腹腔镜治疗继发性胆总管结石的临床应用分析
|
摘要
目的：
对胆囊结石合并继发性胆总管结石的腹腔镜下三种不同治疗方式进行比较和分析，以评价三种术式的治疗效果和临床应用价值。
方法：
对在2010年4月～2012年8月期间无锡市第二人民医院肝胆外科实施腹腔镜治疗的127例胆囊结石合并继发性胆总管结石患者的临床资料进行回顾性分析，分为三种腹腔镜治疗方案，A组：腹腔镜经胆囊管胆道探查术(laparoscopictranscystic common bile duct exploration，LTCBDE)组40例，B组：腹腔镜胆总管切开术(laparoscopic choledochotomy，LD)+一期缝合术(primarysuture，PS)组35例，C组：LD+T管引流(T tube drainage, TD)组52例。病例的分组按照各自的适应症来进行选择，比较各组之间的术后住院时间、住院费用、腹腔引流时间、术后补液量、平均手术时间、术后胃肠功能恢复时间、术后并发症发生率和术后住院时间差异。
结果：
术后住院时间、住院费用、腹腔引流时间、术后补液量A组、B组和C组比较，C组明显高于A、B两组，差异有统计学意义（P<0.05），A组和B组之间差异无统计学意义（P>0.05）；手术时间、术后胃肠功能恢复时间、术后并发症三组间差异无统计学意义（P>0.05）。
结论：
1、针对不同情况、不同程度的胆总管结石患者，严格掌握手术适应症的情况下LTCBDE是安全可靠，疗效确切，具有创伤最小、恢复快的术式，可作为首选治疗方式。
2、LD+PS方案适应症较LTCBDE方案广泛，在解决术后胆漏并发症后将是主要治疗方式。
3、LD+TD方案适应症最宽，但术后恢复慢、经济费用高，并有长期带管和T管相关并发症。
Objective：
Comparison and analysis to evaluate the therapeutic effect and clinicalapplications of three different laparoscopic treatment of gallstones and biliary stones.
Methods：
Retrospective analysis of127cases of laparoscopic treatment of gallstones andbiliary stones in the clinica data from April2010to August2012in the SecondPeople's Hospital of Wuxi. Laparoscopic treatment options are divided into three,Group A: Laparoscopic common bile duct exploration via the cystic duct surgery(LTCBDE) group of40cases, Group B:laparoscopic choledochotomy combined withprimary suture(LD+PS) group of35cases, Group C:laparoscopic choledochotomycombined with T tube drainage(LD+TD) group of52cases. Grouping of cases are inaccordance with the indications to choose their own. Comparison of each group,postoperative hospitalization time, cost of hospitalization, abdominal drainage time,postoperative fluid volume, average operation time, postoperative gastrointestinalfunction recovery time, postoperative complications and postoperative hospitalizationtime.
Results:
The group C was significantly higher than that of the other two groups withpostoperative hospitalization time, cost of hospitalization, abdominal drainage time,postoperative infusion,the difference was statistically significant (P<0.05), there was no statistically significant difference between group A and group B(P>0.05),Theaverage operation time, postoperative recovery time of gastrointestinal function andpostoperative complications in each group had no statistically significantdifference(P>0.05).
Conclusions:
1. for the patients with different situations, varying degrees of common bile ductstones, under mastering the operation indication strictly,LTCBDE is safe, reliable,effective, with minimum trauma, faster recovery technique can be used as thetreatment of choice.
2. The indications of LD+PS compared LTCBDE the wide range,in the solutionof the complications of bile leakage postoperation,the program is the main treatment.
3. The indications of LD+TD is widest, but postoperative recovery was slow,high economic costs, and long-term with a T-tube and T-tube-related complications.
对胆囊结石合并继发性胆总管结石的腹腔镜下三种不同治疗方式进行比较和分析，以评价三种术式的治疗效果和临床应用价值。
方法：
对在2010年4月～2012年8月期间无锡市第二人民医院肝胆外科实施腹腔镜治疗的127例胆囊结石合并继发性胆总管结石患者的临床资料进行回顾性分析，分为三种腹腔镜治疗方案，A组：腹腔镜经胆囊管胆道探查术(laparoscopictranscystic common bile duct exploration，LTCBDE)组40例，B组：腹腔镜胆总管切开术(laparoscopic choledochotomy，LD)+一期缝合术(primarysuture，PS)组35例，C组：LD+T管引流(T tube drainage, TD)组52例。病例的分组按照各自的适应症来进行选择，比较各组之间的术后住院时间、住院费用、腹腔引流时间、术后补液量、平均手术时间、术后胃肠功能恢复时间、术后并发症发生率和术后住院时间差异。
结果：
术后住院时间、住院费用、腹腔引流时间、术后补液量A组、B组和C组比较，C组明显高于A、B两组，差异有统计学意义（P<0.05），A组和B组之间差异无统计学意义（P>0.05）；手术时间、术后胃肠功能恢复时间、术后并发症三组间差异无统计学意义（P>0.05）。
结论：
1、针对不同情况、不同程度的胆总管结石患者，严格掌握手术适应症的情况下LTCBDE是安全可靠，疗效确切，具有创伤最小、恢复快的术式，可作为首选治疗方式。
2、LD+PS方案适应症较LTCBDE方案广泛，在解决术后胆漏并发症后将是主要治疗方式。
3、LD+TD方案适应症最宽，但术后恢复慢、经济费用高，并有长期带管和T管相关并发症。
Objective：
Comparison and analysis to evaluate the therapeutic effect and clinicalapplications of three different laparoscopic treatment of gallstones and biliary stones.
Methods：
Retrospective analysis of127cases of laparoscopic treatment of gallstones andbiliary stones in the clinica data from April2010to August2012in the SecondPeople's Hospital of Wuxi. Laparoscopic treatment options are divided into three,Group A: Laparoscopic common bile duct exploration via the cystic duct surgery(LTCBDE) group of40cases, Group B:laparoscopic choledochotomy combined withprimary suture(LD+PS) group of35cases, Group C:laparoscopic choledochotomycombined with T tube drainage(LD+TD) group of52cases. Grouping of cases are inaccordance with the indications to choose their own. Comparison of each group,postoperative hospitalization time, cost of hospitalization, abdominal drainage time,postoperative fluid volume, average operation time, postoperative gastrointestinalfunction recovery time, postoperative complications and postoperative hospitalizationtime.
Results:
The group C was significantly higher than that of the other two groups withpostoperative hospitalization time, cost of hospitalization, abdominal drainage time,postoperative infusion,the difference was statistically significant (P<0.05), there was no statistically significant difference between group A and group B(P>0.05),Theaverage operation time, postoperative recovery time of gastrointestinal function andpostoperative complications in each group had no statistically significantdifference(P>0.05).
Conclusions:
1. for the patients with different situations, varying degrees of common bile ductstones, under mastering the operation indication strictly,LTCBDE is safe, reliable,effective, with minimum trauma, faster recovery technique can be used as thetreatment of choice.
2. The indications of LD+PS compared LTCBDE the wide range,in the solutionof the complications of bile leakage postoperation,the program is the main treatment.
3. The indications of LD+TD is widest, but postoperative recovery was slow,high economic costs, and long-term with a T-tube and T-tube-related complications.
引文
[1] Morgenstem L．Carl Langenbuch and the．first cholecystectomy [J]．Surg endosc，1992,6(3):113-114.
[2] Gharaibeh KI，Heiss HA. Biliary leakage following T-tube removal[J].IntSurg,2000,85(1):57~63.
[3] Haq A，Morris J，Goddard C，et al. Dalayed cholangitis resulting from a retainedT-tube fragment encased within a stone: a rare complication [J]. Surg Endosc,2002,16(4):714.
[4] Phillip EH. New techniques for the treatment of common bile calculi encounteredduring laparoscopic choleystectomy [J]. Probl Gen Surg,1991,8(5):387-389.
[5] Memon MA，Hassaballa H，Memon MI．Laparoscopic common bile ductexploration：the past，the present，and the future．Am，Surg,2000，179(4)：309—315
[6] Moher D，Sc M．The CONSORT Guidelines：improving the quality ofresearch． Consolidated standards of reporting trials． Interview by BonnieHorrigan．Altern Ther Health Med,2002，8(3)：103-108．
[7] Martin IJ, Bailey IS, Rhodes M,et al. Towward T-tube free laparscopic bileexploration. Ann Surg,1998,288(1):29-34.
[8] Decker G，Borie F，Millat B，et a1．0ne hundred laparoscopic choledochotomeswith primary closure of common duct．Surg En—dosc，2003，17(1)：12-18．
[9] STOKERME.LEVEILLEE Pd，MC CARM JC．et al Laparoscopic Common bileduct exploration[J]．JLaparoendosc Surg1991,1(1)：287-293．
[10]陈建立,张国志,常艳等.腹腔镜联合胆道镜治疗胆囊结石合并胆总管结石100例[J].现代预防医学,2011,38(9):1746-1748.
[11]王栓铎,王延朋.腹腔镜胆囊切除联合胆总管探查术治疗胆囊结石并胆总管结石的临床研究[J].腹腔镜外科杂志2011,16(11):841-843.
[12]陈波,李建平,戴途等.应用超细胆道镜经胆囊管治疗胆总管结石[J].肝胆胰外科杂志,2007,19(5):298-300.
[13]索运生，徐琳，陈安平，等．腹腔镜胆总管探查一期缝合669例报告[J]．中国微创外科杂志,2008,8(10):942-944．
[14]Zhang LD,Bie P,Wang SG,et al.A randomized comparison of primary closure andT—tube drainage of the common bile duct after laparoscopic choledochotomy［J］.Surg Endosc,2008,22(7):1595-1600.
[15] Rojas-Ortega S, Arizpe-Bravo D, Marí n Ló pez ER，et al.Transcysticcommon bile duct exploration in the management of patients with choledocholithiasis［J］. J Gastrointest Surg,2003,7(4):492-496.
[16]马跃美,史念柯,马晓娟等.胆总管探查后内置鼻胆管与T管的比较研究.局部手术学杂志,2004,12(4):237-239．
[17]张凯，潘一明，周建新.拔除T管后致胆汁性腹膜炎非手术治疗。肝胆外科杂志，2002,10(2):110-111．
[18]陈汝福,王捷.胆道手术后常见并发症的预防和治疗.肝胆外科杂志,2002,10(6)：417-418．
[19]戴途,陈波,金慧涵,等.腹腔镜治疗肝外胆管结石个体化方案的临床应用.中华消化内镜杂志,2012,29(1):43-45．
[1] Morgenstem L．Carl Langenbuch and the first cholecystectomy [J]．Surg endosc，1992,6(3):113-114．
[2] Haq A，Morris J，Goddard C，et al. Dalayed cholangitis resulting from a retainedT-tube fragment encased within a stone: a rare complication [J]. Surg Endosc,2002,16(4):714.
[3] Lien HH，Huang CC，Huang CS，et a1．Laparoscopic common bile ductexploration with T-tube choledochotomy for the management of choledocholithiasis.JLap Adv Surg Tech A,2005;15(3):298-302.
[4]秦明放．内镜腹腔镜联合治疗肝外胆管结石的思考.中国实用外科杂志,2005,25(6):336-337.
[5] Kawai K，Akasaka Y，Marakruma K.Endoscopic shineterotomy of the ampulla ofvater[J]．Gastrointest Endo,1974,20(4):148-150．
[6] Cynthia WK,Lee PS.Epidemiology and natural history of common bile ductstones and prediction of disease[J].Gastrointest Endosc,2002,56(6):S165-9．
[7] Hungness ES，Soper NJ．Management of common bile duct stones．J GastrointestSurg,2006,10(4):612-619．
[8]Sgouros SN,Pereira SP.Systematic review:sphincter of Oddidysfunction-non-invasive diagnostic methods and long-term outcome afterendoscopic sphineterotomy．Aliment Pharmacol Ther,2006,24(2):237-246
[9] Hamy A，Hennekinne S，Pessaux P. et a1．Endoscopic sphinetemtomy prior tolaparoscopic cholecystectomy for the treatment of cholelithiasis[J]．Surg Endose，2003,17(6):872-875．
[10] Sarli L,Iusco DR,Roncoroni L.Preoperative endoscopic sphineterotomy andlaparoscopic cholecystectomy for the management of cholecystocholedocholithiasis：lO-year experience[J].World J Surg,2003,27(2):180-186．
[11]冯秋实.微创外科时代继发性胆总管结石的处理[J],中国实用外科杂志，2009，1(29):50-52.
[12] Phillip EH. New techniques for the treatment of common bile calculiencountered during laparoscopic choleystectomy [J]. Probl Gen Surg,1991,8:387-389.
[13] Vecchio R, MacFadyen BV. Laparoscopic common bile duct exploration [J].Langenbeck’s Arch Surg,2002,387(1):45–54.．
[14] Thompson MH,Tranter SE．All-comers policy for laparoscopic exploration of thecommon bile duct[J].Br J Surg,2002,89(12):1608-1612．
[15]张寰.腹腔镜下胆总管切开胆道镜探查取石术现状与评价[J]，中国实用外科杂志,2009,1(29):47-49.
[16] Decker G,Borie F,Millat B,et al.One hundred laparoscopic choledochotomieswith primary closure of the common bile duct[J].SurgEndosc,2003,17(1):12-18.
[17] Rojas-Ortega S, Arizpe-Bravo D, Marí n Ló pez ER，et al.Transcystic commonbile duct exploration in the management of patients with choledocholithiasis［J］. JGastrointest Surg,2003,7(4):492-496.
[18]胡三元.腹腔镜胆总管切开取石术的并发症及其防治［J］.医师进修杂志(外科版),2004,27(7):7-9.
[19] Poulose BK, Arbogast PG, Holzman MD. National analysis of in-hospitalresource utilization in choledocholithiasis management using propensity scores[J］.Surg Endosc,2006,20(2):186-190.
[20] Vecchio R, MacFadyen BV. Laparoscopic common bile duct exploration [J].Langenbeck’s Arch Surg,2002,387(1):45–54.
[21] Tocchi A, Mazzoni G, Liotta G, et al. Late development of bile duct cancer inpatients who had biliary-enteric drainage for benign disease: a follow-up study ofmore than1,000patients ［J］. Ann Surg,2001,234(2):210-214.
[22] Berthou JCh, Dron B, Charbonneau P, et al. Evaluation of laparoscopic treatmentof common bile duct stones in a prospectiveseries of505patients: indications andresults［J］. Surg Endosc,2007,21(11):1970-1974.
[23]李建平，戴途，陈波．腹腔镜联合超细胆道镜经胆囊管治疗肝外胆管结石[J]．中国微创外科杂志，2006，6(2)：101-102．
[24]张雷达，王曙光，别平，等，不同方式的腹腔镜胆道探查术治疗胆总管结石的临床前瞻性研究[J],中国内镜杂志，2006,12(5):474-477.
[25]Cohen S,Bacon BR,Berlin JA,et a1.National Institutes of HealthState-of-the-Science conference statement:ERCP for diagnosis and therapy,January14-16,2002.Gastrointest Endosc,2002,56(6)：803-809．
[26] Tranter SE,Thompson MH.Comparison of endoscopic sphincterotomy andlaparoscopic exploration of the common bile duct.Br J Surg,2002,89(12):1495-1504．
[27] Michel J,Navarro F,Montpeyroux F,et a1.Treatment of common bile duct stoneswith laparoscopy.Retrospective multicenter study with612patients[J].GastroenterolClin Biol,2000,24(4):404-408．
[28] Riciardi R,Islam S,Canete JJ,et al. Effectiveness and long-term results oflaparoscopic common bile duct exploration[J].Surg Endosc，2003，17(1)：19-22．
[29]许卓明,苏树英,甄作均,等，腹腔镜胆总管切开术与内镜括约肌切开术治疗胆总管结石的比较[J],中华普通外科杂志,2007,6(22):410-412.
[2] Gharaibeh KI，Heiss HA. Biliary leakage following T-tube removal[J].IntSurg,2000,85(1):57~63.
[3] Haq A，Morris J，Goddard C，et al. Dalayed cholangitis resulting from a retainedT-tube fragment encased within a stone: a rare complication [J]. Surg Endosc,2002,16(4):714.
[4] Phillip EH. New techniques for the treatment of common bile calculi encounteredduring laparoscopic choleystectomy [J]. Probl Gen Surg,1991,8(5):387-389.
[5] Memon MA，Hassaballa H，Memon MI．Laparoscopic common bile ductexploration：the past，the present，and the future．Am，Surg,2000，179(4)：309—315
[6] Moher D，Sc M．The CONSORT Guidelines：improving the quality ofresearch． Consolidated standards of reporting trials． Interview by BonnieHorrigan．Altern Ther Health Med,2002，8(3)：103-108．
[7] Martin IJ, Bailey IS, Rhodes M,et al. Towward T-tube free laparscopic bileexploration. Ann Surg,1998,288(1):29-34.
[8] Decker G，Borie F，Millat B，et a1．0ne hundred laparoscopic choledochotomeswith primary closure of common duct．Surg En—dosc，2003，17(1)：12-18．
[9] STOKERME.LEVEILLEE Pd，MC CARM JC．et al Laparoscopic Common bileduct exploration[J]．JLaparoendosc Surg1991,1(1)：287-293．
[10]陈建立,张国志,常艳等.腹腔镜联合胆道镜治疗胆囊结石合并胆总管结石100例[J].现代预防医学,2011,38(9):1746-1748.
[11]王栓铎,王延朋.腹腔镜胆囊切除联合胆总管探查术治疗胆囊结石并胆总管结石的临床研究[J].腹腔镜外科杂志2011,16(11):841-843.
[12]陈波,李建平,戴途等.应用超细胆道镜经胆囊管治疗胆总管结石[J].肝胆胰外科杂志,2007,19(5):298-300.
[13]索运生，徐琳，陈安平，等．腹腔镜胆总管探查一期缝合669例报告[J]．中国微创外科杂志,2008,8(10):942-944．
[14]Zhang LD,Bie P,Wang SG,et al.A randomized comparison of primary closure andT—tube drainage of the common bile duct after laparoscopic choledochotomy［J］.Surg Endosc,2008,22(7):1595-1600.
[15] Rojas-Ortega S, Arizpe-Bravo D, Marí n Ló pez ER，et al.Transcysticcommon bile duct exploration in the management of patients with choledocholithiasis［J］. J Gastrointest Surg,2003,7(4):492-496.
[16]马跃美,史念柯,马晓娟等.胆总管探查后内置鼻胆管与T管的比较研究.局部手术学杂志,2004,12(4):237-239．
[17]张凯，潘一明，周建新.拔除T管后致胆汁性腹膜炎非手术治疗。肝胆外科杂志，2002,10(2):110-111．
[18]陈汝福,王捷.胆道手术后常见并发症的预防和治疗.肝胆外科杂志,2002,10(6)：417-418．
[19]戴途,陈波,金慧涵,等.腹腔镜治疗肝外胆管结石个体化方案的临床应用.中华消化内镜杂志,2012,29(1):43-45．
[1] Morgenstem L．Carl Langenbuch and the first cholecystectomy [J]．Surg endosc，1992,6(3):113-114．
[2] Haq A，Morris J，Goddard C，et al. Dalayed cholangitis resulting from a retainedT-tube fragment encased within a stone: a rare complication [J]. Surg Endosc,2002,16(4):714.
[3] Lien HH，Huang CC，Huang CS，et a1．Laparoscopic common bile ductexploration with T-tube choledochotomy for the management of choledocholithiasis.JLap Adv Surg Tech A,2005;15(3):298-302.
[4]秦明放．内镜腹腔镜联合治疗肝外胆管结石的思考.中国实用外科杂志,2005,25(6):336-337.
[5] Kawai K，Akasaka Y，Marakruma K.Endoscopic shineterotomy of the ampulla ofvater[J]．Gastrointest Endo,1974,20(4):148-150．
[6] Cynthia WK,Lee PS.Epidemiology and natural history of common bile ductstones and prediction of disease[J].Gastrointest Endosc,2002,56(6):S165-9．
[7] Hungness ES，Soper NJ．Management of common bile duct stones．J GastrointestSurg,2006,10(4):612-619．
[8]Sgouros SN,Pereira SP.Systematic review:sphincter of Oddidysfunction-non-invasive diagnostic methods and long-term outcome afterendoscopic sphineterotomy．Aliment Pharmacol Ther,2006,24(2):237-246
[9] Hamy A，Hennekinne S，Pessaux P. et a1．Endoscopic sphinetemtomy prior tolaparoscopic cholecystectomy for the treatment of cholelithiasis[J]．Surg Endose，2003,17(6):872-875．
[10] Sarli L,Iusco DR,Roncoroni L.Preoperative endoscopic sphineterotomy andlaparoscopic cholecystectomy for the management of cholecystocholedocholithiasis：lO-year experience[J].World J Surg,2003,27(2):180-186．
[11]冯秋实.微创外科时代继发性胆总管结石的处理[J],中国实用外科杂志，2009，1(29):50-52.
[12] Phillip EH. New techniques for the treatment of common bile calculiencountered during laparoscopic choleystectomy [J]. Probl Gen Surg,1991,8:387-389.
[13] Vecchio R, MacFadyen BV. Laparoscopic common bile duct exploration [J].Langenbeck’s Arch Surg,2002,387(1):45–54.．
[14] Thompson MH,Tranter SE．All-comers policy for laparoscopic exploration of thecommon bile duct[J].Br J Surg,2002,89(12):1608-1612．
[15]张寰.腹腔镜下胆总管切开胆道镜探查取石术现状与评价[J]，中国实用外科杂志,2009,1(29):47-49.
[16] Decker G,Borie F,Millat B,et al.One hundred laparoscopic choledochotomieswith primary closure of the common bile duct[J].SurgEndosc,2003,17(1):12-18.
[17] Rojas-Ortega S, Arizpe-Bravo D, Marí n Ló pez ER，et al.Transcystic commonbile duct exploration in the management of patients with choledocholithiasis［J］. JGastrointest Surg,2003,7(4):492-496.
[18]胡三元.腹腔镜胆总管切开取石术的并发症及其防治［J］.医师进修杂志(外科版),2004,27(7):7-9.
[19] Poulose BK, Arbogast PG, Holzman MD. National analysis of in-hospitalresource utilization in choledocholithiasis management using propensity scores[J］.Surg Endosc,2006,20(2):186-190.
[20] Vecchio R, MacFadyen BV. Laparoscopic common bile duct exploration [J].Langenbeck’s Arch Surg,2002,387(1):45–54.
[21] Tocchi A, Mazzoni G, Liotta G, et al. Late development of bile duct cancer inpatients who had biliary-enteric drainage for benign disease: a follow-up study ofmore than1,000patients ［J］. Ann Surg,2001,234(2):210-214.
[22] Berthou JCh, Dron B, Charbonneau P, et al. Evaluation of laparoscopic treatmentof common bile duct stones in a prospectiveseries of505patients: indications andresults［J］. Surg Endosc,2007,21(11):1970-1974.
[23]李建平，戴途，陈波．腹腔镜联合超细胆道镜经胆囊管治疗肝外胆管结石[J]．中国微创外科杂志，2006，6(2)：101-102．
[24]张雷达，王曙光，别平，等，不同方式的腹腔镜胆道探查术治疗胆总管结石的临床前瞻性研究[J],中国内镜杂志，2006,12(5):474-477.
[25]Cohen S,Bacon BR,Berlin JA,et a1.National Institutes of HealthState-of-the-Science conference statement:ERCP for diagnosis and therapy,January14-16,2002.Gastrointest Endosc,2002,56(6)：803-809．
[26] Tranter SE,Thompson MH.Comparison of endoscopic sphincterotomy andlaparoscopic exploration of the common bile duct.Br J Surg,2002,89(12):1495-1504．
[27] Michel J,Navarro F,Montpeyroux F,et a1.Treatment of common bile duct stoneswith laparoscopy.Retrospective multicenter study with612patients[J].GastroenterolClin Biol,2000,24(4):404-408．
[28] Riciardi R,Islam S,Canete JJ,et al. Effectiveness and long-term results oflaparoscopic common bile duct exploration[J].Surg Endosc，2003，17(1)：19-22．
[29]许卓明,苏树英,甄作均,等，腹腔镜胆总管切开术与内镜括约肌切开术治疗胆总管结石的比较[J],中华普通外科杂志,2007,6(22):410-412.
© 2004-2018 中国地质图书馆版权所有 京ICP备05064691号 京公网安备11010802017129号 地址：北京市海淀区学院路29号 邮编：100083 电话：办公室：(+86 10)66554848；文献借阅、咨询服务、科技查新：66554700 |