胆总管一期缝合在腹腔镜联合胆道镜治疗胆囊结石合并胆总管结石中的应用

doi:10.3877/cma.j.issn.2095-3232.2023.01.014

目的

探讨胆总管一期缝合在腹腔镜联合胆道镜治疗胆囊结石合并胆总管结石中的临床应用价值。

方法

本研究对象为2018年7月至2021年12月在上海浦南医院收治的320例胆囊结石合并胆总管结石患者。患者均签署知情同意书，符合医学伦理学规定。其中男186例，女134例；年龄38~53岁，中位年龄46岁。根据随机数字表法将患者随机分为一期缝合组与T管引流组，各160例。采用四孔法进腹，腹腔镜胆囊切除，胆总管切开，胆道镜取石后分别行胆总管一期缝合和T管引流。观察两组患者围手术期情况和术后并发症发生情况。两组手术时间、术后住院时间等比较采用t检验，术后并发症发生率比较采用χ²检验。

结果

两组患者均手术顺利，无中转开腹。一期缝合组平均手术时间、术后住院时间、住院费用分别为（100±9）min、（12.4±1.6）d、（2.9±0.3）万元，明显低于T管引流组的（113±11）min、（18.3±2.7）d、（3.5±0.5）万元（t=-4.545，-0.485，-3.577；P<0.05）。一期缝合组术后总并发症发生率为11.3%（18/160），T管引流组为10.0%（16/160），差异无统计学意义（χ²=0.131，P>0.05）。

结论

腹腔镜联合胆道镜治疗胆囊结石合并胆总管结石术中，采用胆总管一期缝合安全、有效；与T管引流相比，其具有手术时间短、术后恢复快、住院费用低等优势，更加微创。

关键词: 腹腔镜, 胆道镜, 胆总管结石, 一期缝合

Objective

To evaluate the application of primary closure of common bile duct in the laparoscopic and choledochoscopic treatment of gallstone disease complicated with common bile duct stones.

Methods

Clinical data of 320 patients with gallstone disease complicated with common bile duct stones treated in Punan Hospital from July 2018 to December 2021 were retrospectively analyzed. The informed consents of all patients were obtained and the local ethical committee approval was received. Among them, 186 patients were male and 134 female, aged from 38 to 53 years, with a median age of 46 years. According to the random number table method, all patients were randomly divided into the primary closure (n=160) and T-tube drainage groups (n=160). Four-port laparoscopic cholecystectomy was performed, common bile duct was incised, and primary closure of common bile duct and T-tube drainage were performed after choledochoscopic lithotomy. Perioperative conditions and postoperative complications were observed between two groups. The operation time and length of postoperative hospital stay were compared by t test. The incidence of postoperative complications was compared by Chi-square test.

Results

The surgeries were completed successfully in all the patients, without conversion to open surgery. In the primary closure group, the average operation time, length of postoperative hospital stay and hospitalization expense were (100±9) min, (12.4±1.6) d and (2.9±0.3)×10⁴ Yuan, significantly lower than (113±11) min, (18.3±2.7) d and (3.5±0.5)×10⁴ Yuan in the T-tube drainage group (t=-4.545, -0.485, -3.577; P<0.05).The total incidence of postoperative complications was 11.3%(18/160) in the primary closure group and 10.0%(16/160) in the T-tube drainage group, where no significant difference was observed (χ²=0.131, P>0.05).

Conclusions

Primary closure of common bile duct is safe and effective in the laparoscopic and choledochoscopic treatment of gallstone disease complicated with common bile duct stones. Compared with T-tube drainage, it has multiple advantages including shorter operation time, faster postoperative recovery, lower hospitalization expense and less invasiveness.

Key words: Laparoscopes, Choledochoscope, Choledocholithiasis, Primary closure

表1 一期缝合组和T管引流组胆囊结石合并胆总管结石患者一般资料比较

组别	例数	性别（例）		年龄（岁，±s）	病程（年，±s）	胆总管直径（cm，±s）	腹腔积液（例）	病情程度（例）
组别	例数	男	女	年龄（岁，±s）	病程（年，±s）	胆总管直径（cm，±s）	腹腔积液（例）	轻症	重症
一期缝合组	160	94	66	46±6	5.2±2.7	14±4	3	140	20
T管引流组	160	92	68	45±7	5.4±2.8	15±4	4	138	22
统计值		χ²=0.500		t=0.378	t=-0.529	t=-0.378	χ²=0.000	χ²=0.479
P值		0.480		0.706	0.597	0.705	1.000	0.632

表1 一期缝合组和T管引流组胆囊结石合并胆总管结石患者一般资料比较

组别	例数	性别（例）		年龄（岁，±s）	病程（年，±s）	胆总管直径（cm，±s）	腹腔积液（例）	病情程度（例）
组别	例数	男	女	年龄（岁，±s）	病程（年，±s）	胆总管直径（cm，±s）	腹腔积液（例）	轻症	重症
一期缝合组	160	94	66	46±6	5.2±2.7	14±4	3	140	20
T管引流组	160	92	68	45±7	5.4±2.8	15±4	4	138	22
统计值		χ²=0.500		t=0.378	t=-0.529	t=-0.378	χ²=0.000	χ²=0.479
P值		0.480		0.706	0.597	0.705	1.000	0.632

表2 一期缝合组和T管引流组胆囊结石合并胆总管结石患者围手术期情况比较（±s）

组别	例数	手术时间(min)	术后住院时间（d）	腹腔引流管留置时间（d）	住院费用（万元）
一期缝合组	160	100±9	12.4±1.6	6.4±2.9	2.9±0.3
T管引流组	160	113±11	18.3±2.7	5.4±1.4	3.5±0.5
t值		-4.545	-4.858	1.788	-3.577
P值		<0.001	<0.001	0.074	0.004

表2 一期缝合组和T管引流组胆囊结石合并胆总管结石患者围手术期情况比较（±s）

组别	例数	手术时间(min)	术后住院时间（d）	腹腔引流管留置时间（d）	住院费用（万元）
一期缝合组	160	100±9	12.4±1.6	6.4±2.9	2.9±0.3
T管引流组	160	113±11	18.3±2.7	5.4±1.4	3.5±0.5
t值		-4.545	-4.858	1.788	-3.577
P值		<0.001	<0.001	0.074	0.004

表3 一期缝合组和T管引流组胆囊结石合并胆总管结石患者并发症情况比较[例（%）]

组别	例数	胆道感染	胆漏	结石残留	结石复发	胆汁性腹膜炎
一期缝合组	160	3（1.9）	4（2.5）	2（1.3）	3（1.9）	6（3.8）
T管引流组	160	2（1.3）	2（1.3）	3（1.9）	4（2.5）	5（3.1）
χ²值		0.237	1.646	0.237	0.183	0.139
P值		0.626	0.200	0.626	0.669	0.710

表3 一期缝合组和T管引流组胆囊结石合并胆总管结石患者并发症情况比较[例（%）]

组别	例数	胆道感染	胆漏	结石残留	结石复发	胆汁性腹膜炎
一期缝合组	160	3（1.9）	4（2.5）	2（1.3）	3（1.9）	6（3.8）
T管引流组	160	2（1.3）	2（1.3）	3（1.9）	4（2.5）	5（3.1）
χ²值		0.237	1.646	0.237	0.183	0.139
P值		0.626	0.200	0.626	0.669	0.710

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Application of primary closure of common bile duct in laparoscopic and choledochoscopic treatment of gallstone disease complicated with common bile duct stones

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Application of primary closure of common bile duct in laparoscopic and choledochoscopic treatment of gallstone disease complicated with common bile duct stones