经T管窦道硬镜联合钬激光碎石术治疗肝内外胆管残余结石的临床研究
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摘要
目的:探讨在鞘管保护下经T管窦道采用硬镜联合钬激光治疗肝内外胆道残余结石的临床价值。方法:2015年8月～2018年8月,将62例肝内外胆管残余结石病人,随机将分为硬镜组和纤维胆道镜组(软镜组),各31例,硬镜组在鞘管保护下经T管窦道采用硬镜联合钬激光碎石取石治疗,软镜组则经T管窦道采用纤维胆道镜联合钬激光碎石取石,分析比较两组手术时间、术后住院时间、结石取净率,以及相关主要并发症。结果:硬镜组结石取净率优于软镜组(90.3%vs64.5%, P=0.033),硬镜组手术时间少于软镜组(63±58 min vs 130±44 min, P<0.01);两组术后住院时间、并发症发生率等比较无统计学差异(P>0.05)。结论:对于术后肝内外胆管残余结石,采用经T管窦道硬镜联合钬激光进行碎石取石是安全、可行、高效的,手术时间短,术后恢复快,是治疗胆道外科术后残余结石可优选的微创治疗策略。
Objective To investigate the clinical value of rigid choledochoscope combined with holmium laser lithotripsy in the treatment of residual intrahepatic and extrahepatic bile duct stones through T-tube sinus tract under sheath protection. Methods From August 2015 to August 2018, 62 patients with residual intrahepatic and extrahepatic bile duct stones were randomly divided into rigid choledochoscope group and choledochofiberscope group, with 31 cases in each group. The patients in rigid choledochoscope group were treated with rigid choledochoscope combined with holmium laser lithotripsy through T-tube sinus tract under the protection of sheath tube, while those in choledochofiberscope group were treated with fiberoptic choledochoscope combined with holmium laser lithotripsy through T-tube sinus tract. The operation time, postoperative hospital stay, stone clearance rate and related major complications of two groups were analyzed and compared. Results Compared with choledochofiberscope group, rigid choledochoscope group had a higher clearance rate(90.3% vs 64.5%, P=0.033) and a shorter operation time[(63±58) min vs(130±44) min, P<0.01]. There was no significant difference in postoperative hospital stay and incidence of complications between two groups(P>0.05). Conclusion Using rigid choledochoscope combined with Holmium laser lithotripsy through T-tube sinus tract for the treatment of residual intrahepatic and extrahepatic bile duct stones is proved to be safe, feasible and efficient, with the advantages of short operation time and rapid recovery. Rigid choledochoscope combined with Holmium laser lithotripsy through T-tube sinus tract is an optimal minimally invasive treatment strategy for residual bile duct stones after biliary surgery.
Objective To investigate the clinical value of rigid choledochoscope combined with holmium laser lithotripsy in the treatment of residual intrahepatic and extrahepatic bile duct stones through T-tube sinus tract under sheath protection. Methods From August 2015 to August 2018, 62 patients with residual intrahepatic and extrahepatic bile duct stones were randomly divided into rigid choledochoscope group and choledochofiberscope group, with 31 cases in each group. The patients in rigid choledochoscope group were treated with rigid choledochoscope combined with holmium laser lithotripsy through T-tube sinus tract under the protection of sheath tube, while those in choledochofiberscope group were treated with fiberoptic choledochoscope combined with holmium laser lithotripsy through T-tube sinus tract. The operation time, postoperative hospital stay, stone clearance rate and related major complications of two groups were analyzed and compared. Results Compared with choledochofiberscope group, rigid choledochoscope group had a higher clearance rate(90.3% vs 64.5%, P=0.033) and a shorter operation time[(63±58) min vs(130±44) min, P<0.01]. There was no significant difference in postoperative hospital stay and incidence of complications between two groups(P>0.05). Conclusion Using rigid choledochoscope combined with Holmium laser lithotripsy through T-tube sinus tract for the treatment of residual intrahepatic and extrahepatic bile duct stones is proved to be safe, feasible and efficient, with the advantages of short operation time and rapid recovery. Rigid choledochoscope combined with Holmium laser lithotripsy through T-tube sinus tract is an optimal minimally invasive treatment strategy for residual bile duct stones after biliary surgery.
引文
[1]方兆山,黄海,王平,等.经皮肝穿刺硬质胆道镜治疗复发性肝胆管结石的临床疗效分析[J].实用医学杂志, 2016, 32(18):3030-3033.FANG Z S, HUANG H, WANG P, et al. Clinical effect of percutaneous transhepaticcholangioscopic lithotomy combined with rigid choledochoscopy in treatment of postoperative recurrent hepatolithiasis[J]. The Journal of Practical Medicine, 2016, 32(18):3030-3033.
[2] LIYANAGE A S, GAMAGE B D, DE SILVA W M. Management and outcome of residual bile duct stones following cholecystectomy at a tertiary referral centre in Sri Lanka[J]. Ceylon Med J, 2007, 52(4):122-124.
[3]王平,方兆山,孙北望,等.内置保护性鞘管和硬质胆道镜辅助治疗肝胆管结石临床研究[J].河北医学, 2014, 20(11):1761-1764.WANG P, FANG Z S, SUN B W, et al. The clinical research of builtin protective sheath pipe and rigid choledochoscope auxiliary treatment of hepatolith[J]. Journal of Hebei Medicine, 2014, 20(11):1761-1764.
[4]中华医学会外科学分会胆道外科学组.肝胆管结石病诊断治疗指南[J].中华消化外科杂志, 2007, 7(2):156-160.Group of Biliary Surgery, Surgical Society of Chinese Medical Association. Guidelines for diagnosis and treatment of hepatolithiasis[J]. Chinese Journal of Digestive Surgery, 2007, 7(2):156-160.
[5] CHEON Y K, CHO Y D, MOON J H, et al. Evaluation of long-term results and recurrent factors after operative and nonoperative treatment for hepatolithiasis[J]. Surgery, 2009, 146(5):843-853.
[6] KUSANO T, ISA T T, MUTO Y, et al. Long-term results of hepaticojejunostomy for hepatolithiasis[J]. Am Surg, 2001, 67(5):442-446.
[7] PIERCE R A, JONNALAGADDA S, SPITLER J A, et al. Incidence of residual choledocholithiasis detected by intraoperative cholangiography at the time of laparoscopic cholecystectomy in patients having undergone preoperative ERCP[J]. Surg Endosc, 2008,22(11):2365-2372.
[8]高振华,王军宏,钱宏亮,等.胆道镜治疗胆道残余结石36例临床研究[J].中国实用外科杂志, 2018, 38(12):1428-1429.GAO Z H, WANG J H, QIAN H L, et al. Clinical study of choledochoscopy in the treatment of residual biliary calculi[J].Chinese Journal of Practical Surgery, 2018, 38(12):1428-1429.
[9]方驰华,方兆山,蔡伟,等.肝胆管结石三维可视化诊治平台构建及临床价值研究[J].中国实用外科杂志, 2015, 35(9):974-978.FANG C H, FANG Z S, CAI W, et al. Establishment and value of three-dimensional visualization diagnosis platform in the treatment ofhepatolithiasis[J]. Chinese Journal of Practical Surgery, 2015, 35(9):974-978.
[10]WANG P, SUN B, HUANG B, et al. Comparison between percutaneous transhepatic rigid cholangioscopic lithotripsy and conventional percutaneous transhepatic cholangioscopic surgery for hepatolithiasis treatment[J]. Surg Laparosc Endosc Percutan Tech, 2016, 26(1):54-59.
[11]马德民.硬质胆镜与纤维胆道镜治疗胆管结石的临床优势比较[J].中国现代普通外科进展, 2014, 17(7):520-523.MA D M. Clinical advantages of rigid choledochoscopy versus choledochofiberscopy in the treatment of bile duct stones[J]. Chinese Journal of Current Advances in General Surgery, 2014, 17(7):520-523.
[12]高小峰.高效实用的经皮肾镜碎石工具:钬激光[J].中华泌尿外科杂志, 2008, 29(10):658.GAO X F. Efficient and practical percutaneous nephrolithotripsy tool:holmium laser[J]. Chinese Journal of Urology, 2008, 29(10):658.
[13]朱昱,戴启强,顾玲玲,等.胆道镜联合钬激光治疗复杂性肝内外胆管结石[J].肝胆胰外科杂志, 2017, 29(2):160-161.ZHU Y, DAI Q Q, GU L L, et al. Choledochoscope combined with Holmium laser in the treatment of complex intrahepatic and extrahepatic bile duct stones[J]. Journal of Hepatobiliary and Pancreatic Surgery, 2017, 29(2):160-161.
[14]王平,陈小伍.经皮肝穿刺一期硬镜碎石术在治疗肝胆管结石的应用[J].中国普通外科杂志, 2013, 23(8):1063-1066.WANG P, CHEN X W. Percutaneous transhepatic one-stage lithotomy with rigid choledochoscope for hepatolithiasis[J]. Chinese Journal of General Surgery, 2013, 23(8):1063-1066.
[15]项楠,方驰华.三维可视化指导肝段切除联合胆道硬镜治疗复杂肝胆管结石[J].中华外科杂志, 2015, 35(5):335-339.XIANG N, FANG C H. Three-dimensional visualization guided segmentectomy combined with choledochoscopy for the treatment of complex hepatolithiasis[J]. Chinese Journal of Surgery, 2015, 35(5):335-339.
[16]王平,方兆山,孙北望,等.经皮肝胆道硬镜碎石治疗肝胆管结石手术路径选择的临床研究[J].实用医学杂志, 2014, 30(20):3245-3248.WANG P, FANG Z S, SUN B W, et al. Clinical research of percutaneous liver way hard mirror gravel for the treatment of hepatolith surgery path selection[J]. The Journal of Practical Medicine, 2014, 34(20):3245-3248.
[17]王平.三维可视化技术在经皮肝胆道硬镜碎石(PTCSL)治疗肝胆管结石中的应用研究[D].广州:南方医科大学, 2014.WANG P. Application of three-dimensional visualization technology in percutaneous transhepaticcholedochoscopic lithotripsy(PTCSL)for hepatolithiasis[D]. Guangzhou:Southern Medical University, 2014.
[18]刘允怡,张绍祥,姜洪池,等.肝胆管结石三维可视化精准诊治专家共识[J].中国实用外科杂志, 2017, 37(1):60-66.LIU Y Y, ZHANG S X, JIANG H C, et al. Expert consensus on accurate diagnosis and treatment of hepatolithiasis with threedimensional visualization[J]. Chinese Journal of Practical Surgery, 2017, 37(1):60-66.
[19]FANG C H, LI G, WANG P, et al. Computer-aided rigid choledochoscopy lithotripsy for hepatolithiasis[J]. J Surg Res, 2015,195(1):105-112.
[20]方驰华,蔡伟,莫志康,等.三维可视引导下经3D腹腔镜胆道硬镜靶向碎石治疗肝胆管结石36例临床分析[J].中国实用外科杂志,2016, 36(3):309-312.FANG C H, CAI W, MO Z K, et al. Clinical analysis of 36 cases of hepatolithiasis treated by three-dimensional visual-guided laparoscopic choledochoscopic hard-target lithotripsy[J]. Chinese Journal of Practical Surgery, 2016, 36(3):309-312.
[21]陈佩军,陈亚男,何海平,等.胆道镜下钬激光碎石术治疗复杂肝内胆管结石麻醉误吸1例[J].南京医科大学学报(自然科学版), 2017,37(11):1541-1542.CHEN P J, CHEN Y N, HE H P, et al. Choledochoscopic holmium laser lithotripsy for complex intrahepatic bile duct stones with anesthetic aspiration:1 case[J]. Journal of Nanjing Medical University(Natural Science Edition), 2017, 37(11):1541-1542.
[22]梁力建,郑惊雷,彭宝岗,等.常用抗生素在动物及人胆汁中的浓度分布和药效学研究[J].中华消化外科杂志, 2007, 6(2):107-111.LIANG L J, ZHENG J L, PENG B G, et al. Concentration distribution and pharmacodynamics of commonly used antibiotics in animal and human bile[J]. Chinese Journal of Digestive Surgery, 2007, 6(2):107-111.
[23]郑惊雷,梁力建,赖佳明.胆道感染病原菌及其对抗生素敏感性变化的研究[J].中国实用外科杂志, 2005, 25(2):86-88.ZHENG J L, LIANG L J, LAI J M. Pathogenic bacteria of biliary tract infection and their changes in antibiotic susceptibility[J]. Chinese Journal of Practical Surgery, 2005, 25(2):86-88.
[24]李炳根,梁璇坤,邱敏捷,等.超声引导经皮肝穿刺一期硬质胆道镜碎石术治疗肝胆管结石[J].中华腔镜外科杂志(电子版), 2017, 10(2):85-88.LI B G, LIANG X K, QIU M J, et al. Ultrasound-guided percutaneous transhepatic cholangioscopic lithotripsy for hepatolithiasis[J]. Chinese Journal of Endoscopic Surgery(Electronic Edition), 2017, 10(2):85-88.
[25]莫志康,方驰华,项楠,等.三维可视化辅助3D腹腔镜、胆道硬镜肝胆管结石靶向碎石术并发症防治研究[J].中国实用外科杂志, 2017,37(3):284-287.MO Z K, FANG C H, XIANG N, et al. Study on the prevention and treatment of complications of targeted lithotripsy for hepatolithiasis under three-dimensional visualization assisted by three-dimensional laparoscopy and choledochoscopy[J]. Chinese Journal of Practical Surgery, 2017, 37(3):284-287.
[2] LIYANAGE A S, GAMAGE B D, DE SILVA W M. Management and outcome of residual bile duct stones following cholecystectomy at a tertiary referral centre in Sri Lanka[J]. Ceylon Med J, 2007, 52(4):122-124.
[3]王平,方兆山,孙北望,等.内置保护性鞘管和硬质胆道镜辅助治疗肝胆管结石临床研究[J].河北医学, 2014, 20(11):1761-1764.WANG P, FANG Z S, SUN B W, et al. The clinical research of builtin protective sheath pipe and rigid choledochoscope auxiliary treatment of hepatolith[J]. Journal of Hebei Medicine, 2014, 20(11):1761-1764.
[4]中华医学会外科学分会胆道外科学组.肝胆管结石病诊断治疗指南[J].中华消化外科杂志, 2007, 7(2):156-160.Group of Biliary Surgery, Surgical Society of Chinese Medical Association. Guidelines for diagnosis and treatment of hepatolithiasis[J]. Chinese Journal of Digestive Surgery, 2007, 7(2):156-160.
[5] CHEON Y K, CHO Y D, MOON J H, et al. Evaluation of long-term results and recurrent factors after operative and nonoperative treatment for hepatolithiasis[J]. Surgery, 2009, 146(5):843-853.
[6] KUSANO T, ISA T T, MUTO Y, et al. Long-term results of hepaticojejunostomy for hepatolithiasis[J]. Am Surg, 2001, 67(5):442-446.
[7] PIERCE R A, JONNALAGADDA S, SPITLER J A, et al. Incidence of residual choledocholithiasis detected by intraoperative cholangiography at the time of laparoscopic cholecystectomy in patients having undergone preoperative ERCP[J]. Surg Endosc, 2008,22(11):2365-2372.
[8]高振华,王军宏,钱宏亮,等.胆道镜治疗胆道残余结石36例临床研究[J].中国实用外科杂志, 2018, 38(12):1428-1429.GAO Z H, WANG J H, QIAN H L, et al. Clinical study of choledochoscopy in the treatment of residual biliary calculi[J].Chinese Journal of Practical Surgery, 2018, 38(12):1428-1429.
[9]方驰华,方兆山,蔡伟,等.肝胆管结石三维可视化诊治平台构建及临床价值研究[J].中国实用外科杂志, 2015, 35(9):974-978.FANG C H, FANG Z S, CAI W, et al. Establishment and value of three-dimensional visualization diagnosis platform in the treatment ofhepatolithiasis[J]. Chinese Journal of Practical Surgery, 2015, 35(9):974-978.
[10]WANG P, SUN B, HUANG B, et al. Comparison between percutaneous transhepatic rigid cholangioscopic lithotripsy and conventional percutaneous transhepatic cholangioscopic surgery for hepatolithiasis treatment[J]. Surg Laparosc Endosc Percutan Tech, 2016, 26(1):54-59.
[11]马德民.硬质胆镜与纤维胆道镜治疗胆管结石的临床优势比较[J].中国现代普通外科进展, 2014, 17(7):520-523.MA D M. Clinical advantages of rigid choledochoscopy versus choledochofiberscopy in the treatment of bile duct stones[J]. Chinese Journal of Current Advances in General Surgery, 2014, 17(7):520-523.
[12]高小峰.高效实用的经皮肾镜碎石工具:钬激光[J].中华泌尿外科杂志, 2008, 29(10):658.GAO X F. Efficient and practical percutaneous nephrolithotripsy tool:holmium laser[J]. Chinese Journal of Urology, 2008, 29(10):658.
[13]朱昱,戴启强,顾玲玲,等.胆道镜联合钬激光治疗复杂性肝内外胆管结石[J].肝胆胰外科杂志, 2017, 29(2):160-161.ZHU Y, DAI Q Q, GU L L, et al. Choledochoscope combined with Holmium laser in the treatment of complex intrahepatic and extrahepatic bile duct stones[J]. Journal of Hepatobiliary and Pancreatic Surgery, 2017, 29(2):160-161.
[14]王平,陈小伍.经皮肝穿刺一期硬镜碎石术在治疗肝胆管结石的应用[J].中国普通外科杂志, 2013, 23(8):1063-1066.WANG P, CHEN X W. Percutaneous transhepatic one-stage lithotomy with rigid choledochoscope for hepatolithiasis[J]. Chinese Journal of General Surgery, 2013, 23(8):1063-1066.
[15]项楠,方驰华.三维可视化指导肝段切除联合胆道硬镜治疗复杂肝胆管结石[J].中华外科杂志, 2015, 35(5):335-339.XIANG N, FANG C H. Three-dimensional visualization guided segmentectomy combined with choledochoscopy for the treatment of complex hepatolithiasis[J]. Chinese Journal of Surgery, 2015, 35(5):335-339.
[16]王平,方兆山,孙北望,等.经皮肝胆道硬镜碎石治疗肝胆管结石手术路径选择的临床研究[J].实用医学杂志, 2014, 30(20):3245-3248.WANG P, FANG Z S, SUN B W, et al. Clinical research of percutaneous liver way hard mirror gravel for the treatment of hepatolith surgery path selection[J]. The Journal of Practical Medicine, 2014, 34(20):3245-3248.
[17]王平.三维可视化技术在经皮肝胆道硬镜碎石(PTCSL)治疗肝胆管结石中的应用研究[D].广州:南方医科大学, 2014.WANG P. Application of three-dimensional visualization technology in percutaneous transhepaticcholedochoscopic lithotripsy(PTCSL)for hepatolithiasis[D]. Guangzhou:Southern Medical University, 2014.
[18]刘允怡,张绍祥,姜洪池,等.肝胆管结石三维可视化精准诊治专家共识[J].中国实用外科杂志, 2017, 37(1):60-66.LIU Y Y, ZHANG S X, JIANG H C, et al. Expert consensus on accurate diagnosis and treatment of hepatolithiasis with threedimensional visualization[J]. Chinese Journal of Practical Surgery, 2017, 37(1):60-66.
[19]FANG C H, LI G, WANG P, et al. Computer-aided rigid choledochoscopy lithotripsy for hepatolithiasis[J]. J Surg Res, 2015,195(1):105-112.
[20]方驰华,蔡伟,莫志康,等.三维可视引导下经3D腹腔镜胆道硬镜靶向碎石治疗肝胆管结石36例临床分析[J].中国实用外科杂志,2016, 36(3):309-312.FANG C H, CAI W, MO Z K, et al. Clinical analysis of 36 cases of hepatolithiasis treated by three-dimensional visual-guided laparoscopic choledochoscopic hard-target lithotripsy[J]. Chinese Journal of Practical Surgery, 2016, 36(3):309-312.
[21]陈佩军,陈亚男,何海平,等.胆道镜下钬激光碎石术治疗复杂肝内胆管结石麻醉误吸1例[J].南京医科大学学报(自然科学版), 2017,37(11):1541-1542.CHEN P J, CHEN Y N, HE H P, et al. Choledochoscopic holmium laser lithotripsy for complex intrahepatic bile duct stones with anesthetic aspiration:1 case[J]. Journal of Nanjing Medical University(Natural Science Edition), 2017, 37(11):1541-1542.
[22]梁力建,郑惊雷,彭宝岗,等.常用抗生素在动物及人胆汁中的浓度分布和药效学研究[J].中华消化外科杂志, 2007, 6(2):107-111.LIANG L J, ZHENG J L, PENG B G, et al. Concentration distribution and pharmacodynamics of commonly used antibiotics in animal and human bile[J]. Chinese Journal of Digestive Surgery, 2007, 6(2):107-111.
[23]郑惊雷,梁力建,赖佳明.胆道感染病原菌及其对抗生素敏感性变化的研究[J].中国实用外科杂志, 2005, 25(2):86-88.ZHENG J L, LIANG L J, LAI J M. Pathogenic bacteria of biliary tract infection and their changes in antibiotic susceptibility[J]. Chinese Journal of Practical Surgery, 2005, 25(2):86-88.
[24]李炳根,梁璇坤,邱敏捷,等.超声引导经皮肝穿刺一期硬质胆道镜碎石术治疗肝胆管结石[J].中华腔镜外科杂志(电子版), 2017, 10(2):85-88.LI B G, LIANG X K, QIU M J, et al. Ultrasound-guided percutaneous transhepatic cholangioscopic lithotripsy for hepatolithiasis[J]. Chinese Journal of Endoscopic Surgery(Electronic Edition), 2017, 10(2):85-88.
[25]莫志康,方驰华,项楠,等.三维可视化辅助3D腹腔镜、胆道硬镜肝胆管结石靶向碎石术并发症防治研究[J].中国实用外科杂志, 2017,37(3):284-287.MO Z K, FANG C H, XIANG N, et al. Study on the prevention and treatment of complications of targeted lithotripsy for hepatolithiasis under three-dimensional visualization assisted by three-dimensional laparoscopy and choledochoscopy[J]. Chinese Journal of Practical Surgery, 2017, 37(3):284-287.
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