内镜括约肌切开联合腹腔镜胆囊切除术治疗胆囊结石合并胆总管结石的Meta分析
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摘要
目的系统评价腹腔镜胆囊切除术(laparoscopic cholecystectomy, LC)联合腹腔镜胆总管探查术(laparoscopic common bile duct exploration, LCBDE)与内镜下括约肌切开(endoscopic sphincterotomy, EST)联合LC治疗胆囊结石合并胆总管结石的安全性和有效性。方法检索Cochrane Library、PubMed、CNKI、万方数据库,查找出版日期截至2018年4月的公开发表的关于LC+LCBDE和EST+LC治疗胆囊结石合并胆总管结石的随机对照试验(random controlled trail,RCT),应用RevMan 5.3软件进行Meta分析。结果纳入9项随机对照试验,合计1 154例患者。Meta分析结果表明,两种术式相比,EST+LC能够降低残石率(RR=2.35,95%CI:1.33～4.13,P=0.003),LC+LCBDE能缩短住院天数(WMD=-0.70,95%CI:-1.14～-0.25,P=0.002);两种术式在胆总管结石清除率(RR=0.98,95%CI:0.92～1.04,P=0.44)、手术中转率(RR=1.12,95%CI:0.73～1.70,P=0.60)、并发症发生率(RR=1.00,95%CI:0.77～1.31,P=1.00)及手术时间(WMD=0.89,95%CI:-15.20～16.98,P=0.91)差异无统计学意义。结论 EST+LC治疗胆囊结石合并胆总管结石有较好的安全性及有效性。
Objective To compare the efficacy and safety of laparoscopic cholecystectomy(LC) plus laparoscopic common bile duct stones exploration(LCBDE) and LC plus endoscopic sphincterotomy(EST) in the treatment of concomitant gallstones with common bile duct stones patients. Methods Cochrane Library, PubMed, CNKI and Wanfang were searched to identify randomized controlled trails(RCTs) published before Apr. 2018 between the LC+LCBDE and EST+LC in treatment of gallstone concomitant gallstones with common bile duct stones. Meta analysis was conducted by the RevMan 5.3. Results A total of 9 RCTs involving 1 154 patients were included in this Meta-analysis. Meta-analysis showed there was no difference in CBD stone clear rate(RR=0.98, 95% CI: 0.92-1.04, P=0.44), conversion rate(RR=1.12, 95% CI: 0.73-1.70, P=0.60), incidence of complications(RR=1.00, 95% CI: 0.77-1.31, P=1.00) and operative time(WMD=0.89, 95%CI:-15.20-16.98, P=0.91) between two procedures. LC+LCBDE had less length of hospital stay(WMD=-0.70, 95% CI:-1.14--0.25, P=0.002) and higher retained stones rate(RR=2.35, 95% CI: 1.33-4.13, P=0.003) than EST+LC. Conclusion EST+LC has relatively good efficacy and safety in treatment of concomitant gallstone with common bile duct stones.
Objective To compare the efficacy and safety of laparoscopic cholecystectomy(LC) plus laparoscopic common bile duct stones exploration(LCBDE) and LC plus endoscopic sphincterotomy(EST) in the treatment of concomitant gallstones with common bile duct stones patients. Methods Cochrane Library, PubMed, CNKI and Wanfang were searched to identify randomized controlled trails(RCTs) published before Apr. 2018 between the LC+LCBDE and EST+LC in treatment of gallstone concomitant gallstones with common bile duct stones. Meta analysis was conducted by the RevMan 5.3. Results A total of 9 RCTs involving 1 154 patients were included in this Meta-analysis. Meta-analysis showed there was no difference in CBD stone clear rate(RR=0.98, 95% CI: 0.92-1.04, P=0.44), conversion rate(RR=1.12, 95% CI: 0.73-1.70, P=0.60), incidence of complications(RR=1.00, 95% CI: 0.77-1.31, P=1.00) and operative time(WMD=0.89, 95%CI:-15.20-16.98, P=0.91) between two procedures. LC+LCBDE had less length of hospital stay(WMD=-0.70, 95% CI:-1.14--0.25, P=0.002) and higher retained stones rate(RR=2.35, 95% CI: 1.33-4.13, P=0.003) than EST+LC. Conclusion EST+LC has relatively good efficacy and safety in treatment of concomitant gallstone with common bile duct stones.
引文
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[19] KOC B,KARAHAN S,ADAS G,et al.Comparison of laparoscopic common bile duct exploration and endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy for choledocholithiasis:a prospective randomized study [J].Am J Surg,2013,206(4):457-463.DOI:10.1016/j.amjsurg.2013.02.004.
[20] POH R,HO P,SRITHARAN M,et al.Randomized clinical trial of intraoperative endoscopic retrograde cholangiopancreatography versus laparoscopic bile duct exploration in patients with choledocholithiasis [J].Br J Surg,2016,103(9):1117-1124.DOI:10.1002/bjs.10207.
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[22] RHODES M,SUSSMAN L,COHEN L,et al.Randomised trial of laparoscopic exploration of common bile duct versus postoperative endoscopic retrograde cholangiography for common bile duct stones [J].Lancet,1998,351(9097):159-161.DOI:10.1016/s0140-6736(97)09175-7.
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[24] TAN C,OCAMPO O,ONG R,et al.Comparison of one stage laparoscopic cholecystectomy combined with intra-operative endoscopic sphincterotomy versus two-stage pre-operative endoscopic sphincterotomy followed by laparoscopic cholecystectomy for the management of preoperatively diagnosed patients with common bile duct stones:a meta-analysis [J].Surg Endosc,2018,32:770-778.DOI:10.1007/s00464-017-5739-y.
[25] PLATT E,SMITH K,SINHA S,et al.Laparoscopic common bile duct exploration;a preferential pathway for elderly patients [J].Ann Med Surg (Lond),2018,30:13-17.DOI:10.1016/j.amsu.2018.03.044.
[26] 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[J].中国普通外科杂志,2016,25(2):202-208.DOI:10.3978/j.issn.1005-6947.2016.02.008.LI Y,HAO J,SUN H,et al.One-staged laparoscopic cholecystectomy and common bile duct exploration versus two-staged endoscopic stone extraction followed by laparoscopic cholecystectomy for concomitant cholecystolithiasis and choledocholithiasis [J].Chinese Journal of General Surgery,2016,25(2):202-208.DOI:10.3978/j.issn.1005-6947.2016.02.008.
[27] BORRECA D,BONA A,BELLOMO P,et al.“Ultra-rapid” sequential treatment in cholecystocholedocholithiasis:alternative same-day approach to laparoendoscopic rendezvous [J].Updates Surg,2015,67(4):449-454.DOI:10.1007/s13304-015-0339-7.
[2] TARGARONA E,AYUSO R,BORDAS J,et al.Randomised trial of endoscopic sphincterotomy with gallbladder left in situ versus open surgery for common bileduct calculi in high-risk patients [J].Lancet,1996,347(9006):926-929.DOI:10.1016/s0140-6736(96)91413-0.
[3] VANNIJVEL M,LESURTEL M,BOUCKAERT W,et al.A survey of European-African surgeons’ management of common bile duct stones [J].HPB (Oxford),2016,18(12):959-964.DOI:10.1016/j.hpb.2016.10.007.
[4] BOVE A,DI RENZO RM,PALONE G,et al.Single-stage procedure for the treatment of cholecysto-choledocolithiasis:a surgical procedures review [J].Ther Clin Risk Manag,2018,14:305-312.DOI:10.2147/TCRM.S146461.
[5] BALOYIANNIS I,TZOVARAS G.Current status of laparoendoscopic rendezvous in the treatment of cholelithiasis with concomitant choledocholithiasis [J].World J Gastrointest Endosc,2015,7(7):714-719.DOI:10.4253/wjge.v7.i7.714.
[6] REINDERS S,GOUMA J,UBBINK T,et al.Transcystic or transductal stone extraction during single-stage treatment of choledochocystolithiasis:a systematic review [J].World J Surg,2014,38 (9):2403-2411.DOI:10.1007/s00268-014-2537-8.
[7] NATALY Y,MERRIE E,STEWART D.Selective use of preoperative endoscopic retrograde cholangiopancreatography in the era of laparoscopic cholecystectomy [J].Anz J Surg,2002,72(3):186-189.DOI:10.1046/j.1445-2197.2002.02353.
[8] RICHTER H,VEGA A,HARZ C,et al.Common bile duct stone treated by simultaneous laparoscopic and endoscopic rendezvous approach during cholecystectomy:analysis of 313 consecutive patients [J].Gastroenterology,2017,152(5):S1275.DOI:10.1016/s0016-5085(17)34250-6.
[9] DESAI R,SHOKOUHI N.Common bile duct stones-their presentation,diagnosis and management [J].Indian J Surg,2009,71(5):229-237.DOI:10.1007/s12262-009-0050-3.
[10] LA G,PESCE A,VITALE M,et al.Efficacy of the laparoendoscopic “rendezvous” to treat cholecystocholedocholithiasis in 210 consecutive patients:a single center experience [J].Surg Laparosc Endosc Percutan Tech,2017,27(4):e48-e52.DOI:10.1097/SLE.0000000000000434.
[11] MOHAMED A,BAHRAM A,AMMAR S,et al.One-session laparoscopic management of combined common bile duct and gallbladder stones versus sequential ERCP followed by laparoscopic cholecystectomy [J].J Laparoendosc Adv Surg Tech A,2015,25(6):482-485.DOI:10.1089/lap.2014.0582.
[12] LIVERANI A,MURONI M,SANTI F,et al.One-step laparoscopic and endoscopic treatment of gallbladder and common bile duct stones:our experience of the last 9 years in a retrospective study [J].Am Surg,2013,79(12):1243-1247.DOI:10.1007/BF00760804.
[13] HIGGINS P,ALTMAN G,GOTZSCHE C,et al.The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials [J].BMJ,2011,343:d5928.DOI:10.1136/bmj.d5928.
[14] HIGGINS J,THOMPSON S.Quantifying heterogeneity in a meta-analysis [J].Stat Med,2002,21:1539-1558.DOI:10.1002/sim.1186.
[15] BANSAL K,MISRA C,GARG P,et al.A prospective randomized trial comparing two-stage versus single-stage management of patients with gallstone disease and common bile duct stones [J].Surg Endosc,2010,24(8):1986-1989.DOI:10.1007/s00464-010-0891-7.
[16] ELGEIDIE A,ELSHOBARY M,NAEEM M.Laparoscopic exploration versus intraoperative endoscopic sphincterotomy for common bile duct stones:a prospective randomized trial [J].Dig Surg,2011,28(5-6):424-431.DOI:10.1159/000331470.
[17] HONG D F,XIN Y,CHEN D W.Comparison of laparoscopic cholecystectomy combined with intraoperative endoscopic sphincterotomy and laparoscopic exploration of the common bile duct for cholecystocholedocholithiasis [J].Surg Endosc,2006,20(3):424-427.DOI:10.1007/s00464-004-8248-8.
[18] BANSAL K,MISRA C,RAJAN K,et al.Single-stage laparoscopic common bile duct exploration and cholecystectomy versus two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy for patients with concomitant gallbladder stones and common bile duct stones:a randomized controlled trial [J].Surg Endosc,2014,28(3):875-885.DOI:10.1007/s00464-013-3237-4.
[19] KOC B,KARAHAN S,ADAS G,et al.Comparison of laparoscopic common bile duct exploration and endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy for choledocholithiasis:a prospective randomized study [J].Am J Surg,2013,206(4):457-463.DOI:10.1016/j.amjsurg.2013.02.004.
[20] POH R,HO P,SRITHARAN M,et al.Randomized clinical trial of intraoperative endoscopic retrograde cholangiopancreatography versus laparoscopic bile duct exploration in patients with choledocholithiasis [J].Br J Surg,2016,103(9):1117-1124.DOI:10.1002/bjs.10207.
[21] ROGERS J,CELLO P,HORN K,et al.Prospective randomized trial of LC+LCBDE vs ERCP/S+LC for common bile duct stone disease [J].Arch Surg,2010,145(1):28-33.DOI:10.1001/archsurg.2009.226.
[22] RHODES M,SUSSMAN L,COHEN L,et al.Randomised trial of laparoscopic exploration of common bile duct versus postoperative endoscopic retrograde cholangiography for common bile duct stones [J].Lancet,1998,351(9097):159-161.DOI:10.1016/s0140-6736(97)09175-7.
[23] CUSCHIERI A,CROCE E,FAGGIONI A,et al.EAES ductal stone study.Preliminary findings of multi-center prospective randomized trial comparing two-stage vs single-stage management [J].Surg Endosc,1996,10(12):1130-1135.DOI:10.1007/s004649900264.
[24] TAN C,OCAMPO O,ONG R,et al.Comparison of one stage laparoscopic cholecystectomy combined with intra-operative endoscopic sphincterotomy versus two-stage pre-operative endoscopic sphincterotomy followed by laparoscopic cholecystectomy for the management of preoperatively diagnosed patients with common bile duct stones:a meta-analysis [J].Surg Endosc,2018,32:770-778.DOI:10.1007/s00464-017-5739-y.
[25] PLATT E,SMITH K,SINHA S,et al.Laparoscopic common bile duct exploration;a preferential pathway for elderly patients [J].Ann Med Surg (Lond),2018,30:13-17.DOI:10.1016/j.amsu.2018.03.044.
[26] 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[J].中国普通外科杂志,2016,25(2):202-208.DOI:10.3978/j.issn.1005-6947.2016.02.008.LI Y,HAO J,SUN H,et al.One-staged laparoscopic cholecystectomy and common bile duct exploration versus two-staged endoscopic stone extraction followed by laparoscopic cholecystectomy for concomitant cholecystolithiasis and choledocholithiasis [J].Chinese Journal of General Surgery,2016,25(2):202-208.DOI:10.3978/j.issn.1005-6947.2016.02.008.
[27] BORRECA D,BONA A,BELLOMO P,et al.“Ultra-rapid” sequential treatment in cholecystocholedocholithiasis:alternative same-day approach to laparoendoscopic rendezvous [J].Updates Surg,2015,67(4):449-454.DOI:10.1007/s13304-015-0339-7.