A Retrospective Study Of The Optimal Timing Of Laparoscopic Cholecystectomy After Percutaneous Transhepatic Gallbladder Drainage For Acute Cholecystitis

Background Acute cholecystitis(AC)is an inflammation of gallbladder caused by obstruction of cystic duct or bacterial infection.According to the Tokyo Guideline 2013(TG13),it can be divided into Grade I,Grade II and Grade III based on the symptoms,laboratory tests,and image findings.Laparoscopic cholecystectomy(LC)has become one of the standard operations for treatment of AC,which has even been the first-line operation for mild acute cholecystitis.However,LC could be difficult for patients with severe inflammation because of long operation time,intraoperative blood loss,high rate of conversion to open surgery,bile leakage or bile duct injury.With the rapid development of medical technology,ultrasound guided percutaneous transhepatic gallbladder drainage(PTGBD),which is a minimally invasive but effective treatment method,has gradually replaced the traditional operations.TG13 has pointed out that it can be direct LC or PTGBD followed by elective LC for moderate acute cholecystitis,while for severe acute cholecystitis,they recommend PTGBD and scheduled LC.However,the interval between PTGBD and LC has not already been mentioned.There is still no consensus on this topic.Therefore,the aim of this study isObjective To investigate the optimal timing of laparoscopic cholecystectomy after PTGBD for acute cholecystitis.Methods 150 cases were retrospectively analyzed at the First Affiliated Hospital of Dalian Medical University from January 1,2014 to April 1,2017.They all suffered from moderate or severe acute cholecystitis,and were treated by PTGBD and elective LC.At last,122 patients were enrolled in our study.We searched from the medical records and collected the clinical data of 122 cases.The general information includes hospitalization ID,gender,age,diabetes,hypertention and gallbladder stones.Clinical symptoms include abdominal pain,nausea,vomiting,fever,jaundice and Murphy’s sign.Laboratory tests include white blood cell count(WBC),prothrombin time(PT),activated partial thromboplastin time(APTT),international standardization ratio(INR),aspertate aminotransferase(AST),alanine aminotransferase(ALT),alkaline phosphatase(ALP)and γ transpeptidase(γ-GT)and total bilirubin(TB).The surgical details include operation time,intraoperative blood loss,conversion to open surgery and postoperative hospital stay.The 122 cases were divided into four groups according to the interval between PTGBD and LC,30d≤A<45d,45d≤B<60d,60d≤C<75d,75d≤D<180d.SPSS23.0 statistical software was used to process all of these data.The single factor analysis of variance was used to process normal distribution data and nonparametric test was used to analyze non-normal distribution data.Set the inspection standards of α=0.05,and we recommend that P<0.05 has statistical significance.We analyzed whether there was statistically significant difference among the four groups in operation time,intraoperative blood loss,converstion to open surgery or postoperative hospital stay.Results 122 cases were admitted into our study,including 66 males and 56 females,with a gender ratio of 1.18.Their mean age was(66.8 ± 13.3)years old,with the minimum was 30 years old,and the maximum was 90 years old.There were 24 cases of diabetes mellitus,58 cases of hypertension,79 cases of gallbladder stone,and 25 cases of abdominal surgery.A total of 12 cases were transferred to open surgery,with a conversion rate of 9.8%,including 9 cases of severe adhesion,1 case of biliary tract injury and 2 cases of intraoperative hemorrhage.Intervals between the PTGBD and LC ranged from 30 to 180 days,with an average of(70.3±34.0)days.The remission rate of symptoms such as abdominal pain was 54.5% within 24 hours and 88.6% within 48 hours.The number of cases in group A,group B,group C,group D were respectively29(23.8%),29(23.8%),26(21.3%)and 38(31.1%).There was no statistically significant difference in age,sex,combined diseases,laboratory tests or surgeons among the four groups(P>0.05).Further statistically analysis showed that there was no statistical significance in operation time,intraoperative blood loss,postoperative hospital stay and conversion to open surgery among the four groups(P > 0.05).Conclusion1.PTGBD is an effective treatment for moderate-severe acute cholecystitis and can quickly relieve the clinical symptoms.2.Compared with 30 to 45 days,the scheduled LC after PTGBD does not shorten the operation time or postoperative hospital days,does not reduce intraoperative blood loss or conversion to open surgery when the interval is 45 days or longer.