内镜联合腹腔镜与手术方法治疗胆总管结石的临床分析
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摘要
目的:腹腔镜胆囊切除术治疗胆囊良性疾病己经被公认为一种高效、安全的手术治疗手段。对于胆总管结石,在传统开腹手术基础上,内镜乳头括约肌切开取石术及腹腔镜胆总管探查取石术亦被广泛的推广应用。本文进行回顾性对比研究,比较EST+LC、LCBDE及开腹胆总管探查取石术治疗胆总管结石和/或合并胆囊结石的疗效。
方法:对我院于2006年1月～2008年12月住院期间诊断为胆总管结石有/无合并胆囊结石的447例患者分成3组,其中A组321例行开腹胆总管探查取石术,B组75例行LCBDE,C组51例行EST+LC,分别统计手术时间、术中出血量、结石一次清除率、术后胃肠功能恢复时间、术后腹腔引流管停留时间、术后住院时间、手术相关并发症及总住院费用。
结果:A组321例患者行开腹胆总管探查取石术,术中使用胆道镜探查30例,其中10例未发现结石残留,且胆总管下端通畅,予行一期缝合胆总管,余311例常规留置T管,术后10-14天经T管行胆管造影,59例发现胆管残留结石,A组患者一次结石取净率为81.6%(262/321)。B组患者75例行LCBDE,均未中转开腹,所有患者均于术中使用胆道镜探查、取石,6例患者肝胆管内结石太多,无法一次取净,留置T管,余69例患者行胆总管一期缝合,术后有8例患者出现胆汁漏,1例经保守治疗无效后于术后第二天行开腹探查+腹腔冲洗+T管引流,积极治疗后痊愈出院,B组患者一次结石取净率为92.0%(69/75);C组患者51例先行EST,再行LC,15例接受EST的患者术后出现一过性高淀粉酶血症,2例术中行EST后出现大出血而终止胆总管取石,另择期再次EST成功,所有患者均于胆总管取石成功后3～6天行LC,均未中转开腹。结果EST+LC组(C组)术中出血量更少、切口更小、结石一次清除率更高、术后住院时间更短、胃肠功能恢复更快,无须放置引流管,比其他两组都有优势,但却需要更高的住院费用;在其他两组,LCBDE手术时间较开腹组长,但术中出血量更少、切口更小、术后住院时间更短、胃肠功能恢复更快,停留腹腔引流管时间更短,且总住院费用与开腹组无明显差别。术后并发症发生率开腹组较其他两组常见。
结论:腹腔镜胆总管探查取石术对于开腹胆总管探查取石术更加安全、高效、经济。虽然单纯手术时间较长,但却具有出血少、住院时间短、康复快的优势。EST+LC也有着同样的优势,但需要更高的总住院费用。显然EST+LC、LCBDE及开腹胆总管探查取石术治疗胆总管结石和/或合并胆囊结石各有优势,EST+LC和LCBDE的出现丰富了胆总管结石的治疗方法,但却未能取代开腹胆总管探查术。只要指征选择合适,总能从中选择出一种更适合你的患者的方法,从而使患者获得更大的收益。
Object i ve : Laparoscopic cholecystectomy (LC) has been reported to be a safe and effective approach for the treatment of cholelithiasis. As choledocholith, the endoscopic combines with laparoscopic common bile duct exploration and choledocholithotomy is being applied widely than before also. The author performed a review trial to compare effect of endoscopic combined with laparoscopic CBDEC with those of open CBDEC.
Methods: From January 2006 to December 2008, 447 patients with choledocholith were collected who had underwent EST+LC(n51)、laparoscopic(n75) or open (n321) CBDEC in Guangdong Province Hospital. The three groups were similar in age, sex ratio, ASA class. Main outcome measures included operative time, length of incision, primary stones clearence rate, estimated blood loss, length of postoperative stay, operative complications, the recovery time of gastrointestinal function and the average detention time of drainage pipe. Total hospital costs of the three groups were also compared.
Results: The patients of A group (n321) underwent open CBDEC, among which 30 cases were explored with intraoperative choledochoscope. And 10 cases had primary ductal closure as the end of the common bile duct was patency and no stone residual. The others were layed a T-tube. Everyone underwent cholangiography through the T-tube after 10-14days, among which 59 cases founded stone residual. The primary stones clearence rate of group A was 81. 6%(262/321). The patients of B group (n75) underwent laparoscopic CBDEC, all cases were treated with successful laparoscopic and choledochoscopic procedure without conversion to open surgery, among which 6 cases were layed a T-tube because there were too many stones in the bile duct. The others had primary ductal closure. There were bile leakage in 8 cases and one of them conversion to open surgery as the sever peritonitis. The primary stones clearence rate of group B was 92. 0% (69/75). The patients of group C (n51) underwent endoscopic sphinctertomy first, and then followed laparoscopic cholecystectomy. The procedure of EST was failed in 2 cases as the serve bleeding, 15 cases experienced transient high serum amylase after EST. The successful cases were treated with laparoscopic cholecystectomy in 3-6 days after EST. Then we found that the mean operative time, operative blood loss, length of incision, length of postoperative stay and recovery time of gastrointestinal function of group C were the least, and need not to lay a abdominal drainage pipe, but total hospital costs were the highest. In the other groups, mean operative time was longer for laparoscopic CBDEC than for open CBDEC, but operative blood loss, length of incision, length of postoperative stay, average-detention time of drainage pipe and recovery time of gastrointestinal function were less, the hospital costs were similar. Wound-related complications were more common after open CBDEC.
Conclusions: Laparoscopic CBDEC is a safe and cost-effective alternative to open CBDEC. Despite a longer operative time, patients undergoing laparoscopic CBDEC benefited from less blood loss, a shorter hospital stay, and faster convalescence. It is similar to the EST+LC, but costs more. Obviously, there are respective advantages and disadvantages of the treatment for the common bile duct stone in the three groups. The appearance and application of the EST+LC and LCBDE enrich the treatments of the common bile duct stone, but they can't take place of the traditional open surgery. You can have a good choice from them so that your patients can have benefit from it.
方法:对我院于2006年1月～2008年12月住院期间诊断为胆总管结石有/无合并胆囊结石的447例患者分成3组,其中A组321例行开腹胆总管探查取石术,B组75例行LCBDE,C组51例行EST+LC,分别统计手术时间、术中出血量、结石一次清除率、术后胃肠功能恢复时间、术后腹腔引流管停留时间、术后住院时间、手术相关并发症及总住院费用。
结果:A组321例患者行开腹胆总管探查取石术,术中使用胆道镜探查30例,其中10例未发现结石残留,且胆总管下端通畅,予行一期缝合胆总管,余311例常规留置T管,术后10-14天经T管行胆管造影,59例发现胆管残留结石,A组患者一次结石取净率为81.6%(262/321)。B组患者75例行LCBDE,均未中转开腹,所有患者均于术中使用胆道镜探查、取石,6例患者肝胆管内结石太多,无法一次取净,留置T管,余69例患者行胆总管一期缝合,术后有8例患者出现胆汁漏,1例经保守治疗无效后于术后第二天行开腹探查+腹腔冲洗+T管引流,积极治疗后痊愈出院,B组患者一次结石取净率为92.0%(69/75);C组患者51例先行EST,再行LC,15例接受EST的患者术后出现一过性高淀粉酶血症,2例术中行EST后出现大出血而终止胆总管取石,另择期再次EST成功,所有患者均于胆总管取石成功后3～6天行LC,均未中转开腹。结果EST+LC组(C组)术中出血量更少、切口更小、结石一次清除率更高、术后住院时间更短、胃肠功能恢复更快,无须放置引流管,比其他两组都有优势,但却需要更高的住院费用;在其他两组,LCBDE手术时间较开腹组长,但术中出血量更少、切口更小、术后住院时间更短、胃肠功能恢复更快,停留腹腔引流管时间更短,且总住院费用与开腹组无明显差别。术后并发症发生率开腹组较其他两组常见。
结论:腹腔镜胆总管探查取石术对于开腹胆总管探查取石术更加安全、高效、经济。虽然单纯手术时间较长,但却具有出血少、住院时间短、康复快的优势。EST+LC也有着同样的优势,但需要更高的总住院费用。显然EST+LC、LCBDE及开腹胆总管探查取石术治疗胆总管结石和/或合并胆囊结石各有优势,EST+LC和LCBDE的出现丰富了胆总管结石的治疗方法,但却未能取代开腹胆总管探查术。只要指征选择合适,总能从中选择出一种更适合你的患者的方法,从而使患者获得更大的收益。
Object i ve : Laparoscopic cholecystectomy (LC) has been reported to be a safe and effective approach for the treatment of cholelithiasis. As choledocholith, the endoscopic combines with laparoscopic common bile duct exploration and choledocholithotomy is being applied widely than before also. The author performed a review trial to compare effect of endoscopic combined with laparoscopic CBDEC with those of open CBDEC.
Methods: From January 2006 to December 2008, 447 patients with choledocholith were collected who had underwent EST+LC(n51)、laparoscopic(n75) or open (n321) CBDEC in Guangdong Province Hospital. The three groups were similar in age, sex ratio, ASA class. Main outcome measures included operative time, length of incision, primary stones clearence rate, estimated blood loss, length of postoperative stay, operative complications, the recovery time of gastrointestinal function and the average detention time of drainage pipe. Total hospital costs of the three groups were also compared.
Results: The patients of A group (n321) underwent open CBDEC, among which 30 cases were explored with intraoperative choledochoscope. And 10 cases had primary ductal closure as the end of the common bile duct was patency and no stone residual. The others were layed a T-tube. Everyone underwent cholangiography through the T-tube after 10-14days, among which 59 cases founded stone residual. The primary stones clearence rate of group A was 81. 6%(262/321). The patients of B group (n75) underwent laparoscopic CBDEC, all cases were treated with successful laparoscopic and choledochoscopic procedure without conversion to open surgery, among which 6 cases were layed a T-tube because there were too many stones in the bile duct. The others had primary ductal closure. There were bile leakage in 8 cases and one of them conversion to open surgery as the sever peritonitis. The primary stones clearence rate of group B was 92. 0% (69/75). The patients of group C (n51) underwent endoscopic sphinctertomy first, and then followed laparoscopic cholecystectomy. The procedure of EST was failed in 2 cases as the serve bleeding, 15 cases experienced transient high serum amylase after EST. The successful cases were treated with laparoscopic cholecystectomy in 3-6 days after EST. Then we found that the mean operative time, operative blood loss, length of incision, length of postoperative stay and recovery time of gastrointestinal function of group C were the least, and need not to lay a abdominal drainage pipe, but total hospital costs were the highest. In the other groups, mean operative time was longer for laparoscopic CBDEC than for open CBDEC, but operative blood loss, length of incision, length of postoperative stay, average-detention time of drainage pipe and recovery time of gastrointestinal function were less, the hospital costs were similar. Wound-related complications were more common after open CBDEC.
Conclusions: Laparoscopic CBDEC is a safe and cost-effective alternative to open CBDEC. Despite a longer operative time, patients undergoing laparoscopic CBDEC benefited from less blood loss, a shorter hospital stay, and faster convalescence. It is similar to the EST+LC, but costs more. Obviously, there are respective advantages and disadvantages of the treatment for the common bile duct stone in the three groups. The appearance and application of the EST+LC and LCBDE enrich the treatments of the common bile duct stone, but they can't take place of the traditional open surgery. You can have a good choice from them so that your patients can have benefit from it.
引文
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