LC+LCBDE与ERCP/EST+LC治疗胆囊结石合并胆总管结石效果Meta分析

doi:10.3877/cma.j.issn.2095-3232.2024.01.009

目的

系统评价LC联合胆总管探查术（LCBDE）和LC联合ERCP/内镜下乳头括约肌切开取石术（EST）两种手术方式治疗胆囊结石合并胆总管结石的安全性及有效性。

方法

计算机检索CNKI、VIP、万方等中文数据库和PubMed、Embase、Medline、Cochrane Library等外文数据库。英文检索词：gallbladder stones、common bile duct stones、endoscopy、duodenal sphincterotomy、laparoscopic choledochotomy；中文检索词：胆囊结石合并胆总管结石、内窥镜、十二指肠括约肌切开术、腹腔镜胆总管切开探查术等。检索时间为2005年1月1日至2022年1月1日，按照预先设定的纳入和排除标准，两名研究者对检索所得文献进行筛选、数据提取，采用RevMan 5.4软件进行Meta分析。

结果

最终纳入11个RCT，共1 701例患者，其中LC + LCBDE组883例，ERCP/EST + LC组818例。两组患者结石清除率（OR=0.85，95%CI：0.59～1.22）、手术中转率（OR=1.46，95%CI：0.81～2.62）差异无统计学意义（P>0.05）；两组手术时间（WMD=11.26，95%CI：-13.38～35.89）、住院时间（WMD=-0.65，95%CI：-1.55～0.16）差异亦无统计学意义（P>0.05）。两组术后胆漏（OR=4.89，95%CI：2.13～11.21）、胰腺炎发生率（OR=0.15，95%CI：0.06～0.37）差异有统计学意义（P<0.05）。

结论

两种不同手术方式均是安全、有效的胆囊结石合并胆总管结石治疗手段，LC联合LCBDE术后胰腺炎发生率更低，而LC联合ERCP/EST的胆漏发生率更低。

关键词: 胆囊结石病, 胆总管结石, 胆囊切除术，腹腔镜, 腹腔镜胆总管探查术, 胰胆管造影术，内窥镜逆行, 内镜下乳头括约肌切开术, Meta分析

Objective

To systematically evaluate the safety and efficacy of laparoscopic cholecystectomy (LC) combined with laparoscopic common bile duct exploration (LCBDE) and LC combined with endoscopic retrograde cholangiopancreatography (ERCP)/endoscopic sphincterotomy (EST) in the treatment of gallbladder stones complicated with common bile duct stones.

Methods

Literature review was performed from CNKI, VIP and Wanfang Data, PubMed, Embase, Medline and Cochrane Library using the searching keywords of gallbladder stones, common bile duct stones, endoscopy, duodenal sphincterotomy, laparoscopic choledochotomy in both English and Chinese from January 1, 2005 to January 1, 2022. According to the inclusion and exclusion criteria, two researchers screened the retrieved literatures and extracted data. Meta-analysis was conducted by RevMan 5.4 software.

Results

1 701 patients from 11 RCTs were included, including 883 patients in the LC + LCBDE group and 818 in the ERCP/EST + LC group. No significant differences were observed in stone clearance rate (OR=0.85, 95%CI: 0.59-1.22) and surgical conversion rate (OR=1.46, 95%CI: 0.81-2.62) between two groups (P>0.05). No significant differences were noted in the operation time (WMD=11.26, 95%CI: -13.38-35.89) and length of hospital stay (WMD=-0.65, 95%CI: -1.55-0.16) between two groups (P>0.05). The incidence of postoperative bile leakage (OR=4.89, 95%CI: 2.13-11.21) and pancreatitis (OR=0.15, 95%CI: 0.06-0.37) significantly differed between two groups (P<0.05).

Conclusions

Both two surgical procedures are safe and effective treatment for gallbladder stones complicated with common bile duct stones. The incidence of pancreatitis after LC combined with LCBDE is lower, whereas the incidence of bile leakage after LC combined with ERCP/EST is lower.

Key words: Cholecystolithiasis, Common bile duct stones, Cholecystectomy, laparoscopic (LC), Laparoscopic common bile duct exploration (LCBDE), Cholangiopancreatography, endoscopic retrograde (ERCP), Endoscopic sphincterotomy (EST), Meta-analysis

表1 纳入文献的基本特征

纳入研究	发表年份	国籍	手术方式	例数（例）	性别比（男/女）	年龄（岁）	观察指标
Hong等^[6]	2006	中国	A1	141	47/84	48.0±8.3	a,b,c,d
			B2	93	28/65	45.0±10.2
Rogers等^[7]	2010	美国	A1	57	17/40	39.9±1.9	a,b,c,d
			B2	55	16/39	44.6±1.9
戴国清等^[8]	2010	中国	A1	72	27/45	53.7±21.3	a,c,d,e,f
			B2	60	21/39	54.9±22.3
ElGeidie等^[9]	2011	埃及	A1	115	29/86	32.5（19.0～64.0）	a,b,c,d
			B2	111	31/102	29.2（20.0～67.0）
Koc等^[10]	2013	土耳其	A1	57	20/37	51.5±16.6	a,b,c,e,f
			B2	54	18/36	54.9±17.9
Bansal等^[11]	2014	印度	A1	84	23/61	45.4±15.1	a,b,c,d,e,f
			B2	84	34/50	43.0±13.7
Ding等^[12]	2014	中国	A1	110	53/57	58.4±7.2	a,e,f
			B2	111	53/58	57.5±6.3
Barreras González等^[13]	2016	古巴	A1	43	NA	57.7（20.0～87.0）	a,c,e,f
			B2	45	NA	56.3（22.0～87.0）
Poh等^[14]	2016	澳大利亚	A1	52	23/29	53.4±19.7	a,b,d
			B2	52	21/31	53.9±22.6
岳大成等^[15]	2016	中国	A1	106	49/57	59.8±16.0	a,c,d,e,f
			B2	108	48/60	57.0±17.2
束长新等^[16]	2018	中国	A1	49	32/17	60.5±5.1	a,b,d,e,f
			B2	49	25/24	67.3±4.7

表1 纳入文献的基本特征

纳入研究	发表年份	国籍	手术方式	例数（例）	性别比（男/女）	年龄（岁）	观察指标
Hong等^[6]	2006	中国	A1	141	47/84	48.0±8.3	a,b,c,d
			B2	93	28/65	45.0±10.2
Rogers等^[7]	2010	美国	A1	57	17/40	39.9±1.9	a,b,c,d
			B2	55	16/39	44.6±1.9
戴国清等^[8]	2010	中国	A1	72	27/45	53.7±21.3	a,c,d,e,f
			B2	60	21/39	54.9±22.3
ElGeidie等^[9]	2011	埃及	A1	115	29/86	32.5（19.0～64.0）	a,b,c,d
			B2	111	31/102	29.2（20.0～67.0）
Koc等^[10]	2013	土耳其	A1	57	20/37	51.5±16.6	a,b,c,e,f
			B2	54	18/36	54.9±17.9
Bansal等^[11]	2014	印度	A1	84	23/61	45.4±15.1	a,b,c,d,e,f
			B2	84	34/50	43.0±13.7
Ding等^[12]	2014	中国	A1	110	53/57	58.4±7.2	a,e,f
			B2	111	53/58	57.5±6.3
Barreras González等^[13]	2016	古巴	A1	43	NA	57.7（20.0～87.0）	a,c,e,f
			B2	45	NA	56.3（22.0～87.0）
Poh等^[14]	2016	澳大利亚	A1	52	23/29	53.4±19.7	a,b,d
			B2	52	21/31	53.9±22.6
岳大成等^[15]	2016	中国	A1	106	49/57	59.8±16.0	a,c,d,e,f
			B2	108	48/60	57.0±17.2
束长新等^[16]	2018	中国	A1	49	32/17	60.5±5.1	a,b,d,e,f
			B2	49	25/24	67.3±4.7

图1 LC+LCBDE与ERCP/EST+LC治疗胆囊结石合并胆总管结石患者效果Meta分析的纳入文献风险偏倚评估注：LC为腹腔镜胆囊切除术，LCBDE为腹腔镜胆总管探查术，EST为内镜下乳头括约肌切开术

图2 LC+LCBDE与ERCP/EST+LC治疗胆囊结石合并胆总管结石患者结石清除率的Meta分析森林图注：LC为腹腔镜胆囊切除术，LCBDE为腹腔镜胆总管探查术，EST为内镜下乳头括约肌切开术

图3 LC+LCBDE与ERCP/EST+LC治疗胆囊结石合并胆总管结石患者胆漏发生率的Meta分析森林图注：LC为腹腔镜胆囊切除术，LCBDE为腹腔镜胆总管探查术，EST为内镜下乳头括约肌切开术

图4 LC+LCBDE与ERCP/EST+LC治疗胆囊结石合并胆总管结石患者结石清除率的Meta分析漏斗图注：LC为腹腔镜胆囊切除术，LCBDE为腹腔镜胆总管探查术，EST为内镜下乳头括约肌切开术

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Efficacy of LC+LCBDE and ERCP/EST+LC in the treatment of gallbladder stones complicated with common bile duct stones: a Meta-analysis

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Efficacy of LC+LCBDE and ERCP/EST+LC in the treatment of gallbladder stones complicated with common bile duct stones: a Meta-analysis