ERCP+LC与LCBDE+LC治疗胆囊结石合并胆总管结石疗效对比研究

doi:10.3877/cma.j.issn.2095-3232.2021.02.009

目的

比较ERCP联合腹腔镜胆囊切除术（LC）与腹腔镜胆总管探查术（LCBDE）联合LC治疗胆囊结石合并胆总管结石疗效及安全性。

方法

回顾性分析2016年6月至2019年6月广州医科大学附属第二医院收治的147例胆囊结石合并胆总管结石患者临床资料。患者均签署知情同意书，符合医学伦理学规定。其中男77例，女70例；年龄24～65岁，中位年龄53岁。根据治疗方法不同分为ERCP+LC组和LCBDE+LC组。观察两组围手术期情况和疗效。两组住院时间、住院费用等比较采用t 检验，并发症等发生率比较采用χ2检验或Fisher确切概率法。

结果

ERCP+LC组单次净石率为92%（67/73），LCBDE+LC组为92%（60/65），差异无统计学意义（χ²=0.013，P>0.05）。ERCP+LC组胆总管最大直径≤ 8 mm者14例、>15 mm者9例，LCBDE+LC组相应为0、19例，差异有统计学意义（χ²=-，6.077；P<0.05）。ERCP+LC组平均住院时间、住院费用分别为（12±3）d、（6.6±1.1）万元，均明显高于LCBDE+LC组的（9±3）d、（4.6±1.0）万元（t=4.223，11.149；P<0.05）。ERCP+LC组术后急性胰腺炎、胆漏分别为7、0例，LCBDE+LC组相应为0、6例，差异有统计学意义（P<0.05）。ERCP+LC组和LCBDE+LC组术后结石复发分别为14、11例，差异无统计学意义（χ²=0.209，P>0.05）。

结论

ERCP+LC和LCBDE+LC治疗胆囊结石合并胆总管结石疗效相当，两种微创术式各有优势，胆总管无扩张者首选ERCP+LC，而胆总管明显扩张、结石较大者LCBDE+LC更具优势。

关键词: 胆囊结石病, 胆总管结石, 胆囊切除术, 腹腔镜, 胰胆管造影术, 内窥镜逆行, 腹腔镜胆总管探查术

Objective

To compare the clinical efficacy and safety between endoscopic retrograde cholangiopancreatography (ERCP) combined with laparoscopic cholecystectomy (LC) and laparoscopic common bile duct exploration (LCBDE) combined with LC in the treatment of cholecystolithiasis complicated with choledocholithiasis.

Methods

Clinical data of 147 patients with cholecystolithiasis complicated with choledocholithiasis admitted to the Second Affiliated Hospital of Guangzhou Medical University from June 2016 to June 2019 were retrospectively analyzed. The informed consents of all patients were obtained and the local ethical committee approval was received. Among them, 77 patients were male and 70 female, aged from 24 to 65 years, with a median age of 53 years. All patients were divided into the ERCP+LC and LCBDE+LC groups according to different treatments. Perioperative conditions and clinical efficacy were observed between two groups. The length of hospital stay and hospitalization expense were statistically compared between two groups by t test. The incidence of complications and other parameters were compared by Chi-square test or Fisher's exact probability test.

Results

The single-time stone removal rate was 92%(67/73) in ERCP+LC group and 92%(60/65) in LCBDE+LC group, where no significant difference was noted (χ2=0.013, P>0.05). In ERCP+LC group, the maximum diameter of single common bile duct ≤8 mm was observed in 14 cases and >15 mm in 9 cases, significantly differed from 0 and 19 cases in LCBDE+LC group (χ2=-, 6.077; P<0.05). In ERCP+LC group, the mean length of hospital stay and hospitalization expenses were (12±3) d and (6.6±1.1)×104 yuan, which were significantly higher than (9±3) d and (4.6±1.0)×104 yuan in LCBDE+LC group (t=4.223, 11.149; P<0.05). In ERCP+LC group, acute pancreatitis were observed in 7 cases and no bile leakage, significantly differed from 0 and 6 cases in LCBDE+LC group (P<0.05). Stone recurrence was observed in 14 and 11 cases respectively in ERCP+LC and LCBDE+LC groups, where no significant difference was noted (χ2=0.209, P>0.05).

Conclusions

ERCP+LC and LCBDE+LC yield equivalent efficacy in treating cholecystolithiasis complicated with choledocholithiasis. These two minimally invasive operations have its own advantages. ERCP+LC is recommended for patients without common bile duct dilatation, whereas LCBDE+LC is suitable for those with significant common bile duct dilatation and larger stones.

Key words: Cholecystolithiasis, Choledocholithiasis, Cholecystectomy, laparoscopic, Cholangiopancreatography, endoscopic retrograde, Laparoscopic common bile duct exploration

表1 ERCP+LC与LCBDE+LC组胆囊结石合并胆总管结石患者一般资料比较

组别	例数	年龄（岁，±s）	男/女（例）	合并症（例）			腹部手术史（例）	胆源性胰腺炎（例）
组别	例数	年龄（岁，±s）	男/女（例）	高血压	糖尿病	冠心病	腹部手术史（例）	胆源性胰腺炎（例）
ERCP+LC组	78	50±10	40/38	25	19	3	10	11
LCBDE+LC组	69	52±11	37/32	12	9	1	8	5
统计值		t=-0.779	χ²=0.080	χ²=4.178	χ²=3.040	χ²=0.147	χ²=0.051	χ²=1.774
P值		0.437	0.777	0.041	0.081	0.701	0.821	0.183

表1 ERCP+LC与LCBDE+LC组胆囊结石合并胆总管结石患者一般资料比较

组别	例数	年龄（岁，±s）	男/女（例）	合并症（例）			腹部手术史（例）	胆源性胰腺炎（例）
组别	例数	年龄（岁，±s）	男/女（例）	高血压	糖尿病	冠心病	腹部手术史（例）	胆源性胰腺炎（例）
ERCP+LC组	78	50±10	40/38	25	19	3	10	11
LCBDE+LC组	69	52±11	37/32	12	9	1	8	5
统计值		t=-0.779	χ²=0.080	χ²=4.178	χ²=3.040	χ²=0.147	χ²=0.051	χ²=1.774
P值		0.437	0.777	0.041	0.081	0.701	0.821	0.183

表2 ERCP+LC与LCBDE+LC组胆囊结石合并胆总管结石患者结石及胆管情况比较

组别	例数	结石最大直径（mm，±s）	结石多发（例）	胆总管最大直径（mm，±s）	胆总管最大直径（例）
组别	例数	结石最大直径（mm，±s）	结石多发（例）	胆总管最大直径（mm，±s）	≤8 mm	8～10 mm	10～15 mm	>15 mm
ERCP+LC组	78	9.6±2.9	25	11.7±3.3	14	18	37	9
LCBDE+LC组	69	10.3±2.3	21	13.2±2.9	0	11	39	19
统计值		t=-1.563	χ²=0.044	t=-2.961	-	χ²=1.177	χ²=1.210	χ²=6.077
P值		0.120	0.833	0.004	0.000	0.306	0.322	0.020

表2 ERCP+LC与LCBDE+LC组胆囊结石合并胆总管结石患者结石及胆管情况比较

组别	例数	结石最大直径（mm，±s）	结石多发（例）	胆总管最大直径（mm，±s）	胆总管最大直径（例）
组别	例数	结石最大直径（mm，±s）	结石多发（例）	胆总管最大直径（mm，±s）	≤8 mm	8～10 mm	10～15 mm	>15 mm
ERCP+LC组	78	9.6±2.9	25	11.7±3.3	14	18	37	9
LCBDE+LC组	69	10.3±2.3	21	13.2±2.9	0	11	39	19
统计值		t=-1.563	χ²=0.044	t=-2.961	-	χ²=1.177	χ²=1.210	χ²=6.077
P值		0.120	0.833	0.004	0.000	0.306	0.322	0.020

表3 ERCP+LC与LCBDE+LC组胆囊结石合并胆总管结石患者近期并发症发生情况比较（例）

组别	例数	急性胰腺炎	急性胆管炎	出血	伤口感染	胆漏	合计
ERCP+LC组	73	7	5	2	0	0	14
LCBDE+LC组	65	0	1	1	2	6	10
χ²值		-	1.230	0.000	-	-	0.344
P值		0.014	0.267	1.000	0.220	0.010	0.557

表3 ERCP+LC与LCBDE+LC组胆囊结石合并胆总管结石患者近期并发症发生情况比较（例）

组别	例数	急性胰腺炎	急性胆管炎	出血	伤口感染	胆漏	合计
ERCP+LC组	73	7	5	2	0	0	14
LCBDE+LC组	65	0	1	1	2	6	10
χ²值		-	1.230	0.000	-	-	0.344
P值		0.014	0.267	1.000	0.220	0.010	0.557

表4 ERCP+LC与LCBDE+LC组胆囊结石合并胆总管结石患者远期疗效比较（例）

组别	例数	急性胆管炎	胆总管狭窄	结石复发	总并发症	再次手术
ERCP+LC组	69	5	1	14	20	12
LCBDE+LC组	64	2	4	11	17	12
χ²值		0.456	0.996	0.209	0.097	0.041
P值		0.500	0.318	0.647	0.755	0.839

表4 ERCP+LC与LCBDE+LC组胆囊结石合并胆总管结石患者远期疗效比较（例）

组别	例数	急性胆管炎	胆总管狭窄	结石复发	总并发症	再次手术
ERCP+LC组	69	5	1	14	20	12
LCBDE+LC组	64	2	4	11	17	12
χ²值		0.456	0.996	0.209	0.097	0.041
P值		0.500	0.318	0.647	0.755	0.839

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Comparison of clinical efficacy between ERCP+LC and LCBDE+LC for cholecystolithiasis complicated with choledocholithiasis

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Comparison of clinical efficacy between ERCP+LC and LCBDE+LC for cholecystolithiasis complicated with choledocholithiasis