿刺引流術(shù)。術(shù)前使用濃度為1.0%利多卡因麻醉藥給予局部麻醉處理,以18G穿刺針,經(jīng)皮穿入膽囊,置入導(dǎo)絲并擴(kuò)張針道,后將引流管置入膽囊內(nèi),超聲監(jiān)測(cè)狀態(tài)下輔助對(duì)引流管長(zhǎng)度調(diào)整,抽取膽汁,接無(wú)菌引流袋引流。術(shù)后3~4 h后患者腹痛明顯緩解,對(duì)患者進(jìn)行動(dòng)態(tài)B超監(jiān)測(cè),48 h后復(fù)查B超顯示膽囊水腫均減退,結(jié)石出現(xiàn)松動(dòng)現(xiàn)象后,行腹腔鏡膽囊切除術(shù)治療。術(shù)中應(yīng)用三孔或四孔法操作。術(shù)中可見(jiàn)炎性水腫程度比對(duì)照組減輕,根據(jù)患者手術(shù)情況,2例患者因有膽漏風(fēng)險(xiǎn)術(shù)中放置引流管引流。
1.3 統(tǒng)計(jì)方法
該研究數(shù)據(jù)使用SPSS 17.0軟件進(jìn)行分析與計(jì)算,計(jì)量資料以均數(shù)±標(biāo)準(zhǔn)差(x±s)表示,以t檢驗(yàn);計(jì)數(shù)資料以%表示,以χ2檢驗(yàn)。
2 結(jié)果
對(duì)照組25例患者中,20例患者腹腔鏡手術(shù)取得成功,手術(shù)成功率為80.00%,另有5例患者因腹腔鏡下術(shù)野炎癥水腫嚴(yán)重,結(jié)構(gòu)不清,改為中轉(zhuǎn)開(kāi)腹后仍難以完整切除膽囊,予行膽囊部分切除術(shù)。研究組25例患者中,25例患者腹腔鏡手術(shù)取得成功,手術(shù)成功率為100.00%,研究組腹腔鏡手術(shù)成功率明顯高于對(duì)照組;對(duì)照組患者平均住院時(shí)間為(8.6±0.7)d,研究組患者平均住院時(shí)間為(5.2±0.3)d,研究組患者住院時(shí)間明顯短于對(duì)照組;對(duì)照組患者平均術(shù)中出血量為(68.6±7.2)mL,研究組患者平均術(shù)中出血量為(16.2±3.9)mL,研究組患者平均術(shù)中出血量明顯低于對(duì)照組;研究組患者術(shù)后未出現(xiàn)手術(shù)并發(fā)癥,并發(fā)癥發(fā)生率為0.00%(0/25),術(shù)中留置引流管者予術(shù)后48 h后拔除。對(duì)照組出現(xiàn)膽漏,為12.00%(3/25),研究組術(shù)后并發(fā)癥發(fā)生率明顯低于對(duì)照組;膽漏在術(shù)后12~24 h后出現(xiàn),量約6~10 mL/d,經(jīng)術(shù)中留置的腹腔引流管引出體外,患者未出現(xiàn)全身腹膜炎表現(xiàn),均經(jīng)保持腹腔管引流通暢及加強(qiáng)靜脈營(yíng)養(yǎng)支持4~5 d后膽漏停止,膽漏停止后再觀察48 h未見(jiàn)異常后拔除引流管。對(duì)照組膽漏病例其中2例為中轉(zhuǎn)開(kāi)腹手術(shù),另1例為腹腔鏡下手術(shù),膽漏原因考慮為膽囊殘端炎性水腫,結(jié)扎線孔膽漏。以上數(shù)據(jù)對(duì)比存差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。見(jiàn)表1、2、3。
3 討論
對(duì)于急性結(jié)石梗阻性膽囊炎患者而言,由于炎癥嚴(yán)重,往往導(dǎo)致患者膽囊以及肝門(mén)部位并發(fā)極為嚴(yán)重的黏連以及水腫問(wèn)題[1-3],此時(shí)無(wú)論是以腹腔鏡方式還是以開(kāi)腹方式行膽囊切除,都潛在大量的危險(xiǎn)性因素[4]。因此,爭(zhēng)取時(shí)間控制膽道炎癥、膽道壓力,避免病情的發(fā)展[5]。而經(jīng)皮膽囊穿刺引流被證實(shí)具有良好的膽道減壓效果。該分析過(guò)程當(dāng)中認(rèn)識(shí)到以下幾個(gè)方面的問(wèn)題:首先,針對(duì)急性結(jié)石梗阻性膽囊炎患者而言,給予經(jīng)皮膽囊穿刺引流治療能夠避免急診腹腔鏡切除術(shù)潛在的安全性隱患,結(jié)合抗感染等基礎(chǔ)治療,能夠使患者膽囊部位的炎癥癥狀得到及時(shí)的控制,將無(wú)法耐受急診腹腔鏡膽囊切除術(shù)治療的患者轉(zhuǎn)變?yōu)檫m應(yīng)癥患者[6];其次,經(jīng)皮膽囊穿刺引流手術(shù)無(wú)需全身麻醉,局部麻醉即可?;颊呤中g(shù)創(chuàng)傷較小,手術(shù)操作簡(jiǎn)便,并發(fā)癥發(fā)生率低。該次研究中,研究組25例患者術(shù)后無(wú)一例患者發(fā)生并發(fā)癥,而對(duì)照組患者并發(fā)癥發(fā)生率為12.00%,數(shù)據(jù)對(duì)比差異有統(tǒng)計(jì)學(xué)意義(P<0.05),證實(shí)經(jīng)皮膽囊穿刺引流聯(lián)合腹腔鏡膽囊切除對(duì)降低并發(fā)癥的確切效果。但需要特別注意在穿刺過(guò)程當(dāng)中,所選擇的穿刺點(diǎn)能夠避開(kāi)肝內(nèi)血管;最后,在患者行腹腔鏡膽囊切除術(shù)治療的過(guò)程當(dāng)中,由于炎癥尚未完全消除,因而導(dǎo)致術(shù)中對(duì)于Calot三角的解剖存在一定難度,因此,需要避免過(guò)分游離并顯露肝外膽管。同時(shí),離斷膽囊管也需要在對(duì)頸部以及膽囊管連接變細(xì)位置加以確認(rèn)的基礎(chǔ)之上實(shí)施,以確?;颊吣懩仪谐g(shù)的成功率[7-8],在特別關(guān)注對(duì)以上措施實(shí)施條件下,確保了實(shí)施腹腔鏡膽囊切除患者的手術(shù)成功率,該次研究中數(shù)據(jù)顯示:研究組25例患者中,25例患者腹腔鏡手術(shù)取得成功,手術(shù)成功率為100.00%,明顯高于對(duì)照組。數(shù)據(jù)對(duì)比差異有統(tǒng)計(jì)學(xué)意義(P<0.05),故而認(rèn)為在手術(shù)實(shí)施中,針對(duì)出現(xiàn)Calot三角解剖高難度的患者,遵循以上操作方法對(duì)于提高手術(shù)成功率有確切價(jià)值。。
綜上所述,急性結(jié)石梗阻性膽囊炎患者應(yīng)用經(jīng)皮膽囊穿刺引流聯(lián)合腹腔鏡膽囊切除術(shù)進(jìn)行干預(yù)具有安全、有效的優(yōu)勢(shì),可早期控制膽道炎癥,降低膽道壓力,提高腹腔鏡手術(shù)的成功率、降低術(shù)后并發(fā)癥發(fā)生率,提高患者預(yù)后水平,值得臨床應(yīng)用。
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(收稿日期:2014-01-20)