术中造影联合腹腔镜超声诊断隐匿性胆总管结石的研究

Prospective research of intraoperative cholangiography combined with laparoscopic ultrasonography for detection of occult choledocholithiasis

目的探讨腹腔镜胆囊切除(LC)术中胆道造影(IOC)联合腹腔镜超声(LUS)诊断隐匿性胆总管结石(CBDS)的临床价值。方法2002年12月至2005年8月,对103例CBDS可疑病人进行IOC联合LUS诊断的前瞻性研究。结果IOC和LUS的操作成功率分别为91.3%和100%,操作时间分别为(13.8±3.7)min和(8.5±1.9)min(P<0.01)。IOC的敏感度、特异度、准确度、阳性预测值、阴性预测值、阳性似然比、阴性似然比分别为75.0%、98.7%、92.2%、95.5%、91.4%、57.7、0.253,LUS分别为82.1%、98.7%、94.2%、95.8%、93.7%、63.2、0.181,两种方法的诊断率经McNemar检验差异无显著性意义(P=0.754),一致性检验KAPPA值为0.720。IOC联合LUS后敏感度上升为92.9%。结论有IOC禁忌证或操作失败时,可选择LUS替代,两种方法联合应用可提高诊断隐匿性CBDS的敏感度。

Objective To evaluate the clinical effect of intraoperative cholangiography （IOC） combined with laparoscopic ultrasonography （LUS） for detection of occult common bile duct stones （CBDS） at laparoscopic cholecystectomy. Methods From December 2002 to August 2005, 103 patients with intermediate and moderate levels of suspicion of CBDS underwent IOC and LUS simultaneously during LC were analyzed prospectively. Results The successful rate of IOC and LUS were 91.3% and 100% respectively. The time required for LUS （8. 5 ± 1.9）min was significantly shorter than for IOC （ 13.8 ± 3.7） min （ P 〈 0. 01 ）. The sensitivities, specificities, accuracies, positive and negative predictive values, positive and negative likelihood ratios identifying occult CBDS were 75.0%, 98. 7%, 92.2%, 95.5%, 91.4%, 57.7 and 0. 253 by IOC,and 82. 1% ,98. 7% ,94. 2% ,95.8% ,93.7% ,63.2 and 0. 181 by IUS respectively. The McNemar test showed no significant difference between two methods （ P = 0. 754） with a higher diagnasis concordance （ KAPPA coefficient = 0. 720）. The sensitivity of IOC combined with LUS was 92.9% ,which was clearly superior to that of IOC and LUS taken separately. Conclusion LUS can be performed in case IOC has failed or is contraindicated. The combination of both methods maximizes intraoperative detection of CBDS and should be recommended.