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中华肝脏外科手术学电子杂志

中华肝脏外科手术学电子杂志 ›› 2018, Vol. 07 ›› Issue (04) : 289 -294. doi: 10.3877/cma.j.issn.2095-3232.2018.04.009

所属专题： 文献；

临床研究

高龄胆总管结石合并胆囊结石患者腹腔镜手术疗效
蔡健华1, 何嘉琦1, 姜翀弋1, 梁赟1, 刘猛1, 王巍1,†()   
  1. 1. 200040　上海，复旦大学附属华东医院普通外科　上海市老年医学临床重点实验室
  • 收稿日期:2018-05-10 出版日期:2018-08-10
  • 通信作者: 王巍

Efficacy of laparoscopic surgery in the treatment of elderly patients with choledocholithiasis and cholecystolithiasis

Jianhua Cai1, Jiaqi He1, Chongyi Jiang1, Yun Liang1, Meng Liu1, Wei Wang1,†()   

  1. 1. Department of General Surgery, East China Hospital Affiliated to Fudan University; Shanghai Key Laboratory of Clinical Geriatric Medicine, Shanghai 200040, China
  • Received:2018-05-10 Published:2018-08-10
  • Corresponding author: Wei Wang
  • About author:
    Corresponding author: Wang Wei, Email:
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引用本文：

蔡健华, 何嘉琦, 姜翀弋, 梁赟, 刘猛, 王巍. 高龄胆总管结石合并胆囊结石患者腹腔镜手术疗效[J]. 中华肝脏外科手术学电子杂志, 2018, 07(04): 289-294.

Jianhua Cai, Jiaqi He, Chongyi Jiang, Yun Liang, Meng Liu, Wei Wang. Efficacy of laparoscopic surgery in the treatment of elderly patients with choledocholithiasis and cholecystolithiasis[J]. Chinese Journal of Hepatic Surgery(Electronic Edition), 2018, 07(04): 289-294.

目的

探讨腹腔镜胆囊切除+胆总管切开探查术（LC+LCBDE）治疗高龄胆总管结石合并胆囊结石患者的疗效及安全性。

方法

回顾性分析2011年4月至2017年5月复旦大学附属华东医院收治的130例年龄80岁以上高龄胆总管结石合并胆囊结石患者临床资料。患者均签署知情同意书，符合医学伦理学规定。按手术方式分为LC+LCBDE组（腔镜组）和传统开腹组（开腹组）。腔镜组66例，男38例，女28例；平均年龄（84±4）岁。开腹组64例，男30例，女34例；年龄（84±4）岁。两组手术时间、出血量等围手术期指标比较采t检验，并发症发生率比较采用χ2检验或Fisher确切概率法。

结果

两组患者手术均成功。腔镜组手术时间、术后首次肛门排气时间、止痛药物使用时间分别为（105±44）min、（2.2±0.8）d、（2.4±1.3）d，明显短于开腹组的（121±39）min、（3.2±1.5）d、（3.2±1.5）d（t=-2.175，-4.072，-3.397；P<0.05）。腔镜组肺部感染发生率为3%（2/66），明显低于开腹组的14%（9/64） （χ2=5.106，P<0.05）。腹腔镜组术后30 d内死亡1例，开腹组3例，差异无统计学意义（χ2=0.291，P>0.05）。

结论

高龄并不是腹腔镜手术的禁忌证，在积极合理的围术期处理下，LC+LCBDE治疗高龄胆总管结石合并胆囊结石患者可行、有效、安全，可有效缩短手术时间，加速康复，减轻术后疼痛，降低术后并发症发生率。

关键词: 老年人, 胆总管结石, 胆囊结石病, 腹腔镜
Objective

To explore the efficacy and safety of laparoscopic cholecystectomy + laparoscopic common bile duct exploration (LC+LCBDE) in the treatment of elderly patients with choledocholithiasis and cholecystolithiasis.

Methods

Clinical data of 130 patients, aged 80 years and above and with choledocholithiasis and cholecystolithiasis, who were admitted in East China Hospital Affiliated to Fudan University from April 2011 to May 2017 were analyzed retrospectively. The informed consents of all patients were obtained and the local ethical committee approval was received. The patients were divided into LC+LCBDE group (laparoscopy group) and traditional laparotomy group (laparotomy group) according to different surgical procedure. There were 66 patients in laparoscopy group, including 38 males and 28 females, with an average age of (84±4) years. There were 64 patients in laparotomy group, including 30 males and 34 females, with an average age of (84±4) years. Perioperative indicators such as operation time and amount of bleeding between two groups were compared by t test, and the incidence of complications was compared by Chi-square test or Fisher's exact probability test.

Results

The operations of all the patients were performed successfully. In laparoscopy group, the operation time, postoperative first anus exhaust time and use time of analgesic medication were (105±44) min, (2.2±0.8) d and (2.4±1.3) d, which were significantly shorter than (121±39) min, (3.2±1.5) d and (3.2±1.5) d in laparotomy group (t=-2.175, -4.072, -3.397; P<0.05). The incidence of pulmonary infection in laparoscopy group was 3%(2/66), which was significantly lower than 14%(9/64) in laparotomy group (χ2=5.106, P<0.05). 1 case in laparoscopy group and 3 cases in laparotomy group died within 30 d after operation, where no significant difference was observed (χ2=0.291, P>0.05).

Conclusions

Advanced age is not a contraindication for laparoscopic operation. With the positive and reasonable perioperative management, LC+LCBDE is feasible, effective and safe for the elderly patients with choledocholithiasis and cholecystolithiasis. It can effectively shorten the operation time, accelerate the recovery, reduce postoperative pain and incidence of postoperative complications.

Key words: Aged, Choledocholithiasis, Cholecystolithiasis, Laparoscopes
表1 腔镜组和开腹组胆总管结石合并胆囊结石患者一般资料比较
临床参数 腔镜组 开腹组 统计值 P值
年龄（岁，±s） 84±4 84±4 t=-0.144 0.886
性别（男/女，例） 38/28 30/34 χ2=1.491 0.222
BMI（kg/m2，±s） 23±4 23±4 t=0.151 0.880
上腹部手术史（例） 10 8 χ2=0.191 0.662
ERCP史（例） 5 3 χ2=0.469 0.493
合并疾病（例） ? ? ? ?
? 高血压 39 22 χ2=7.970 0.005
? 糖尿病 9 10 χ2=0.103 0.748
? 冠心病 13 11 χ2=0.136 0.712
? COPD 8 8 χ2=0.004 0.948
? 2种以上 17 14 χ2=0.270 0.604
Charcot三联征（例） 10 14 χ2=0.976 0.323
ASA评分（分，±s） 2.2±0.5 2.3±0.5 t=-0.777 0.439
急诊手术（例） 3 13 χ2=7.484 0.006
表2 腔镜组和开腹组胆总管结石合并胆囊结石患者术后手术相关指标比较
临床参数 腔镜组 开腹组 统计值 P值
手术时间（min，±s） 105±44 121±39 t=-2.175 0.031
术中出血量[ml，M（QR）] 19(5～200) 90(10～600) Z=-8.291 0.000
胆总管一期缝合（例） 8 0 - 0.004
胆总管结石数量（单/多枚，例） 21/45 21/43 χ2=0.015 0.904
胆总管直径（mm，±s） 12±3 17±6 t=-5.308 0.000
胆总管结石最大径[mm，M（QR）] 17.5(2.0～30.0) 11.2(2.0～40.0) Z=-3.597 0.000
术后首次肛门排气时间（d，±s） 2.2±0.8 3.2±1.5 t=-4.072 0.000
腹腔引流管留置时间[d，M（QR）] 3.7(2.0～9.0) 4.9(0～45.0) Z=-3.207 0.001
留置尿管（例） 47 60 χ2=11.334 0.001
留置尿管时间[d，M（QR）] 4.3(1.0～26.0) 5.7(0～44.0) Z=-2.825 0.005
留置胃管（例） 6 45 χ2=51.083 0.000
胃管拔除时间[d，M（QR）] 2.3(1.0～3.0) 2.4(0～11.0) Z=-0.516 0.606
术后止痛药物使用时间（d） 2.4±1.3 3.2±1.5 t=-3.397 0.001
术后住院时间[d，M（QR）] 7(4～50) 13(1～58) Z=-5.986 0.000
住院总费用[万元，M（QR）] 2.8(1.1～33.3) 3.8(1.4～16.8) Z=-2.077 0.038
ICU治疗（例） 8 16 χ2=3.580 0.058
表3 腔镜组和开腹组胆总管结石合并胆囊结石患者术后并发症比较[例（%）]
术后并发症 腔镜组 开腹组 χ2值 P值
切口感染 1（2） 5（8） 1.671 0.196
胆道感染 3（5） 1（2） 0.227 0.634
肺部感染 2（3） 9（14） 5.106 0.024
结石残余 1（2） 1（2） 0 1.000
胆漏 0（0） 2（3） - 0.463
术后30 d内死亡 1（2） 3（5） 0.291 0.590a
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