218例巨大胆总管结石病人临床诊疗分析

Clinical analysis of 218 patients with huge choledocholith

目的探讨分析218例巨大胆总管结石病人的临床表现、辅助检查、内镜治疗及并发症发生情况。方法将218例胆总管结石（直径≥2cm）病人作为观察组，并按结石数量分为1枚结石组、2枚结石组和〉2枚结石组；另取231例胆总管结石（直径〈2cm）病人作为对照组。分析各组的病史资料、临床表现、实验室检查、内镜下治疗情况及并发症发生情况。结果观察组病人中，有胆系感染、胆总管切开取石病史的比例显著高于对照组（26．6％、15．6％与15．2％、7．8％），有急性胰腺炎病史的比例显著低于对照组（9．6％与16．9％）。2枚结石组和〉2枚结石组中腹痛、发热的发生率显著高于对照组（88％、94．2％与74．5％，64％、65．4％与41．6％），〉2枚结石组中黄疸、腹泻的发生率显著高于对照组（78．8％与51．1％，44．2％与26．8％）。2枚结石组和〉2枚结石组中血总胆汁酸、碱性磷酸酶及γ-谷氨酰转酞酶水平均显著高于对照组，〉2枚结石组血总胆红素及直接胆红素水平显著高于对照组。取石术后总胆红素、直接胆红素、总胆汁酸及碱性磷酸酶水平较术前显著降低。2枚结石组和〉2枚结石组中内镜下取石的成功率及一次取石成功率均显著低于对照组（88％、79％与94％，72％、56％与82％），平均住院天数显著高于对照组（13±4．6、16±5．2与10±3．8）。〉2枚结石组在取石过程中发生结石嵌顿、乳头部出血及心律失常的比例显著高于对照组（21％、33％、15％与6．9％、19％、9％）。2枚结石组和〉2枚结石组取石后发生急性轻型胰腺炎的比例显著高于对照组（15％、23％与7．4％），〉2枚结石组取石后出现高淀粉酶血症的比例显著高于对照组（17％与6％）。结论反复胆系感染、胆总管切开取石与胆总管巨大结石的发生密切相关，胆总管巨大结石病人更易出现黄疸、腹泻及胆汁淤积，且内镜取石的难度显著增加，术中及术后更易出现并发症。

Objective To investigate the clinical situation, laboratory examination, endoscopic therapy and complications in 218 patients with huge choledocholith. Methods A total of 218 patients with choledocholith were enrolled in the observational group （diameter≥2 cm）. They were then subdivided into the lstone group, 2 stone group and 〉2 stone group according to the stone number. The other 231 patients with choledocholith were regarded as control group（diameter〈2 cm）. The history information, clinical situation, laboratory examination, endoscopic therapy and complications in all the patients were analyzed. Results The ratio of patients with history of biliary infection and choledocho- lithotomy was significantly higher in the observational group than in the control（26.6 %, 15.6 % versus 15.2% , 7.8% ）. And the ratio of patients with history of acute pancreatitis was markedly lower in the former than in the latter group （9.6% vs 16.9%）. In 2 stone group and 〉2 stone group, the incidence of abdominalgia and fever was higher than that in the control group significantly（88% , 94.2% vs 74.5% ,64% , 65.4% vs 41.6% ）. The incidence of jaundice and diarrhea was remarkably higher in 〉2 stone group than in the control group（78.8% vs 51.1% ,44.2% vs 26.8% ）. In 2-stone group and 〉2-stone group, the serum levels of TA, AKP, T-GT were significantly increased as compared with the control group. Meanwhile, the serum levels of total bilirubin and direct bilirubin were markedly higher in 〉2 stone group than in the control group. After operation, the serum levels of total bilirubin, direct bilirubin and AKP were reduced as compared with those before operation. The total and one-time success rate of endoscopic stone extraction was remarkably lower in 2 stone group and 〉2 stone group than in the control（88%, 79% vs 94% ,72% , 56% vs 82% ）. The mean duratgion of hospitalization was much higher than control group （13±4.6, 16±5.2 vs 10±3.8）. In 〉2 stone group, the incidence of stone obstruction, papilla bleeding and arrhythmia was significantly increased as compared with the control group in the course of operation（ 21% , 33% , 15% vs 6.9% , 19%, 9%）. In 2 stone group and 〉2 stone group, the incidence of acute pancreatitis after operation was significantly higher than that in the control group（15%, 23% vs 7.4% ）. The incidence of hyperamylasemia after operation was significantly higher than that in the control group in 〉2 stone group（ 17% vs 6 % ）. Conclusion Repeated biliary infection and choledocholithotomy have close relation with huge eholedocholith. Jaundice, diarrhea and lesion of liver function occur more easily in the patients with huge choledocholith, and the endoscopic therapy is more diffieult. Complications occur much easily during and after operation.