一步法和分步法治疗胆囊结石合并胆总管结石患者疗效及并发症分析

doi:10.3969/j.issn.1672-5069.2021.03.033

摘要/Abstract

摘要： 目的探讨一步法与分步法手术治疗胆囊结石合并胆总管结石患者的疗效。方法 2016年1月～2019年6月我院诊治的胆囊结石合并胆总管结石患者152例,其中87例接受一步法手术,即行腹腔镜胆囊切除(LC)和胆总管探查取石(LCBDE)术,65例接受分步法手术,即行内镜逆行胰胆管造影/乳头括约肌切开(ERCP/EST)和LC术,比较两组疗效。结果一步法组总手术时间为(156.3±42.6)min,术后置管率为98.9%,显著长于或高于分步法组【(124.4±31.4)min和15.4%,P<0.05】,而住院日为(14.4±3.9)d,住院费用为(27.9±7.0)千元,均显著短于或低于分步法组【(18.7±4.2)d和(31.24±5.8)千元,P<0.05】;一步法组手术成功率为95.4%、结石清除率为93.1%,分步法组分别为100.0%和96.9%,差异均无统计学意义(P>0.05);一步法组术后反流性胆管炎发生率0.0%,显著低于分步法组的7.7%(P<0.05),但两组并发症发生率比较差异无统计学意义(19.5%对 32.3%,P>0.05)。结论一步法和分步法手术均可应用于治疗胆囊结石合并胆总管结石患者,但在合适的患者采取一步法手术可能更迅速地解除病痛,疗效好。

关键词: 胆囊结石, 胆总管结石, 腹腔镜胆囊切除术, 腹腔镜胆总管探查, 内镜逆行胰胆管造影, 治疗

Abstract: Objective The aim of this study was to investigate the efficacy of one-step and step-by-step laparoscopic cholecystectomy (LC) in the treatment of patients with gallbladder stones and common bile duct stones. Methods 152 patients with gallbladder stones and common bile duct stones were admitted to our hospital between January 2016 and June 2019, 87 patients received one-step surgery, e.g., LC and laparoscopic common bile duct exploration (LCBDE), and 65 patients received step-by-step surgery, e.g., endoscopic retrograde cholangiopancreatography/papillary endoscopic sphincterotomy (ERCP/EST) and afterward LC.Results The total surgical time and postoperative catheter placement rate in patients with one-step surgery were (156.3±42.6)min and 98.9%, significantly longer or higher than [(124.4±31.4)min and 15.4%, P<0.05] in patients receiving step-by-step surgery, while the hospital stay and hospitalization cost were (14.4±3.9)d and (27.9±7.0)thousand yuan, significantly shorter or lower than(18.7±4.2)d and(31.24±5.8)thousand yuan (P<0.05) in the latter; there were no statistically significant differences in the surgical success rate and stone clearance rate between the two groups (95.4% vs. 93.1% and 100.0% vs. 96.9%, respectively, P>0.05); the incidence rate of reflux cholangitis in one-step-treated patients was significantly lower than step-by-step surgery-treated patients (0.0% vss 7.7%, P<0.05), while there was no significant difference in the total incidence of complications between the two groups (19.5% vs. 32.1%, P>0.05).Conclusion Both the one-step and step-by-step with patients with gallbladder surgery are efficacious in dealing stones and common bile duct stones, and under some circumstances, the one-step surgery might eradicate the stones rapidly and get a good efficacy.

Key words: Gallbladder stones, Common bile duct stones, Laparoscopic cholecystectomy, Laparoscopic common bile duct exploration, Endoscopic retrograde cholangiopancreatography, Therapy

冯浩, 吕海涛, 王子伟, 吴娟. 一步法和分步法治疗胆囊结石合并胆总管结石患者疗效及并发症分析[J]. 实用肝脏病杂志, 2021, 24(3): 435-438.

Feng Hao, Lyu Haitao, Wang Ziwei, et al. Efficacy of one-step and step-by-steplaparoscopic cholecystectomy in the treatment of patients with gallbladder stones and common bile duct stones[J]. Journal of Practical Hepatology, 2021, 24(3): 435-438.

参考文献

[1] Sakai A, Masuda A, Shiomi H, et al. Intracholecystic papillary neoplasm of the gallbladder protruding into the common bile duct. Gastrointest Endosc, 2018, 88(2):405-406.
[2]Williams E, Beckingham I, El Sayed G, et al. Updated guideline on the management of common bile duct stones (CBDS). Gut, 2017, 66(5):765-782.
[3] Frederiksen NA, Tveskov L, Helgstrand F, et al. Treatment of common bile duct stones in gastric bypass patients with laparoscopic transgastric endoscopic retrograde cholangiopancreatography. Obes Surg, 2017,27(6):1409-1413.
[4] Mejía R, Achurra P, Gabrielli M, et al. Laparoscopy-assisted trans-gastric rendez-vous for the treatment of common bile duct stones in patients with prior roux-en-y gastric bypass. Obes Surg, 2016, 26(11):2809-2813.
[5] 顾进, 涂奎, 王芳, 等. 血清肝功能指标对胆囊结石合并无症状继发性胆总管结石的诊断价值. 中华消化外科杂志, 2017, 16(2):183-187.
[6] Singh AD, Simons-Linares CR, Chahal P. A dilated common bile duct with "atypical" gallbladder. Gastroenterology, 2020, 159(2):e6-e7.
[7] El Nakeeb A, Ezzet H, Askar W, et al. Early versus late cholecystectomy after clearance of common bile duct stones by endoscopic retrograde cholangiopancreatography:a prospective randomized study. Surg Laparosc Endosc Percutan Tech, 2016, 26(3):202-207.
[8] Sklerovsky BF, Yassin S, Assaf S, et al. Sa1432 - small and numerous gallbladder stones are risk factors for complicated common bile duct stones. Gastroenterol, 2018, 154(6):S303-S304.
[9] Gilsdorf D, Henrichsen J, Liljestrand K, et al. Laparoscopic common bile duct exploration for choledocholithiasis:analysis of practice patterns of intermountain healthcare. J Am Coll Surg, 2018,226(6):1160-1165.
[10] Park CH, Jung JH, Nam E, et al. Comparative efficacy of various endoscopic techniques for the treatment of common bile duct stones:a network meta-analysis. Gastrointest Endosc, 2018,87(1):43-57.
[11] Podda M, Polignano FM, Luhmann A, et al. Systematic review with meta-analysis of studies comparing primary duct closure and T-tube drainage after laparoscopic common bile duct exploration for choledocholithiasis. Surg Endosc, 2016, 30(3):845-861.
[12] Di Mauro D, Ricciardi E, Siragusa L, et al. Outcome of laparoscopic common bile duct exploration after failed endoscopic retrograde cholangiopancreatography: a comparative study. J Laparoendosc Adv Surg Tech A, 2019, 29(11):1391-1396.
[13] Plewka M, Rysz J, Kujawski K. Complications of endoscopic retrograde cholangiopancreatography. Pol Merkur Lekarski, 2017, 43(258):272-275.
[14] 蒋铁民, 郭强, 邵英梅. LCBDE+LC与ERCP/EST联合LC治疗胆囊结石并胆总管结石的疗效分析. 中华普通外科杂志, 2017, 32(32):941-944.
[15] Paranandi B, Nayar M, Scott J, et al. Endoscopic cholecystogastrostomy in a patient with gallbladder empyema secondary to cholangiocarcinoma. Endoscopy, 2016, 48:e163.
[16] Gomez D, Cox MR. Laparoscopic transcystic stenting and postoperative ERCP for the management of common bile duct stones at laparoscopic cholecystectomy. Ann Surg, 2018, 267(5):e86-e88.
[17] 陈平, 苏秉忠, 丛春莉, 等. 胆囊结石合并胆总管结石不同治疗方案的临床分析. 中华消化杂志, 2019, 39(1):40-44.
[18] 王国泰, 杨兴武, 王旗, 等. 一步法腹腔镜与分步法内镜加腹腔镜治疗胆囊结石合并胆总管结石. 中华肝胆外科杂志, 2020, 26(2):115-118.
[19] 桂亮, 刘晔, 秦骏, 等. 腹腔镜手术治疗胆囊结石伴肝硬化的疗效观察. 中华腔镜外科杂志(电子版), 2016, 9(3):175-179.
[20] Ahn KS, Yoon YS, Han HS, et al. Use of liver function tests as first-line diagnostic tools for predicting common bile duct stones in acute cholecystitis patients. World J Surg, 2016, 40(8):1925-1931.