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Effectiveness and safety of two-step percutaneous transhepatic choledochoscopic lithotomy in treatment of complex hepatolithiasis
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摘要:
目的 探讨两步法经皮肝穿刺胆道镜取石术(PTCSL)治疗复杂肝胆管结石的效果。 方法 回顾性分析2018年1月—2020年6月西安交通大学医学部附属三二〇一医院收治的118例复杂肝胆管结石患者的临床资料，按手术方式分为PTCSL组(n=60)及手术组(n=58), 术后两组患者通过电话及门诊随访0.5~3年。对比分析两组一般资料、围术期指标(包括手术时间、术中出血量、切口长度、术后肛门恢复排气排便时间、腹腔引流管拔除时间、住院时间)，肝功能及炎性指标变化情况，术后并发症(胆漏、急性胆管炎、伤口感染、下肢静脉血栓形成)发生情况，结石清除率及复发率，生活质量等指标。计量资料两组间比较采用两独立样本t检验；组内不同时间段间比较采用配对t检验，计数资料两组间比较采用χ2检验。 结果 PTCSL组在手术时间、术中出血量、切口长度、术后肛门恢复排气排便时间、腹腔引流管拔除时间均少于手术组(P值均＜0.05)。术后第1天，PTCSL组及手术组患者ALT水平均低于术前(P值均＜0.05)，AST水平低于术前(P值均＜0.05)，WBC水平高于术前(P值均＜0.05)；PTCSL组患者术后第1天ALT、AST、WBC水平均明显低于外科手术组(P值均＜0.05)。PTCSL组在术后胆漏(5.0% vs 17.2%)、急性胆管炎(3.3% vs 13.8%)、伤口感染(1.7% vs 10.3%)、下肢静脉血栓发生率(1.7% vs 12.1%)均低于外科手术组(P值均＜0.05)。PTCSL组结石清除率高于外科手术组(58.3% vs 37.9%)，PTCSL组远期结石复发率(10.0% vs 20.7%)低于手术组(P值均＜0.05)。PTCSL组术后各生存质量评分均高于手术组(P值均＜0.05)。 结论 针对复杂肝胆管结石，两步法PTCSL可有效清除结石，术后康复快，复发率及并发症发生率低，预后生活质量高，是一种有效的可供选择的手术方式。 -
关键词:
- 胆石 /
- 两步法经皮肝穿刺胆道镜取石术 /
- 最小侵入性外科手术
Abstract:Objective To investigate the clinical effect of two-step percutaneous transhepatic choledochoscopic lithotomy (PTCSL) in the treatment of complex hepatolithiasis. Methods A retrospective analysis was performed for the clinical data of 118 patients with complex hepatolithiasis who were admitted to 3201 Hospital of Xi'an Jiaotong University Health Science Center from January 2018 to June 2020, and according to the surgical procedure, they were divided into PTCSL group with 60 patients and surgery group with 58 patients. All patients were followed up for half a year to 3 years via telephone and outpatient service. The two groups were compared in terms of general information, perioperative indicators (including time of operation, intraoperative blood loss, incision length, time to first flatus and time to first defecation after surgery, time to extraction of abdominal drainage tube, and length of hospital stay), changes in liver function and inflammatory indicators, postoperative complications (bile leakage, acute cholangitis, wound infection, and venous thrombosis of lower extremities), stone clearance rate and recurrence rate, and quality of life. The two-independent-samples t-test was used for comparison of continuous data between two groups; the paired t-test was used for comparison between different periods of time within group; the chi-square test was used for comparison of categorical data between two groups. Results Compared with the surgery group, the PTCSL group had significantly shorter time of operation, time to first flatus and time to first defecation after surgery, and time to extraction of abdominal drainage tube, a significantly lower intraoperative blood loss, and a significantly shorter incision length (all P < 0.05). On day 1 after surgery, both groups had significant reductions in alanine aminotransferase (ALT) and aspartate aminotransferase (AST) (P < 0.05) and a significant increase in white blood cell count (WBC) (P < 0.05), and the PTCSL group had significantly lower levels of ALT, AST, and WBC than the surgery group (all P < 0.05). Compared with the surgery group, the PTCSL group had significantly lower incidence rates of postoperative bile leakage (5.0% vs 17.2%, P < 0.05), acute cholangitis (3.3% vs 13.8%, P < 0.05), wound infection (1.7% vs 10.3%, P < 0.05), and venous thrombosis of lower extremities (1.7% vs 12.1%, P < 0.05). Compared with the surgery group, the PTCSL group had a significantly higher stone clearance rate (58.3% vs 37.9%, P < 0.05) and a significantly lower long-term stone recurrence rate (10.0% vs 20.7%, P < 0.05). The PTCSL group had significantly higher quality of life scores than the surgery group (all P < 0.05). Conclusion For the treatment of complex hepatolithiasis, two-step PTCSL can effectively remove stones, with the advantages of fast postoperative recovery, low recurrence rate and incidence rate of complications, and high quality of life, and therefore, it is an effective alternative surgical procedure. -
注：a.胆总管囊肿行胆肠Roux-en-Y术后因腹痛不适复查MRCP示胆肠吻合口处及肝内胆管多发结石；b.超声联合介入行经皮肝穿刺胆道置管；c.PTCSL术中胆道镜下液电碎石；d.术后复查肝内胆管及胆肠吻合口处未见结石残留。
图 1 胆肠吻合术后胆肠吻合口及肝内多发结石行PTCSL治疗前后对比
表 1 两组患者一般资料比较
项目 PTCSL组(n=60) 手术组(n=58) 统计值 P值 男/女(例) 32/28 29/29 χ2=0.131 0.717 年龄(岁) 60.75±14.54 60.95±16.01 t=-0.070 0.944 伴有慢性病[例(%)] 17(28.3) 16(27.6) χ2=0.008 0.928 美国麻醉师协会评分Ⅲ级[例(%)] 2(3.3) 2(3.4) χ2=0.001 0.972 
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表 2 两组患者围术期指标比较
项目 PTCSL组(n=60) 手术组(n=58) t值 P值 手术时间(min) 95.33±20.56 150.21±21.43 -14.195 ＜0.001 术中出血量(mL) 50.07±14.76 205.72±16.06 -54.850 ＜0.001 切口长度(cm) 1.83±0.46 8.02±2.32 -19.923 ＜0.001 术后肛门恢复排气排便时间(d) 0.97±0.37 1.91±0.35 -14.302 ＜0.001 腹腔引流管拔除时间(d) 4.48±0.59 6.81±0.62 -21.045 ＜0.001 住院时间(d) 12.63±2.48 12.24±3.96 0.642 0.522
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表 3 两组患者围术期肝功能及炎性指标变化情况比较
项目 PTCSL组(n=60) 手术组(n=58) t值 P值 ALT(U/L) 术前 169.32±67.74 175.80±68.31 -0.517 0.606 术后第1天 67.63±24.741) 84.90±40.531) -2.805 0.006 AST(U/L) 术前 127.97±54.45 120.60±61.21 0.691 0.491 术后第1天 51.58±18.201) 82.93±44.411) -4.987 ＜0.001 WBC(×109/L) 术前 8.96±3.78 9.08±4.28 -0.169 0.866 术后第1天 10.77±3.851) 13.74±4.611) -3.809 ＜0.001 注：与同组术前比较，1)P＜0.05。
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表 4 两组患者术后并发症发生情况比较
术后并发症 PTCSL(n=60) 手术组(n=58) χ2值 P值 胆漏[例(%)] 3(5.0) 10(17.2) 4.508 0.034 急性胆管炎[例(%)] 2(3.3) 8(13.8) 4.160 0.041 伤口感染[例(%)] 1(1.7) 6(10.3) 3.980 0.046 下肢静脉血栓[例(%)] 1(1.7) 7(12.1) 5.049 0.025
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表 5 两组患者结石清除率及远期复发率比较
结石清除率及复发率 PTCSL(n=60) 手术组(n=58) χ2值 P值 结石清除[例(%)] 35(58.3) 22(37.9) 10.92 ＜0.001 结石复发[例(%)] 6(10.0) 12(20.7) 7.84 ＜0.001
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表 6 两组患者术后生存质量评分比较
评分 PTCSL(n=60) 手术组(n=58) t值 P值 总分(分) 术前 83.85±7.29 83.36±6.22 0.391 0.697 术后 129.07±9.901) 110.74±8.071) 11.003 ＜0.001 生理功能(分) 术前 8.70±2.14 8.33±1.888 1.003 0.318 术后 18.30±3.871) 15.12±3.261) 4.819 ＜0.001 社会活动(分) 术前 13.15±2.70 12.66±3.01 0.942 0.348 术后 16.53±4.351) 14.48±4.421) 2.541 0.012 主观症状(分) 术前 51.42±4.50 51.95±5.09 -0.602 0.548 术后 74.47±6.931) 65.93±6.451) 6.920 ＜0.001 心理情绪(分) 术前 10.58±3.00 10.43±3.00 0.276 0.783 术后 19.77±3.961) 15.21±3.761) 6.408 ＜0.001 注：与同组术前比较，1)P＜0.05。
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