不同方式的腹腔镜胆道探查术治疗胆总管结石的临床前瞻性研究

A clinical prospective study on three methods of laparoscopic common bile duct exploration for common bile duct stone

目的通过比较分析腹腔镜下经胆囊管和经胆总管切开T管引流及胆管一期缝合胆道镜取石治疗胆囊结石继发胆总管结石病人的疗效,以评价各种腹腔镜胆道探查方式治疗胆总管结石的临床价值。方法自2000年1月￣2003年6月根据4项筛选标准,对符合条件的61例病人按胆道探查途径不同分为经胆囊管组(n=14)和胆总管切开组,后者又分为胆总管一期缝合组(n=23)和T管引流组(n=24)。比较观察3组病例的手术时间、腹腔引流时间、术后住院日、恢复正常工作时间、术后平均输液量、住院费用、手术并发症及术后随访结果。结果经胆囊管组手术时间明显短于一期缝合组和T管引流组(P<0.05),T管引流组腹腔引流时间、术后住院日、恢复正常工作时间、术后平均输液量、住院费用明显长于或高于经胆囊管组和一期缝合组(P<0.05),而经胆囊管组和一期缝合组除手术时间外其他指标无明显差异(P>0.05)。经胆囊管组出现手术并发症1例(7.1%),一期缝合组出现手术并发症3例(13.0%),均为胆道并发症;T管引流组出现手术并发症7例(29.2%),其中胆道并发症5例(20.8%)。3组患者随访结果无明显差异。结论经胆囊管途径的腹腔镜胆道探查术治疗适合的胆囊结石继发胆总管结石病人的疗效优于胆管切开途径的腹腔镜胆道探查术,而后者中胆管一期缝合的疗效又明显优与T管引流。

[Objective] To evaluate the effects of transcystic laparoscopic common bile duct exploration（TLCBDE） and primary duct closure and T-tube drainage after laparoscopy choledochotomy for common bile duct stones. [Methods] The enrollment of the patients was in accordance with 4 criteria. Appropriate 61 patients with cholecystolithiasis and secondary common bile duct stones from January 2000 to June 2003 were divided into three groups： TLCBDE group （n =14） and primary duct closure group （n =23） and T-tube drainage group （n =24）. Their all data were recorded and studied prospectively,and patients were followed up after discharge. [Results] TLCBDE group had the least operation time in three groups. T-tube drainage group had the most total quantity of postoperative transfusion and hospital costs, the longest postoperative hospital stay. There were no significant difference between TLCBDE group and primary duct closure group except operation time. The incidence of postoperative complications in TLCBDE group was 7.1%（1/14）. The incidence of postoperative complications in primary duct closure group was 13.0%（3/23）, and all of them were biliary complications. The incidence of postoperative complications in T-tube drainage group was 29.2%（7/24）, and five of them were biliary complications. There was no mortality in three groups. The results of following up had no difference in three groups. [Concision] Transcystic laparoscopic common bile duct exploration for common bile duct stone have the advantage of laparoscopy choledochotomy. The primary duct closure after laparoscopic choledochotomy have the advantage of T-tube drainage. So we advocate transcystic laparoscopic common bile duct exploration or primary duct closure after laparoscopic choledochotomy for common bile duct stone in appropriate cases.