Optimal Timing For PTGD And The Appropriate Interval From PTGD To Elective LC In The Elderly Patients With Acute Cholecystitis

Background and Objective:Laparoscopic choelcystectomy(LC)is the first choice for the treatment of acute cholecystitis,especially for patients from acute cholecystitis onset within 72 h.But for the elderly patients with acute cholecystitis,emergency LC operation complications and mortality were high.However,percutaneous transhepatic gallbladder drainage(PTGD)is an effective measure to treat the elderly patients with acute cholecystitis.After PTGD,LC performed when the inflammation controled and systemic conditions improved,The emergency operation was transferred to the relative safety of elective surgery,effectively reduced the complications and mortality.But the Optimal timing of PTGD from acute cholecystitis onset and the appropriate interval from PTGD to elective LC is no clear standard.This study retrospectively analyzed 51 cases of elderly patients with acute cholecystitis who underwent LC after PTGD in Liaoning Provincial People's Hospital from January 2012 to June 2015,to clarify the appropriate timing for PTGD and the appropriate interval from PTGD to elective LC in the elderly patients with acute cholecystitis.Materials and methods:Retrospective analysis of 51 cases of elderly patients with acute cholecystitis who underwent LC after PTGD in the Department of general surgery,Liaoning Provincial People's Hospital,from January 2012 to June2015,Comparison the relevant indicators between before PTGD and after PTGD,to observe the efficacy of PTGD.Receiver operating characteristic(ROC)analysis was performed,The area under the curve(AUC)was evaluated to determine the accuracy of the relationship between the duration from onset of acute cholecystitis to PTGD andlaparoscopic retrograde cholecystectomy,then using the Youden index calculate the cut-off value.Based on the cut-off value and the interval from PTGD to elective LC,the patients were divided into the A1B1,A1B2,A2B1,A2B2 four groups(A1 :the duration from onset of acute cholecystitis to PTGD ?72h,A2 :the duration from onset of acute cholecystitis to PTGD > 72 h,B1:the interval from PTGD to elective LC?60 days,B2 :the interval from PTGD to elective LC > 60 days).Intraoperative blood loss,operating time,postoperative exhaust time,hospitalization time,rate of laparoscopic retrograde cholecystectomy,complications,and pathological results compared between the four groups,for evaluation of the effects of the duration from onset of acute cholecystitis to PTGD and the interval from PTGD to elective LC on the efficacy of LC.Results:1.There were 51 cases in this study,including 21 males and 30 females.The average age was 75.0±6.4 years old.After PTGD treatment,the symptoms,signs and inflammation related indexes of the patients were significantly improved in a short time.2.The AUC for the relationship between the duration from onset of acute cholecystitis to PTGD and laparoscopic retrograde cholecystectomy was 0.672,95%confidence interval was 0.511 ~ 0.834,P=0.047.The cut-off value according to the Youden Index was calculated as 72 h.3.A1B1 compared with A2B1,A1B1 had shorter operative time,less lntraoperative blood loss,shorter postoperative exhaust time and postoperative hospitalization time,differences were statistically significant(P < 0.05);however,rate of laparoscopic retrograde cholecystectomy,postoperative complications,pathological results were not significant difference(P > 0.05).A1B2 compared with A2B2,A1B2 had shorter operative time,less lntraoperative blood loss,shorter postoperative exhaust time and hospitalization time,differences were statistically significant(P < 0.05);however,rate of laparoscopic retrograde cholecystectomy,postoperative complications,pathological results were not significant difference(P > 0.05).4.A1B2 compared with A1B1,A1B2 had shorter operative time,less lntraoperative blood loss,shorter postoperative exhaust time,shorter hospitalization time,less chronic cholecystitis acute changes in pathological results,differences were statistically significant(P <0.05);however,rate of laparoscopic retrograde cholecystectomy,postoperative complications were not significant difference(P>0.05).A2B2 compared with A2B1,A2B2 had shorter operative time,less lntraoperative blood loss,shorter postoperative exhaust time,shorter hospitalization time,less chronic cholecystitis acute changes in pathological results,differences were statistically significant(P<0.05);however,rate of laparoscopic retrograde cholecystectomy,postoperative complications were not significant difference(P>0.05).5.A1B2 group operation time,intraoperative blood loss,postoperative exhaust time,postoperative hospitalization time were lower than the A1B1 group,A2B1 group,A2B2 group,differences were statistically significant(P < 0.05).The rate of laparoscopic retrograde cholecystectomy between A1B2 and A2B1 differences were statistically significant,(P< 0.05).There was no significant difference in postoperative complications between the four groups(P > 0.05).Conclusion: PTGD is an effective treatment for elderly patients with acute cholecystitis.the duration from onset of acute cholecystitis to PTGD ?72h and the interval from PTGD to elective LC>60 days could shorter operative time,decrease lntraoperative blood loss,shorter postoperative exhaust time and postoperative hospitalization time respectively.With the above two conditions,the effect of LC surgery is the best.Therefore,PTGD should be performed immediately in cases who early cholecystectomy is not indicated and the interval from PTGD to elective LC more than 60 days is the appropriate Interval.