老年性急性胆囊炎伴胆总管结石的手术时机再探讨

发布时间：2018-09-07 20:03

【摘要】：目的：老年性急性胆囊炎伴胆总管结石急诊就诊的患者，传统认为常合并有心脑血管病、糖尿病及慢性呼吸系统疾病等内科疾病，建议采用保守治疗的方法。但是当保守治疗的疗效不理想时急诊手术，术后死亡率较高。本研究主要目的再次探讨老年患者急性胆囊炎伴胆总管结石行胆囊切除+胆总管探查取石T管引流术的最佳手术时机。方法：回顾2004年3月-2014年3月金州区第一人民医院普外科取123例60岁（含60岁）以上的老年急性胆囊炎伴胆总管结石患者开腹胆囊切除+胆总管切开取石T管引流手术治疗的临床资料进行回顾性分析。按患者自发病至手术的时间分为早期手术组（72小时内）、中期手术组（72小时至7天）、晚期手术组（7天以上）。分析比较3组手术并发症（胆瘘、切开感染、肺内感染、感染性休克）的发生率，手术时间、术后住院时间、总住院时间及术后病理（单纯性胆囊炎、化脓性胆囊炎、坏疽性胆囊炎和胆囊周围脓肿）的差别，来探讨研究最佳手术时机。结果：各组间并发症（胆瘘、切口感染、肺内感染、感染性休克）发生率比较差异无统计学意义（P0.05）。中期手术组的手术治疗时间高于早期手术组和晚期手术组（P0.05）。观察早期、中期、晚期患者术后住院时间及总住院时间逐渐增加，早期手术组术后住院天数4-23天，平均13.0天；中期手术组术后住院天数10-60天，，平均16.1天；晚期手术组术后住院天数15-62天，平均20.3天。早期手术组患者术后病理出现化脓性胆囊炎及坏疽性胆囊炎的比例较高（65.9%），中期组最高（90.5%），晚期组次之（65.5%）。结论： 1、病程72小时内尽早手术治疗。胆总管切开取石、T管引流术式为其首选。 2、病程超过72小时，合并心脑血管疾病，慢性阻塞性肺疾病等，如果胆总管梗阻不是很明显，身体其他情况允许的情况下，应尽量避免急诊手术；如果保守治疗效果不明显，建议行内窥镜十二指肠乳头切开取石(EST)或经皮肝穿刺胆管引流术（PTCD）解除胆道梗阻。 3、病程超过7天，经保守治疗有效，症状好转者，仍建议择期手术，原因（1）症状反复发作；（2）胆管恶变可能。
[Abstract]:Objective: patients with acute cholecystitis associated with choledocholithiasis in the emergency department were traditionally considered to have cardiovascular and cerebrovascular diseases, diabetes mellitus and chronic respiratory diseases, and conservative treatment was recommended. But when conservative treatment is not satisfactory, the postoperative mortality is higher. Objective to study the optimal time of cholecystectomy with choledocholithiasis for T tube drainage in elderly patients with acute cholecystitis and choledocholithiasis. Methods: from March 2004 to March 2014, 123 elderly patients with acute cholecystitis and choledocholithiasis with choledocholithiasis underwent cholecystectomy and choledocholithotomy with T-tube drainage were collected from the General surgery Department of the first people's Hospital of Jinzhou District. The clinical data of flow surgery were retrospectively analyzed. The patients were divided into early operation group (72 hours), middle operation group (72 hours to 7 days) and late operation group (more than 7 days) according to the time from onset to operation. The incidence of postoperative complications (biliary fistula, incision infection, intrapulmonary infection, septic shock), operative time, postoperative hospitalization time, total hospitalization time and postoperative pathology (simple cholecystitis, suppurative cholecystitis) were analyzed and compared among the three groups. The difference between gangrenous cholecystitis and perigallbladder abscess was used to explore the best operative time. Results: there was no significant difference in the incidence of complications (biliary fistula, incision infection, intrapulmonary infection, septic shock) among the groups (P0.05). The duration of operation in the intermediate operation group was higher than that in the early operation group and the late operation group (P 0.05). The postoperative hospitalization time and total hospitalization time of the early, middle and late stage patients were gradually increased. The postoperative hospitalization days of the early operation group were 4-23 days (mean 13.0 days), and that of the intermediate operation group was 10-60 days (average 16.1 days). The postoperative hospitalization days were 15-62 days (average 20.3 days) in the late operation group. The proportion of suppurative cholecystitis and gangrenous cholecystitis was higher in the early operation group (65.9%), the highest in the middle stage group (90.5%), and the second in the late stage group (65.5%). Conclusion: 1. The course of disease was treated as early as possible within 72 hours. Choledocholithotomy and T tube drainage is the first choice. 2. The course of disease is more than 72 hours, complicated with cardio-cerebrovascular disease, chronic obstructive pulmonary disease, etc. If the common bile duct obstruction is not obvious and other conditions of the body permit, Emergency operation should be avoided as far as possible, and if the effect of conservative treatment is not obvious, endoscopic duodenal papilla lithotomy with (EST) or percutaneous transhepatic bile duct drainage with (PTCD) should be used to relieve biliary obstruction. 3, the course of the disease is more than 7 days. If conservative treatment is effective and symptoms are improved, elective operation is recommended for (1) recurrence of symptoms and (2) possibility of malignant change of bile duct.
【学位授予单位】：大连医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R657.4

【参考文献】