两种微创治疗方案治疗老年患者胆总管结石的临床对照研究

Comparison between Two Approaches for Minimally Invasive Surgery for Common Bile Duct Stones in Elderly Patients

目的比较腹腔镜胆囊切除联合胆总管探查术(LC联合LCBDE)与内镜乳头切开取石联合腹腔镜胆囊切除术(EST联合LC)治疗老年患者(≥65岁)胆总管结石的临床疗效。方法 2005年7月～2010年12月,胆总管直径≥8mm且既往未接受乳头括约肌切开、胆囊切除或胆道手术的110例老年胆总管结石患者,LC联合LCBDE组47例,先行LC,确认胆总管后行LCBDE,结石取净后胆道镜检查胆道系统以确认有无结石残留;EST联合LC组63例,十二指肠镜确认十二指肠乳头,常规ERCP进一步明确诊断后行EST,取石后鼻胆管引流2～5 d后行LC。对两组结石清除率、术后并发症、中转开腹率及单次治疗成功率等指标进行对比,并进行随访。结果 2组结石清除率、术后并发症、中转开腹率差异无显著性(P>0.05),而单次治疗成功率LC联合LCBDE组显著高于EST联合LC组[87.2%(41/47)vs.68.3%(43/63),χ2=5.372,P=0.020]。所有病例随访1～3年,平均2.1年,未出现腹痛、发热及黄疸等症状,B超未见结石复发。结论LC联合LCBDE和EST联合LC都是治疗老年患者胆总管结石安全有效的方法,而在减少治疗次数方面,LC联合LCBDE更有优势。

Objective To compare the efficiency of laparoscopic cholecystectomy combined with common bile duct exploration （ LC ＋ LCBDE） and endoscopic sphincterotomy followed by laparoscopic cholecystectomy （ EST ＋ LC） for elderly patients with common bile duct stones. Methods Since July 2005 to December 2010, totally 110 elderly patients with common bile duct stones, who had never received sphincterotomy, cholecystectomy or common bile duct exploration （the common bile duct was larger than 8 mm in diameter in all the cases） , were enrolled into this study. Among the patients, LC ＋ LCBDE was performed on 47 cases, for whom, LCBDE was carried out after LC, and choledochoscopy was used to explore the biliary system after removing all the stones; the other 63 patients received EST ＋ LC, EST was carried out when duodenal papilla was identified with duodenoscopy and the stones were confirmed with ERCP, and then LC was carried out after 2- to 5-day nasobiliary drainage. The stone clearance rate, postoperative complications, rate of conversion to open surgery, and success rate of single-session operation were compared between the two groups. Results No significant difference was detected in the stone clearance rate, postoperative complications, and rate of conversion to open surgery between the two groups （P 〉 0.05）. However, LC ＋ LCBDE group showed a significantly higher success rate of single-session operation than the EST ＋ LC group [87.2% （41/47） vs. 68.3% （43/63）, X2 = 5. 372, P = O. 020]. In both the groups, all the patients received a follow-up for a mean of 2.1 years （ranged from 1 to 3 years） , during which no abdominal pain, fever, or jaundice were detected, and re-examination by B-uhrasonography showed no recurrent stones. Conclusion Both LC ＋ LCBDE and EST ＋ LC are effective for elderly patients with common bile duct stones, however, with LC ＋ LCBDE, the patients undergo less sessions of oneration.