腹腔镜、胆道镜及十二指肠镜联合免T管引流对胆囊结石合并胆总管结石的治疗效果分析

王云峰; 徐斌; 王杰; 张文忠; 李刚; 凌杰; 邱伟; 王月明; 王永兵

doi:10.3969/j.issn.1001-5256.2021.04.029

腹腔镜、胆道镜及十二指肠镜联合免T管引流对胆囊结石合并胆总管结石的治疗效果分析

DOI: 10.3969/j.issn.1001-5256.2021.04.029

上海市健康医学院附属浦东新区人民医院普外科，上海 201200

基金项目:

上海市浦东新区卫生健康委员会重点学科建设项目 (PWZxk2017-11);

上海市卫生和计划生育委员会科研课题计划资助 (201740295)

利益冲突声明：本研究不存在研究者、伦理委员会成员、受试者监护人以及与公开研究成果有关的利益冲突。

作者贡献声明：王云峰、徐斌、王永兵负责课题设计，资料分析，撰写论文；徐斌、王杰、张文忠、李刚、凌杰、邱伟参与收集数据，修改论文；王月明、王永兵负责拟定写作思路，指导撰写文章并最后定稿。

详细信息

作者简介:
王云峰(1979—)，男，副主任医师，博士，主要从事肝胆胰疾病微创治疗研究

通信作者:
王云峰，wangyunfeng197911@163.com

中图分类号: R657.42
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出版历程
- 收稿日期: 2020-10-07
- 录用日期: 2020-11-09
- 出版日期: 2021-04-20

Clinical effect of laparoscopy, choledochoscopy, and duodenoscopy combined with T-tube-free drainage in treatment of gallstones with common bile duct stones

Department of General Surgery, Pudong New Area People's Hospital, Shanghai University of Medicine & Health Sciences, Shanghai 201200, China

摘要

摘要: 目的探讨腹腔镜、胆道镜及十二指肠镜联合免T管引流对胆囊结石合并胆总管结石的治疗效果。方法选取2017年12月—2019年12月上海市健康医学院附属浦东新区人民医院普外科收治的胆囊结石合并胆管结石患者564例，根据手术方式分为腹腔镜经胆囊管胆道探查术(LTCBDE)组191例；三镜联合腹腔镜胆总管切开取石一期缝合术(LBEPS)组138例；十二指肠镜逆行胰胆管造影术(ERCP)+内镜乳头括约肌切开取石术(EST)/乳头柱状球囊扩张术(EPBD)+腹腔镜胆囊切除术(LC)组235例。统计3组患者性别、年龄、胆管直径、结石大小/数量等一般资料，比较手术及并发症情况。正态分布的计量资料组间比较采用单因素方差分析；非正态数据的计量资料组间比较采用Kruskal-Wallis H检验；计数资料组间比较采用χ²检验。结果 LTCBDE组、LBEPS组、ERCP+EST/EPBD+LC组3组间住院费用、引流量、排气时间、住院时间、引流管拔除时间，差异均有统计学意义(F值分别为416.40、7.799、33.99、143.70、13.08，P值分别为 < 0.001、0.020、 < 0.001、 < 0.001、 < 0.001)，且LTCBDE组较其他2组住院费用更低、排气时间更早、住院时间更短、引流管拔除时间更短(P值均 < 0.05)。3组术后均未见严重并发症，并发症发生率差异无统计学意义(P>0.05)。所有患者术后均顺利出院。结论 3种微创方式联合免T管引流治疗肝外胆管结石均达到了创伤小、痛苦小、术后恢复快、无严重并发症的目标，其中LTCBDE组治疗费用最低及术后恢复效果最佳。
- 胆囊结石病 /
- 胆总管结石 /
- 胰胆管造影术, 内窥镜逆行 /
- 胆囊切除术, 腹腔镜 /
- 十二指肠镜检查 /
- 引流术
Abstract: Objective To investigate the clinical effect of laparoscopy, choledochoscopy, and duodenoscopy combined with T-tube-free drainage in the treatment of gallstones with common bile duct stones. Methods A retrospective analysis was performed for the clinical data of 564 patients with gallstones and common bile duct stones who were admitted to Department of General Surgery, Pudong New Area People's Hospital, Shanghai University of Medicine & Health Sciences, from December 2017 to December 2019. According to the surgical procedure, the patients were divided into laparoscopic transcystic common bile duct exploration (LTCBDE) group with 191 patients, three endoscopies+laparoscopic common bile duct exploration and primary suture (LBEPS) group with 138 patients, and endoscopic retrograde cholangiopancreatography (ERCP)+endoscopic sphincterotomy (EST)/endoscopic papillary balloon dilation (EPBD)+laparoscopic cholecystectomy (LC) group with 235 patients. The three groups were analyzed in terms of the general data including sex, age, bile duct diameter, and stone size/number, and surgical condition and complications were compared between groups. A one-way analysis of variance was used for comparison of normally distributed continuous data between groups, and the Kruskal-Wallis H test was used for comparison of non-normally distributed continuous data between groups; the chi-square test was used for comparison of categorical data between groups. Results There were significant differences between the LBEPS group, the ERCP+EST/EPBD+LC group and the LTCBDE group in hospital costs, drainage volume, time to first flatus, length of hospital stay and time to extraction of drainage tube (F=416.40, 7.80, 33.99, 143.70, and 13.08, P < 0.001, P=0.020, P < 0.001, P < 0.001, and P < 0.001). Compared with the LBEPS group and ERCP+EST/EPBD+LC groups, the LTCBDE group had significantly lower hospital costs and a significantly longer time to first flatus, and significantly shorter length of hospital stay and time to extraction of drainage tube(all P < 0.05). No serious complication was observed after surgery, and there was no significant difference in the incidence rate of complications between the three groups (P>0.05). All patients were discharged successfully after surgery. Conclusion The three minimally invasive surgical procedures combined with T-tube-free drainage achieve the goal of little trauma and pain, fast postoperative recovery, and few serious complications, among which LTCBDE has the lowest treatment costs and the best postoperative recovery.
- Cholecystolithiasis /
- Choledocholithiasis /
- Cholangiopancreatography, Endoscopic Retrograde /
- Cholecystectomy, Laparoscopic /
- Duodenoscopy /
- Drainage

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图 1 LTCBDE组术中示意图

注：a，胆囊管微切开；b，胆道取石钳取石；c，取石网篮取石；d，4-0可吸收线缝合胆囊管。

下载: 全尺寸图片幻灯片

图 2 LBEPS组术中示意图

注：a，胆道支架；b，术中显示胆道支架；c，4-0可吸收线缝合胆总管；d，4-0可吸收线缝合胆囊管和胆管汇合处。

下载: 全尺寸图片幻灯片

图 3 ERCP+EST/EPBD+LC组术中示意图

下载: 全尺寸图片幻灯片

图 4 笔者中心治疗胆囊结石合并胆总管结石临床路径

下载: 全尺寸图片幻灯片

表 1 3组患者一般资料及手术情况比较

项目	合计(n=564)	LTCBDE组(n=191)	LBEPS组(n=138)	ERCP+EST/EPBD+LC组(n=235)	统计值	P值
年龄(岁)	62.55±12.22	64.30±12.50	65.78±14.03	66.03±13.00	F=1.834	0.180
性别[例(%)]					χ²=1.150	0.562
男	266(47.2)	96 (50.3)	62(44.9)	108(46.0)
女	298(52.8)	95 (49.7)	76(55.1)	127(54.0)
手术成功[例(%)]	560(99.2)	175(91.6)	134(97.1)	217(92.3)	χ²=0.154	0.931
术前TBil(mmol/L)	19.9±7.8	18.9±3.1	21.2±4.6	20.1±3.7	F=0.896	0.639
病程(月)	21.2±4.3	19.4±5.5	21.5±5.9	22.5±6.2	F=0.920	0.631
胆总管直径(mm)	8.96±3.46	9.03±3.14	8.98±3.09	8.93±3.65	F=3.150	0.207
结石数量(个)	2.2±0.5	2.2±0.5	2.2±0.6	1.8±0.5	F=2.161	0.339
结石大小(mm)	8.38±2.89	7.18±1.60	8.76±3.34	8.42±3.19	F=3.015	0.221
手术情况
手术时间(min)	92.2±15.7	92.4±14.7	90.2±15.1	93.2±16.6	F=2.052	0.358
住院费用(万元)	3.0±0.4	2.1±0.6	3.1±0.7	3.6±0.5	F=416.400	< 0.001
24 h引流量(ml)	37±13	39±13	37±16	36±12	F=7.799	0.020
排气时间(d)	2.1±0.6	1.9±0.5	2.1±0.7	2.2±0.5	F=33.990	< 0.001
拔引流管时间(d)	2.3±0.5	2.1±0.5	2.3±0.5	2.4±0.5	F=13.080	0.001
住院时间(d)	2.8±0.7	2.3±0.4	2.7±0.6	3.2±0.7	F=143.700	< 0.001
并发症[例(%)]
胆漏	3(0.5)	1(0.5)	2 (1.4)	0	χ²=3.067	0.115
胰腺炎	4(0.7)	0	0	4(1.7)	χ²=3.891	0.090
结石残留	1(0.2)	1(0.5)	0	0	χ²=1.853	0.584
切口感染	3(0.5)	1(0.5)	1(0.7)	1(0.4)	χ²=0.639	>0.05
出血	6(1.1)	3(1.5)	3(2.2)	0	χ²=5.000	0.056
胆管炎	2(0.4)	0	0	2(0.9)	χ²=1.800	0.512
穿孔	0	0	0	0
死亡	0	0	0	0

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