吲哚菁绿荧光引导腹腔镜胆囊切除术治疗急性胆囊炎的临床疗效及其术后并发症相关因素分析

Analysis of the therapeutic effect and postoperative complications related factors of indocyanine green fluorescence guided laparoscopic cholecystectomy for acute cholecystitis

摘要:

目的 探究吲哚菁绿（ICG）荧光引导腹腔镜胆囊切除术（LC）治疗急性胆囊炎的临床疗效，并分析发生术后并发症的相关因素。方法 回顾性分析2020年9月－2024年9月于该院行LC治疗的279例急性胆囊炎患者的临床资料。其中，行ICG荧光引导LC的179例患者为荧光组［按术前注射剂量和时间分为：A组（47例，15 min，2.5 mg）、B组（45例，30 min，2.5 mg）、C组（48例，30 min，5.0 mg）和D组（39例，60 min 5.0 mg），观察4组术中荧光显影情况］，同期行常规LC的100例患者为白光组。比较荧光组和白光组患者围术期指标、肝功能及术后3个月并发症的发生情况；采用多因素Logistic回归模型，分析急性胆囊炎患者行ICG荧光引导LC术后发生并发症的危险因素，并构建决策树模型。结果 A组肝脏荧光强度高于B组、C组和D组，差异有统计学意义（P < 0.05）；B组的胆囊管与肝脏荧光强度对比值高于A组、C组和D组，差异有统计学意义（P < 0.05）。荧光组的完全解剖胆囊三角时间、手术时间和术后住院时间明显短于白光组，术中出血量少于白光组，差异均有统计学意义（P < 0.05）。多因素Logistic回归分析显示，体重指数（BMI） ≥ 25 kg/m²（OR＾ = 3.534，95%CI：1.057～11.811）、发作至手术时间 ≥ 72 h（OR＾ = 3.208，95%CI：1.227～8.390）、有三角解剖变异（OR＾ = 2.870，95%CI：1.085～7.590）、胆囊壁厚度 ≥ 5 mm（OR＾ = 2.957，95%CI：1.147～7.625）和美国麻醉医师协会（ASA）分级为Ⅲ级～Ⅳ级（OR＾ = 3.179，95%CI：1.245～8.118），均为急性胆囊炎患者行ICG荧光引导LC术后发生并发症的独立危险因素（P < 0.05），医师熟练程度 ≥ 5年（OR＾ = 0.280，95%CI：0.081～0.970）是急性胆囊炎患者行ICG荧光引导LC术后发生并发症的保护因素（P < 0.05）。决策树模型显示，医师熟练程度是最重要的预测因子，模型的分类准确率为91.40%。结论 急性胆囊炎患者术前30 min注射2.5 mg的ICG，可获得最佳术中荧光显影。对于行LC治疗的急性胆囊炎患者，ICG荧光引导LC，安全有效，可缩短手术时间，减少出血，加快康复。BMI ≥ 25 kg/m²、发作至手术时间 ≥ 72 h、三角解剖变异、胆囊壁厚度 ≥ 5 mm和ASA分级为Ⅲ级～Ⅳ级，是急性胆囊炎患者行ICG荧光引导LC术后发生并发症的独立危险因素，医师熟练程度 ≥ 5年是保护因素，术前应充分评估，以降低术后发生并发症的风险。

Abstract:

Objective To investigate the clinical efficacy of indocyanine green (ICG) fluorescenceguided laparoscopic cholecystectomy (LC) for acute cholecystitis (AC) and analyze factors associated with postoperative complications (PCs).Methods A retrospective analysis was conducted on 279 AC patients who underwent LC (September 2020 to September 2024). Among them, 179 underwent ICG fluorescence guided LC (fluorescence group) and were subdivided by injection timing/dose: group A (47 cases, 15 min, 2.5 mg), group B (45 cases, 30 min, 2.5 mg), group C (48 cases, 30 min, 5.0 mg), and group D (39 cases, 60 min, 5.0 mg) to assess biliary visualization. Concurrently, 100 patients underwent conventional LC (white light group). Perioperative indicators, liver function, and 3-month PCs were compared. Multivariate Logistic regression and a decision tree model identified risk factors for PCs.Results Liver fluorescence intensity was highest in group A (P < 0.05). The cystic duct-to-liver fluorescence contrast ratio was highest in group B (P < 0.05). The fluorescence group showed shorter Calot triangle dissection time, operative time, postoperative hospital stay, and less intraoperative blood than the white light group (all P < 0.05). Multivariate Logistic regression identified independent risk factors for PCs: body mass index (BMI) ≥ 25 kg/m2 (OR＾ = 3.534, 95%CI:1.057 ~ 11.811), onset-to-surgery time ≥ 72 h (OR＾ = 3.208, 95%CI:1.227 ~ 8.390), anatomical variation of Calot's triangle (OR＾ = 2.870, 95%CI: 1.085 ~ 7.590), gallbladder wall thickness ≥ 5 mm (OR＾ = 2.957, 95%CI: 1.147 ~ 7.625), and American Society of Anesthesiologists (ASA) grade III ~ Ⅳ (OR＾ = 3.179, 95%CI: 1.245 ~ 8.118) (all P < 0.05). Surgeon experience ≥ 5 years was a protective factor (OR＾ = 0.280, 95%CI: 0.081 ~ 0.970, P < 0.05). The decision tree model (accuracy 91.40%) identified surgeon experience as the most important predictor.Conclusion Preoperative ICG injection (2.5 mg, 30 min) provides optimal fluorescence imaging. ICG-guided LC is safe and effective for AC, reducing operative time, blood loss, and hospital stay. Independent risk factors for PCs include BMI ≥ 25 kg/m2, onset-to-surgery time ≥ 72 h, anatomical variation of Calot's triangle, gallbladder wall thickness ≥ 5 mm, and high ASA grade III ~Ⅳ; Surgeon experience ≥ 5 years is protective. Preoperative thorough evaluation is essential to reduce the risk of postoperative complications.