- 1 -

의학 의학 의학 의학 석사학위 석사학위 석사학위 석사학위 논문논문논문논문

Surgical Surgical Surgical Surgical Outcomes Outcomes Outcomes Outcomes of of of of

Laparoscopic Laparoscopic Laparoscopic Laparoscopic Cholecystectomy Cholecystectomy Cholecystectomy Cholecystectomy for for for for

Severe Severe Severe Severe Acute Acute Acute Acute CholecystitisCholecystitisCholecystitisCholecystitis

아 아 아 아 주 주 주 주 대 대 대 대 학 학 학 학 교 교 교 교 대 대 대 대 학 학 학 학 원원원원

의 의 의 의 학 학 학 학 과과과과

김 김 김 김 정 정 정 정 운운운운

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Surgical Surgical Surgical Surgical Outcomes Outcomes Outcomes Outcomes of of of of Laparoscopic Laparoscopic Laparoscopic Laparoscopic

Cholecystectomy Cholecystectomy Cholecystectomy Cholecystectomy

for for for for Severe Severe Severe Severe Acute Acute Acute Acute CholecystitisCholecystitisCholecystitisCholecystitis

by

Jeong Woon Kim

A Dissertation Submitted to The Graduate School of Ajou University

in Partial Fulfillment of the Requirements for the Degree of

MASTER OF MEDICAL SCIENCES

Supervised by

Wook Hwan Kim, M.D., Ph.D.

Department Department Department Department of of of of Medical Medical Medical Medical SciencesSciencesSciencesSciences

The The The The Graduate Graduate Graduate Graduate School, School, School, School, Ajou Ajou Ajou Ajou UniversityUniversityUniversityUniversity

August, August, August, August, 2008 2008 2008 2008

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김정운의 김정운의 김정운의 김정운의 의학 의학 의학 의학 석사학위 석사학위 석사학위 석사학위 논문을 논문을 논문을 논문을 인준함인준함인준함인준함....

심사위원장심사위원장심사위원장심사위원장 김 김 김 김 욱 욱 욱 욱 환 환 환 환 인인인인

심 사 위 원 심 사 위 원 심 사 위 원 심 사 위 원 김 김 김 김 진 진 진 진 홍 홍 홍 홍 인인인인

심 사 위 원심 사 위 원심 사 위 원심 사 위 원 유 유 유 유 병 병 병 병 무 무 무 무 인인인인

아 아 아 아 주 주 주 주 대 대 대 대 학 학 학 학 교 교 교 교 대 대 대 대 학 학 학 학 원원원원

2008200820082008년 년 년 년 6666월 월 월 월 23232323일일일일

- 4 -

- ABSTRACT -

SSSeeevvveeerrreeeAAAcccuuuttteeeCCChhhooolllSSSuuurrrgggiiicccaaalllOOOuuutttcccooommmeeesssooofffLLLaaapppaaarrrooossscccooopppiiicccCCChhhooollleeecccyyysssttteeeccctttooommmyyyfffooorrreeecccyyyssstttiiitttiiisss...

Theaim ofthisstudywastoevaluatesurgicaloutcomesofLaparoscopiccholecystectomy (LC)in patients who were diagnosed with severe acutecholecystitis(SAC)andtoclarifyusefultreatmentmodalitiesofSAC.Of112patientswhopresentedSAC,weselected99paatientsanddividedthem intothree groups; 37 patients who underwent preoperative percutaneoustranshepaticgallbladderdrainage(PTGBD)(Group1),62patientswithSACbutnotindicated forPTGBD (Group 2)and 59 patientswith acuteandchroniccholecystitis(Group3).Theconversionratewas2.7% (1/37)ingroup1,6.5% (4/62)ingroup2,and1.7% (1/59)ingroup3.Ingroups1and2,thepostoperativestayandoperativetimewerelongerthanthoseingroup3withsignificantdifference,respectively(P<0.05).Ingroup2,therewascorrelationnotonlybetweenpostoperativestayand

agebutalsobetweenpostoperativestayandASA class(P<0.05).Ingroup2,therewasnocorrelationbetweentimetooperationandoperativetimeandalsobetween time to operation and postoperative stay,however,there wassurprisinglysignificantcorrelationbetweentimetooperationandconversionrateinSAC(P=0.018).Inconclusion,PTGBD shouldselectivelybeperformedinpatientswithseverecomorbiditiesratherthanimprovingsurgicaloutcomes

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ofLCforsevereacutecholecystitis.IfpatientsarenotindicatedforPTGBD,anearlylaparoscopiccholecystectomyisrecommendedbecauseitcandecreaseconversionrate,althoughitcan’tdecreaseoperativetimeandpostoperativestay.

Keywords Severeacutecholecystitis,Laparoscopiccholecystectomy

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TTTAAABBBLLLEEEOOOFFFCCCOOONNNTTTEEENNNTTTSSS

ABSTRACT·····················································································································1TABLEOFCONTENTS ····························································································3LIST OFFIGURES ······································································································4LIST OFTABLES ·······································································································5Ⅰ.INTRODUCTION ···································································································6Ⅱ.PATIENTSANDMETHODS ············································································8A.PATIENTS ···········································································································81.Selection ············································································································82.Division ·············································································································83.ModalityofDiagnosisAndTreatment····················································9

B.METHODS ···········································································································10Ⅲ.RESULTS ················································································································11Ⅳ.DISCUSSION ··········································································································23Ⅴ.CONCLUSION ········································································································27REFERENCES ··············································································································28국문요약 ··························································································································32

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그그그림림림 차차차례례례

Fig.1.Comparisonofseverityofillnessbetweenthethreegroups············13Fig.2.Comparisonofoperativetimesbetweenthethreegroups···················16Fig.3.Comparisonofpostoperativehospitalstaybetweenthethreegroups

································································································································17Fig.4.Correlationsamongpostoperativestay,ageandASA classinsevere

cholecystitis········································································································19Fig.5.Correlationbetweentimetooperationandsurgicaloutcomesinsevere

cholecystitis········································································································21

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표표표 차차차례례례

Table1.Clinicalcharacteristicsofthethreegroupsonadmission················12Table2.Correlationsbetweenpostoperativestayandotherfactorsingroup

····························································································································18

- 9 -

ⅠⅠⅠ...IIINNNTTTRRROOODDDUUUCCCTTTIIIOOONNN

Acutecholecystitis(AC)isthemostcommonlyencountereddisease,causedby obstruction of the cystic duct with or without gallstones.For thetreatmentofAC,therehasbeencontroversyovertheadvantagesofearlylaparoscopic cholecystectomy (LC)versus delayed surgicaltreatmentaftergallbladder drainage such as PTGBD.17, 21, 23 Recently, early LC isrecommendedonthebasisofrandomizedstudies,10,12,13sincefailureofinitialconservativetreatmentshasbeenreportedinupto32% ofcasesandearlycholecystectomyhasbeenprovedtoreducetotalhospitalstay.AC canalsobecomplicatedbyempyema,gangrene,orperforation.Both

gangrenousand empyematousacutecholecystitiscan bedefinedassevereacutecholelecystitis(SAC),anditispresentinupto30% ofpatientsadmittedtohospitalwithacutecholecystitis.15Furthermore,SAC hasbeenreportedtobeassociated with increased mortality (15%-50%),especially in elderly orcritically illpatients.24 Higher conversion and morbidity rates have beenreportedwhengangrenouscholecystitisorempyemaofthegallbladderwereapproachedbylaparoscopy.4,7Moreover,treatmentmodalitiesotherthanLC,suchascholecystostomyorsubtotalcholecystectomyhavebeenconsidered,3,5,19,23however,thetreatmentofSAChasnotexactlybeenspecifiedinmostliterature.Theaim ofthisstudywastoevaluatesurgicaloutcomesofLCinpatients

whowerediagnosedwithSACandtoclarifytheusefultreatmentmodalities

- 10 -

ofSAC.

- 11 -

ⅡⅡⅡ...PPPAAATTTIIIEEENNNTTTSSSAAANNNDDD MMMEEETTTHHHOOODDDSSS

AAA...PPPAAATTTIIIEEENNNTTT

1.Selection

From January2003toSeptember2006,total1330LC wereperformedatAjouUniversityMedicalCenter.Of427patientswhowereadmittedwithaclinicaldiagnosisofAC,26.2% ofpatients(112/427)whopresentedSACweresurgicallytreatedduringthestudy.Amongthe112patients,weselected99patients excluding 2 patients who underwent other biliary drainage(percutaneous transhepatic biliary drainage), 2 patients who developedcholecystitis during the evaluation ofotherproblems and 9 patients whounderwentinitialopencholecystectomy.Fortyfivepatientsweremaleand54patientswerefemale,whoseagerangedfrom 31to94years.

2.Division

We also divided the patients into two groups,depending on whetherpreoperativegallbladderdrainagewasperformed(group1)ornot(group2).TocomparethelengthofhospitalstayandoutcomesofsurgeryoftheSACwiththatofothercholecystitis,patientswhowerediagnosedwithacuteandchroniccholecystitis(group3)werealsoreviewedinaretrogradeorder.

- 12 -

3.ModalityofDiagnosisandTreatment

The diagnosis ofAC was based on clinicalsigns (fever,rightupperquadrantabdominalpain,orright-sidedabdominaltenderness)andcomputedtomographyfindings(thickeningofgallbladderwallandpericholecysticfluidcollections).Both gangrenous and empyematous acute cholecystitis weredefined as severe acute cholelecystitis.SAC was confirmed by operativefindings,inspectionofgallbladderchangedfrom wallcolortodarkgreenorgray and infected bileorpus contained.Finally,SAC wasconfirmed bypostoperativepathologicfindings.Abdominalcomputedtomographywastheinitialimagingmodalityofchoice

in all patients. Patients with CT findings of severe cholecystitis (ahypoechogenic band in the gallbladderwalland/ora pericholecystic fluidcollectionand/orthickening ofthegallbladderwallto8mm ormore),withcritically ill combined medical disease (diabetes mellitus,cardiovasculardisease,oldCVA),and/orwithsepticcondition,whoweresuspectedofseverecholecystitis,were treated with the emergency PTGBD.Following theresolutionofacuteattackandmedicaltreatmentofanydiseasesassociatedwithcholecystitis,patientswereconsideredforcholecystectomy.Patientswithpreoperativehyperbilirubinemia[serum bilirubinhigherthantwicethenormalvalue and/or dilated common bile duct (>8mm)] underwent endoscopicretrograde cholangiopancreatography (ERCP).Laparoscopic cholecystectomywasperformedusingthestandardfour-trocartechnique.

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BBB...MMMEEETTTHHHOOODDDSSS

WecollectedconsecutiveidentificationofpatientswhounderwentLC forSAC or who underwentLC afterPTGBD for SAC.We retrospectivelyreviewed the medicalrecords ofallpatients and analyzed data includingdemographicinformation,clinicalpresentation,resultsoflaboratory studies,operativerecords,postoperativecomplicationsandpre-/postoperativehospitalstay.Onpreoperativeassessment,patientswereclassifiedintotheAmericanSocietyofAnesthesiologists(ASA)score.Thetimetooperationwasdefinedasintervalbetweenadmissionandoperation.StatisticalanalysiswasperformedwithFisher'sexacttest,independentt-test,and Spearman's correlation. P-value<0.05 was considered statisticallysignificant.

- 14 -

ⅢⅢⅢ...RRREEESSSUUULLLTTTSSS

AAA...CCCllliiinnniiicccaaalllFFFiiinnndddiiinnngggsss

Thirty sevenpatientshadpreoperativegallbladderdrainage.PTGBD wasperformedsuccessfully inallpatients,andcomplication ofPTGBD didnotoccur.ThedemographicandpreoperativelaboratorydataforeachgrouparecomparedinTable1.Patientsingroup1weresignificantlyolderthanothergroups(P<0.05).On theotherhand,therewasno significantdifferenceingenderandlaboratoryfindingsbetweengroup1and2(P>0.05).Ingroup3,WBC countwas significantly lowerthan thatofothergroups (P<0.05).Preoperative CT findings and hyperbilirubinemia yielded a diagnosis ofcommon bile duct stones in 19 patients; and preoperative endoscopicsphincterotomyandstoneextractionwereperformedcompletely.Hypertension(n= 56)anddiabetesmellitus(n=35)werepresentinmost

patients ofthree groups.There were other associated diseases such asischemicheartdisease(n=8),cerebrovasculardisease(n=10),livercirrhosis(n=1),and bronchialasthma (n=4).Diabetes mellitus was presentin 15patientsingroup1(37.5%),12patientsingroup2(17.9%)and8patientsingroup2(13.6%);itwasstatisticallysignificantinthethreegroups(P<0.05),respectively(datanotshown).

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TTTaaabbbllleee111...CCCllliiinnniiicccaaalllccchhhaaarrraaacccttteeerrriiissstttiiicccsssooofffttthhheeettthhhrrreeeeeegggrrrooouuupppsssooonnnaaadddmmmiiissssssiiiooonnn...

Severity of illness in the three groups of patients was assessedpreoperativelybycomparingtheirASA classification.ThemeanASA scorewas1.27±0.6ingroup1,0.89±0.54ingroup2and0.59±0.69ingroup3.TherewassignificantdifferenceinASA classbetweenthethreegroups(P<0.05):ThenumberofASAⅠ patientsincreased(3,13,and30patientsingroup1,2,and3respectively),whereasthenumberofASA Ⅲ patientsdecreased(13,6,and5patientsingroup1,2,and3respectively).ComorbidconditionsweresignificantlymorecommoninthePTGBDgroup(Figure1).

group 1

(n=37)

group 2

(n=62)group 3

(n=59)AgeÞ 66.8±11.7 60.5±13.4 50.2±14.4Sex (M/F) 13/24 32/30 32/27Symptom duration (days) 2.8±1.7 5.2±5.8 3.6±3.3Fever (℃) 37.6±0.8 37.2±0.8 36.8±0.5Laboratory findings WBC count (/㎣) 15551.3±6485.6 13281.4±4930.4 9743±4157.0Total bilirubin (㎎/㎗) 2.4±2.4 1.7±1.5 1.8±1.9AST (IU/l) 89.6±132.0 56.5±107.4 59.9±85.9ALT (IU/l) 109.3±176.6 60.4±101.1 84.5±104.6

Associated diseaseÞ 7 4 12 CBD stone 4 (10.8%) 4 (6.5%) 11 (18.6%) Sepsis 3 (8.1%) Acute cholangitis 1 (2.7%) 1 (1.7%)

- 16 -

0

0.5

1

1.5

2

AS

A c

lass

* **

0

0.5

1

1.5

2

AS

A c

lass

* **

FFFiiiggg...111...CCCooommmpppaaarrriiisssooonnnooofffssseeevvveeerrriiitttyyyooofffiiillllllnnneeessssssbbbeeetttwwweeeeeennnttthhheeettthhhrrreeeeeegggrrrooouuupppsss...ThemeanASA was1.27±0.6ingroup1,0.89±0.54ingroup2and0.59±0.69ingroup3.Therewassignificantdifferencebetweenthethreegroups(P<0.05).ComorbidconditionsweresignificantlymorecommoninthePTGBD group.(Þ;P<0.05).

- 17 -

BBB...CCCooonnnvvveeerrrsssiiiooonnnaaannndddCCCooommmpppllliiicccaaatttiiiooonnnsss

Of112patients,LC wastheinitialsurgicalapproachin99patients,andwassuccessfully completed in 94patients(94.9%),whereasconversion toopenprocedurewasnecessaryin5patients(5.1%).Theconversionratetoopencholecystectomywas2.7% (1/37)ingroup1,6.5% (4/62)ingroup2,and1.7% (1/59)ingroup3.Eightpatientsunderwentopencholecystectomy(OC).Moderatetosevereadhesionaroundthegallbladderwasobservedinallcases;however,theadhesion couldbedissectedwith carefulmanipulation.Onepatient(2.7%)ofgroup1andtwoofgroup2wereconvertedtoopencholecystectomy becauseofasevereadhesion aroundthegallbladder.Onepatienteachofgroup2,3wasconvertedtoopencholecystectomybecauseofasuperintenseCalot’striangle.Otheronepatientofgroup2wasconvertedtoopencholecystectomybecauseofinjuryofsmallbowel:Perforatedsmallbowelwasprimarilyrepairedimmediatelyby3-0blacksilk,andthispatientwasdischargedatpostoperativeday8afterwoundseromamanaged.ThecomplicationratesafterLC was8.1% (3/37)ingroup1,11.3% (7/62)

ingroup2,and5.1% (3/59)ingroup3.Intraoperativeuncontrolledbleedingdid notoccurin any patientofthe three groups.Postoperative woundinfection occurred in three patients in group 2 and one in group 3.Atransientbiliaryleakageoccurredinoneeachpatientofgroup2and3,anditwasmanagedby endoscopictherapy.Onepatientin group1showedbileleakageatthepuncturesiteofPTGBD afterLC.Thispatientunderwent

- 18 -

emergencyoperation,sincegeneralconditionwasthenaggravated,however,finallyexpiredbymultipleorganfailure.Themortalityratewas1.7% (2/112)inSAC.

CCC...OOOpppeeerrraaatttiiivvveeeTTTiiimmmeee

TheoperativetimeforLCwas74.86±35.42miningroup1,82.18±26.69miningroup2,and61.27±22.60miningroup3.Ingroup3,theoperativetimewasshorterthan in groups1 and 2 with significantdifference(P<0.05).Interestingly,however,theoperativetimeofgroup1wasshorterthanthatofgroup2withnosignificantdifference(P>0.05)(Figure2).

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Op

erat

ive

tim

e (m

in)

0

20

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Group 1Group 1Group 1Group 1 Group 2Group 2Group 2Group 2 Group 3Group 3Group 3Group 3

P <0.05

P >0.05

Op

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in)

0

20

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60

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Group 1Group 1Group 1Group 1 Group 2Group 2Group 2Group 2 Group 3Group 3Group 3Group 3

P <0.05

P >0.05

P <0.05

P >0.05

FFFiiiggg...222...CCCooommmpppaaarrriiisssooonnnooofffooopppeeerrraaatttiiivvveeetttiiimmmeeesssbbbeeetttwwweeeeeennnttthhheeettthhhrrreeeeeegggrrrooouuupppsss...Therewasnosignificantdifferencebetweengroup1and2(P>0.05).TheoperativetimeofbothPTGBD groupandseverecholecystitisgroupwassignificantlongerthanacuteandchroniccholecystitis(P<0.05).

DDD...PPPrrreee///PPPooosssttt---ooopppeeerrraaatttiiivvveeeHHHooossspppiiitttaaalllSSStttaaayyy

Thetotalhospitalstaywas12.5±4.3daysingroup1,7.6±4.0daysingroup2and4.6±3.7daysingroup3.Anaveragepreoperativestay was8.3±3.1daysingroup1,3.2±2.6daysingroup2.Ingroup3,thepreoperativestaywasshorterthan othertwogroups(2.6±2.8days)(datanotshown).Themean hospitalstay afterLC was3.9±2.6daysin group1,3.7±2.8daysingroup 2,and 2.1±1.8 days in group 3.In groups 1 and 2,the meanpostoperativestaywassignificantlylongerthanthatingroup3,respectively(P<0.05).However,therewasnodifferencebetweengroup1and2(P>0.05)

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(Figure3).

0

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8

Group 1Group 1Group 1Group 1

Po

sto

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Group 2Group 2Group 2Group 2 Group 3Group 3Group 3Group 3

P <0.05

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0

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Group 1Group 1Group 1Group 1

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Group 2Group 2Group 2Group 2 Group 3Group 3Group 3Group 30

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Group 1Group 1Group 1Group 1

Po

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Group 2Group 2Group 2Group 2 Group 3Group 3Group 3Group 3

P <0.05

P >0.05

FFFiiiggg...333...CCCooommmpppaaarrriiisssooonnn ooofffpppooossstttooopppeeerrraaatttiiivvveeehhhooossspppiiitttaaalllssstttaaayyy bbbeeetttwwweeeeeennn ttthhheeettthhhrrreeeeeegggrrrooouuupppsss... The postoperative stay of both PTGBD group and severecholecystitisgroupwassignificantlongerthanacuteandchroniccholecystitis(P<0.05).However,therewasnosignificantdifferencebetweengroups1and2(P>0.05).

Ingroup2,thereweresignificantcorrelationsbetweenpostoperativestayandage(r=0.254,P<0.05),betweenpostoperativestayandASA class(r=0.311,P<0.05),andbetweenoperativetimeandpostoperativestay(r=0.322,P=0.011)(Table2,Figure4).

- 21 -

TTTaaabbbllleee222...CCCooorrrrrreeelllaaatttiiiooonnnsssbbbeeetttwwweeeeeennnpppooossstttooopppeeerrraaatttiiivvveeessstttaaayyyaaannndddooottthhheeerrrfffaaaccctttooorrrsssiiinnngggrrrooouuuppp222...

Postoperative stay in group 2

Correlation Coefficient P value

Age 0.254 0.046

Symptom duration 0.168 NS

ASA class 0.311 0.014

Time to operation 0.043 NS

Operative time 0.322 0.011

Conversion to open 0.417 0.001

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0 2 4 6 8 10 12 14

Postoperative stay (day)

30

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e (y

ear)

Rsq=0.065

A

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Op

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Op

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C

FFFiiiggg...444...CCCooorrrrrreeelllaaatttiiiooonnnsssaaammmooonnnggg pppooossstttooopppeeerrraaatttiiivvveeessstttaaayyy,,,aaagggeeeaaannndddAAASSSAAA ccclllaaassssssiiinnnssseeevvveeerrreeeccchhhooollleeecccyyyssstttiiitttiiisss...A.Therewascorrelationbetweenpostoperativestayand age (r=0.254,P<0.05).B.There was significant correlation betweenpostoperativestayandASA class(r=0.311,P<0.05).C.Therewassignificantcorrelationbetweenpostoperativestayandoperativetime(r=0.322,P<0.05).

- 23 -

FFF...TTTiiimmmeeetttoooOOOpppeeerrraaatttiiiooonnn

After PTGBD,the mean duration ofdrainage was 7.1±3.5 days.Thecatheterwasremovedinallpatientsatthetimeofcholecystectomy.Therewasnocorrelationbetweentimetooperationafterdrainageandconversion(P>0.05)(datanotshown).In group 2,there were no correlations between time to operation and

operativetimeandalsobetweentimetooperationandpostoperativestay.Theoldaged patientswith high ASA classspentmoretimebeforeoperation.Surprisingly,therewasasignificantcorrelationbetweentimetooperationandconversionrateingroup2(r=0.299,P=0.018)(Figure 5):Thelongertheintervalbetweenadmissionandoperation,thehighertheconversionrate.

- 24 -

0 2 4 6 8 10 12

Time to Operation (day)

30

60

90

120

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180

Op

erat

ive

tim

e (m

in)

Rsq=0.03

A

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Time to Operation (day)

30

60

90

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180

Op

erat

ive

tim

e (m

in)

Rsq=0.03

0 2 4 6 8 10 12

Time to Operation (day)

30

60

90

120

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180

Op

erat

ive

tim

e (m

in)

Rsq=0.03

A

0 2 4 6 8 10 12

Time to Operation (day)

0

2

4

6

8

10

12

14

Po

sto

pera

tive

sta

y (d

ay)

Rsq=0.004

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0 2 4 6 8 10 12

Time to Operation (day)

0

2

4

6

8

10

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14

Po

sto

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tive

sta

y (d

ay)

Rsq=0.004

0 2 4 6 8 10 12

Time to Operation (day)

0

2

4

6

8

10

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14

Po

sto

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tive

sta

y (d

ay)

Rsq=0.004

B

0 1

Conversion to Open

0

4

8

12

Tim

e to

Op

erat

ion

(d

ay)

Rsq = 0.09

C

0 1

Conversion to Open

0

4

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12

Tim

e to

Op

erat

ion

(d

ay)

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0 1

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Op

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ion

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ay)

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C

FFFiiiggg...555...CCCooorrrrrreeelllaaatttiiiooonnnbbbeeetttwwweeeeeennntttiiimmmeeetttoooooopppeeerrraaatttiiiooonnnaaannndddsssuuurrrgggiiicccaaalllooouuutttcccooommmeeesssiiinnnssseeevvveeerrreeeccchhhooollleeecccyyyssstttiiitttiiisss...A.Therewasnocorrelationbetweentimetooperationandoperativetime(r=-0.070,P>0.05).B.Therewasnocorrelationbetweentimeto operation and postoperativestay (r=0.043,P>0.05).C.Therewassignificantcorrelation between times to operation and conversion rate insevereacutecholecystitis(r=0.299,P=0.018).Astimetooperationisdelayed,

- 25 -

conversiontoopencholecystectomyincreased.

- 26 -

ⅣⅣⅣ...DDDiiissscccuuussssssiiiooonnn

The etiology of gallbladder gangrene is related mainly to vascularcompromisesecondary to continuing obstruction ofthecysticduct,whichcauses the intraluminalpressure within the gallbladder to activate andincreasean immediateinflammatory reaction.9 Gangrenouscholecystitis,thelaststageofgallbladderinflammation,isasevereform ofacutecholecystitisandisassociatedwithsignificantlygreatermorbidityandmortalityrelativetootherformsofacutecholecystitis,especiallyinelderly,immunocompromisedordiabeticpatients.15, 24 Inourcases,patientsingroup2wereolderthanothercholecystitisgroup(60.5vs.50.2years).Moreover,therateofdiabetesmellitusingroup1washigherthanthatofgroup2.However,therewasnosignificantdifferenceingenderbetweenthethreegroups.Therateofconversiontoopensurgeryincasesofseverecholecystitishasbeenreportedtobebetween8.7% and75%,2,8,11,15,19Inmanystudies,therate of complications in cases of severe cholecystitis,including severecomplicationssuchasbileductinjuryorbleeding,isbetween0% and40%,7,8,15,16,19andearlyconsiderationofconversiontoopencholecystectomyhasbeen advocated by Cox etal,6 although Merriam etal2 reported a 65%successratewith thelaparoscopicapproach:They contended thataswiftconversion to an open cholecystectomy maybe warranted if gangrenouscholecystitisisfoundInthepresentstudy,therateofconversiontoopensurgeryingroup2

- 27 -

was6.5%,being lowerthan thatofotherreports.Moreover,even thoughtherewasonecaseofbileleakageatthecysticductstump,therateofcomplicationswas11.3% withoutseverecomplications.Noticeably,therewasnosignificantdifferenceintherateofconversionandcomplicationsbetweenthethreegroups.According to some literature,LC after PTGBD as another treatment

modality for severe cholecystitis may decrease the conversion andcomplicationrates.Chikamorietal5reportedthatearlyscheduledLCfollowingPTGBD isasafeand effectivetherapeuticoption forpatientswith acutecomplicatedcholecystitis,especiallyinelderlypatientsandpatientswithpoorgeneralcondition.Tseng etal18 reported thatthecomplicationsrelated toPTGBD werenotedin2patients(1.4%).However,theconversion ratetoopencholecystectomyinLCwas27% (32/117)withameanof4daysafterPTGBD.Ontheother hand,zero conversionratewasreportedin34daysofintervaltooperationafterPTGBD.23

Inourstudy,patientswithPTBGD weresignificantlyolderandcomorbidconditionsweresignificantlymorecommonthanothergroups.TherewasonecomplicationrelatedtoPTGBD:bileleakageatthepuncturesiteafterLC.Therateofcomplicationswas8.1% andlowerthanotherstudies.Inaddition,there was no correlation between time to operation after drainage andconversion,eventhoughtherewasonecaseofconversiontoopen.The results from recent randomized trials have shown that early

cholecystectomy issuperiortodelayed surgery becauseofshorterhospital

- 28 -

stayandeconomicbenefits.13,14Forpatientswithsevereacutecholecystitis,delayedsurgeryafterinitialconservativetherapyoropencholecystectomyhasbeen selected,because of difficulties associated with early laparoscopictreatment. However, technical advances and increased experience havegradually led surgeons to attemptlaparoscopic surgery in cases ofacutegangrenouscholecystitis.8,11,15Tsushimietal20reportedthattherewerenopostoperativecomplications.Thus,earlylaparoscopiccholecystectomyseemstobeappropriateforacutegangrenouscholecystitis.Wangetal22reportedthatthe timing ofurgentlaparoscopic cholecystectomy had no impacton theconversion rate.In the present study,there was significant correlationbetweenthetimetooperationandconversionrateingroup2.Indeed,earlyLCforseverecholecystitisdecreasedtheconversiontoopencholecystectomy.Therearemanyreportsthattheoperativetimewaslongerinpatientswith

SAC becauseofdenseadhesiontocalot’striangle.Tsumuraetal19reportedthatsurgicalduration was 124 min in PTGBD group and 107 min innon-PTGBD groupwithsignificantdifference.Ontheother hand,Chikamorietal5 found thatthe duration ofsurgery was shortened when LC wasperformedassoonaspossibleafterPTGBD.Inourstudy,theoperativetimeofgroup1wasshorterthanthatofgroup

2;however,itwasnotsignificant.Thismighthavebeenduetothefactthatmuchoperativetimewasspentingroup2becauseofedematous,tenseandhypervasculartissue.OtherreasonforshortoperativetimeofPTGBD groupwas laparoscopic subtotalcholecystectomy;9 patients in group 1 and 5

- 29 -

patients in group 2. Beldi et al1 observed that laparoscopic subtotalcholecystectomyforAC offersasimpleandsafesolutionthatpreventsbileductinjuriesanddecreasestherateofconversion in anatomically difficultsituations.According to some studies, postoperative stay after LC for severe

cholecystitisrangesfrom 3.2daysto8.6days.5,8,15,20Inourpresentcases,postoperativestay wassimilarorshorterthanotherreports;3.7daysingroup2.In group2,therewassignificantcorrelation among postoperativestay,age,andASA class.ElderlypatientswithhighASA classstayedinhospitallongerpostoperatively.

- 30 -

ⅤⅤⅤ...CCCOOONNNCCCLLLUUUSSSIIIOOONNN

InSACnotindicatedforPTGBD,therewerenocorrelationsbetweentimeto operation and operative time, and between time to operation andpostoperativestay.However,therewasasignificantcorrelationbetweentimetooperationandconversionrate.Moreover,theoldagedpatientswithhighASA class took longertime to operation and stayed in hospitallongerpostoperatively.In conclusion,PTGBD should selectively be performed in patients with

severe comorbidities ratherthan to improve surgicaloutcomesofLC forsevere acute cholecystitis.Ifpatientwas notindicated forPTGBD,werecommend early laparoscopic cholecystectomy,because it can decreaseconversionrate,althoughitcan’tdecreaseoperativetimeandpostoperativestay.

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RRREEEFFFEEERRREEENNNCCCEEESSS

1.BeldiG,GlattliA.:Laparoscopic subtotalcholecystectomy for severecholecystitis.SurgEndosc17:1437-9,2003

2.BingenerJ,StefanidisD,RichardsML,SchwesingerWH,Sirinek KR.:Early conversion forgangrenouscholecystitis:impacton outcome.SurgEndosc19:1139-41,2005

3.BorzellinoG,deManzoniG,RicciF,CastaldiniG,GuglielmiA,CordianoC.:Emergencycholecystostomyandsubsequentcholecystectomyforacutegallstonecholecystitisintheelderly.BrJSurg86:1521-5,1999

4.Brodsky A,Matter I,Sabo E,Cohen A,Abrahamson J,Eldar S.:Laparoscopic cholecystectomy foracute cholecystitis:can the need forconversion and the probability of complications be predicted? Aprospectivestudy.SurgEndosc14:755-60,2000

5.ChikamoriF,KuniyoshiN,Shibuya S,Takase Y.:Early scheduledlaparoscopic cholecystectomy following percutaneous transhepaticgallbladderdrainageforpatientswith acutecholecystitis.Surg Endosc16:1704-7,2002

6.Cox MR,Wilson TG,Luck AJ,Jeans PL,Padbury RT,ToouliJ.:Laparoscopic cholecystectomy foracuteinflammation ofthegallbladder.AnnSurg218:630-4,1993

7.Eldar S,Sabo E,Nash E,Abrahamson J,Matter I.:Laparoscopiccholecystectomy for the various types of gallbladder inflammation:a

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prospectivetrial.SurgLaparoscEndosc8:200-7,1998

8.HabibFA,Kolachalam RB,KhilnaniR,PreventzaO,MittalVK.:Roleoflaparoscopic cholecystectomy in the management of gangrenouscholecystitis.Am JSurg181:71-5,2001

9.IndarAA,Beckingham IJ.:Acutecholecystitis.Bmj325:639-43,2002

10.JohanssonM,ThuneA,BlomqvistA,NelvinL,LundellL.:Managementofacutecholecystitisin thelaparoscopicera:resultsofaprospective,randomizedclinicaltrial.JGastrointestSurg7:642-5,2003

11.KiviluotoT,Siren J,Luukkonen P,KivilaaksoE.:Randomisedtrialoflaparoscopic versus open cholecystectomy for acute and gangrenouscholecystitis.Lancet351:321-5,1998

12.KollaSB,AggarwalS,KumarA,KumarR,ChumberS,Parshad R,Seenu V.:Early versusdelayed laparoscopiccholecystectomy foracutecholecystitis:aprospectiverandomizedtrial.SurgEndosc18:1323-7,2004

13.LoCM,LiuCL,FanST,LaiEC,WongJ.:Prospectiverandomizedstudof early versus delayed laparoscopic cholecystectomy for acutecholecystitis.AnnSurg227:461-7,1998

14.MadanAK,Aliabadi-WahleS,TesiD,FlintLM,Steinberg SM.:Howearlyisearlylaparoscopictreatmentofacutecholecystitis?Am JSurg183:232-6,2002

15.Merriam LT,KanaanSA,DawesLG,AngelosP,PrystowskyJB,Rege

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RV,JoehlRJ.:Gangrenous cholecystitis:analysis ofrisk factors andexperiencewith laparoscopiccholecystectomy.Surgery 126:680-5,1999;discussion685-6

16.NavezB,MutterD,RussierY,VixM,JamaliF,LipskiD,CambierE,GuiotP,LeroyJ,MarescauxJ.:Safetyoflaparoscopicapproachforacutecholecystitis:retrospectivestudyof609cases.WorldJSurg 25:1352-6,2001

17.PattersonEJ,McLoughlinRF,MathiesonJR,CooperbergPL,MacFarlaneJK.: An alternative approach to acute cholecystitis. Percutaneouscholecystostomyandintervallaparoscopiccholecystectomy.Surg Endosc10:1185-8,1996

18.Tseng LJ,TsaiCC,MoLR,Lin RC,Kuo JY,Chang KK,JaoYT.:Palliative percutaneous transhepatic gallbladderdrainage ofgallbladderempyema before laparoscopic cholecystectomy.Hepatogastroenterology47:932-6,2000

19.TsumuraH,IchikawaT,HiyamaE,KagawaT,NishiharaM,MurakamiY, Sueda T.: An evaluation of laparoscopic cholecystectomy afterselective percutaneous transhepatic gallbladder drainage for acutecholecystitis.GastrointestEndosc59:839-44,2004

20.TsushimiT,MatsuiN,TakemotoY,KurazumiH,OkaK,SeyamaA,Morita T.:Early laparoscopic cholecystectomy for acute gangrenouscholecystitis.SurgLaparoscEndoscPercutanTech17:14-8,2007

21.VanSteenbergenW,PonetteE,MarchalG,PelemansW,AertsR,Fevery

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J,De Groote J.:Percutaneous transhepatic cholecystostomy foracutecomplicated cholecystitis in elderly patients. Am J Gastroenterol85:1363-9,1990

22.WangYC,YangHR,ChungPK,JengLB,ChenRJ.:Urgentlaparoscopiccholecystectomy in themanagementofacutecholecystitis:timing doesnotinfluenceconversionrate.SurgEndosc20:806-8,2006

23.WatanabeY,SatoM,AbeY,IsekiS,SatoN,KimuraS.:PrecedingPTGBD decreases complications of laparoscopic cholecystectomy forpatients with acute suppurative cholecystitis.J Laparoendosc Surg6:161-5,1996

24.WeissCA,3rd,Lakshman TV,SchwartzRW.:Currentdiagnosisandtreatmentofcholecystitis.CurrSurg59:51-4,2002

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－ 국문요약 －

중중중증증증 급급급성성성 담담담낭낭낭염염염 치치치료료료에에에 있있있어어어 복복복강강강경경경 담담담낭낭낭절절절제제제술술술의의의 유유유용용용성성성

아주대학교 대학원 의학과김 정 운

(지도교수:김 욱 환)

연구목적：이 연구는 중증 급성 담낭염 환자의 복강경 담낭 절제술후 수술 결과 및 이에 대한 분석을 토대로 중증 급성 담낭염 환자에있어 복강경 담낭절제술이 유용한 치료방법이 될 수 있는지 알아보기위하여 시행되었다．

재료 및 방법： １１２명의 중증 급성 담낭염 환자중 ９９명을 선택하여 ３７명의 수술전 경피경간 담낭 배액술을 시행받은 군（group1)과６２명의 수술전 경피경간 담낭 배액술을 시행받지 않은 군 （group2)으로 나누고 ５９명의 급성 및 만성 담낭염 환자 군 (group3)을 비교군으로 선정하였다．

결과： 개복술로의 전환율은 １군（group 1) ２.７％（１／３７），２군（group2) ６.５％（４／６２），３군（group 3) 1.7% (1/59)이었다．수술후입원기간 및 수술시간은 １군과 ２군이 ３군에 비해 유의하게 차이가

- 36 -

있었다．２군에서 수술후 입원기간과 나이，수술후 입원기간과 ASA class사이에는 각각 서로 상관관계가 있었으나 수술까지 걸린 시간 과 수술시간， 수술까지 걸린 시간과 수술후 입원 기간 사이에는 각각 상관관계가 없었다．그러나 중증 급성 담낭염 환자에 있어 수술까지 걸린 시간과 개복술로의 전환율은 높은 상관관계를 보였다．

결론：중증 급성 담낭염 환자 치료에 있어 경피 경간 담낭 배액술은중증의 중복 이환자에게 선택적으로 시행되어야 하며， 경피 경간 담낭배액술이 적용되지 않는 중증 급성 담낭염 환자의 경우， 조기 복강경담낭 절제술은 개복술로의 전환율을 낮추는 유용한 수술방법이다．

핵심되는 말:중증 급성 담낭염,복강경 담낭 절제술