腹腔镜下胆总管切开取石术与经胆囊管取石术治疗胆总管结石伴胆囊结石患者疗效分析

doi:10.3969/j.issn.1672-5069.2018.02.028

摘要/Abstract

摘要： 目的探讨胆总管结石伴胆囊结石患者治疗的最佳腹腔镜微创术式选择。方法 2013年6月~2016年6月本院收治的胆总管结石伴胆囊结石患者500例,其中234例患者接受腹腔镜下胆总管切开取石（LCBDE）术,266例接受腹腔镜下经胆囊管取石术（LTSE）。在LCBDE组,采用腹腔镜胆囊切除术（LC）联合LCBDE和T管引流,在LTSE组,采用LC联合LTSE。比较两组治疗后结石清除率、手术时间、术后首次排气时间和住院时间、术后并发症和结石复发率。结果 LCBDE组结石数量为（4.6±1.7）个,显著多于LTSE组的（3.1±2.4）个（P<0.05）,结石直径为（11.8±5.4） mm,显著大于LTSE组的（5.2±2.2） mm（P<0.05）,手术时间、首次肛门排气时间和住院时间分别为（114±27） min、（3.4±1.3）d和（7.1±3.2） d,显著长于LTSE组的（73±21） min、（2.2±0.9） d和（3.5±1.8）d（P<0.05）; LCBDE组结石清除率为94.9%,与LTSE组的94.7%比,差异无统计学意义（P>0.05）;LCBDE组并发症发生率为24.4%,显著高于LTSE组的10.9%（P<0.05）;在随访1年期间,LCBDE组结石复发率为4.7%,显著高于LTSE组的1.5%（P<0.05）。结论采用LC联合LTSE术治疗胆总管结石伴胆囊结石患者恢复较快,可明显缩短住院时间,且并发症发生率和远期结石复发率较低。

关键词: 胆石症, 胆总管切开取石术, 经胆囊管取石术, 腹腔镜手术, 治疗

Abstract: Objective To explore the optimal laparoscopic minimally invasive surgery for the treatment of patients with choledocholithiasis and cholecystolithiasis. Methods 500 patients with choledocholithiasis and cholecystolithiasis were recruited in our hospital between June 2013 and June 2016,and 234 of them received laparoscopic common bile duct exploration（LCBDE） and 266 received laparoscopic transcystic stone extraction （LTSE）. The patients in LCBDE group was treated with laparoscopic cholecystectomy（LC） plus LCBDE and T tube drainage,and the patients in LTSE group was given LC and LTSE. The number of calculus,the diameters of stones,the removal rates of stones,the periods of operations,the times of first exhaust,the hospital stays,and the postoperative complications and recurrence rates of gallstones were compared between the two groups. Results The number of stones in the LCBDE group was greater than that in the LTSE group [（4.6±1.7） vs. （3.1±2.4）,P<0.05],and the stone diameter in the LCBDE group was larger than that in the LTSE group [（11.8±5.40） mm vs.（5.2±2.2） mm,P<0.05];the operative time,first exhaust time and hospital stays were（114±27） min,（3.4±1.3） d and （7.1±3.2） d,respectively in the LCBDE group,much longer than those in the LTSE group[（73±21） min,（2.2±0.9） d and（3.5±1.8） d,respectively,P<0.05];there was no significant difference in the removal rates of stones between the LCBDE group and the LTSE group（94.9% vs.94.7%,P>0.05）;the total incidence rate of complications was 24.4% in the LCBDE group,significantly higher than that in the LTSE group（10.9%,P<0.05）;during the 1 year of follow-up,the stone recurrence rate in the LCBDE group was 4.7%,much higher than that in the LTSE group（1.5%,P<0.05）. Conclusions The application of LC plus LTSE in treatment of patients with choledocholithiasis and cholecystolithiasis have a good efficacy with fast recovery,short hospital stays,and low morbidity of complications and long-term stone recurrence.

Key words: Choledocholithiasis, Cholecystolithiasis, Common bile duct exploration, Transcystic stone extraction, Therapy

黄健. 腹腔镜下胆总管切开取石术与经胆囊管取石术治疗胆总管结石伴胆囊结石患者疗效分析[J]. 实用肝脏病杂志, 2018, 21(2): 269-272.

Huang Jian. Efficacy of laparoscopic common bile duct exploration and transcystic stone extraction in treatment of patients with choledocholithiasis and cholecystolithiasis[J]. JOURNAL OF PRACTICAL HEPATOLOGY, 2018, 21(2): 269-272.

参考文献

[1] Demirbas BT,Gulluoglu BM,Aktan AO.Retained abdominal gallstones after laparoscopic cholecystectomy:A systematic review. Surg Lap Endosc Percut Tech,2015,25(2):97-99.
[2] Thielemann H,Christiane L.Diagnostic and therapeutic management,of symptomatic cholecystolithiasis and pre-operatively suspected choledocholithiasis. Zentralbl Chir,2002,127(11):987-991.
[3] 鲁德斌,刘西平,胡林忠. 腹腔镜胆囊切除术与开腹胆囊切除术治疗胆囊结石患者外周血淋巴细胞和细胞因子水平的变化. 实用肝脏病杂志,2016,19(3):335-338.
[4] Gottschalk U,Gottschalk E.Symptomatic choledocholithiasis during pregnancy-the role of ultrasound,ERCP and EUS. Z Gastroenterol,2011,49(4):452-460.
[5] Dietrich C,Gouder S.Endoscopic ultrasound in the differential diagnosis of choledocholithiasis. Endosk Heute,2004,17(03):160-166.
[6] Gilsdorf D,Henrichsen JL,Liljestrand K,et al.Single-stage management of common bile duct stones with laparoscopic common duct exploration and cholecystectomy is safe and cost effective in a large multi-hospital health care system. J Am Coll Surg,2015,221(4):S77-S77.
[7] Paik KY,Kim EK.Laparoscopic common bile duct exploration after unsuccessful endoscopic stone removal. J Laparoendosc Adv Surg Tech(Part A),2013,23(2):137-140.
[8] Tadeusz P,Tomasz S.Endoscopic treatment of the choledocholithiasis-effectiveness,safety and limitations of the Method. Polish J Surg,2012,84(7):333-340.
[9] Lee JY,Keane M G,Pereira S.Diagnosis and treatment of gallstone disease. Practitioner,2015,259(1783):15.
[10] Kim CW,Chang JH,Lim YS,et al.Initial large diameter of common bile duct is associated with long-term dilatation of bile duct after endoscopic extraction of stones. J Dig Dis,2014,15(1):35-41.
[11] Janis L,Ieva R.Laparoscopic common bile duct exploration for choledocholithiasis during apregnancy:a case report. Acta Chirurgica Latviensis,2016,16(1):41-43.
[12] Piotr M,Marcin D.A periampullary duodenal diverticula in patient with choledocholithiasis-single endoscopic center experience. Polish J Surg,2016,88(6):328-333.
[13] Mouret P.How I developed laparoscopic cholecystectomy. Ann Acad Med Sing,1996,25(5):744.
[14] Heo J,Jung MK,Cho CM. Should prophylactic cholecystectomy be performed in patients with concomitant gallstones after endoscopic sphincterotomy for bile duct stones Surg Endosc,2015,29(6):1574-1579.
[15] 张智勇,杜立学,郑伟,等. 腹腔镜胆总管探查术与内镜下十二指肠乳头括约肌切开术治疗胆总管结石的临床对照研究. 中国普通外科杂志,2015,24(8):1088-1092.
[16] 蔡宇,何彦安. 胆囊结石合并胆总管结石患者行腹腔镜胆囊切除联合胆总管切开取石T管引流术后结石复发危险因素分析. 肝胆外科杂志,2016,24(3):203-205.
[17] 李宇,郝杰,孙昊,等. 一期腹腔镜胆囊切除联合胆总管探查取石与分期内镜取石和腹腔镜胆囊切除术治疗胆囊结石合并胆总管结石的比较. 中国普通外科杂志,2016,25(2):202-208.
[18] Evoy DA,Regan MC,Attwood SEA,et al.The role of ERCP and laparoscopic cholecystectomy in gallstone-related pancreatitis. Mini Invas Ther,2016,3(3):149-152.
[19] Zhang RC,Luo HP,Pan YL,et al.Rate of duodenal-biliary reflux increases in patients with recurrent common bile duct stones:evidence from barium meal examination. Gastrointest Endosc,2015,82(4):660-665.
[20] 吴定泉,杨明芳. 胆囊结石合并胆总管结石的腹腔镜术式选择. 腹腔镜外科杂志,2012,17(4):280-281.
[21] Mussack T,Ladurner R.The place of magnetic resonance cholangiography in theeffective diagnosis of choledocholithiasis. Dtsch Med Wochenschr,2002,127(15):786-790.
[22] Weickert U,Jakobs Rl.Cholangioscopy for possible retained bile duct stone fragments after successful treatment of complicated choledocholithiasis. Dtsch Med Wochenschr,2003,128(10):481-484.
[23] 彭颖,王立新,徐智,等. 腹腔镜联合胆道镜经胆囊管汇入部微切开治疗胆囊结石合并胆总管结石. 中国微创外科杂志,2015,15(3):224-227.
[24] Das SK,Choupoo NS,Momin K,et al.A single preoperative dose of levetiracetam has no effect on pain or analgesic requirements after laparoscopic cholecystectomy. Eur J Anaesthesiol,2015,32(4):278-280.
[25] Alessandro B,Alessia F.Use of a simplified consent form to facilitate patient understanding of informed consent for laparoscopic cholecystectomy. Open Med,2016,11(1):564-573.
[26] 李红阳,周世骥,谭晶,等. 不同微创术式治疗胆囊结石合并胆总管结石的临床研究. 医学临床研究,2012,29(4):710-713.
[27] 苏立强. 开腹手术和腹腔镜手术治疗老年胆囊及胆总管结石疗效对比. 河南外科学杂志,2016,22(3):74-75.
[28] 赵二鹏,张洪义,孔亚林. 两种术式治疗胆囊结石伴胆总管结石效果对比观察. 人民军医,2016,59(5):473-474.
[29] 张智勇,杜立学,郑伟,等. 腹腔镜胆总管探查术与内镜下十二指肠乳头括约肌切开术治疗胆总管结石的临床对照研究. 中国普通外科杂志,2015,24(8):1088-1092.
[30] 吴定泉,杨明芳. 胆囊结石合并胆总管结石的腹腔镜术式选择. 腹腔镜外科杂志,2012,17(4):280-281.
[31] 陈辉,章旭明,范恒伟,等. 腹腔镜联合胆道镜经胆囊管钬激光碎石术治疗胆总管结石. 肝胆胰外科杂志,2017,29(3):192-195.