经皮经肝穿刺胆囊引流术对不同ASA分级急性胆囊炎患者行腹腔镜胆囊切除术的影响
王金涛 张成 安东均 王羊 韩立 赵宝国 杨林
摘 要
目的：探讨经皮经肝穿刺胆囊引流术（PTGBD）对不同美国麻醉师协会（ASA）分级急性胆囊炎患者行腹腔镜胆囊切除术的影响。
方法：选取2010年3月～2014年12月在咸阳市中心医院住院治疗的324例接受腹腔镜胆囊切除术的急性胆囊炎患者为研究对象，根据患者腹腔镜胆囊切除术前有无PTGBD治疗史，将研究对象分为2组，其中单纯行腹腔镜胆囊切除术的184例患者为对照组，PTGBD+择期腹腔镜胆囊切除术的140例患者为实验组，观察2组的中转开腹率、总住院天数、胆囊切除术后住院天数、术后并发症和术后引流情况等。比较不同ASA分级下2组患者临床资料的差异。计量资料以（
±s）表示，组间比较使用t检验。计数资料比较使用x2检验。
结果：2组患者的术中中转开腹率、术后平均住院天数、并发症率及腹腔引流等无统计学差异（P＞0.05），但实验组患者的总住院天数显著高于对照组患者（P＜0.001）。根据ASA分级进行亚组分析，ASA-Ⅰ级的2组患者在体温、C反应蛋白及总的住院天数相比，实验组患者显著高于对照组患者，差异有统计学意义（P＜0.05）。ASA-Ⅱ级的2组患者在年龄、白细胞计数、C反应蛋白及总的住院天数相比，实验组患者明显高于对照组患者，差异有统计学意义（P＜0.05）。ASA-Ⅲ级的2组患者中，在中转开腹手术比例、术后天数、总住院天数及术后并发症，2组差异无统计学意义（P＞0.05）
结论：PTGBD对不同ASA分级急性胆囊炎患者行腹腔镜胆囊切除术的影响不同；PTGBD术后择期行腹腔镜胆囊切除术是一种安全、有效地把急诊胆囊手术变成择期胆囊手术的方法，值得广泛运用。
关键词
胆囊炎，急性；经皮经肝穿刺胆囊引流术；腹腔镜胆囊切除术
Percutaneous transhepatic gallbladder drainage for different ASA grading of laparoscopic cholecystectomy in patients with acute cholecystitis
Wang Jintao，Zhang Cheng，An Dongjun，Wang Yang，Han Li，Zhao Baoguo，Yang Lin.Department of Hepatobiliary Surgery，Xianyang Central Hospital，Xianyang712000，China Corresponding author:Yang Lin，Email:Doctor0523@163.comm
ABSTRACT
Objective:To investigate the effect of percutaneous transhepatic gallbladder drainage（PTGBD）on different ASA grading of laparoscopic cholecystectomy in patients with acute cholecystitis.
Methods:The 324 patients with acute cholecystitis undergoing laparoscopic cholecystectomy who were hospitalized in our hospital from March 2010 to December 2014 were enrolled.According to the history of the patients with or without PTGBD before laparoscopic cholecystectomy，all patients were divided into 2 groups.184 patients who underwent directly laparoscopic cholecystectomy were the control group，and the other 140 patients who underwent PTGBD+elective laparoscopic cholecystectomy were the study group.The rates of conversion to laparotomy，total days of hospitalization，hospitalization days after cholecystectomy，postoperative complications，postoperative drainage were compared between two groups.The difference of clinical data between the two groups were compared under different ASA classification，Measurement data were expressed as（
±s）and t-tests were used for comparison between groups.Count data were compared using the x2 test.
Results:In the two groups，there was no significant difference in the rate of conversion，the average days after the operation，the rate of postoperative complications and the abdominal drainage（P＞0.05），but the total hospitalization days of the patients in the experimental group were significantly higher than those in the control group（P＜0.001）.According to the subgroup analysis by ASA classification，the two groups of ASA-Ⅰ patients in the experimental group were significantly higher than the control group in the temperature，C reactive protein and the total number of days of hospitalization，and the difference was statistically significant（P＜0.05）.The two groups of ASA-Ⅱ patients in the experimental group were significantly higher than those of the control group in age，white blood cell count，C reactive protein and total hospitalization days，and the difference was statistically significant（P＜0.05）.Among the two groups of ASA-Ⅲ patients，there was no statistically significant difference between the two groups（P＞0.05）in the proportion of transabdominal surgery，postoperative days，total days of hospitalization，and postoperative complications.
Conclusion:①PTGBD has different effects on laparoscopic cholecystectomy in patients with different ASA grade acute cholecystitis；② PTGBD combined with LC is a safe and effective method that can turn emergent operation into selective operation.It is worthy of extensive application.
KEY WORDS
Cholecystitis，acute；Percutaneous transhepatic gallbladder drainage；Laparoscopic cholecystectomy
急性胆囊炎是老年人常见的外科急腹症，腹腔镜胆囊切除术是治疗早期急性胆囊炎的主要手术方法［1］。但是，急性胆囊炎患者若伴有胆囊穿孔、胆囊坏疽等症状则不能实施腹腔镜胆囊切除术，而且该手术较为费力、费时，不仅极易引起并发症，而且容易提高中转开腹手术的概率［2］。对于有严重并发症的需要外科干预的急性胆囊炎患者，经皮经肝穿刺胆囊引流术（Percutaneous transhepatic gallbladder drainage，PTGBD）被认为是一种相对安全的治疗方法［3］。当前，PTGBD是一些年老危重患者首选的安全有效的治疗方法，在胆囊切除术前可以有效地改善患者的病情［4］。行腹腔镜胆囊切除术麻醉前需根据患者体质状况和手术危险性进行分级，美国麻醉师协会（American society of anesthesiologists，ASA）分级是常用方法，该方法明确了患者重要器官、系统功能以及对麻醉和手术的耐受性。然而，不同ASA分级患者中应用PTGBD的研究报道缺乏。本研究主要探究了PTGBD后择期行经腹腔镜手术的不同ASA分级急性胆囊炎患者的临床疗效。