Study on Severity Score of Intra-operative Findings of Acute Cholecystitis and Difficulty of Laparoscopic Cholecystectomy

急性膽囊炎手術中嚴重度分數及腹腔鏡膽囊摘除困難度之研究

柯成國(Chen-Guo Ker) ； 董弘一(Hong-Yi Tong) ； 楊明元(Ming-Yuen Yang) ； 曾譯諏(I-Tsou Tseng) ； 張德銘(Der-Ming Chang) ； 洪國禎(Kuo-Chen Hung) ； 羅燕君(Yin-Chun Lo) ； 林順久(Soon-Keu Ling) ； 陳鴻曜(Hong-Yaw Chen) ； 陳昱甫(Yu-Fu Chen)

《南臺灣醫學雜誌》 16卷1期 (2020/06) Pp. 8-18

https://doi.org/10.6726/MJST.202006_16(1).0002

摘要

Objective: Laparoscopic cholecystectomy (LC) has been a standard procedure for acute cholecystitis nowadays. The purpose of this study was to measure the surgical difficulty by cholecystectomy time from the scoring system of intra-operative findings including inflamed gallbladder (GB) and surroundings during LC. Methods: There were 206 patients (89 male, and 117 female) and age ranged 23-85 year-old were treated with LC for acute cholecystitis in 2015-2016. The grading of inflammation of acute cholecystitis(AC) was based on the criteria of Tokyo Guideline 2013(TG13). The cholecystectomy time was measured from the visualization of GB to the end of completely separation and homeostasis of GB. The scales of scoring were included the intra-operative findings of GB appearance(0-9), Calot's triangle(0- 9), GB bed(0-9) and additional three conditions which were gangrene of GB, GB fistule and impacted gallstone in cystic duct (0-9). The total score was 0-36 for analysis of the relationship between cholecystectomy time and severity. Results: The cholecystectomy time more than 60 minutes was found in the patients of scores of 4.7±2.3, 5.0±2.2, and 4.5±2.3 for the appearance of GB, Calot's traiangle and GB liver bed respectively. The scores were higher with longer cholecystectomy time with significant difference (p＜0.001). The cholecystectomy times were 29.7±17.6, 47.3±27.4, and 111.8±59.1 minutes for Grade I, II and III with significant difference(p＜0.001).There were 5(13.9%), 28(77.8%) and 3(8.3%) patients with Grade I, II, and III respectively having cholecystectomy time more than 60 minutes respectively. In addition, cholecystectomy time more than 60 min was also found in the patients of mean age 60.9±13.3 year-old and in the Grade II and III (P＜.0.001) as well. If the GB total score was higher, the surgical difficulty (＞60 mininute) was 8.59 times more difficult. The linear regression of operation time and total GB scores of intra-operative findings was measured as Y=2.78X+21.45, R^2=0.475. Conclusion: Cholecystectomy will be more difficult and time consuming in patients of high score of inflamed gallbladder, Calot's triangle and GB bed. Therefore, a director of LC training program should be aware of this situation especially for a trainee in our clinical training practice.

關鍵字

cholecystitis ； laparoscopic cholecystectomy ； operation time ； surgical difficulty ； inflamed gallbladder score

並列摘要

目的：腹腔鏡膽囊摘除手術以治療急性膽囊炎已是一種標準手術,本研究之目的是要探討影響腹腔鏡膽囊摘除手術摘除時間及急性胆囊炎之膽囊週邊發炎程度術中所見給於分數，以利分析。方法：本院自2015－2016年起收集資料完整者共206例判定為急性膽囊炎且接受腹腔鏡膽囊摘除手術以治療者以供分析研究，其中男89、女117，而年齡23－85歲。本研究急性膽囊炎發炎程度依東京指引（Tokyo Guide line 2013）分級輕中重（Grade I、II及III），而手術時間是指腹腔鏡看到膽囊至完全分離取下膽囊及止血完全為止之時間計算。本研究中所見發炎程度加給分數包括膽囊（0-9分）、Calot's三角區（0-9分）、膽囊床（0-9分）及附加嚴重三條件（膽囊壞死、膽囊廔管及膽石嵌膽囊管，0-9分）所見指數總計0-36分。再統計分析手術摘除膽囊時間與膽囊術中發炎程度相關性統計學上分析。結果：膽囊摘除手術手術時間超過60分鐘者在膽囊4.7±2.3分、Calot's三角區5.0±2.2分及膽囊床4.5 ± 2.3分嚴重指數，可見嚴重指數愈高者手術時間愈多（p＜0.001）。膽囊炎Grade I、II、III膽囊摘除手術手術時間分別為29.7±17.6、47.3±27.4及111.8±59.1分鐘（p＜0.001）。然而膽囊摘除手術手術時間超過60分者在膽囊炎Grade I、II、III分別為5（13.9%）、28（77.8%）及3（8.3%）。此外，手術手術時間超過60分鐘者其年齡平均在60.9 ± 13.3歲及發炎在膽囊炎GradeI I及III（P＜0.001）。如果膽囊發炎總分數高者將會造成8.59倍之機會膽囊摘除時間超過60分鐘，膽囊發炎總分數高會延長摘除膽囊時間，其線性相關為Y=2.78X+21.45，R^2=0.475。結論：會影響腹腔鏡膽囊摘除時間之影響因素主要是術中膽囊炎發炎分數及Calot三角及膽囊床等發炎程度而異，因此嚴重發炎高分數確實造成延長摘除時間手術困難度。因此，本研究可供主持者注意受訓者在腹腔鏡胆囊摘除手術臨床教學中之參考。

並列關鍵字

膽囊炎 ； 腹腔鏡膽囊切除術 ； 手術時間 ； 手術困難度 ； 胆囊炎嚴重度分數