腹腔镜胆总管结石探查后胆总管不同闭合方式的对比研究
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摘要
目的探讨腹腔镜胆总管结石探查后不同胆总管闭合方式的治疗效果。方法回顾性分析2012年6月至2017年5月佛山市第一人民医院和佛山市禅城中心医院298例行腹腔镜胆囊切除和同期胆总管取石患者的临床资料。比较腹腔镜胆囊切除术和胆总管探查术后胆总管不同闭合方式患者的严重并发症发生率(Clavien-Dindo分级≥Ⅲ级)、术后胆漏发生率(Grade分级A/B/C)、住院时间、再入院率、胆总管结石复发和其他相关并发症。结果 74例(24.8%)行胆总管一期缝合术,118例(39.6%)行T管引流术,106例(35.6%)行胆总管支架引流术。一期缝合、T管引流术以及内支架引流的患者住院时间分别为2～30(5.8±3.7) d、7～75(11.6±8.9) d和7～56(9.8±5.1) d,差异有统计学意义(F=5.96,P=0.04);再入院率分别为0(0/74)、10.2%(12/118)、5.7%(6/106),差异有统计学意义(χ~2=8.25,P=0.02);术后总并发症发生率分别为28.4%(21/74)、31.4%(37/118)、27.4%(29/106),严重并发症的发生率分别为0(0/74)、7.6%(9/118)、4.7%(5/106),差异有统计学意义(χ~2=6.52,P=0.04);术后胆漏并发症分别为23.0%(17/74)、16.9%(20/118)和8.5%(9/106),差异有统计学意义(χ~2=7.34,P=0.02)。但胆总管一期缝合术无C级胆漏发生,B级胆漏通过延长引流而治愈;术后结石复发率分别为2.7%(2/74)、4.2%(5/118)、11.3%(12/106),差异有统计学意义(χ~2=6.91,P=0.03)。结论腹腔镜胆总管结石探查术后采用T管引流和内支架植入并不能带来更多的益处,反而有较多相关的并发症。尽管胆总管一期缝合容易出现术后胆漏,但很少出现严重的并发症。
Objective To analyze the therapeutic effect of different bile duct closure methods for laparoscopic common bile duct exploration for choledocholithiasis. Methods The clinical data of two hundred and ninety-eight patients who underwent laparoscopic cholecystectomy and choledocholithotomy from June 2012 to May 2017 in Chancheng Central Hospital of Foshan and the First People's Hospital of Foshan were retrospectively analyzed. The incidence of severe complications(Clavien-Dindo> III), the incidence of bile leakage(Grade A/B/C), hospitalization time, re-admission rate, recurrence of common bile duct stones and other related complications were compared among patients with different closure modes of common bile duct. Results There were 74 cases(24.8%) undergoing primary suture of common bile duct, 118 cases(39.6%) undergoing T-tube drainage and 106 cases(35.6%) undergoing stent drainage.The hospitalization time of patients with primary suture, T-tube drainage and stent drainage was 2-30(5.8±3.7) days, 7-75(11.6±8.9) days and 7-56(9.8±5.1) days, respectively, the difference was statistically significant(F=5.96, P=0.04); the re-admission rates were 0(0/74), 10.2%(12/118) and 5.7%(6/106), respectively(χ~2=8.25, P=0.02); the total incidence of postoperative complications was 28.4%(21/74),31.4%(37/118) and 27.4%(29/106) and the incidence of severe complications was 0(0/74), 7.6%(9/118)and 4.7%(5/106), respectively, the difference was statistically significant(χ~2=6.52, P=0.04); postoperative complications of biliary leakage was 23.0%(17/74), 16.9%(20/118) and 8.5%(9/106), respectively(χ~2=7.34,P=0.02). However, Grade C bile leakage did not occur in primary suture of common bile duct and Grade B bile leakage was cured by prolonging drainage. Postoperative stone recurrence rates of patients with primary suture, T-tube drainage and stent drainage were 2.7%(2/74), 4.2%(5/118) and 11.3%(12/106), with statistically significant difference(χ~2=6.91, P=0.03). Conclusions T-tube drainage and stent implantation after laparoscopic choledocholithotomy do not bring more benefits, on the contrary, there are many related complications. Although primary suture of common bile duct is prone to bile leakage after operation, there are few serious complications.
Objective To analyze the therapeutic effect of different bile duct closure methods for laparoscopic common bile duct exploration for choledocholithiasis. Methods The clinical data of two hundred and ninety-eight patients who underwent laparoscopic cholecystectomy and choledocholithotomy from June 2012 to May 2017 in Chancheng Central Hospital of Foshan and the First People's Hospital of Foshan were retrospectively analyzed. The incidence of severe complications(Clavien-Dindo> III), the incidence of bile leakage(Grade A/B/C), hospitalization time, re-admission rate, recurrence of common bile duct stones and other related complications were compared among patients with different closure modes of common bile duct. Results There were 74 cases(24.8%) undergoing primary suture of common bile duct, 118 cases(39.6%) undergoing T-tube drainage and 106 cases(35.6%) undergoing stent drainage.The hospitalization time of patients with primary suture, T-tube drainage and stent drainage was 2-30(5.8±3.7) days, 7-75(11.6±8.9) days and 7-56(9.8±5.1) days, respectively, the difference was statistically significant(F=5.96, P=0.04); the re-admission rates were 0(0/74), 10.2%(12/118) and 5.7%(6/106), respectively(χ~2=8.25, P=0.02); the total incidence of postoperative complications was 28.4%(21/74),31.4%(37/118) and 27.4%(29/106) and the incidence of severe complications was 0(0/74), 7.6%(9/118)and 4.7%(5/106), respectively, the difference was statistically significant(χ~2=6.52, P=0.04); postoperative complications of biliary leakage was 23.0%(17/74), 16.9%(20/118) and 8.5%(9/106), respectively(χ~2=7.34,P=0.02). However, Grade C bile leakage did not occur in primary suture of common bile duct and Grade B bile leakage was cured by prolonging drainage. Postoperative stone recurrence rates of patients with primary suture, T-tube drainage and stent drainage were 2.7%(2/74), 4.2%(5/118) and 11.3%(12/106), with statistically significant difference(χ~2=6.91, P=0.03). Conclusions T-tube drainage and stent implantation after laparoscopic choledocholithotomy do not bring more benefits, on the contrary, there are many related complications. Although primary suture of common bile duct is prone to bile leakage after operation, there are few serious complications.
引文
[1]李志钰,冯亮,尹飞飞,等.胆囊结石合并胆总管结石诊治进展[J].中国综合临床, 2014, 30(11):1227-1229.
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[7]Ding G, Cai W, Qin M. Single-stage vs two-stage management for concomitant gallstones and common bile duct stones:A prospective randomized trial with long-term follow-up[J]. J Gastroinest Surg,2014, 18(5):947-951.
[8]Pan L, Chen M, Ji L, et al. The safety and efficacy of laparoscopic common bile duct exploration combined with cholecystectomy for the management of cholecysto-choledocholithiasis:An up-to-date Meta-analysis[J]. Ann Surg, 2018, 268(2):247-253.
[9]Baucom RB, Feurer ID, Shelton JS, et al. Surgeons, ERCP, and laparoscopic common bile duct exploration:Do we need a standard approach for common bile duct stones?[J]. Surg Endosc, 2016,30(2):414-423.
[10] Zhang W, Li G, Chen YL. Should T-tube drainage be performed for choledocholithiasis after laparoscopic common bile duct exploration? A systematic review and Meta-analysis of randomized controlled trials[J]. Surg Laparosc Endosc Percutan Tech, 2017,27(6):415-423.
[11]邵文浩,徐钧.腹腔镜胆总管探查术与内置管引流术的临床应用进展[J].中国临床实用医学, 2017, 8(4):100-102.
[12] Lyon M, Menon S, Jain A, et al. Use of biliary stent in laparoscopic common bile duct exploration[J]. Surg Endosc, 2015, 15, 29(5):1094-1098.
[13]吴鹏,方路,付小伟,等.单向倒刺线与普通可吸收线在腹腔镜胆总管切开取石一期缝合术中应用的对比研究[J].中国内镜杂志, 2016, 22(9):52-56.
[14] HeMY,ZhouXD,ChenH,et al.Variousapproachesof laparoscopic common bile duct exploration plus primary duct closure for choledocholithiasis:A systematic review and metaanalysis[J]. Hepatobiliary Pancreat Dis Int, 2018, 17(3):183-191.
[2]Samardzie J, Latic F, Kraljik D, et al. Treatment of common bile duct stones-is the role of ERCP chaged in era of minimally invasive surgery?[J]. Med Arh, 2010, 64(3):187-188.
[3]Dasari BV, Tan CJ, Gurusamy KS, et al. Surgical versus endoscopic treatment of bile duct stones[J]. Cochrane Database Syst Rev,2013, 3(9):CD003327.
[4]Dindo D, Demartines N, Clavien PA. Classification of surgical complications:A new proposal with evaluation in a cohort of 6 336patients and results of a survey[J]. Ann Surg, 2004, 240(2):205-213.
[5]Koch M, Garden OJ, Padbury R, et al. Bile leakage after hepatobiliary and pancreatic surgery:A definition and grading of severity by the International Study Group of Liver Surgery[J].Surgery, 2011, 149(5):680-688.
[6]Bansal VK, Misra MC, Rajan K, et al. Single-stage laparoscopic common bile duct exploration and cholecystectomy versus twostage 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.
[7]Ding G, Cai W, Qin M. Single-stage vs two-stage management for concomitant gallstones and common bile duct stones:A prospective randomized trial with long-term follow-up[J]. J Gastroinest Surg,2014, 18(5):947-951.
[8]Pan L, Chen M, Ji L, et al. The safety and efficacy of laparoscopic common bile duct exploration combined with cholecystectomy for the management of cholecysto-choledocholithiasis:An up-to-date Meta-analysis[J]. Ann Surg, 2018, 268(2):247-253.
[9]Baucom RB, Feurer ID, Shelton JS, et al. Surgeons, ERCP, and laparoscopic common bile duct exploration:Do we need a standard approach for common bile duct stones?[J]. Surg Endosc, 2016,30(2):414-423.
[10] Zhang W, Li G, Chen YL. Should T-tube drainage be performed for choledocholithiasis after laparoscopic common bile duct exploration? A systematic review and Meta-analysis of randomized controlled trials[J]. Surg Laparosc Endosc Percutan Tech, 2017,27(6):415-423.
[11]邵文浩,徐钧.腹腔镜胆总管探查术与内置管引流术的临床应用进展[J].中国临床实用医学, 2017, 8(4):100-102.
[12] Lyon M, Menon S, Jain A, et al. Use of biliary stent in laparoscopic common bile duct exploration[J]. Surg Endosc, 2015, 15, 29(5):1094-1098.
[13]吴鹏,方路,付小伟,等.单向倒刺线与普通可吸收线在腹腔镜胆总管切开取石一期缝合术中应用的对比研究[J].中国内镜杂志, 2016, 22(9):52-56.
[14] HeMY,ZhouXD,ChenH,et al.Variousapproachesof laparoscopic common bile duct exploration plus primary duct closure for choledocholithiasis:A systematic review and metaanalysis[J]. Hepatobiliary Pancreat Dis Int, 2018, 17(3):183-191.