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1、 LC+LCBDE+PS治疗胆囊结石合并胆总管结石的临床观察 胡长和 方圆 洪士林【Summary】 目的:探討胆囊结石合并胆总管结石行腹腔镜胆囊切除(LC)+胆总管探查(LCBDE)+一期缝合(PS)治疗的效果。方法:选择2017年2月-2020年4月于本院就诊的胆囊结石合并胆总管结石患者84例,按随机数字表法将其分为治疗组和对照组,每组42例。治疗组行一步法术式治疗,对照组行分步法术式治疗。比较两组术中、术后情况和炎性因子指标,观察并发症发生情况。结果:治疗组残余结石率为2.38%,与对照组的4.76%比较,差异无统计学意义(P0.05)。两组手术用时、术中出血量比较,差异均无统计学意义(
2、P0.05);治疗组住院费用少于对照组,术后住院时间短于对照组,差异均有统计学意义(P0.05);术后1 d,两组IL-6、CRP水平均高于术前,差异均有统计学意义(P0.05)。结论:一步法术式与分步法术式治疗胆囊结石合并胆总管结石患者效果相当,安全性相似,但前者存在治疗费用低、住院时间短等优点。【Key】 胆囊结石 胆总管结石 腹腔镜胆囊切除 胆总管探查 一期缝合Clinical Observation of LC+LCBDE+PS in the Treatment of Cholecystolithiasis Complicated with Common Bile Duct Stone
3、s/HU Changhe, FANG Yuan, HONG Shilin. /Medical Innovation of China, 2021, 18(28): 0-064Abstract Objective: To investigate the effect of laparoscopic cholecystectomy (LC) + common bile duct exploration (LCBDE) + primary suture (PS) for cholecystolithiasis complicated with common bile duct stones. Met
4、hod: A total of 84 patients with cholecystolithiasis complicated with common bile duct stones treated in our hospital from February 2017 to April 2020 were selected, they were divided into treatment group and control group according to random number table method, 42 cases in each group. The treatmen
5、t group was treated with one-step method, the control group was treated with step-step method. The intraoperative and postoperative conditions and inflammatory factors of the two groups were compared, and the incidence of complications was observed. Result: The residual stone rate in the treatment g
6、roup was 2.38%, compared with 4.76% in the control group, there was no significant difference (P0.05). Comparison of operative time and intraoperative blood loss between the two groups, there were no significant differences (P0.05); the hospitalization cost of the treatment group was less than that
7、of the control group, the postoperative hospitalization time was shorter than that of the control group, the differences were statistically significant (P0.05); 1 day after surgery, IL-6 and CRP levels in both groups were higher than those before surgery, the differences were statistically significa
8、nt (P0.05). Conclusion: One-step and step-step methods have similar efficacy and safety in the treatment of patients with cholecystolithiasis complicated with choledocholithiasis, but the former has advantages of low treatment cost and short hospitalization time.Key words Cholecystolithiasis Common
9、bile duct stones Laparoscopic cholecystectomy Common bile duct exploration Primary sutureFirst-authors address: Leping Hospital of Traditional Chinese Medicine, Leping 333300, Chinadoi:10.3969/j.issn.1674-4985.2021.28.015胆囊结石是由胆囊内结石所致疾病,部分患者会同时患有胆总管结石,机体内结石难以自行排出,易诱发疼痛、寒战、黄疸等,若结石不及时取出,将胆道梗阻解除,易诱发肝硬化
10、、胆道出血、全身感染、急慢性胆管炎等疾病,严重危害患者身体健康1-3。胆囊结石合并胆总管结石易反复发作,病情迁延难愈,需尽早治疗。以往临床对于本病患者多使用常规开腹手术治疗,但具有手术创伤大、并发症多、恢复时间长等不足4-5。腹腔镜胆囊切除(LC)+胆总管探查(LCBDE)+一期缝合(PS)与内镜逆行性胆管造影(ERCP)/内镜下括约肌切开取石术(EST)+LC逐渐成为临床治疗胆囊结石合并胆总管结石的常见术式,均可达到治疗目的。本研究分析两种术式治疗胆囊结石合并胆总管结石的临床效果,旨在为临床手术方案制定提供参考,现报道如下。1 资料与方法1.1 一般资料 选择2017年2月-2020年4月于
11、本院就诊的胆囊结石合并胆总管结石患者84例。(1)纳入标准:经CT、磁共振胰胆管造影、超声等检查确诊为胆囊结石合并胆总管结石;结石数量5枚,直径15 mm;首次接受胆道手术治疗。(2)排除标准:肝内胆管结石;重症胰腺炎或胆管炎;胆道肿瘤;血液系统疾病;精神疾患;凝血功能异常。按随机数字表法将患者分为治疗组和对照组,每组42例。患者签署知情同意书,研究经医学伦理委员会批准。1.2 方法 (1)治疗组行一步法术式(LC+LCBDE+PS)治疗:全麻后取仰卧位,在脐下缘切开,气腹针穿刺创建人工气腹,维持气腹压约为13 mmHg。分别在右侧肋缘下、剑突下和右侧肋缘与右腋前线交界位置穿刺,置入5 mm、
12、10 mm和5 mm Trocar。解剖Calot三角,对胆囊管、胆囊动脉游离,在距胆总管5 mm处夹闭胆囊管,牵引显露胆总管。做一长815 mm的纵向切口于胆总管正中,将5 mm奥林巴斯胆道镜置入,探查胆总管,网篮取石,必要时可用液电碎石法处理嵌顿或较大的结石,用网篮取出,明确无结石残留且肝内外胆管无狭窄后,经乳头,将网篮张开、回抽,确保乳头无结石、通畅。对于乳头无狭窄和水肿、胆总管直径8 mm、无合并胰腺炎和胆管炎患者直接实施胆总管一期缝合,即切口用4-0普迪思可吸收缝线间断性缝合。其余则自行脱落J管胆管引流、一期缝合:在胆道镜下经乳头斑马导丝插入肠道,用6-0可吸收线快速固定末端,打结成
13、环形(10.0 mm)的J管,插入十二指腸,在导丝引导下操作,确保其末端平行于胆总管切口下缘,将导丝退出。自J管末端经环内穿过1根5-0可吸收线,于切口下缘固定,胆总管前壁用4-0普迪思可吸收缝线间断缝合。常规切除胆囊,将1根引流管经Winslow孔留置。(2)对照组在侧卧位下行分步法术式(ERCP/EST+LC)治疗:术前30 min肌注盐酸哌替啶注射液(生产厂家:青海制药厂有限公司,批准文号:国药准字H63020021,规格:2 mL100 mg)50 mg和盐酸消旋山莨菪碱注射液(安徽城市药业股份有限公司,批准文号:国药准字H34022987,规格:1 mL5 mg)20 mg。口服盐酸
14、奥布卡因凝胶(沈阳绿洲制药有限责任公司,批准文号:国药准字H21023203,规格:10 mL30 mg)。置入十二指肠镜,常规实施乳头插管、造影,明确胆管解剖结构和结石大小、数量后,在乳头11点方向与导丝引导下实施EST,用网篮取石,造影明确无结石残留后,常规留置鼻胆管。若患者有并发症发生,则择期实施LC,若病情稳定,则术后12 d行LC,手术操作方式同治疗组。术后,两组患者均禁食24 h,给予抗感染、抑酸、抑酶等治疗,24 h后实施淀粉酶、肝功能和血常规等检查。1.3 观察指标 (1)比较两组术中、术后情况,前者为术中出血量、残余结石率、手术用时,后者为术后住院时间、住院费用。(2)比较两
15、组手术前后炎性因子水平,在术前、术后1 d分别抽取两组患者3 mL空腹肘静脉血,离心取血液,用酶联免疫吸附试验法(ELISA)测定白细胞介素-6(IL-6)、C反应蛋白(CRP)水平。(3)比较两组术后并发症发生情况,包括术后胆漏、胰腺炎、高淀粉酶血症、胆道出血。1.4 统计学处理 采用SPSS 21.0软件对所得数据进行统计分析,计量资料用(xs)表示,组间比较采用独立样本t检验,组内比较采用配对t检验;计数资料以率(%)表示,比较采用字2检验。以P0.05为差异有统计学意义。2 结果2.1 两组一般资料比较 治疗组女20例,男22例;年龄2768岁,平均(48.363.45)岁;病程318个月,平均(11.961.21)个月。对照组女17例,男25例;年龄2666岁,平均(48.293.34)岁;病程219个月,平均(12.051.16)个月。两组一