不同手术方案治疗胆囊结石合并胆总管结石的临床研究
徐垚 安东均 王羊 王金涛 杨林 韩立 赵宝国 张成
摘 要
目的：探讨一期腹腔镜胆囊切除（LC）联合胆总管探查术（LCBDE）与分期内镜逆行胰胆管造影（ERCP）/内镜十二指肠乳头括约肌切开术（EST）联合LC治疗胆囊结石合并胆总管结石的临床疗效。
方法：回顾分析2016年11月～2018年11月收治的320例胆囊结石合并胆总管结石患者的临床资料。按手术方式分为LC+LCBDE组与ERCP/EST+LC组。对比2组患者一般资料、手术总时间、术中出血量、术中放置引流管例数、手术成功率、结石残余率、术后高淀粉酶血症、术后并发症发生率、术后首次下床活动时间、住院时间、住院总费用等指标。
结果：LC+LCBDE组与ERCP/EST+LC组术前临床资料差异无统计学意义，具有可比性；LC+LCBDE组与ERCP/EST+LC组手术总时间［（136.6±31.3）minvs.（127.1±27.8）min，P=0.004］、术中放置腹腔引流管例数［156（100%）vs.53（32.3%），P＜0.001］、术后发生高淀粉酶血症例数［1（0.6% ）vs.10（6.1%），P=0.026］、术后首次下床活动时间［（22.7±8.2）h vs.（15.6±7.8）h，P＜0.001］、总住院时间［（8.1±4.2）d vs.（13.7±7.3）d，P=0.002］、住院总费用［（22471.1±8 244.8）元vs.（24 899.3±7625.6）元，P=0.007］差异有统计学意义。2组手术成功率、术中出血量、结石残余率、术后总并发症发生率差异无统计学意义。
结论：LC+LCBDE与ERCP/EST+LC治疗胆囊结石合并胆总管结石均是安全、有效的。LC+LCBDE能减少住院总费用，降低术后高淀粉酶血症发生率，缩短住院时间；ERCP/EST+LC能缩短手术时间，加速术后下床活动。术者应根据患者具体病情及医院设备、技术合理选择术式。
关键词
胆囊结石病；胆总管结石；胆囊切除术，腹腔镜；胆总管探查术；胰胆管造影术，内窥镜逆行；括约肌切开术，内窥镜
Clinical research of one-stage LC+LCBDE and two-stage ERCP/EST+LC in the treatment of cholecystolithiasis with choledocholithiasis
XU Yao，AN Dongjun，WANG Yang，et al.Department of Hepatobiliary Surgery，the Central Hospital of Xianyang City Affiliated to Xi'an Jiaotong University，Xianyang 712000，China
ABSTRACT
Objective:To investigate the clinical efficacy of one-stage laparoscopic cholecystectomy（LC）combined with laparoscopic common bile duct exploration（LCBDE）and staged endoscopic retrograde cholangiopancreatography（ERCP）/endoscopic sphincterotomy（EST）combined with LC in the treatment of cholecystolithiasis with choledocholithiasis.
Methods:Clinical data of 320 patients with cholecystolithiasis and choledocholithiasis from Nov.2016 to Nov.2018 were retrospectively analyzed.According to the surgical method，patients were divided into LC+LCBDE group and ERCP/EST+LC group.General data，total operation time，intraoperative blood loss，intraoperative drainage tube placement，operation success rate，stone residual rate，postoperative hyperamylasemia，postoperative complication rate，postoperative ambulation time，hospital stay，total hospitalization cost and other indicators were compared between the two groups.
Results:The general data of the patients in the LC+LCBDE group and the FRCP/EST+LC group were comparable.In the LC+LCBDE group and the ERCP/EST+LC group，the total operation time was［（136.6±31.3）min vs.（127.1±27.8）min，P=0.004］，the number of intra-abdominal drainage tubes placed during operation was［156（100%）vs.53（32.3% ），P＜0.001］，the number of postoperative hyperamylasemia was［1（0.6% ）vs.10（6.1% ），P=0.026］，the first postoperative ambulation time was［（22.7±8.2）h vs.（15.6±7.8）h，P＜0.001］，the total hospital stay was［（8.1±4.2）d vs.（13.7±7.3）d，P=0.002）］，and the total hospitalization cost was［（22 471.1±8 244.8）yuan vs.（24 899.3±7 625.6）yuan，P=0.007］.All the things mentioned above were statistically significantly different.There was no significant difference in the success rate of surgery，the amount of intraoperative blood loss，the residual rate of stone removal or the incidence of postoperative total complications.
Conclusion:LC+LCBDE and ERCP/EST+LC are safe and effective in the treatment of gallstones with choledocholithiasis.LC+LCBDE can reduce the total cost of hospitalization，the incidence of postoperative hyperamylasemia and the hospital stay；FRCP/EST+LC can shorten the operation time and accelerate the time of postoperative ambulation.The specific surgical procedure should be chosen based on the patient's specific condition and hospital equipment and technology.
KEY WORDS
Cholecystolithiasis；Choledocholithiasis；Cholecystectomy，laparoscopic；Common bile duct exploration；Cholangiopancreatography，endoscopic retrograde；Sphincterotomy，endoscopic
胆囊结石合并胆管结石是常见病，发病率呈逐年增高趋势［1］。随着内镜与腹腔镜技术的不断提高，传统开腹手术逐步被微创手术取代［2］。目前治疗胆囊结石合并胆总管结石的微创手术方式分为两种：腹腔镜胆囊切除术（laparoscopic cholecystectomy，LC）+腹腔镜胆总管探查取石术（laparoscopic common bile duct exploration，LCBDE）、先行内镜逆行胰胆管造影（endoscopic retrograde cholangiopancreatography，ERCP）或内镜十二指肠乳头括约肌切开术（endoscopic sphincterotomy，EST）取出胆总管结石，再行LC。两种术式各有优缺点，哪种治疗方式更优一直存有争议［3］。探索胆囊结石合并肝外胆管结石的治疗方式具有临床指导意义。本研究回顾分析2016年11月至2018年11月咸阳市中心医院分别采用LC+LCBDE及ERCP/EST+LC治疗的320例胆囊结石合并胆总管结石患者的临床资料，比较2种术式的安全性及疗效，现将体会报道如下。