發(fā)布時間：2018-09-07 20:03

【摘要】：目的：老年性急性膽囊炎伴膽總管結(jié)石急診就診的患者，傳統(tǒng)認(rèn)為常合并有心腦血管病、糖尿病及慢性呼吸系統(tǒng)疾病等內(nèi)科疾病，建議采用保守治療的方法。但是當(dāng)保守治療的療效不理想時急診手術(shù)，術(shù)后死亡率較高。本研究主要目的再次探討老年患者急性膽囊炎伴膽總管結(jié)石行膽囊切除+膽總管探查取石T管引流術(shù)的最佳手術(shù)時機。 方法：回顧2004年3月-2014年3月金州區(qū)第一人民醫(yī)院普外科取123例60歲（含60歲）以上的老年急性膽囊炎伴膽總管結(jié)石患者開腹膽囊切除+膽總管切開取石T管引流手術(shù)治療的臨床資料進行回顧性分析。按患者自發(fā)病至手術(shù)的時間分為早期手術(shù)組（72小時內(nèi)）、中期手術(shù)組（72小時至7天）、晚期手術(shù)組（7天以上）。分析比較3組手術(shù)并發(fā)癥（膽瘺、切開感染、肺內(nèi)感染、感染性休克）的發(fā)生率，手術(shù)時間、術(shù)后住院時間、總住院時間及術(shù)后病理（單純性膽囊炎、化膿性膽囊炎、壞疽性膽囊炎和膽囊周圍膿腫）的差別，來探討研究最佳手術(shù)時機。 結(jié)果：各組間并發(fā)癥（膽瘺、切口感染、肺內(nèi)感染、感染性休克）發(fā)生率比較差異無統(tǒng)計學(xué)意義（P0.05）。中期手術(shù)組的手術(shù)治療時間高于早期手術(shù)組和晚期手術(shù)組（P0.05）。觀察早期、中期、晚期患者術(shù)后住院時間及總住院時間逐漸增加，早期手術(shù)組術(shù)后住院天數(shù)4-23天，平均13.0天；中期手術(shù)組術(shù)后住院天數(shù)10-60天，，平均16.1天；晚期手術(shù)組術(shù)后住院天數(shù)15-62天，平均20.3天。早期手術(shù)組患者術(shù)后病理出現(xiàn)化膿性膽囊炎及壞疽性膽囊炎的比例較高（65.9%），中期組最高（90.5%），晚期組次之（65.5%）。 結(jié)論： 1、病程72小時內(nèi)盡早手術(shù)治療。膽總管切開取石、T管引流術(shù)式為其首選。 2、病程超過72小時，合并心腦血管疾病，慢性阻塞性肺疾病等，如果膽總管梗阻不是很明顯，身體其他情況允許的情況下，應(yīng)盡量避免急診手術(shù)；如果保守治療效果不明顯，建議行內(nèi)窺鏡十二指腸乳頭切開取石(EST)或經(jīng)皮肝穿刺膽管引流術(shù)（PTCD）解除膽道梗阻。 3、病程超過7天，經(jīng)保守治療有效，癥狀好轉(zhuǎn)者，仍建議擇期手術(shù)，原因（1）癥狀反復(fù)發(fā)作；（2）膽管惡變可能。
[Abstract]:Objective: patients with acute cholecystitis associated with choledocholithiasis in the emergency department were traditionally considered to have cardiovascular and cerebrovascular diseases, diabetes mellitus and chronic respiratory diseases, and conservative treatment was recommended. But when conservative treatment is not satisfactory, the postoperative mortality is higher. Objective to study the optimal time of cholecystectomy with choledocholithiasis for T tube drainage in elderly patients with acute cholecystitis and choledocholithiasis. Methods: from March 2004 to March 2014, 123 elderly patients with acute cholecystitis and choledocholithiasis with choledocholithiasis underwent cholecystectomy and choledocholithotomy with T-tube drainage were collected from the General surgery Department of the first people's Hospital of Jinzhou District. The clinical data of flow surgery were retrospectively analyzed. The patients were divided into early operation group (72 hours), middle operation group (72 hours to 7 days) and late operation group (more than 7 days) according to the time from onset to operation. The incidence of postoperative complications (biliary fistula, incision infection, intrapulmonary infection, septic shock), operative time, postoperative hospitalization time, total hospitalization time and postoperative pathology (simple cholecystitis, suppurative cholecystitis) were analyzed and compared among the three groups. The difference between gangrenous cholecystitis and perigallbladder abscess was used to explore the best operative time. Results: there was no significant difference in the incidence of complications (biliary fistula, incision infection, intrapulmonary infection, septic shock) among the groups (P0.05). The duration of operation in the intermediate operation group was higher than that in the early operation group and the late operation group (P 0.05). The postoperative hospitalization time and total hospitalization time of the early, middle and late stage patients were gradually increased. The postoperative hospitalization days of the early operation group were 4-23 days (mean 13.0 days), and that of the intermediate operation group was 10-60 days (average 16.1 days). The postoperative hospitalization days were 15-62 days (average 20.3 days) in the late operation group. The proportion of suppurative cholecystitis and gangrenous cholecystitis was higher in the early operation group (65.9%), the highest in the middle stage group (90.5%), and the second in the late stage group (65.5%). Conclusion: 1. The course of disease was treated as early as possible within 72 hours. Choledocholithotomy and T tube drainage is the first choice. 2. The course of disease is more than 72 hours, complicated with cardio-cerebrovascular disease, chronic obstructive pulmonary disease, etc. If the common bile duct obstruction is not obvious and other conditions of the body permit, Emergency operation should be avoided as far as possible, and if the effect of conservative treatment is not obvious, endoscopic duodenal papilla lithotomy with (EST) or percutaneous transhepatic bile duct drainage with (PTCD) should be used to relieve biliary obstruction. 3, the course of the disease is more than 7 days. If conservative treatment is effective and symptoms are improved, elective operation is recommended for (1) recurrence of symptoms and (2) possibility of malignant change of bile duct.
【學(xué)位授予單位】：大連醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2014
【分類號】：R657.4

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