Tokyo Guidelines 2013 may be too restrictive and patients with moderate and severe acute cholecystitis can be managed by early cholecystectomy too
Tokyo Guidelines 2013 may be too restrictive and patients with moderate and severe acute cholecystitis can be managed by early cholecystectomy too
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DOI：
10.1007/s00464-016-5300-4
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发表时间：
2017-07-01
影响因子：
3.1
通讯作者：
Shelat, Vishalkumar
中科院分区：
文献类型：
--
作者：
Amirthalingam, Vinoban;Low, Jee Keem;Shelat, Vishalkumar
目的本研究的目的是确定早期腹腔镜胆囊切除术（LC）是否是安全和可行的中度（2级）和重度（3级）急性胆囊炎（AC）患者诊断为根据东京指南2013（TG 13）。背景早期胆囊切除术是目前接受的护理标准为轻度（1级）和选定的2级AC患者的TG 13。方法对确诊时间超过14个月的急性胆囊炎患者进行回顾性分析，根据TG 13分级和严重程度指标将其分为3级。结果149例急性胆囊炎患者行急诊LC。82例（55%）患者为男性。84例（56.4%）患者被分类为1级AC，49例（32.9%）被分类为2级，16例（10.7%）被分类为3级。83例（98.8%）1级AC患者接受了急诊LC，1例（1.2%）患者接受了PC，随后接受了急诊LC。1级AC患者的中位住院时间为2（1-11）天。有2例（2.4%）因发热再次入院，无其他并发症。在65例2级或3级AC患者中，6例（9.2%）接受了PC，然后是紧急LC。急诊胆囊切除术9例（90.8%），其中LC 58例（98.3%），开腹胆囊切除术1例（1.7%）。58例LC患者中，3例（5.2%）患者中转开腹，10例（17.2%）患者需行次全胆囊切除术。1例因胆管损伤中转开腹，行肝管空肠吻合术。另外2名患者因粘连致密和无法安全分离Calot三角而转换。住院时间中位数为4（1-28）天。结论AC的严重程度分级不是早期LC的唯一决定因素。患者合并症也影响临床决策。需要在更大的队列中进行确认。
Objective The aim of this study was to determine whether early laparoscopic cholecystectomy (LC) is safe and feasible for patients diagnosed with moderate (grade 2) and severe (grade 3) acute cholecystitis (AC) according to the Tokyo Guidelines 2013 (TG13).Background Early cholecystectomy is the current accepted standard of care for patients with mild (grade 1) and selected grade 2 AC based on TG13. For selected grade 2 and grade 3 AC, early percutaneous cholecystostomy (PC) followed by delayed cholecystectomy is recommended.Methods Patients diagnosed with AC over a 14-month period were identified and divided into three grades of AC based upon chart review using the grading and severity indicators according to TG13.Results A total of 149 patients underwent emergency LC. Eighty-two (55 %) patients were male. Eighty-four (56.4 %) patients were classified as grade 1 AC, 49 (32.9 %) as grade 2, and 16 (10.7 %) as grade 3. Eighty-three (98.8 %) patients with grade 1 AC underwent emergency LC, and 1 patient (1.2 %) underwent PC followed by emergency LC. The median length of hospital stay for grade 1 AC patients was 2 (1-11) days. There were 2 (2.4 %) readmissions with fever and no additional complications. Among the 65 patients identified with grade 2 or 3 AC, 6 (9.2 %) underwent PC followed by emergency LC. nine (90.8 %) patients underwent emergency cholecystectomy: 58 (98.3 %) LC and one (1.7 %) open cholecystectomy. Among the 58 patients with LC, 3 (5.2 %) patients had open conversion and 10 (17.2 %) patients required subtotal cholecystectomy. One patient was converted to open due to bile duct injury and had hepaticoje-junostomy repair. Two other patients were converted due to dense adhesions and inability to safely dissect Calot's triangle. The median length of hospital stay was 4 (1-28) days. There was one readmission for ileus.Conclusion Severity grading of AC is not the sole determinant of early LC. Patient comorbidity also impacts clinical decision. Confirmation in a larger cohort is warranted.