66例经ERCP联合熊去氧胆酸治疗老年胆总管并胆囊结石患者与其他疗法比较

Comparison among ERCP combined with ursodeoxycholic acid and other therapies in the treatment of choledocholithiasis complicated with cholecystolithiasis

目的探讨经内镜逆行胰胆管造影(ERCP)联合熊去氧胆酸(UDCA)与其他两种主流疗法治疗75岁以上老年胆总管结石合并胆囊结石的疗效及术后生存质量的影响因素。方法选取2017年6月至2019年6月山东第一医科大学附属省立医院收治的184例年龄≥75岁胆总管结石合并胆囊结石患者,根据治疗方案不同分为ERCP+UDCA组(66例)、腹腔镜胆囊切除术(LC)+腹腔镜胆总管探查术(LCBDE)组(64例)和ERCP+LC组(54例)。统计三组患者一般资料,比较手术疗效、术后近期及远期并发症情况,选择胃肠疾病生存质量指数(GIQLI)量表评定患者术后2年生存质量。计量资料组间比较采用单因素方差分析或Kruskal-Wallis H检验,计数资料组间比较采用χ^(2)检验或Fisher确切概率法。数据两两多重比较均采用Bonferroni校正法。采用多项式Logistic回归模型分析术后2年GIQLI评分的独立影响因素。结果3组患者的年龄、性别、结石数量、合并基础疾病等基线水平具有可比性(P>0.05)。ERCP+UDCA组、LC+LCBDE组和ERCP+LC组在手术时间[43.0(37.0,61.8)min vs 200.0(170.0,243.8)min vs 189.0(172.0,215.5)min]、住院费用[3.19(2.71,3.80)万元vs 4.58(3.81,5.25)万元vs 5.44(4.86,6.52)万元]、住院时间[6.0(5.0,8.8)d vs 10.5(8.0,12.0)dvs 13.0(9.0,15.5)d]、引流管拔除时间[3(2,4)d vs 30(28,30)dvs 4(4,7)d]方面差异均有统计学意义(P均<0.001),其中ERCP+UDCA组的手术时间、住院费用、住院时间和引流管拔除时间较其余两组减少,差异有统计学意义(P均<0.05);3组的手术成功率和术后引流管放置率无统计学差异(P均>0.05)。3组患者的术后近、远期并发症发生率及GIQLI评分组间差异无统计学意义(P均>0.05)。患者年龄增高与术后发生并发症是影响术后2年GIQLI评分的独立危险因素。结论ERCP+UDCA疗法能在不降低老年患者生存质量的前提下使疾病得到有效控制。临床治疗中应避免盲目实行LC,要根据疾病特点进行综合考虑,实现个体化治疗。早发现、早治疗和减少术后并发症是提高老年患者术后生存质量的有效途径。

Objective To investigated the curative effects of endoscopic retrograde cholangiopancreatography(ERCP)combined with ursodeoxycholic acid(UDCA)and other two mainstream therapies in the treatment of patients over 75 with choledocholithiasis complicated with cholecystolithiasis,and to analyze factors affecting quality of life after surgery.Methods Clinical data of 184 elderly patients(≥75 years old)with choledocholithiasis and cholecystolithiasis treated in Shandong Provincial Hospital Affiliated to Shandong First Medical University during June 2017 and June 2019 were retrospectively analyzed.According to the treatment options,the patients were divided into ERCP+UDCA group with 66 patients,laparoscopic cholecystectomy(LC)+laparoscopic common bile duct exploration(LCBDE)group with 64 patients,and ERCP+LC group with 54 patients.The general data,short-term and long-term complications,and surgical condition were compared,and the quality of life was assessed with Gastrointestinal Quality of Life Index(GIQLI)scale two years after surgery.One-way analysis of variance or the Kruskal-Wallis H test was used for comparison of continuous data,and chi-square test or Fisher?s exact test was used for comparison of categorical data between groups.Bonferroni correction was used for multiple comparisons.Multinomial Logistic regression model was used to explore the independent factors of GIQLI scale two years after surgery.Results The three groups were comparable in age,sex,stone number and previous history(P>0.05).There were statistically significant differences among the ERCP+UDCA group,LC+LCBDE group and ERCP+LC group in operation time[43.0(37.0,61.8)min vs 200.0(170.0,243.8)min vs 189.0(172.0,215.5)min],hospitalization costs[31.9(27.1,38.0)thousand yuan vs 45.8(38.1,52.5)thousand yuan vs 54.4(48.6,65.2)thousand yuan],hospital stay[6.0(5.0,8.8)d vs 10.5(8.0,12.0)d vs 13.0(9.0,15.5)d]and time to extraction of drainage tube[3(2,4)d vs 30(28,30)d vs 4(4,7)d,all P<0.001].Compared with the other two groups,the ERCP+UDCA group had shorter operation time,hospital stay and extraction of drainage tube,and lower hospital costs(all P<0.05).There were no significant differences in the rate of surgical success,postoperative catheterization,incidence of short-term and long-term complications,and GIQLI score among the three groups(all P>0.05).Age increase and postoperative complications were independent risk factors affecting GIQLI scale 2 years after surgery.Conclusion ERCP+UDCA could effectively control the disease without reducing elderly patients?quality of life.Comprehensive therapy and individualized treatment based on the characteristics of the disease should be carried out in clinical treatment instead of performing the LC blindly.Early detection,early treatment and reduction of postoperative complications are effective ways to improve postoperative quality of life.