| Objective:This study aims at providing guidance for the strategies of using the laparoscopic cholecystectomy for the acute cholecystitis in elderly patient.Retrospective analysis is applied to identify the clinical manifestations,treatment process and treatment effect of the elderly patients who was with acute cholecystitis and underwent laparoscopic cholecystectomy.Methods:121 elderly patients with acute cholecystitis admitted to the department of hepatobiliary surgery of Shandong Provincial Hospital from January 2015 to January 2020,aged 60-96 years,with an average age of 68.2±6.5 years,were retrospectively collected and analyzed.There were 53 male patients and 68 female patients,and the ratio of male to female was 1:1.28.All patients underwent laparoscopic cholecystectomy by a fixed group of physicians.Patients were divided into three groups by different preoperative treatments.Group A was emergency LC group.Group B was electived LC group after percutaneous transhepatic gallbladder drainage while group C was electived LC group after conservative treatment.There were 26 cases in group A,52 cases in group B and 43 cases in group C.A comparative analysis was conducted on the differences in the general condition of admission,clinical manifestations,grade of severity,duration of operation,intraoperative blood loss,intraoperative conversion to laparotomy rate,postoperative ICU care rate,postoperative complication incidence,mortality,total length of stay and postoperative pathology of patients in different groups.SPSS 25.0 statistical software was used for analysis.The chi-square test,t-test and Fisher’s exact test were used to compare the counting data and measurement data.P<0.05 was considered as statistically significant.Result:(1)Preoperative statusThe preoperative status included the general condition of admission,clinical manifestation,complicated disease and severity grade.According to the Tokyo guidelines 2018 acute cholecystitis(TG18)severity classification,Grade Ⅲ acute cholecystitis patients in group A accounted for 7.7%,group C accounted for 14.0%and group B accounted for 14.0%.Group A and group C were significantly lower than group B(P<0.05).(2)Intraoperative situationThe evaluation indexes included operative duration,intraoperative blood loss,intraoperative conversion to laparotomy and drainage tube placement.The average surgical duration was 98.4±27.5min in group A,89.2±30.1min in group B,and 78.2±26.9min in group C.There was no significant difference in operation duration between the three groups(P>0.05).The average intraoperative blood loss was 17.2±18.7ml in group A,17.5±15.5ml in group B,and 20.1±11.5ml in group C,with no significant difference(P>0.05).Due to the difficulties in separating the gallbladder triangle during the operation,patients would turn to laparotomy.The rate of conversion to laparotomy was 23.1%in group A(6 cases),9.6%in group B(5 cases),and 7.0%in group C(3 cases).It was obviously shown that the intraoperative conversion to laparotomy rate in group B and group C was far lower than that in group A(P<0.05).The drainage tube placement rate was 53.8%in group A,46.2%in group B,and 41.9%in group C.There was no significant difference in drainage tube placement rate among the three groups(P>0.05).(3)Postoperative situationEvaluation indicators included postoperative ICU care rate,postoperative complication rate,mortality,postoperative pathological results,total length of stay,and postoperative length of stay.A total of 19 patients in the three groups were admitted to ICU after surgery.The rate of ICU care was 42.3%in group A,11.5%in group B,and 4.7%in group C.Group A was much higher than group B and group C(P<0.05).Common postoperative complications included postoperative bleeding,bile leakage,infection of incisional wound,pulmonary infection,urinary tract infection,etc.The incidence of complications was 15.4%(4/26)in group A,17.3%(9/52)in group B,and 14.0%(6/43)in group C.There was no significant difference in the incidence of postoperative complications between the three groups(P>0.05).The mortality rate of group A was 3.8%.There were no deaths in groups B and C.The average total length of stay was 6.1 ±2.3 days in group A,16.22±4.2 days in group B,and 10.7±6.9 days in group C.The total hospital days of group B was significantly higher than that of group A and group C(P<0.05).The length of hospitalization after surgery was 6.1±2.3 days in group A,5.1±1.8 days in group B,and 4.9±2.8 days in group C,with no significant difference(P>0.05).Postoperative pathological results illustrated that the proportion of acute inflammation reached 69.2%in group A,46.2%in group B,and 7.0%in group C.Both group A and group B were significantly higher than group C(P<0.05).However,there was no significant difference between group A and group B(P>0.05).Conclusion:Elderly patients with acute cholecystitis had complex conditions,difficult treatment and severe postoperative complications.Therefore,individual treatment options should be selected for patients with different conditions.When grade Ⅰelderly patients weren’t benefit from the conservative treatment within 24 hours and generally tolerate surgery,LC could be performed within 24 hours.Grade Ⅱ elderly patients with general tolerance to surgery were preferred to choose the emergency line LC.Besides,LC could be selected after the PTGD in the emergency department when the general condition of the patient and the degree of surgical tolerance were insufficient.Grade Ⅲ elderly patients should be performed electived LC after PTGD. |
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