肝内胆管结石手术与内镜取石的疗效对比与危险因素分析

Results of open surgery or endoscopic choledocholithotomy in the treatment of hepatolithiasis and risk factors

目的探讨手术与内镜取石治疗肝内胆管结石的近远期疗效及其危险因素分析。方法对安徽医科大学附属省立医院2001--2008年收治的254例接受手术或内镜取石的肝内胆管结石患者的临床资料进行回顾性分析，其中189例患者得到完整随访，手术组127例，内镜取石组62例。采用单因素及多因素Logistic回归分析影响肝内胆管结石疗效的相关因素。结果手术治疗（包括肝切除）肝内胆管结石的清除率为85．0％（108／127），内镜取石的为61．3％（38／62）；平均随访时间6．0（2．5～10．5）年，总体复发率（结石复发或反复发作胆管炎症状）为32．8％（62／189），山现胆汁性肝硬化的为7．4％（14／189），发展为胆管癌的为3．7％（7／189）；7例均死亡。单因素及多因素Logistic回归分析显示：胆管狭窄、结石分布在双侧肝内胆管和内镜取石是结石残留的独立高危因素，OR值分别为7．522（95％C1：2．642～21．415），11．630（95％C1：3．989—33．912），21．374（95％凹：6．713～68．056）；结石残留、胆管狭窄、内镜取石是结石复发或反复发作胆管炎的独立高危因素，OR值分别为3．059（95％CI：1．307～7．159），3．702（95％CI：1．567～8．745），4．841（95％CI：1．946～12．043）。结论胆管狭窄、结石分布在双侧肝内胆管和内镜取石是结石残留的独立高危因素；结石残留、胆管狭窄及内镜取石治疗足胆管炎发作的独立高危因素。

Objective To investigate the short and long-term outcomes and risk factors after open surgery or and endoscopic hepatolithotomy for hepatolithiasis. Methods A retrospective study was made on cases of hepatolithiasis who underwent hepatolithotomy by open surgery or endoscopically from Jan 2001 to Dec 2008. Of 254 patients, 189 were followed-up including 127 after open surgery and 62 endoscopically. The univariate and multivariate analyses were performed to determine the risk factors. Results Complete stone clearance was achieved in 85.0% （ 108/127 ） of open surgery including hepatecomy, 61.3% （38/62） of endoscopic treatment. After a median follow-up period of 6. 0 years （2. 5 to 10. 5 years）, stone recurred in 32. 8% （62/189） of patients, biliary cirrhosis in 7. 4% （14/189）, cholangiocarcinoma in 7（3.7% ）, all cancer cases were dead with a mortality rate of 7（3.7% ）. Bile duct stricture （ 0R：7. 522,95% C1：2. 642 - 21.415）, stones in both lobes （OR： 11.630,95% CI：3.989 -33.912）, and endoscopic treatment （ OR：21. 374,95% CI： 6. 713 - 68. 056 ） were independent risk factors （ P 〈 0.05 ） for incomplete stone clearance by unconditional Logistic regression analysis. In addition, recurrent stones and/or cholangitis were associated with residual stones （ OR： 3. 059,95% CI： 1. 307 - 7. 159 ） , stricture （ OR： 3. 702, 95% CI： 1.567-8.745） and endoscopic therapy （ OR： 4.841, 95% CI： 1.946 - 12.043 ） （ P 〈 0.05 ）. Conclusions Stricture, stone in both lobes and endoscope therapy were independent risk factors for residual stones ; Residual stones, bile duct stricture and endoscope therapy were independent risk factors for recurrent stones and/or cholangitis.