腹腔镜胆总管探查取石术后一期缝合与T管引流随机对照试验的系统评价和meta-分析

Evaluation and meta analysis of randomly controlled trail primary sature and T tube drainage after laparoscopic choledochotomy with exploration and choledocholithotomy

目的腹腔镜下对天伴急性炎症的胆总管结石患者行胆总管探查术后一期缝合和T管放置的比较分析。方法选取国内外大型数据库Pubmed、Embase、Springerlink和CNKI进行文献搜索,筛选关于腹腔镜下对胆总管进行探查取石术后行一期缝合或T管引流措施比较的随机对照研究,对纳入比较的研究进行系统评价和meta分析,比较分析一期缝合和T管引流的手术时间、术后并发症、残留结石数量、术后住院时间和住院费用等相关评价指标。结果通过文献筛选,共七个随机对照试验,615人(一期缝合组310人,T管引流组305人)纳入分析,其中六个为腹腔镜胆管取石术后行单纯一期缝合与T管放置的随机对照研究,一个为术后胆总管一期缝合+鼻胆管引流与T管放置的随机对照研究。腹腔镜胆总管探查取石术后行一期缝合的主要并发症和胆管相关并发症的发生率显著低于T管放置组,合并效应值OR分别是0.49(95%CI:0.31,0.76),0.51(95%CI:0.29,0.91)。两者的术后残留结石量、切口感染率和腹腔积液均无统计性差异。此外,一期缝合组在手术时间、术后住院天数、手术费用和腹腔引流时间上均显著低于T管引流组。结论对于非重症急性胆管炎、重症胆源性胰腺炎、急性化脓性胆管炎等非急性重症患者,腹腔镜下胆总管探查术后对胆总管行一期缝合是安全有效的,相对于传统的T管放置方法,能减少术后相关并发症,缩短手术时间和术后住院天数,减少手术费用,从而减轻病人痛苦和经济负担。因此,在严格掌握适应症的基础上,一期缝合疗效优于T管放置引流。

Objective To evaluate and compare primary duct closure and T-tube drainage placement in patients without severe inflections choledocholithiasis after laparoscopic common bile duct exploration.Methods Literature search included domestic and foreign large-scale databases：Pubmed,Embase,Springerlink and CNKI,screened for randomized controlled trials comparing primary closure and T-tube drainage in laparoscopic common bile duct exploration.A systematic review and meta-analysis based on the included studies was performed,and relevant evaluations comprised operative time,postoperative complications,residual stones,postoperative hospital stay and hospital expenses between the arms of primary closure and T-tube drainage.Results By screening the literature,seven RCTs with a total of six hundred and fifteen patients （primary closure：310,T-tube drainage：305） were analyzed.Six RCTs were performed on simply primary closure versus T-tube drainage,one RCT was performed on primary duct closure combined with endoscopic nasobiliary drainage versus T-tube drainage placement in laparoscopic common bile duct exploration.The incidence of main postoperative complications and biliary tract associated complications in primary closure arm were statistically lower to T-tube drainage arm,the pooled estimates of odds ratio were 0.49 （95%CI：0.31,0.76）,0.51 （95%CI：0.29,0.91） respectively.There was no significant difference regarding the residual stones,incision infection and abdominal collections.Besides,primary closure was significant lower compared to T-tube drainage in terms of operative time,postoperative hospital stay,hospital expenses and abdominal drainage time.Conclusions In non-critical patients as without severe acute cholangitis,acute severe biliary pancreatitis or acute suppurative cholangitis,primary duct closure is safe and effective in laparoscopic common bile duct exploration,compared with traditional methods of T-tube drainage placement,can reduce postoperative complications,operative time,postoperative hospital stay and operation costs,thus reducing patient sufferings and economic burdens.In strictly controlled indications,primary duct closure is better than T-tube drainage placement.