腹腔镜胆总管探查术一期缝合术后胆漏危险因素Meta分析

doi:10.3877/cma.j.issn.2095-3232.2023.05.014

目的

探讨腹腔镜胆总管探查术（LCBDE）一期缝合术后胆漏的危险因素。

方法

检索PubMed、Embase、Cochrane Library、Web of Science、知网、万方、维普等数据库1990年1月1日至2022年5月1日关于LCBDE一期缝合术后胆漏危险因素的临床研究。中文检索词：胆总管结石、腹腔镜胆总管探查、胆漏、危险因素。英文检索词：choledocholithiasis、common bile duct stone、laparoscopic common bile duct exploration、LCBDE、bile leakage。对研究报道数量≥3的指标进行Meta分析。

结果

最终纳入7项研究共930例患者，其中男431例，女499例。Meta分析结果显示，术前血ALB<35 g/L的患者术后胆漏发生率明显高于术前血ALB≥35 g/L的患者（OR=2.23，95%CI：1.16~4.28）；术中胆总管切开长度<1.5 cm的患者术后胆漏发生率明显低于切开长度≥1.5 cm的患者（OR=0.42，95%CI：0.20~0.87）；胆总管连续缝合患者术后胆漏发生率明显低于间断缝合患者（OR=0.51，95%CI：0.29~0.90）；胆总管直径<1 cm的患者术后胆漏发生率明显高于胆总管直径≥1 cm的患者（OR=4.00，95%CI：2.23~7.17）。

结论

选择胆总管直径<1 cm患者，术前纠正血ALB水平，术中切开胆总管长度控制1.5 cm以内，切口采用连续缝合可有效降低LCBDE一期缝合术后胆漏发生风险。

关键词: 腹腔镜胆总管探查, 一期缝合, 胆漏, 危险因素, Meta分析

Objective

To investigate the risk factors of bile leakage after primary duct suture of laparoscopic common bile duct exploration (LCBDE).

Methods

Clinical studies related to the risk factors of bile leakage after primary suture of LCBDE were searched from PubMed, Embase, Cochrane Library, Web of Science, CNKI, Wanfang Data and Chongqing VIP from January 1, 1990 to May 1, 2022. The Chinese searching words included common bile duct stone, laparoscopic common bile duct exploration, bile leakage and risk factor. The English searching words consisted of choledocholithiasis, common bile duct stone, laparoscopic common bile duct exploration, LCBDE and bile leakage. The indexes which were reported in ≥3 clinical studies were subject to Meta-analysis.

Results

7 studies of 930 patients were finally selected, including 431 male and 499 female. Meta-analysis showed that the incidence of postoperative bile leakage in patients with preoperative albumin (ALB) level of <35 g/L was significantly higher than that in their counterparts with preoperative ALB level of ≥35 g/L (OR=2.23, 95%CI: 1.16-4.28). The incidence of postoperative bile leakage in patients with common bile duct incision length of <1.5 cm during operation was significantly lower than that in those with a length of ≥1.5 cm (OR=0.42, 95%CI: 0.20-0.87). The incidence of postoperative bile leakage in patients receiving continuous suture of common bile duct was significantly lower than that in those treated with interrupted suture (OR=0.51, 95%CI: 0.29-0.90). The incidence of postoperative bile leakage in patients with common bile duct diameter of <1 cm was significantly higher than that in their counterparts with common bile duct diameter of ≥1 cm (OR=4.00, 95%CI: 2.23-7.17).

Conclusions

Selecting patients with common bile duct diameter of <1 cm, correcting ALB level before operation, maintaining the common bile duct incision length of within 1.5 cm during operation and adopting continuous suture can effectively reduce the risk of bile leakage after primary suture of LCBDE.

Key words: Laparoscopic common bile duct exploration, Primary duct closure, Bile leakage, Risk factors, Meta-analysis

表1 LCBDE一期缝合术后胆漏危险因素Meta分析文献的基本特征及质量评价

第一作者	年份	样本量（例）	男/女（例）	胆漏（例）	NOS评分
饶尚锐^[10]	2007	115	55/60	10	5
刘学礼^[11]	2016	82	46/36	8	7
段宁^[12]	2017	154	79/75	18	6
Liu^[13]	2017	141	72/69	16	8
张鸣杰^[14]	2020	92	29/63	11	6
汤海波^[15]	2020	200	92/108	44	7
付振东^[16]	2021	146	58/88	14	7

表1 LCBDE一期缝合术后胆漏危险因素Meta分析文献的基本特征及质量评价

第一作者	年份	样本量（例）	男/女（例）	胆漏（例）	NOS评分
饶尚锐^[10]	2007	115	55/60	10	5
刘学礼^[11]	2016	82	46/36	8	7
段宁^[12]	2017	154	79/75	18	6
Liu^[13]	2017	141	72/69	16	8
张鸣杰^[14]	2020	92	29/63	11	6
汤海波^[15]	2020	200	92/108	44	7
付振东^[16]	2021	146	58/88	14	7

图1 LCBDE一期缝合术后胆漏危险因素Meta分析森林图注：LCBDE为腹腔镜胆总管探查术

表2 LCBDE一期缝合术后胆漏危险因素的Meta分析结果

因素	异质性检验		Meta分析		Egger's检验
因素	I²	P	OR	95%CI	t	P
性别	0	0.83	0.83	0.55~1.26	-0.51	0.64
年龄	0	0.99	0.78	0.43~1.41	0.24	0.84
术前ASA分级	0	0.61	0.59	0.32~1.10	3.08	0.09
术前血WBC水平	0	0.44	0.98	0.47~2.03	0.17	0.88
术前血TB水平	0	0.48	1.63	0.94~2.82	0.76	0.53
糖尿病	44%	0.13	1.09	0.57~2.09	-0.96	0.41
胆囊结石	0	0.98	0.91	0.42~1.01	2.96	0.21
胆总管结石数量	0	0.68	0.85	0.43~1.70	9.01	0.07
术中出血量	5%	0.37	1.46	0.71~3.00	1.39	0.29

表2 LCBDE一期缝合术后胆漏危险因素的Meta分析结果

因素	异质性检验		Meta分析		Egger's检验
因素	I²	P	OR	95%CI	t	P
性别	0	0.83	0.83	0.55~1.26	-0.51	0.64
年龄	0	0.99	0.78	0.43~1.41	0.24	0.84
术前ASA分级	0	0.61	0.59	0.32~1.10	3.08	0.09
术前血WBC水平	0	0.44	0.98	0.47~2.03	0.17	0.88
术前血TB水平	0	0.48	1.63	0.94~2.82	0.76	0.53
糖尿病	44%	0.13	1.09	0.57~2.09	-0.96	0.41
胆囊结石	0	0.98	0.91	0.42~1.01	2.96	0.21
胆总管结石数量	0	0.68	0.85	0.43~1.70	9.01	0.07
术中出血量	5%	0.37	1.46	0.71~3.00	1.39	0.29

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Risk factors of bile leakage after primary suture of laparoscopic common bile duct exploration: a Meta-analysis

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Risk factors of bile leakage after primary suture of laparoscopic common bile duct exploration: a Meta-analysis