经腹腔顺行放置鼻胆管引流联合胆总管一期缝合在胆总管结石治疗中的应用
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摘要
目的探讨经腹腔顺行放置鼻胆管引流联合胆总管一期缝合在胆总管结石治疗中的应用价值。方法 2014年3月～2017年3月我科收治的164例胆囊结石合并胆总管结石患者,采用随机数字表法将患者分成观察组82例和对照组82例。两组均采用腹腔镜胆囊切除术,然后行胆总管探查。在观察组,行腹腔顺行放置鼻胆管引流联合胆总管一期缝合,在对照组行放置T管引流,观察两组患者术中出血量、手术时间、肠功能恢复时间等相关临床指标,比较两组患者胆汁漏、肠道出血、胰腺炎等并发症发生情况。结果观察组患者术中出血量为(36.1±10.2)m L,与对照组[(32.2±13.2)m L,P>0.05]比,差异无统计学意义;手术时间为(96.6±21.5) min,与对照组[(91.5±19.1) min,P>0.05]比,差异也无统计学意义;肠功能恢复时间为(1.4±0.5) d,显著短于对照组[(2.3±0.5)d,P<0.05];引流管放置时间为(5.5±1.6) d,显著短于对照组[(90.8±2.3) d,P<0.05];住院时间为(7.4±1.4)d,显著短于对照组[(9.5±2.4)d,P<0.05],但住院费用为(38822.2±4019.7)元,显著高于对照组[(26744.5±3277.7)元,P<0.05];术后1 d,观察组患者胆汁引流量为(267.3±102.8)m L,与对照组[(266.5±112.6)m L,P>0.05]比,差异无统计学意义;术后2 d,胆汁引流量为(221.3±128.2)m L,显著少于对照组[(313.3±117.6)m L,P<0.05];术后3 d,胆汁引流量为(191.9±138.5)m L,显著少于对照组[(270.8±121.8) m L,P<0.05];两组引流失败、胆汁漏、肠道出血和胰腺炎等并发症发生率比较,无显著差异(8.4%对12.2%,P>0.05)。结论采用腹腔顺行放置鼻胆管引流联合胆总管一期缝合治疗胆囊结石合并胆总管结石患者具有较好的临床应用价值,显著缩短了带管和住院时间,但需掌握好手术适应证。
Objective To explore the application value of nasobiliary drainage combined with primary suture of common bile duct in the treatment of patients with choledocholithiasis. Methods 164 patients with cholecystolithiasis and cholelithiasis were recruited in our hospital between March 2014 and March 2017,and were randomly divided into observation group(n=82) and control group(n=82). Laparoscopic cholecystectomy and bile duct exploration were performed in both groups. The patients in the observation group were treated with intraperitoneal anterograde nasobiliary drainage combined with primary suture of common bile duct,and the patients in the control group were treated with T tube drainage. The amount of blood loss during operation and the operation time were observed in both groups. The recovery of intestinal functions,bile drainage and the complications were compared between the two groups. Results The amount of intraoperative bleeding in the observation group was(36.1±10.2) mL,similar to [(32.2±13.2) m L,P>0.05] in the control;the operative time was(96.6±21.5) min,also similar to [(91.5±19.1) min,P>0.05] in the control;the recovery time of intestinal function was(1.4 ±0.5) days,significantly shorter than(2.3 ±0.5) d(P <0.05) in the control;the time of drainage tube placement was(5.5±1.6) days,significantly shorter than(90.8 ±2.3) d(P <0.05) in the control;the hospitalization stay was(7.4 ±1.4) days,significantly shorter than(9.5 ±2.4) days(P <0.05) in the control,while the hospitalization cost was(38822.2 ±4019.7) yuan,significantly higher than(26744.7±3277.7) yuan in the control group;at day one postoperation the bile drainage in observation group was(267.3±102.8) mL,not significantly different as compared to(266.5±112.6) mL in the control(P>0.05);at day 2 the bile drainage was(221.3±128.2) mL,significantly lower than(313.3±117.6) m L in the control(P<0.05) and at day 3 the bile drainage was(191.9±138.5) mL,significantly lower than(270.8 ±121.8) mL in the control(P <0.05);the incidences of complications,such as bile leakage,intestinal hemorrhage,nausea and vomiting,and pancreatitis,in the two groups were not significantly different(8.4% vs. 12.2%,x2 =0.591,P >0.05).Conclusion The application of intraperitoneal anterograde nasobiliary drainage combined with primary suture of common bile duct in the treatment of patients with choledocholithiasis and cholelithiasis is efficient,which might significantly shorten the hospital stay and tube drainage.
Objective To explore the application value of nasobiliary drainage combined with primary suture of common bile duct in the treatment of patients with choledocholithiasis. Methods 164 patients with cholecystolithiasis and cholelithiasis were recruited in our hospital between March 2014 and March 2017,and were randomly divided into observation group(n=82) and control group(n=82). Laparoscopic cholecystectomy and bile duct exploration were performed in both groups. The patients in the observation group were treated with intraperitoneal anterograde nasobiliary drainage combined with primary suture of common bile duct,and the patients in the control group were treated with T tube drainage. The amount of blood loss during operation and the operation time were observed in both groups. The recovery of intestinal functions,bile drainage and the complications were compared between the two groups. Results The amount of intraoperative bleeding in the observation group was(36.1±10.2) mL,similar to [(32.2±13.2) m L,P>0.05] in the control;the operative time was(96.6±21.5) min,also similar to [(91.5±19.1) min,P>0.05] in the control;the recovery time of intestinal function was(1.4 ±0.5) days,significantly shorter than(2.3 ±0.5) d(P <0.05) in the control;the time of drainage tube placement was(5.5±1.6) days,significantly shorter than(90.8 ±2.3) d(P <0.05) in the control;the hospitalization stay was(7.4 ±1.4) days,significantly shorter than(9.5 ±2.4) days(P <0.05) in the control,while the hospitalization cost was(38822.2 ±4019.7) yuan,significantly higher than(26744.7±3277.7) yuan in the control group;at day one postoperation the bile drainage in observation group was(267.3±102.8) mL,not significantly different as compared to(266.5±112.6) mL in the control(P>0.05);at day 2 the bile drainage was(221.3±128.2) mL,significantly lower than(313.3±117.6) m L in the control(P<0.05) and at day 3 the bile drainage was(191.9±138.5) mL,significantly lower than(270.8 ±121.8) mL in the control(P <0.05);the incidences of complications,such as bile leakage,intestinal hemorrhage,nausea and vomiting,and pancreatitis,in the two groups were not significantly different(8.4% vs. 12.2%,x2 =0.591,P >0.05).Conclusion The application of intraperitoneal anterograde nasobiliary drainage combined with primary suture of common bile duct in the treatment of patients with choledocholithiasis and cholelithiasis is efficient,which might significantly shorten the hospital stay and tube drainage.
引文
[1]路夷平,叶晋生,姚力.腹腔镜胆总管探查顺行鼻胆管引流胆总管一期缝合的临床应用.中华普通外科杂志,2016,31(11):893-896.
[2]张胜龙,陈安平,李华林,等.经腹与经口鼻胆管引流在腹腔镜手术中的应用比较.中华肝胆外科杂志,2016,22(8):534-536.
[3]Lin H,Li S,Xi L.The safety and efficacy of nasobiliary drainage versus biliary stenting in malignant biliary obstruction.Medicine,2016,95(46):e5253.
[4]Zhang GQ,Li Y,Ren YP,et al.Outcomes of preoperative endoscopic nasobiliary drainage and endoscopic retrograde biliary drainage for malignant distal biliary obstruction prior to pancreaticoduodenectomy.World J Gastroenterol,2017,23(29):5386-5394.
[5]殷俊杰,蔡阳,张筱凤,等.腹腔镜胆囊切除术并发胆管损伤患者的诊治.中华肝胆外科杂志,2016,22(1):27-29.
[6]Hegade VS,Krawczyk M,Kremer AE,et al.The safety and efficacy of nasobiliary drainage in the treatment of refractory cholestatic pruritus:a multicentre European study.Aliment Pharmacol Therapeut,2016,43(2):294-302.
[7]Tang Z,Yang Y,Meng W,et al.Best option for preoperative biliary drainage in Klatskin tumor.Medicine,2017,96(43):e8372.
[8]申权,余淼,贾江坤,等.腹腔镜联合胆道镜胆管探查取石术治疗急性梗阻性化脓性胆管炎疗效观察.中华实用诊断与治疗杂志,2016,30(9):878-880.
[9]Chao D,Lou S,Fan Z.Associating pancreaticostomy and biliary-irrigation for staged pancreaticoduodenectomy approach to pancreatic intraductal papillary mucinous neoplasm with recurrent cholangitis and severe jaundice:A case report.Medicine,2016,95(48):e5500.
[10]杜军卫,靳君华,胡文秀,等.胆囊结石继发肝外胆管结石的三种术式比较.中华医学杂志,2017,97(4):276-279.
[11]Nakai Y,Isayama H,Yamamoto N,et al.Conversion to endoscopic ultrasound-guided biliary drainage by temporary nasobiliary drainage placement in patients with prior biliary stenting.Endoscopic Ultrasound,2017,6(5):323-328.
[12]Digibeyaz S,Oztas E,Akpinar MY,et al.A rarely seen biliary variation:Right posterior and right anterior hepatic ducts were opening to the cystic duct.Acta Gastroenterologica Belgica,2016,79(2):275.
[13]Glendining KA,Liu SC,Nguyen M,et al.Downstream mediators of Ten-m3 signalling in the developing visual pathway.Bmc Neurosci,2017,18(1):78.
[14]孙科,肖宏,陈安平,等.腹腔镜下经胆囊管逆向乳头插管法治疗胆囊结石合并细径胆总管结石的临床疗效.中华消化外科杂志,2016,15(4):363-367.
[15]蒋遗云,邬林泉,李恩亮,等.加速康复外科在肝切除术治疗肝胆管结石病中的应用.中华肝胆外科杂志,2016,22(12):814-818.
[16]胡伟东,陈超波,赵万文,等.阿托伐他汀在肝切除治疗梗阻型肝胆管结石患者中的应用.中华肝胆外科杂志,2016,22(3):168-171.
[17]Higuchi R,Yazawa T,Uemura S,et al.ENBD is associated with decreased tumor dissemination compared to PTBD in perihilar cholangiocarcinoma.J Gastrointest Surg,2017,21(Suppl3):1-9.
[18]Sagami R,Tsuji H,Nishikiori H,et al.Endoscopic ultrasound-guided transduodenal drainage of idiopathic retroperitoneal abscess in an immunocompromised patient:A case report.Medicine,2017,96(50):e9132.
[19]李民,汪岩,张陈,等.加速康复外科在营养不良肝胆管结石病胆肠吻合术中的应用价值.中华消化外科杂志,2016,15(1):42-46.
[20]Bian AZL,Fuks D,Valle RD,et al.Effectiveness and risk of biliary drainage prior to pancreatoduodenectomy:review of current status.Surg Today,2017,48(4):1-9.
[21]牛小娟,宋京海,陈剑,等.腹腔镜下经胆囊管汇入部微切开途径行胆道探查术在老年胆总管结石患者中的应用.中华老年医学杂志,2016,35(9):960-963.
[22]曹占国,李宁,王震宇,等.内镜逆行胆胰管造影术在胆总管结石合并壶腹部憩室中的应用.中华消化内镜杂志,2018,35(7):497-500.
[23]童里,耿小平,谢坤,等.肝内外胆管结石多次手术原因及预后分析.中华消化外科杂志,2016,15(4):368-373.
[24]Deufel CL,Furutani KM,Dahl RA,et al.Technique for the administration of high-dose-rate brachytherapy to the bile duct using a nasobiliary catheter.Brachytherapy,2018,17(4):718-725.
[2]张胜龙,陈安平,李华林,等.经腹与经口鼻胆管引流在腹腔镜手术中的应用比较.中华肝胆外科杂志,2016,22(8):534-536.
[3]Lin H,Li S,Xi L.The safety and efficacy of nasobiliary drainage versus biliary stenting in malignant biliary obstruction.Medicine,2016,95(46):e5253.
[4]Zhang GQ,Li Y,Ren YP,et al.Outcomes of preoperative endoscopic nasobiliary drainage and endoscopic retrograde biliary drainage for malignant distal biliary obstruction prior to pancreaticoduodenectomy.World J Gastroenterol,2017,23(29):5386-5394.
[5]殷俊杰,蔡阳,张筱凤,等.腹腔镜胆囊切除术并发胆管损伤患者的诊治.中华肝胆外科杂志,2016,22(1):27-29.
[6]Hegade VS,Krawczyk M,Kremer AE,et al.The safety and efficacy of nasobiliary drainage in the treatment of refractory cholestatic pruritus:a multicentre European study.Aliment Pharmacol Therapeut,2016,43(2):294-302.
[7]Tang Z,Yang Y,Meng W,et al.Best option for preoperative biliary drainage in Klatskin tumor.Medicine,2017,96(43):e8372.
[8]申权,余淼,贾江坤,等.腹腔镜联合胆道镜胆管探查取石术治疗急性梗阻性化脓性胆管炎疗效观察.中华实用诊断与治疗杂志,2016,30(9):878-880.
[9]Chao D,Lou S,Fan Z.Associating pancreaticostomy and biliary-irrigation for staged pancreaticoduodenectomy approach to pancreatic intraductal papillary mucinous neoplasm with recurrent cholangitis and severe jaundice:A case report.Medicine,2016,95(48):e5500.
[10]杜军卫,靳君华,胡文秀,等.胆囊结石继发肝外胆管结石的三种术式比较.中华医学杂志,2017,97(4):276-279.
[11]Nakai Y,Isayama H,Yamamoto N,et al.Conversion to endoscopic ultrasound-guided biliary drainage by temporary nasobiliary drainage placement in patients with prior biliary stenting.Endoscopic Ultrasound,2017,6(5):323-328.
[12]Digibeyaz S,Oztas E,Akpinar MY,et al.A rarely seen biliary variation:Right posterior and right anterior hepatic ducts were opening to the cystic duct.Acta Gastroenterologica Belgica,2016,79(2):275.
[13]Glendining KA,Liu SC,Nguyen M,et al.Downstream mediators of Ten-m3 signalling in the developing visual pathway.Bmc Neurosci,2017,18(1):78.
[14]孙科,肖宏,陈安平,等.腹腔镜下经胆囊管逆向乳头插管法治疗胆囊结石合并细径胆总管结石的临床疗效.中华消化外科杂志,2016,15(4):363-367.
[15]蒋遗云,邬林泉,李恩亮,等.加速康复外科在肝切除术治疗肝胆管结石病中的应用.中华肝胆外科杂志,2016,22(12):814-818.
[16]胡伟东,陈超波,赵万文,等.阿托伐他汀在肝切除治疗梗阻型肝胆管结石患者中的应用.中华肝胆外科杂志,2016,22(3):168-171.
[17]Higuchi R,Yazawa T,Uemura S,et al.ENBD is associated with decreased tumor dissemination compared to PTBD in perihilar cholangiocarcinoma.J Gastrointest Surg,2017,21(Suppl3):1-9.
[18]Sagami R,Tsuji H,Nishikiori H,et al.Endoscopic ultrasound-guided transduodenal drainage of idiopathic retroperitoneal abscess in an immunocompromised patient:A case report.Medicine,2017,96(50):e9132.
[19]李民,汪岩,张陈,等.加速康复外科在营养不良肝胆管结石病胆肠吻合术中的应用价值.中华消化外科杂志,2016,15(1):42-46.
[20]Bian AZL,Fuks D,Valle RD,et al.Effectiveness and risk of biliary drainage prior to pancreatoduodenectomy:review of current status.Surg Today,2017,48(4):1-9.
[21]牛小娟,宋京海,陈剑,等.腹腔镜下经胆囊管汇入部微切开途径行胆道探查术在老年胆总管结石患者中的应用.中华老年医学杂志,2016,35(9):960-963.
[22]曹占国,李宁,王震宇,等.内镜逆行胆胰管造影术在胆总管结石合并壶腹部憩室中的应用.中华消化内镜杂志,2018,35(7):497-500.
[23]童里,耿小平,谢坤,等.肝内外胆管结石多次手术原因及预后分析.中华消化外科杂志,2016,15(4):368-373.
[24]Deufel CL,Furutani KM,Dahl RA,et al.Technique for the administration of high-dose-rate brachytherapy to the bile duct using a nasobiliary catheter.Brachytherapy,2018,17(4):718-725.