Korean Journal of HBP Surgery 원 저 Vol. 5, No., February 0 70 세이상의급성담낭염환자에서조기복강경담낭절제술과경피적담낭조루술후지연담낭절제술의임상적결과의비교 Comparison of Clinical Result between Early Laparoscopic Cholecystectomy and Delayed Laparoscopic Cholecystectomy after Percutaneous Transhepatic Gallbladder Drainage (PTGBFD) in more than 70 Years Old Patients with Acute Cholecystitis Purpose: Operative management of acute cholecystitis in aged patients has been shown to have relatively higher morbidity and mortality. The aim of this study was to determine appropriate management protocols for acute cholecystitis in those more than 70 years old. Methods: From May 003 to Dec 009, we performed this study of patients over 70 years old that were diagnosed with acute cholecystitis (n=57). We excluded patients that had a hepatobilliary malignancy, a previous laparotomy history, secondary cholecystitis, or a high operative risk factor (n=78). Eligible participants were divided into two groups according to the first management of acute cholecystitis. One hundred two of the 79 (group A) had undergone a laparoscopic cholecystectomy (LC) or open cholecystectomy (OC) within 48 hr after arriving at the emergency room; 77 of the 79 (group ) had PTGBD done as the first management protocol. We divided group into group C (n=47) and D (n=30) according to cholecystectomy or not. We compared clinical outcomes of the two groups. Results: The mean age of patients was 77.5 years old (0 for Group A and 77 for Group B. Univariant analysis of pre-operative clinical findings between groups A and B showed a significant difference only in age and in type of acute cholecystitis, However, the pre-operative co-morbidity of group B was significantly higher than that for group A. Comparing postoperative results between groups A and C, postoperative complications, open conversion rate, and mortality after cholecystectomy were not significantly different. Conclusion: PTGBD could be considered as appropriate management in aged patients with acute cholecystitis. Moreover, PTGBD can reduce unnecessary cholecytectomies. Key Words : Acute cholecystitis, Old age patients, Percutaneous transhepatic cholecystostomy, Early laparoscopic cholecystectomy, Delayed laparoscopic cholecystectomy 중심단어 : 급성담낭염, 고령환자, 경피적담낭조루술, 조기복강경담낭절제술, 지연복강경담낭절제술 김소희, 정금오, 채권묵, 오정택, 박동은 원광대학교의과대학외과학교실, 간담췌분과 So Hee Kim, M.D., Gum O Jung, M.D., Kwon Mook Chae, M.D., Jung Taek Oh, M.D., Dong Eun Park, M.D. Department of Surgery, Division of Hepatobiliary Surgery, Wonkwang University College of Medicine 책임저자 박동은전북익산시신용동 344- 원광대학교병원외과학교실우편번호 570-7 Tel: 063-859-490 Fax: 063-855-389 E-mail: Knife@wonkwang.ac.kr * 이논문은 009 학년도원광대학교교비지원에의해서수행됨. Received: 00. 8. 7 Accepted: 00. 0. 서론 복강경담낭절제술은 987년 Mouret 에의해발표된이후로담낭담석증및담낭용종등의담낭양성질환에있어서개복술을대체할수있는표준술식이되었다. 급성담낭염은복강경수술시주변조직과의과도한유착및부종, 해부학적 변화로인하여복강경담낭절제술의상대적인금기증으로인식되어왔지만복강경수술의술기, 장비등의비약적인발전과축적된경험을통해급성담낭염에서도역시표준술식으로인식되고있다.,3 하지만아직까지급성담낭염은복강경담낭절제술중여전히높은개복술로의전환 (6 3%) 을보이고있다. 4 담낭염은나이가증가함에따라발생률이증가하고, 특히고령혹은고위험군에서는여러장기의기능저하및면역 8
김소희외 : 노령환자급성담낭염치료에서경피적담낭조루술의효과 기능의저하또한동반질환들로인해개복이나복강경에의한담낭절제술후비교적높은사망률과이환률을보이고있어 5-7 이런환자군에서의급성담낭염치료방법의선택은어려운일이다. Radder 8 에의해 980년초음파유도하경피담낭조루술을시행한이래로고령의환자혹은수술고위험군에서급성담낭염의급성염증치료에효과적으로시행되어왔으며 9 또한일부저자들은담낭조루술을시행한환자에서급성염증의감소후에시행한담낭절제술은낮은개복전환률을보인다고보고하였다. 0 하지만몇몇저자들은고령및고위험군환자에서도일차적으로복강경담낭절제술은안정하고적절한치료가될수있다고보고하고있다. 이에저자들은고연령 (>70세) 에서급성담낭염환자의일차적인치료로복강경담낭절제술을시행한군과초음파유도하담낭조루술후일정기간후복강경담낭절제술을시행한군의비교분석을통해고령환자에서급성담낭절제술의일차적치료방법의선택에도움을주고자하였다. 방법. 대상군 003년 3월부터 009년 월까지급성담낭염으로진단된 70세이상환자 57명중에급성담낭염진단후 48시간이내복강경담낭절제술을시행한환자 0명과경피담낭배액술 (percutaneous transhepatic gallbladder drainage; PTGBD) 을시행한환자 77명을대상으로하였다. 급성담낭염의진단은수술전백혈수증가증 (>0 4 /mm 3 ), 심한우상복부동통및 Murphy 증후양성환자에서컴퓨터복부단층촬영또는복부초음파를통해서담낭벽의비후, 담낭주위의삼출물의저류및담낭주위농양소견으로진단하였다. 또한만성담낭염으로진단하에시행한수술중담낭벽의비후및염증소견, 담낭주위농양, 칼로씨삼각대 (Carot s triangle) 의비후및소실, 담낭점막의육안적급성염증소견을보인경우에는만성담낭염의급성악화로진단하여급성담낭염의범주에포함하였다. 저자들은원발성급성담낭염의환자군의선정에서총담관및간내담도의병적소견에 ( 종괴및담석 ) 의해합병증으로발생한급성담낭염의경우는배제하였다. 또한수술의부적합자로알려진 ASA (American society of anesthesiology) grade IV, 뇌경색으로진단받고치료한지 3개월미만의환자, 최근 3개월사이에허혈성심장질환으로치료를받은기왕력이있는환자, 호흡부전및심한폐렴및폐병변을가지환자, 수술후호흡부전을일으킬수있다고판단되는환자의경우이연구에서배제되었다. 저자들은급성담낭염의일차적치료로복강경담낭절제술을선택하였고, 수술할수있는상태가되는환자에서의료진의충분한설명에도불구하고보호자또는환자가수술을거부하거나간담도전문의의판단하에동반된내과적질환및현재상태가수술의안정성및복강경담낭절제술중개복전환가능성이높다고판단되었을때경피담낭조루술을시행하였다. 복강경담낭절제술은 5년이상의경력을가진간담췌외과전문의 명에의해서이루어졌고환자가응급실내원한지 48시간이내에시행하였고전신마취하에제대부하방에.0 cm 정도의절개와함께담침 (Veres needle) 을이용하여이산화탄소를복강내주입하여 0 mmhg복압을유지하였고제대부절제에 0 mm 투관침 (trocar) 을통하여복강경카메라를삽입하여표준 3공식으로수술을진행하였고필요에따라서 개의투관침추가하여 4공식으로진행하였다. 만일해부학적구조의판단이어렵거나주변주직의손상위험및더이상복강경수술의진행이어렵다고판단된경우개복술로전환하였다. 경피담낭조루술은영상의학과전문의에의해서만시행되었고초음파유도하에 8.5 F catheter를삽입한후담낭액 0 cc정도를흡입하여배양검사를실시하였고광범위항생제를초기에적용한후담낭액배양검사에서동정된세균에민감도를보이는항생제로교체후 주일간투여하였다. 경피담낭조루술을시행한모든환자는시술후 주일후에담도조영술을시행하였고담도조영술에서담낭내담석이있거나담낭관의폐쇄소견이보이는경우시술후 3주이후복강경또는개복적담낭절제술을시행하였고담낭내담석소견이없으면서담낭관폐쇄의소견이없는경우시술후 3주째담낭배액관을제거하였다. 환자및보호자가수술을원하지않을경우경피담낭조루술제거후 개월동안담낭염의재발및합병증발생에대해서외래추적관찰을시행하였다.. 방법 70세이상의급성담낭염환자에서일차적치료로초기담낭절제술을시행받았던 0명의환자들은 group A로, 경피담낭조루술을시행했던 77명의환자들은 group B로분류하였고, 또한경피담낭조루술을시행한환자군에서환자의상태 9
한국간담췌외과학회지 : 제 5 권 호 0 Fig.. Classification of the patients. *Four of 47 who were underwent delayed laparoscopic cholecystectomy have been belong among group D. 및증상이호전된후담낭절제술을시행했던 47명을 group C로, 수술적치료없이담낭배액관을제거한군을 group D로분류하였다. 각군의환자들에대해서후향적방법으로성별, 나이, 수술전신체검진및검사실소견을조사하였으며수술중소견을통해서급성담낭염을담낭의염증및비후, 주변조직과의단순유착을보이는경우는단순급성담낭염으로분류하였으며담낭의괴사및담낭주위농양및주위조직과의심한유착을보이는경우합병성급성담낭염으로분류하였고복강경담낭절제술중개복술로전환된비율을조사하였으며수술후환자의사망및합병증발생과함께퇴원까지의기간에대해서조사하였다. 저자들은급성담낭염진단후초기치료로조기복강경또는개복적담낭절제술을시행한군과경피적담낭조루술후지연담낭절제술을시행한환자의임상적결과를비교하였다. 3. 통계 SPSS package (ver 3.0) 이용하여통계분석을실시하였으며연속변수에대해서는분산검증후 T-test를시행하였으며명목변수에서대해서는 Chi-square를시행하였다. 통계적유의성은 p값이 0.05 미만인경우로정의하였다. 결과 연구기간중급성담낭염으로진단된 70세이상의환자는 57명이었으며이중 78명은정의된배제요건에따라서배제되어 79명을대상으로연구가진행되었다. 이중 0명은진단후 48시간이내에복강경하또는개복하담낭절제술을시행하였으며 77명은경피담낭조루술를시행하였다. 경피담낭조루술을시행한환자중 47명에서담낭절제술이시행되었고 47명중 4명은배액관제거후급성담낭염의재발로인하여복강경담낭절제술을시행받았으며 30명은수술없이배액관을제거하였다 (Fig. ). 79명의평균나이는 77.5세였고남녀성비는.08 : 로남성이조금많았으며 70세에서 79세가전체환자의 명 (67.6%), 80세이상의환자는 58명 (3.4%) 였다. 담낭염의원인으로는담낭내담석이 45명 (8.0%) 였으며무결석성담낭염은 34명 (9.0%) 였다. 급성담낭염의형태적으로단순급성담낭염과담낭주위농양및담낭괴사성담낭염, 담낭축농을복잡성담낭염으로분류하였고각각 75 (4.9%) 와 04명 (58.%) 였다 (Table ). 수술전임상적소견에따라서 group A와 group B을비교하였을때나이가많을경우특히 80세이상의환자에서그리고급성담낭염이외에내과적으로동반질환및그에따른 30
김소희외 : 노령환자급성담낭염치료에서경피적담낭조루술의효과 Table. Demographic finding of patients Chracteristics N=79 (%) Sex Age (years) Distribution Cause of acute cholecystitis Type of acute cholecystitis Type of management Male female 70 79 80 Simple Complicated* Early operation PTGBD late operation PTGBD only 93 (5.0%) 86 (48.0%) 77.5±5.50 (67.6%) 58 (3.4%) 34 (9%) 45 (8%) 75 (4.9%) 04 (58.%) 0 (57%) 47 (6.3%) 30 (6.8%) *Gallbladder empyema, pericholecytic abscess, and acute gangrenous cholecystitis were defined as acute complicated cholecystitis; Early operation was performed within 48 hours after patients have arrived at hospital; Late operation was defined as case that underwent cholecystectomy after 3 week, since PTGBD 치료를시행하고있을때통계적으로유의하게초기급성담낭염의치료로경피적담낭조루술이선택되었고급성담낭염의형태적인분류에따른초기급성담낭염의치료방법은통계적으로유의한차이를보이고있었다. 하지만환자의증상발견기간, 급성담낭염의원인이나수술전검사실소견에따라치료적방법의선택에서는차이가없었다. Group A와 group B에서급성담낭염의치료전임상증상의발현기간은각각.8 일및 3.일이었고통계적인차이는없었다. Group B에서경피적담낭조루술후담낭배액관의담낭내탈출은 6예에서발생하였고이중 예는삽관후 주일이내발생하였고신체검사상복막자극증상을보여복강경담낭절제술을시행하였고 4예는삽관후 주이후발생하였으나특별한증상이발견되지않아관찰중 4주째 명, 8주째 명에서급성담낭염소견을보여복강경담낭절제술을시행하였다. 명은배액관제거후 3개월에담낭염의재발로복강경담낭절제술을시행하였다. 경피담낭조루술후발생한합병증으로 8명에서흉낭삼출이발생하였으나특별한치료없이경과관찰후회복되었으며 명에서출혈이있었으나시술후 4시간이내지혈되어즉시수술없이경과관찰할수있었다. 경피담낭조루술후담즙누출에의한환자의복막염증상은연구기간중발생하지않았다 (Table ). 초기담낭절제술을시행했던환자군 (group A) 과급성담낭염의치료로서경피담낭조루술를우선적으로선택했던환자중에서지연담낭절제술을시행한군 (group C) 과의수술후결과를비교하였을때각각의수술시간은 75 분과 69분이었고복강경수술을시도한후개복술로전환한경우는각각 3명 (.7%) 와 4명 (8.5%) 였고수술후수술과연관된합병증은각각 6예 (5.8%) 와 예 (4.%) 였고입원기간중발생한합병증은각각 8예 (7.8%) 와 3예 (6.4%) 였고입원기간은각각 9.6일과 6.6일로각군간의비교에서수술기간, 개복전환률, 수술후합병증및입원기간의합병증발생에대한통계적차이는보이지않았고, 수술후사망자는 group A에서 예로담즙누출에의한다장기부전증에의한사망 예와폐렴의악화에의한급성호흡부전증에의한사망 예가있었으며 group C에서는폐렴에의한급성호흡부전증으로 예가발생하였고이는통계적인차이를보이고있지않았다 (Table 3). 급성담낭염의치료로경피담낭조루술 3주후에시행한담도조영술상담낭내담석이없으면서담도계의폐쇄소견이나담낭관의협착및담도또는유두팽대부의협착이없는환자의경우와담낭내담석이있더라도환자가수술을거부하는경우는담낭절제술없이배액관을제거하여치료를중단하였던 group D의환자는 34명으로모두단순급성담낭염소견을보여주고있었다. 4명에서 3주이내배액관의탈출이있었고 명에서담낭염의재발이있었고또한 3개월이후 명에서담낭염의재발이발생하여모두복강경하담낭절제술을시행후특별한합병증은발생하지않았다 (Table 4). 고찰 나이가증가함에따라서신체장기기능의저하, 면역기능의저하및연령증강에따른동반된내과적질환의증가는수술후합병증의발생을증가시키는동시에수술후사망률의증가에직간접적인영향을미치고있다. 현재평균생존연령의증가로인하여고연령군에대한정의는최근수술기술및마취기술의발전에의해서점차적으로상향조정되고있는것이현실이지만아직까지고연령군의수술은특히, 응급수술의경우더욱더환자에게상당한스트레스로작용하여수술후심폐장기및위장관, 비뇨기계통의합병증을증가시켜재원일수를증가시키는동시에동반된내과적질환의악화로인하여수술사망률의증가로연결된다. 5-7 급성담낭염의치료에서도과거에는고령환자에서수술은상대적금기증이이었지만점 3
한국간담췌외과학회지 : 제 5 권 호 0 Table. Comparison of preoperative clinical findings according to management of acute cholecystits between two groups in over 70 year old patients Group A (0) Group B (77) p-value sex Age Age distribution Cause of cholecystitis Type of acute cholecysitits Cormorbidity before operation Preoperative Laboratory study WBC AST ALT GGT Duration of Sx Complication of PTGBD Man Female 0 79 80 Simple Complicated DM Hypertension Heart disease Lung disease CVA Kidney Liver Dislogement Pleural effusion Bleeding 5 (54.8%) 5 (59.3%) 75.6±4.4 83 (68.6%) 9 (3.8%) 7 (50.0%) 85 (58.6%) 36 (48.0%) (.%) 34 (59.6%) 66 (63.5%) 5 (93.8%) 5 (58.0%) 66 (64.7%) 5 0 5 4 3.45±5.00 56.4±6.3 50.7±63.5 9.6±9.8.8±0.8 4 (45.%) 35 (40.7%) 80.±5.8 38 (3.4%) 39 (67.%) 7 (50.0%) 60 (4.4%) 39 (5.0%) 6 (88.9%) 3 (40.4%) 38 (36.5%) (6.%) 37 (43.0%) 6 (80.4%) 6 35 4 4 6.65±5.74 70.9±09.4 63.7±8.8 7.8±0.6 3.3±. 6 (7.8%) 8 (0.4%) (.%) 0.65 <0.00 <0.00 0.44 0.047 0.09 0.088 0.65 0.3 0.006 0.30 0.890 0.733 0.39 0.30 0.345 0.79 0.54 차적으로 차적으로복강경담낭절제술의안전성이보고되고있으며, 이는고령에서도역시수술후통증이적어회복이빠르고폐합병증이낮고면역학적인이점이있기때문에복강경담낭절제술은표준술식으로언급되고있다. 하지만급성담낭염의복강경수술을통한치료는일반양성담낭양성질환 ( 담석증, 폴립등 ) 에의한복강경담낭절제술과비교해서상대적으로높은개복술로의전환및합병증의발생등은고령환자에서적극적인수술적치료만으로고집할수없는이유이기도하다. 4,7 그리고 Bergman 등은고령일수록특히 75세이상에서동반질환의심각성때문에수술적치료보다는보전적치료로경피적담낭조루술이나역행성담도조영술을통한방법 으로증상이있는담낭석을치료하고있는것으로보고하면서고령은비수술적치료의중요한인자로보고하였다. 3 98년 Radder에의해서발표된초음파유도하담낭배액술은수술고위험군에서일시적으로급성담낭염의증상을완화시키는방법으로소개되었다. 8 급성담낭증환자에게경피적담낭조루술를먼저시행함으로서담낭과주위조직의유착을완화시키고염증의진행을경감시켜담낭의팽대완화및담낭벽비후의경감으로증상을경감시킬수있고이후시행될수있는복강경수술을더욱용이해질수있고또한응급수술을피할수있어수술전환자의전신상태와기왕력또는동반될수있는담도계질환을파악할수있어환자의안전성확보에 3
김소희외 : 노령환자급성담낭염치료에서경피적담낭조루술의효과 Table 3. Comparison of postoperative result between group A and group C Operation time (±SD) Open & open conversion Postoperative complication Subphrenic abscess Trocar site infection Bile leak* Postop bleeding Perioeprative complication Ischemic heart disease Pneumonia Pyelonephritis Ileus (>7 day) Hospital day (±S.E.) Death Sepsis (d/t bile leak) pneumonia Group A (n=0) 75.6±45.5 6 (5.7%) 6 (5.8%) 8 (7.8%) 3 9.67±.56 (.0%) Group C (n=47) 69.3±30.0 5 (0.6%) (4.%) 3 (6.4%) 6.65±0.6 (.%) p-value 0.5 0.584 0.83 0.764 0.00 0.946 *This patient recovered completely without surgical management; Patients of each group was converted from laparoscopic cholecystectomy to open cholecystectomy 정점이있다. 0,4 본연구의경우경피적담낭조루술을실시한후 주일때담도조영술을시행하였고모든환자들은 3주이후에계획된지연담낭절제술을시행하였는데지연복강경담낭절제술을시행하는시기뿐만아니라지연담낭절제술에대한효과에대해서는저자들마다이견이존재한다. Kim 등 5 은담낭조루술후 3주이후시행된지연복강경담낭절제술은.6% 의개복전환률과함께 5.4% 의합병증을발생률을보였다고보고하고있으며 Kim 등 6 은담낭조루술 7시간이후복강경담낭절제술을시행한군에서개복전환은.7%, 합병증발생은 4.5% 로보고하여경피담낭조루술 7시간후그리고 5일이내하는것이더좋은결과를보일수있다고보고하였다. 본연구에서는개복전환률은 0.6%, 합병증발생률은 4.% 로통계적으로의의는없었지만조기복강경담낭절제술을시행한환자군보다는상대적으로낮은것을보여주었다. 본연구에서 70세이상의급성담낭염환자들에게서초기치료방법의선택으로복강경담낭절제술또는경피적담낭조루술의선택에있어서명확한기준을제시하기는어렵지만절 Table 4. Characteristics and progression of removed PTGBD patients without operation Age 70 79 80 Cause of cholecystitis Type of cholecystitis - simple - simple In hospital complication Dislodgment of catheter Pneumonia Death Recurrent cholecysitis* Group D (n=30) 8.±6. 8 4 (46.7%) 6 (53.3%) 6 (46.7%) 4 (53.3%) 3 0 4 (3%) *Four patients who experienced a recurrent acute cholecystitis were belong among group C 대적수술의금기증이아닌상태에서저자들은우선적으로복강경담낭절제술을원칙으로하였다. 내당시동반된내과적질환의심각도및항혈소판제약물또는항응고제복용의기왕력등과함께환자의연령이 80세를넘는경우에경피적담낭조루술를우선적으로선택하는경향을보이고있었다. 경피담낭조루술를시행했던환자들중다시복강경담낭절제술을시행했던환자는 77명중 47명이이었고이들의수술후임상적결과는초기급성담낭염의치료로조기복강경담낭절제술을시행했건환자군과비교했을때수술시간, 개복전환률, 합병증발생률및사망률은통계적차이를보이고있지않았지만상대적으로경피담낭조루술후지연복강경담낭절제술에서개복전환및합병증은발생은낮을것을보였다. 이런결과는경피적담낭조루술의경우계획된수술전까지충분한염증의조절및환자의상태를파악한후내과적문제의조절과수술이가능한상태를유지할수있는충분한시간을가질수있기때문에고령환자에서경피적담낭조루술이후적극적인수술적치료를시행할수있었다경피담낭조루술후지연복강경담낭절제술을시행하지않고담도조영술상담도및담낭관의폐쇄소견이관찰되지않아배액관을제거한 34명의환자중 4명의환자에서재발이있었고재발된환자들에게경피담낭조루술당시수술을염두에둔충분한검사및환자상태파악이시행되어있었고환자및보호자에게재발에대한적절한 33
한국간담췌외과학회지 : 제 5 권 호 0 교육이있었기때문에재발시이른시간에병원도도착할수있었고 (4명은증상발현 4시간이내병원재방문을하였음 ) 조기에복강경담낭절제술을통하여특별한합병증없이퇴원할수있었다. 그리고 30명중일부에서는저자들의의도와는다를지라도 ( 환자및보호자의수술거부 ) 부가적인수술적치료를피할수있었다. 저자들은 000년이전시행된급성담낭염의치료로복강경담낭절제술중개복술로의전환인자연구에서 60세이상에서 40% 가넘는개복전환을보여주어중요한인자로제시하였으나 7 본연구에서는 70세이상에서도 9% 정도로낮은개복전환을보이고있었고이는 000년이후괄목한말한복강경기술및장비의발달에의한것으로사료되며이런복강경의기술은연령에상관없이안전하게사용될수있지만결국고령환자에서는환자의전신상태의안정이수술을결정짓는가장중요한요인으로고려할수있을것이다 결 론 저자들은원발성급성담낭염환자 79명중 77명에서경피담낭조루술을시행하였고이중 47명에서지연복강경담낭절제술을시행하여조기복강경담낭절제술을시행한환자군에서비해낮은합병증및개복전환률을보여주었고또한 30명에서는배액관을제거후에도더이상의추가적인복강경담낭절제술없이치료를마칠수있었다. 따라서위의결과로볼때경피담낭조루술후지연담낭절제술은수술에대한심각한위험인자를지니고있는환자에서뿐만아니라고령의원발성급성담남염환자에서도급성담낭염의치료에서 차적인치료방법으로선택할수있는치료방법으로생각된다. 참고문헌. Mouret P. From the first laparoscopic cholecystectomy. Dig Surg 987;8:4-5.. Kim DD, Kang KJ, Lim TJ. The comparative study of laparoscopic and open cholecystectomy for acute cholecystitis. J Korean Endosc Laparosc Soc 00;4:-9. 3. Ahrent SA Pitt HA. Biliary tract. In: Townsend CM Jr. editor. Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 6th ed. Philadelphia: WB Saunders; 00.086-09. 4. Knight JS, Mercer SJ, Somers SS, Walters AM, Sadek SA, Toh SK. Timing of urgent laparoscopic cholecystectomy does not influence conversion rate. Br J Surg 004;9:60-604. 5. Vogelzang RL, Nemcek AA Jr. Percutaneous cholecystostomy: diagnosis and therapeutic efficacy. Radiology 988;68:9-34. 6. Savoca PE, Longo WE, Zucker KA, McMillen MM, Modlin IM. The increasing prevalence of acalculous cholecystitis in outpatients. Results of a 7-year study. Ann Surg 990;: 433-437. 7. Zucker KA, Flowers JL, Bailey RW, Graham SM, Buell J, Imbembo AL. Laparoscopic management of acute cholecystitis. Am J Surg 993;65:508-54. 8. Radder RW. Percutaneous cholecystostomy. AJR Am J Roentgenol 98;39:40-4. 9. Sugiyama M, Tokuhara M, Atomi Y. Is percutaneous cholecystostomy the optimal treatment for acute cholecystitis in the very elderly? World J Surg 998;:459-463. 0. Chikamori F, Kuniyoshi N, Shibuya S, Takase Y. Early scheduled laparoscopic cholecystectomy following percutaneous transhepatic gallbladder drainage for patients with acute cholecystitis. Surg Endosc 00;6:704-707.. Yi NJ, Han HS, Kim YW, Min SK, Choi YM. The Safety of a Laparoscopic Cholecystectomy in Acute Cholecystitis in High Risk Patients Older than Sixty. J Korean Surg Soc 003;64:396-40.. Volpino P, Cangemi V, D'Andrea N, Cangemi B, Piat G. Hemodynamic and pulmonary changes during and after laparoscopic cholecystectomy. A comparison with traditional surgery. Surg Endosc 998;:9-3. 3. Bergman S, Sourial N, Vedel I, et al. Gallstone disease in the elderly: are older patients managed differently? Surg Endosc 0;5:55-6. 4. Lee SM, Joe S, Lee MK, Park JS. Usefulness of Preoperative Percutaneous Transhepatic GB Drainge on Laparoscopic Cholecystectomy in Patients with Acute Cholecystitis. Korean J Hepatobiliary Pancreat Surg 00;6:67-7. 5. Kim H, Kim HO, Shin JH. Comparison of early versus delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage (PTGBD) for patient with complicated acute cholecystitis. J Korean Surg Soc 007;73: 39-333. 6. Kim JM, Kim KS, Kim KH. Percutaneous gallbladder drainage and optimal timing for successful laparoscopic cholecystectomy in acute complicated cholecystitis. J Korean Surg Soc 007;73:4-45. 7. Jung GO, So BJ, Chae KM, Park DE. The preoperative and intraoperative factors for conversion from laparoscopic to open cholecystectomy for treatment of acute cholecystitis. J Korean Endosc Laparosc Soc 00;5:-9. 34