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逆行胰胆管造影联合内镜与腹腔镜联合胆道镜治疗单纯胆总管结石的临床效果

2017-01-06李作安张建民钱长春查文章

中国医药导报 2016年28期
关键词:微创治疗胆总管结石

李作安 张建民 钱长春 查文章

[摘要] 目的 探讨内镜下逆行胰胆管造影术(ERCP)+内镜乳头括约肌切开术(EST)与腹腔镜胆囊切除术(LC)+腹腔镜胆总管探查术(LCBDE)治疗单纯胆总管结石的临床效果。 方法 回顾性分析2012年2月~2015年6月于江苏省盐城市第一人民医院行微创手术治疗的170例单纯胆总管结石患者的临床资料,按手术方式分为ERCP+EST组(简称ERCP组,n=97)和LC+LCBDE组(简称LCBDE组,n=73)。比较两组手术时间、术后禁食时间、术后住院时间、住院费用、取石成功率、中转开腹率、术后并发症发生率、结石复发率。 结果 ①两组均无围术期死亡。两组患者结石数量、最大结石直径、胆总管内径、手术取石成功率及中转开腹率比较,差异均无统计学意义(P > 0.05)。ERCP组手术时间、术后禁食时间、术后住院时间及住院费用均明显短或少于LCBDE组,差异有统计学意义(P < 0.05)。②LCBDE组患者总并发症发生率稍低于ERCP组,但差异无统计学意义(P > 0.05)。 结论 ERCP与LCBDE治疗单纯胆总管结石均安全、有效,可根据患者情况个体化选择应用。

[关键词] 胆总管结石;腹腔镜胆总管探查取石术;内镜逆行胰胆管造影/内镜乳头括约肌切开术;微创治疗

[中图分类号] R575.62 [文献标识码] A [文章编号] 1673-7210(2016)10(a)-0056-04

Analysis of clinical efficacy of endoscopic retrograde cholangiopancreatography combined with endoscopic sphincterectomy versus laparoscopic cholecystectomy combined with laparoscopic common bile duct exploration in the treatment of primary cholecystolithiasis

LI Zuo'an1 ZHANG Jianmin1 QIAN Changchun1 ZHA Wenzhang2

1.Department of General Surgery, Chengnan Hospital of Yancheng City, Jiangsu Province, Yancheng 224003, China; 2.Department of General Surgery, the First People's Hospital of Yancheng City, Jiangsu Province, Yancheng 224000, China

[Abstract] Objective To investigate the clinical efficacy of endoscopic retrograde cholangiopancreatography (ERCP) plus endoscopic sphincterectomy (EST) and laparoscopic cholecystectomy (LC) plus laparoscopic common bile duct exploration (LCBDE) in the treatment of primary choledocholithiasis. Methods The clinical data of 170 patients with primary choledocholithiasis, who underwent minimally invasive surgical treatment in the First People's Hospital of Yancheng City from February 2012 to June 2015, were retrospectively analyzed. According to the operation methods, the patients were divided into the ERCP+EST group ("ERCP group" for short) with 97 cases and the LC+LCBDE group ("LCBDE group" for short) with 73 cases. The relevant clinical indexes including the operation time, fasting time after operation, duration of postoperative hospital stay, hospitalization charges and the clearance rate of calculus, conversion to open surgery ratio, postoperative complications and the recurrence of stones between the two groups of patients were compared. Results ①No perioperative mortality occurred, and no significant differences were observed in terms of the number and maximum diameter of common bile duct stone, internal diameter of common bile duct, the clearance rate of calculus and conversion to open surgery ratio between the two groups (P > 0.05). The operation time, postoperative fasting time and the length of postoperative hospital stay were significantly shorter in the ERCP group than those in the LCBDE group (P < 0.05), and the total hospitalization cost in the former group was less than that in the latter group (P < 0.05). ②No significant difference was noted in overall incidence of complications between the two groups (P > 0.05). Conclusion Both ERCP and LCBDE are safe and effective approaches for patients with primary cholecystolithiasis, and either of them can be selected according to the individual patient's condition.

[Key words] Choledocholithiasis; Laparoscopic common bile duct exploration; Endoscopic retrograde cholangiopancreatography/endoscopic sphincterectomy; Minimally invasive treatment

随着腔镜及内镜技术在胆道微创外科的广泛应用,胆总管结石由传统开腹胆总管切开取石+胆囊切除+T管引流术,转变为经内镜或腔镜联合下取石手术。目前最常用的微创手术方式有两种,一种是内镜逆行胰胆管造影(endoscopic retrograde cholangiopancreatography,ERCP)+乳头括约肌切开术(endoscopic sphincterectomy,EST),另一种是腹腔镜胆囊切除术(1aparoscopic cholecystectomy,LC)+胆总管切开探查(laparoscopic common bile duct exploration,LCBDE)。以上两种方法符合微创外科理念,但对于单纯胆总管结石患者,两种手术方法各有利弊,究竟采用ERCP好还是LCBDE好,尚待进一步探讨[1-2]。本研究通过回顾性分析评估两种方法的治疗效果,以期为胆总管结石患者选择更合适的个体化手术方案。

1 资料与方法

1.1 一般资料

选取2012年2月~2015年6月江苏省盐城市第一人民医院普外科及消化科收治的170例单纯胆总管结石患者,按术式不同分为两组:ERCP+EST治疗组(简称ERCP组)97例,LC+LCBDE治疗组(简称LCBDE组)73例。患者均无上腹部手术史,并经B超、CT或MRCP等检查确诊为胆总管结石。排除合并肝内胆管结石、胆囊结石、急性胆源性胰腺炎及重症胆管炎患者。两组患者术前一般临床资料比较,差异无统计学意义(P > 0.05),具有可比性。见表1。

1.2 方法

1.2.1 ERCP+EST 患者局麻下常规进镜至十二指肠降部,找到十二指肠乳头,导丝引导下插管造影,确定胆管结石的位置、大小、数量后,沿11~13点方向切开Oddi括约肌(切开长度为1~1.5 cm)。EST术后插入取石网篮取石,较大结石(>1.5 cm)采取机械性碎石后取出。取石完成后均经造影证实胆总管无结石残留,常规放置鼻胆管(ENBD管)引流胆汁,24~48 h后无出血及胰腺炎证据后拔管。EST术后常规监测淀粉酶并给予抗感染、保肝及对症处理。

1.2.2 LC+LCBDE 患者全身麻醉,常规四孔法处理胆囊后(暂不剥离胆囊床及离断胆囊管)留做牵引,找到胆总管,用电切模式纵行切开胆管前壁0.8~1.5 cm(以取出最大结石为宜),由剑突下10 mm Trocar插入胆道镜,用冲洗及取石网篮取出结石,放置T管,用4-0可吸收缝线间断缝合胆总管前壁,T管经右锁骨中线肋缘下穿刺孔引出固定。继续完成腔镜下胆囊切除。术后1周夹闭T管,术后1个月复查B超,若无残余结石可拔T管。腹腔留置引流管于温氏孔处,术后3~5 d拔管。术后常规给予抗感染、保肝药物。

1.3 观察指标及随访

比较两组患者的手术情况(手术时间、胆总管内径、取石成功率、中转开腹率),结石情况(最大结石直径、结石数量),住院情况(术后禁食时间、术后住院时间、住院费用),术中、术后并发症。ERCP术后胰腺炎:术后出现胰腺炎相关的临床症状,且伴有术后24 h血清淀粉酶超过正常上限的3倍[3]。术后1个月复查腹部超声,之后每半年通过门诊复查及电话方式随访。随访截至日期为2015年12月31日。

1.4 统计学方法

采用SPSS 16.0统计学软件进行数据分析,计量资料数据用均数±标准差(x±s)表示,两组间比较采用t检验;计数资料用率表示,组间比较采用χ2检验,以P < 0.05为差异有统计学意义。

2 结果

2.1 两组患者手术及住院情况比较

两组均无围手术期死亡。ERCP组有6例取石未成功,其中2例取石网篮嵌顿,1例十二指肠较大憩室无法行EST,3例为结石较大(直径>2.0 cm)且嵌顿在胆总管下端无法取出者,中转开腹手术后成功取石。LCBDE组有3例手术失败,其原因是胆囊三角炎症,粘连严重,通过中转开腹后手术成功。两组手术取石成功率及中转开腹率比较差异无统计学意义(P > 0.05)。两组患者结石数量、最大结石直径及胆总管内径比较,差异均无统计学意义(P > 0.05)。ERCP组手术时间、术后禁食时间、术后住院时间均明显短于LCBDE组,前者住院费用明显少于后者,差异均有统计学意义(P < 0.05)。见表2。

2.2 两组患者术中、术后并发症情况比较

术中并发症:ERCP组术中取石网篮嵌顿2例,即刻中转开腹后成功取石。术后早期并发症(术后15 d内):ERCP组中5例术后发生急性胰腺炎,经保守治疗后痊愈;EST术后切缘出血2例,均通过止血等保守治疗后痊愈;急性胆管炎1例,经抗感染治疗后痊愈。LCBDE组中3例术后发生轻微胆汁漏(<100 mL/d),经持续腹腔引流7~9 d后痊愈;2例肺部感染。术后远期并发症:ERCP组术后结石复发3例,均再行ERCP下取石成功。LCBDE组术后结石复发者2例,1例行ERCP取石,1例经T管窦道行胆道镜取石成功;1例糖尿病老年患者术后16 d T管脱落,出现腹膜炎,给予抗感染、充分引流后治愈。LCBDE组患者总并发症发生率11.0%(8/73)虽然低于ERCP组13.4%(13/97),但差异无统计学意义(χ2=0.080,P > 0.05)。

3 讨论

随着内镜及腔镜技术在临床的广泛应用,多镜联合下微创治疗胆总管结石取得了难以想象的奇迹,鼓舞人们不断地进行新的尝试[4-5],目前ERCP+EST和LC+LCBDE是最常用的两种微创手术方法。ERCP具有无切口、免麻醉、创伤小、恢复快等特点,同时保持了胆总管壁的完整性,且可多次操作反复取石,从而被内镜医师所推崇[6]。然而,即使由经验丰富的专科医师实施EST,术后仍有较高的早期及远期并发症[7],EST可破坏乳头括约肌的生理功能,引起肠液反流,增加逆行胆道感染机会及结石复发[8-9]。LCBDE的优点是一次性完成胆总管探查取石,避免ERCP可能多次取石的痛苦,且保留Oddi括约肌功能。然而,其对术者腔镜外科技术要求较高,且胆总管切开后破坏了胆管完整性,易引起术后胆总管狭窄,结石复发,以及术后放置T管,给患者生活、工作带来不便。更重要的是,LCBDE治疗胆总管结石,无论是否合并胆囊结石,都常规切除胆囊,有功能的胆囊切除后明显增加大肠癌的患病率[10-11],这与“以人为中心,以人的健康为中心”的医学理念背道而驰。

随着观念转变,器官切除已向保留器官及保留器官功能的方向发展。因此,Oddi括约肌系统及胆囊的功能愈加引起胆道外科医生的重视。Oddi括约肌具有单向阀门的作用,它在维持胆胰管系统的正常压力、流体力学及无菌生理状态方面具有不可替代的关键作用。Natsui等[12]报道,EST治疗胆总管结石术后6个月胆汁受细菌污染的发生率可达78%。EST术后急性胆管炎发生率达2.4%~10.3%[13-14]。另有研究显示,EST取净胆管结石后,结石复发率较高[15]。对于胆总管直径<8 mm者,可首选ERCP+内镜下乳头气囊扩张术(endoscopic papillary balloon dilatation,EPBD)取石,以保护乳头括约肌功能复合体的完整性。有研究显示,EPBD治疗胆总管结石术后远期胆道并发症发生率显著低于EST取石者[13-14];对于必须行EST者,应严格控制切开长度,尽量保存部分Oddi括约肌生理功能。LCBDE已广泛应用于临床,尤其胆总管结石合并胆囊结石患者,既可避免损伤Oddi括约肌,又能一次手术同时解决两个问题,因此备受腔镜医师的青睐。但是腔镜手术,胆囊切除的命运不可避免。有研究显示,胆囊切除是大肠癌的独立危险因素,并随着切除后时间的累积,病变范围也会随之扩大[11]。以中国为基础的数据库相关性分析显示,无论男女,胆囊切除术与大肠癌两者之间均存在显著相关性[16]。这一结论可对临床进行指导性预警,因此对于单纯胆总管结石的年轻患者(年龄<40岁)建议首选经自然腔道下的ERCP+EPBD取石手术,这与“以人为本”的医学理念相符合。

多镜联合下微创取石术代表着胆管结石治疗的新趋势。有研究显示,ERCP与LCBDE都是安全有效治疗胆总管结石的方法[17]。研究显示,围术期ERCP与开腹胆总管探查手术、LCBDE相比,在结石清除率、病死率、并发症等方面无显著差异[18]。有研究证实,胆总管结石患者开腹手术和ERCP+EST,其血清胆红素水平是术后并发症的重要危险因素之一,对合并梗阻性黄疸的高危患者应采用ERCP+EST[19]。有学者认为,LCBDE安全、有效,但是胆红素水平的上升会增加手术风险及中转开腹概率[20-24]。本研究资料显示,两组取石成功率及中转开腹率比较,差异无统计学意义(P > 0.05),但ERCP组手术时间、术后禁食时间、术后住院时间及总住院费用明显短或少于LCBDE组(P < 0.05)。综上可以看出,ERCP+EST更容易被患者接受。

目前,我国多数医院ERCP的操作由消化内科内镜医生施行,因此存在不同科室各自发展的状况,缺乏沟通联系,使患者错失更好的治疗方案,甚至造成不必要的损害。因此,当内镜医师遇上腔镜医师,选择LCBDE或ERCP,应根据患者具体情况,遵循个体化原则,应谨慎考虑以下几个问题:①对于年龄<40岁、胆总管直径<1.0 cm者,宜首选ERCP;②若胆总管内结石数量多(>5个)、结石直径较大(>2.0 cm),LCBDE更具优势;③对于胆总管下端结石伴乳头部炎性狭窄、不排除癌性病变的梗阻性黄疸、LCBDE术后未留置T管而结石残留、胆总管结石术后复发者,ERCP更有优势;④对于高龄、病情重、基础病多、黄疸严重者宜首选ERCP,能迅速解除胆管梗阻,畅通引流,改善患者预后。

综上所述,ERCP与LCBDE治疗单纯胆总管结石均安全、有效,两种方案的选择应个体化。

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(收稿日期:2016-07-01 本文编辑:程 铭)

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改进法二镜联合治疗胆总管结石合并胆囊结石
腹腔镜胆总管探查术对胆总管结石的治疗作用研究
腹腔镜和胆道镜联合治疗胆总管结石的疗效分析
胆总管结石与幽门螺杆菌感染的相关性分析
腹腔镜和胆道镜联合治疗胆总管结石临床分析
高龄患者粗隆间骨折的微创治疗应用探讨
射频消融术治疗颈椎间盘突出症的研究进展
微创手术治疗肝胆管结石的临床效果观察