Analysis Of The Effectiveness And Safety Of PTGBD Cholangiography Before The Operation Of Acute Cholecystitis

Background:Acute cholecystitis is usually caused by gallbladder stones blocking the cystic duct,followed by cholestasis that causes the gallbladder to swell and secondary chemical or bacterial inflammation.Patients with acute cholecystitis usually have persistent right upper quadrant abdominal pain,and symptoms of digestive tract,such as anorexia,nausea or vomiting.Some patients can have fever.Severe acute cholecystitis can lead to necrosis or perforation of the gallbladder wall,known as gangrenous cholecystitis.Laparoscopic cholecystectomy(LC)is the standard treatment for acute cholecystitis.Compared with open cholecystectomy(OC),LC is associated with lower complication rates and shorter postoperative hospital stay.The Tokyo guidelines(2007)(TG07)was the first internationally published and widely recognized and used guideline for the management of acute cholecystitis,with two revisions in 2013(TG13)and 2018(TG18).TG18 stated that the diagnostic criteria for acute cholecystitis should include clinical symptoms,physical examination,laboratory examination and data of medical imaging,and that acute cholecystitis should be classified into three grades according to the severity,including mild(grade I),moderate(grade Ⅱ)and severe(grade Ⅲ)acute cholecystitis.TG18 also recommended appropriate treatment options based on the grade of acute cholecystitis.Patients with grade Ⅰ acute cholecystitis may undergo immediate laparoscopic cholecystectomy.Patients with grade Ⅱ acute cholecystitis may undergo laparoscopic cholecystectomy or first drainage of bile duct,and then laparoscopic cholecystectomy as the case may be.For patients with grade Ⅲ acute cholecystitis,the extent of damage to other systems should first be fully evaluated.If the general condition of the patients can be improved quickly after treatment and the patient can tolerate the operation,laparoscopic cholecystectomy can be performed by a very experienced specialist.If surgery is not tolerated,conservative treatment and bile duct drainage are performed.In the 1980s,Radder suggested that percutaneous transhepatic drainage of gallbladder(PTGBD)could relieve symptoms of the patients with acute cholecystitis.TG18 recommended PTGBD as the preferred method for drainage of gallbladder.It is believed that the application of various imaging examinations,including cholangiography,intraoperative ultrasound,and preoperative MRCP,may reduce the occurrence of bile duct injury(BDI).According to previous Meta-analysis evidence,direct cholangiography(ERCP,intraoperative cholangiography)show higher sensitivity and specificity for the diagnosis of biliary tract variation and stones than non-invasive ultrasound,CT and MRCP cholangiography.In recent years,direct cholangiography was performed through PTGBD for patients with severe acute cholecystitis undergoing selective LC after PTGBD,so that cholecystolithiasis,cystic duct deformation,biliary tract variation and whether choledocholithiasis were combined could be observed more clearly.However,there are not relevant clinical studies on the effectiveness and safety of PTGBD cholangiography.So we conducted a retrospective study to analyze the effectiveness and safety of PTGBD cholangiography before the operation of acute cholecystitis.Purpose:To discuss the effectiveness and safety of PTGBD cholangiography before the operation of acute cholecystitis.Methods:Patients with acute cholecystitis who underwent laparoscopic cholecystectomy and had received PTGBD before surgery in the General Surgery Department of Qilu Hospital of Shandong University from January 2015 to October 2019 were included in this study.All the patients were divided into two groups,that was PTGBD cholangiography group and non-cholangiography group.The clinical data of the patients were collected with the method of case information query,including patients’ age,gender,medical history,white blood cell count,ASA grade on admission,date of PTGBD,date of PTGBD cholangiography,interval from PTGBD to LC,operation time,intraoperative blood loss,placement of drainage tube in operation,the conversion rate of laparotomy,postoperative complications,duration of drainage tube and length of hospital stay.The data of each group was statistically analyzed using SPSS 25.0 software;P value represented two-sided probability,with significance level a=0,05,and P<0.05 was considered statistically significant.Results:A total of 93 patients met the inclusion criteria,including 32 cases in the PTGBD cholangiography group and 61 cases in the non-cholangiography group.All the patients were performed the operations successfully.The mean operation time of the cholangiography group was(83.21±22.32)min,while that of the non-cholangiography group was(108.36±42.16)min,with statistically significant difference(P=0.034).The mean intraoperative blood loss in the PTGBD cholangiography group was(27.14±27.78)ml,while that in the non-cholangiography group was(46.56+31.21)ml,with statistically significant difference(P=0.047).There were 5 patients in the PTGBD cholangiography group without drainage tube,accounting for 15.63%of the patients in this group,and 9 patients in the contrast group without drainage tube,accounting for 17.75%of the patients in the non-cholangiography group,with no statistically significant difference(P=0.911).The duration of drainage tube in the PTGBD cholangiography group was(2.92±1.32)days,while that in the non-cholangiography group was(4.23±2.25)days,with statistically significant difference(P=0.042).There were no postoperative complications in the PTGBD cholangiography group,and 3 patients in the non-cholangiography group occurred fat liquefaction after surgery,accounting for 4.92%of the patients in this group,with no significant difference(P=0.213).The length of hospital stay was(11.14±4.17)days in the PTGBD cholangiography group and(9.54±4.00)days in the non-cholangiography group,showing no significant difference(P=0.183).Besides,all of patients with PTGBD cholangiography were performed laparoscopic cholecystectomy,however two cases in the non-cholangiography group were converted to open cholecystectomy.Conclusions:PTGBD cholangiography before the operation of acute cholecystitis is an effective and safe clinical approach for patients.It decreases operative time,estimated blood loss and duration of drainage tube.It may also decrease conversion to open cholecystectomy,while it doesn’t influence postoperative complications and length of hospital stay.