目的:比较经腹腔镜胆总管切开取石术(LCBDE)术中联合胆道镜与内镜下逆行胰胆管造影术(ERCP)及Oddi括约肌切开取石术(EST)治疗胆囊切除术后胆总管结石的疗效,对此类胆总管结石患者手术方式的选择提供依据。方法:选取胆囊切除术后胆总管结石患者临床资料120例,其中采用经腹腔镜下胆总管切开取石术患者60例,ERCP/EST取石术患者60例,比较两种手术方式治疗胆总管结石的成功率、手术时间、术中出血、平均住院时间、术后并发症及平均住院费用等指标。结果:两组患者在性别、年龄、合并基础疾病等术前相关指标无统计学差异(P > 0.05)。LCBDE组与ERCP/EST组患者取石成功率(95.0% VS 93.3%),术中出血量[(40.36 ± 8.45) ml VS (30.25 ± 6.25) m]等比较无统计学意义(P > 0.05);ERCP/EST组在手术时间[(45.73 ± 13.25) min VS (155.36 ± 23.25) min]及平均住院时间[(9.23 ± 1.78) d VS (13.25 ± 2.36) d]上要优于LCBDE组(P < 0.05),但ERCP/EST组术后并发症(30% VS 1%)及平均住院费用[(23.125 ± 1.23 VS 14.849 ± 1.84)千元]要高于LCBDE组,差异有统计学意义(P < 0.05)。结论:两组手术方式均能够安全、有效治疗胆总管结石,ERCP在手术时间、术后住院时间方面较LCBDE有明显优势,但对于年轻病人及结石较大的病人LCBDE是更好的选择,但选择哪种手术方式需要根据患者身体情况及经济条件制定个体化方案。 Objective: To compare the efficacy of Laparoscopic common bile duct exploration (LCBDE) combined with endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy of Oddi (EST) in the treatment of common bile duct stones after cholecystectomy, to provide the basis for the choice of surgical methods in patients with common bile duct stones. Methods: The clinical data of 120 patients of common duct bile stones after cholecystectomy treated with LCBDE (n = 60) and ERCP/EST (n = 60) were retrospectively analyzed. The success rate, operation time, intra-operative bleeding, the average of hospital stay, postoperative complications and average hospitalization expense of the two operations were compared. Results: Between LCBDE and ERCP/EST group, there was no significant difference in terms of sex, age , basic diseases before Operation, the successful rate of stone remova (95.0% VS 93.3%) and intra-operative bleeding (40.36 ± 8.45 ml VS 30.25 ± 6.25 ml) (P > 0.05). ERCP/EST group had shorter operative time [(45.73 ± 13.25) min VS (155.36 ± 23.25) min] and average length of hospital stay [(9.23 ± 1.78) d VS (13.25 ± 2.36) d] than LCBDE Group (P < 0.05), but the postoperative complications (30% VS 1%) and the average hospitalization expenses (23.125 ± 1.23 VS 14.849 ± 1.84) thousand yuan) were significantly higher than LCBDE Group (P < 0.05). Conclusions: Both LCBDE and ERCP are safe and effective method for the treatment of common bile duct stones. ERCP has obvious advantages over LCBDE in terms of operative time and postoperative hospital stay, but for younger patients with large stones, LCBDE is a better choice, however, the clinical treatment should be individualized according to the patient’s own and economic conditions.
目的:比较经腹腔镜胆总管切开取石术(LCBDE)术中联合胆道镜与内镜下逆行胰胆管造影术(ERCP)及Oddi括约肌切开取石术(EST)治疗胆囊切除术后胆总管结石的疗效,对此类胆总管结石患者手术方式的选择提供依据。方法:选取胆囊切除术后胆总管结石患者临床资料120例,其中采用经腹腔镜下胆总管切开取石术患者60例,ERCP/EST取石术患者60例,比较两种手术方式治疗胆总管结石的成功率、手术时间、术中出血、平均住院时间、术后并发症及平均住院费用等指标。结果:两组患者在性别、年龄、合并基础疾病等术前相关指标无统计学差异(P > 0.05)。LCBDE组与ERCP/EST组患者取石成功率(95.0% VS 93.3%),术中出血量[(40.36 ± 8.45) ml VS (30.25 ± 6.25) m]等比较无统计学意义(P > 0.05);ERCP/EST组在手术时间[(45.73 ± 13.25) min VS (155.36 ± 23.25) min]及平均住院时间[(9.23 ± 1.78) d VS (13.25 ± 2.36) d]上要优于LCBDE组(P < 0.05),但ERCP/EST组术后并发症(30% VS 1%)及平均住院费用[(23.125 ± 1.23 VS 14.849 ± 1.84)千元]要高于LCBDE组,差异有统计学意义(P < 0.05)。结论:两组手术方式均能够安全、有效治疗胆总管结石,ERCP在手术时间、术后住院时间方面较LCBDE有明显优势,但对于年轻病人及结石较大的病人LCBDE是更好的选择,但选择哪种手术方式需要根据患者身体情况及经济条件制定个体化方案。
胆总管结石,胆囊切除术后,经腹腔镜胆总管切开探查术,内镜逆行胰胆管造影术,Oddi括约肌切开取石术
Shili Zang, Li Ma, Jie Zhao
The Fifth People’s Hospital of Datong, Datong Shanxi
Received: Aug. 17th, 2021; accepted: Sep. 16th, 2021; published: Sep. 22nd, 2021
Objective: To compare the efficacy of Laparoscopic common bile duct exploration (LCBDE) combined with endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy of Oddi (EST) in the treatment of common bile duct stones after cholecystectomy, to provide the basis for the choice of surgical methods in patients with common bile duct stones. Methods: The clinical data of 120 patients of common duct bile stones after cholecystectomy treated with LCBDE (n = 60) and ERCP/EST (n = 60) were retrospectively analyzed. The success rate, operation time, intra-operative bleeding, the average of hospital stay, postoperative complications and average hospitalization expense of the two operations were compared. Results: Between LCBDE and ERCP/EST group, there was no significant difference in terms of sex, age , basic diseases before Operation, the successful rate of stone remova (95.0% VS 93.3%) and intra-operative bleeding (40.36 ± 8.45 ml VS 30.25 ± 6.25 ml) (P > 0.05). ERCP/EST group had shorter operative time [(45.73 ± 13.25) min VS (155.36 ± 23.25) min] and average length of hospital stay [(9.23 ± 1.78) d VS (13.25 ± 2.36) d] than LCBDE Group (P < 0.05), but the postoperative complications (30% VS 1%) and the average hospitalization expenses (23.125 ± 1.23 VS 14.849 ± 1.84) thousand yuan) were significantly higher than LCBDE Group (P < 0.05). Conclusions: Both LCBDE and ERCP are safe and effective method for the treatment of common bile duct stones. ERCP has obvious advantages over LCBDE in terms of operative time and postoperative hospital stay, but for younger patients with large stones, LCBDE is a better choice, however, the clinical treatment should be individualized according to the patient’s own and economic conditions.
Keywords:Common Duct Bile Stones, Post Cholecystectomy, Laparoscopic Common Bile Duct Exploration, Endoscopic Retrograde Cholangiopancreatography, Oddi Endoscopic Sphincterotomy
Copyright © 2021 by author(s) and Hans Publishers Inc.
This work is licensed under the Creative Commons Attribution International License (CC BY 4.0).
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目前,胆总管结石是临床上的常见的肝胆外科疾病,正常人群中的发病率8%左右 [
1) 资料:收集2018年1月~2020年12月在我院行ERCP治疗的胆囊切除术后胆总管结石患者60例(ERCP/EST组),行腹腔镜下联合胆道镜胆总管切开取石的患者60例(LCBDE组)。入组条件:a) 经腹部彩超或MRCP确诊为胆总管结石,且不合并肝内胆管结石;b) 既往有胆囊切除病史(开腹或腹腔镜均包括)无其它腹部手术史;c) 无重症胆管炎及胰腺炎患者;d) 术前肝功能Child-Pugh评分为A或B级者;e) 无严重并发症,心肺肾等重要脏器功能正常。两组术前一般情况见表1,各术前指标均无统计学意义(P > 0.05)。
LCBDE组 | ERCP/EST组 | χ2或t值 | P值 | |
---|---|---|---|---|
性别(男/女) | 26/34 | 25/35 | 0.211 | >0.05 |
年龄(岁) | 52.21 ± 14.68 | 62.36 ± 12.48 | 1.269 | >0.05 |
既往OC/LC | 13/47 | 39/21 | 0.000 | >0.05 |
基础疾病* | 23 | 30 | 0.215 | >0.05 |
合并黄疸 | 26 | 32 | 0.596 | >0.05 |
结石单发/多发 | 12/48 | 16/44 | 0.856 | >0.05 |
胆总管内径(cm) | 1.53 ± 0.42 | 1.48 ± 0.44 | 0.796 | >0.05 |
TBIL (mmol/L) | 30.56 ± 22.36 | 32.36 ± 19.57 | 0.232 | >0.05 |
AST (U/L) | 58.61 ± 39.54 | 46.87 ± 38.52 | 0.597 | >0.05 |
ALT (U/L) | 32.32 ± 17.68 | 33.96 ± 15.78 | 0.102 | >0.05 |
表1. 术前资料比较(n = 60)
注:*基础疾病包括高血压病、2型糖尿病、冠心病及慢阻肺等。
2) 方法:a) LCBDE组通常采用四孔法,患者在手术室经气管插管全身麻醉,脐部Trocar不从原切口置入,避免切口下可能存在的粘连,于脐部无疤痕区切开皮肤1.5 cm,插入一次性气腹针,充入CO2建立气腹,一般腹内压达到12~14 mmHg后拔出气腹针。将Trocar置入,进镜观察腹腔内粘连情况,腹腔镜直视下建立其余三孔(具体位置以方便术者操作为宜)。病人一般采取头高脚低向左侧倾斜体位,用超声刀或电凝钩分离腹腔粘连,暴露肝十二指肠韧带,解剖胆总管位置,对辨别胆总管困难者,可用细针穿刺溢出胆汁加以确认 [
3) 观察指标:比较两组患者在手术成功率、结石清除率,手术耗时,术中出血量,术后并发症及患者住院时间、费用等方面的差距。两组患者术后至少随访半年,主要询问术后恢复状况及有无特殊不适,结石是否复发,并提出意见。
4) 统计学分析:采用SPSS20.0软件进行分析,计量资料以( X ¯ ± S )表示,采用独立样本t检验;计数资料以频数(n)表示,比较采用χ2检验,P < 0.05为差异有统计学意义。
ERCP/EST组取石成功率为93.3%,其中有2例患者因结石太大取石失败转入外科行LCBDE,1例由于大体积结石通过碎石操作后患者手术耐受力及手术时间的的影响,仍然无法取尽结石,行鼻胆管引流,二期再次行ERCP术取尽结石,1例患者因导丝置入十二指肠乳头困难导致手术失败;术后并发胰腺炎患者4例,高淀粉酶血症者13例,胆道出血1例,以上患者经积极保守治疗全部治愈。随访发现结石复发者5例。LCBDE组取石成功率95.0%,2例因腹腔粘连严重,无法解剖胆总管,中转行OCBDE,这表明腹腔内粘连程度是制约腹腔镜再次手术成功的关键;1例系结石数量较多,考虑手术时间长及麻醉药物用量多,恐术后患者不能苏醒,放弃取尽结石,果断放置T管结束手术,该患者3月后待T管窦道形成后经窦道胆道镜下取尽结石。术后出现胆漏1例,经腹腔引流管引流胆汁逐渐减少,1周后胆漏消失。LCBDE组随访无结石复发。在手术时间上,ERCP/EST组[(45.73 ± 13.25) min]明显少于LCBDE组[155.36 ± 23.25) min],同时ERCP/EST组住院时间[(9.23 ± 1.87) d]上也短于LCBDE组[(13.25 ± 2.36) d],但ERCP/EST组在住院费用[(23.125 ± 1.23 VS 14.849 ± 1.84)千元]及术后并发症(30% VS 1%)上明显高于LCBDE组,均有统计学意义(P < 0.05);在术中出血、结石清除率上无统计学意义(P > 0.05)。见表2。
LCBDE组 | ERCP/EST组 | χ2或t值 | P值 | |
---|---|---|---|---|
取石成功率(%) | 95.0 | 93.3 | 1.365 | >0.05 |
术中出血(ml) | 40.36 ± 8.45 | 30.25 ± 6.25 | 2.315 | >0.05 |
术后并发症 | 1/60 | 18/60 | 9.835 | <0.05 |
手术时间(min) | 45.73 ± 13.25 | 155.36 ± 23.25 | 8.269 | <0.05 |
住院时间(d) | 13.25 ± 2.36 | 9.23 ± 1.87 | 0.215 | <0.05 |
住院费用(千元) | 14.849 ± 1.84 | 23.125 ± 1.23 | 3.586 | <0.05 |
表2. 两组手术情况比较[n, X ¯ ± S ]
胆囊切除术后胆总管残留结石或远期再生结石均可保持一定的静止状态(即无任何临床表现),直径较小或泥沙型结石有自行排入十二指肠的可能,较大的结石持续存在迟早会阻塞胆管,引起严重并发症进而危及生命,因此即使无症状的胆总管结石也必须及时治疗 [
腹腔镜再次手术必须分离腹腔内影响操作的粘连,粘连越重则操作时间越长,这与本次研究LCBDE组在手术时间上明显高于ERCP/EST组相符。腹腔镜下的操作如解剖胆管,器械取石,放置T管,缝合胆管等均需一定的手术技巧,致手术时间延长。相信随术者操作技术的熟练以及手术例数的增加,手术时间会逐渐缩短。另外LCBDE需在全麻下进行,全麻本身对患者要求较ERCP/EST更为严格,尤其是高龄患者或合并心脑肺等基础疾病者,可能需花费更多的时间在术前准备及术后恢复上,这也是导致LCBDE组患者住院时间偏高的原因所在。而ERCP无需全麻,创伤小,术后疼痛轻,术后可早期进食及下床活动,术后恢复快,致其术后住院时间较LCBDE短,与本次研究结果相符。本次研究中2例ERCP组患者因结石太大取石失败,转外科行腹腔镜手术,又显示了ERCP一定的局限性,切开括约肌太小,不足以取出结石,太大则可能到导致十二指肠破裂,损伤胰腺等并发症出现,LCBDE术中胆总管可利用的切开空间比十二指肠乳头要大,所以该术式较少受结石大小的影响。故而对结石较大患者,术前应充分评估,避免贸然尝试ERCP,增加对患者的创伤及再次行手术的经济负担,预计ERCP成功率不高者应果断采取LCBDE。ERCP/EST虽然住院时间短,但在住院费用上明显高于LCBDE,估计与其术中所用一次性耗材如斑马导丝、取石网篮、切开刀、扩张球囊及鼻胆管等有关,希望日后通过医疗改革费用有所下降。
两组在术中出血、术后并发症,取石成功率上无差异,提示二者安全性、有效性相当。术后结石复发、胰腺炎并发症的发生率ERCP明显较高,考虑跟内镜插管、乳头切开、造影等诱发胰腺炎及高淀粉酶血症有关。在随访过程中发现,ERCP/EST组有5名患者出现结石复发,LCBDE组术后行T管造影均无结石残留,在随访过程中亦无结石复发。这与相关报道ERCP/EST取石术后结石复发率达4.3%~13.2% [
LCBDE比ERCP在手术技巧方面对外科医生要求更高,主要是建立气腹、分解粘连及寻找与辨认胆总管。由于上次手术造成的粘连,所以要求术者操作时应十分谨慎和保持足够的耐心。为避免损伤,首枚穿刺孔的建立位置应尽量远离原手术部位3 cm以上,切皮后可采用一次性气腹针穿刺,进腹后有明显的突破感,针尖穿破腹膜后回弹,可以有效减少损伤,接盐水注射器观察,水柱下降顺利,表明气腹针成功进入腹腔,否则需重新穿刺,实在进腹无把握,可用小切口逐层切开放置trocar建立气腹。分离粘连,不影响手术操作的不予处理;粘连严重的可用超声刀钳夹或电凝钩灼烧缓慢推进为主,结合吸引器的推、拨、刮、吸一般可找到分离的间隙。分离时应遵循紧贴肝脏脏面,从右向左,由浅到深,由疏松到致密的顺序进行;腹腔粘连严重经反复尝试仍无法分离时要果断转为开腹手术。显露胆总管使用电凝钩要及时转换电凝频率,避免损伤肝动脉,门静脉等结构,辨别胆总管可利用如小网膜孔、胆囊管残端、十二指肠球部、上次手术的缝线及塑料夹或钛夹,甚至可直接触到胆总管内的结石等周围的解剖标志,依据这些标志经细针穿刺证实 [
胆总管结石的治疗原则是取尽结石、解除梗阻,通畅引流,在治疗方式的选择时应注意安全、简捷、有效且花费较少。两种方式在治疗胆总管结石上各具有其独特的优势及局限性,实际应用中还需结合胆总管直径、结石大小与位置、患者身体及经济条件等因素综合考虑。
臧世利,马 丽,赵 洁. 胆囊切除术后胆总管结石手术方式的选择分析 Selection of Operative Methods for Common Bile Duct Stones after Cholecystectomy[J]. 外科, 2021, 10(04): 63-68. https://doi.org/10.12677/HJS.2021.104011