腹腔镜十二指肠镜联合治疗胆囊胆总管结石的两种术式临床分析

Clinical analysis of two approaches of combining laparoscopy and duodenoscopy in treatment for chloecystocholedocholithiasis

目的探讨腹腔镜术中联合应用十二指肠镜对接技术(LER)与十二指肠镜、腹腔镜分步处理治疗胆囊胆总管结石两种术式临床效果。方法回顾性分析自2009年1月至2010年11月收治51例胆囊合并胆总管结石患者。其中一期处理组25例实施LER进行一期处理,分期处理组26例实施分期处理,先行经内镜逆行性胰胆管造影+十二指肠乳头括约肌切开取出胆总管结石,5 d后行腹腔镜胆囊切除术(LC)。比较两组手术时间、胆总管结石取净率、手术成功率、术后并发症发生率、总体住院天数。结果两组胆总管结石成功取净,术中各有1例因胆囊三角严重粘连中转开腹,一期处理组与分期处理组的手术成功率96.0%vs 96.2%(χ2=0.481,P=0.509),平均手术时间为(85±20)min vs(120±18)min(t=-0.613,P<0.01),术后胰腺炎并发症发生率为4%vs 11%(χ2=5.063,P=0.020),平均住院时间分别为(5.0±1.2)d vs(11±1.6)d(Z=-6.230,P<0.01)。所有患者均未出现出血、穿孔等与十二指肠镜检操作相关的并发症。结论 LER手术一期治疗胆囊胆管结石安全、有效,与分期治疗相比,术后胰腺炎并发症发生率较低,总体住院时间大为缩短,但其推广应用,尚需待大样本临床研究和长期随访评价。

Objective To evaluate the efficacy of two approaches in treatment for chloecystocholedocholithiasis：laparoscopy combined with duodenoscopy （laparo-endoscopic rendenvous, LER） and two-stage treatment- laparoscopic cholecystectomy （LC） following preoperative endoscopic retrograde cholangiopancreatography （ERCP）. Methods From January 2009 to November 2010, fifty-one cases of chloecystocholedocholithiasis were adopted to our hospital. Twenty-five cases underwent LER, while the other 26 cases underwent a two-stage treatment：LC 5 days after the preoperative ERCP. Operating time, cleanses rate of common bile duct stones, surgical success rate, incidence of complications of postoperative pancreatitis and the overall length of hospital stay were compared. Results Both groups had one case converting to laparotomy because of severe adhesions of gallbladder triangle. Surgical success rates were 96.0%vs 96.2%（χ2=0.481,P=0.509）. Average operative time were （85±20） min vs （120±18） min （t=-0.613,P〈0.01）. Pancreatitis complications were 4%vs 11%（χ2=5.063,P=0.020）. The average hospital stay were （5.0±1.2）d vs （11±1.6）d （Z=-6.230,P〈 0.01）. The whole group of patients had no complications of bleeding and perforation related to duodenal microscopic operations. Conculsions LER technique of the single-stage treatment for chloecystocholedocholithiasis is safe, effective, and has a lower incidence of postoperative complications of pancreatitis, greatly shortening the overall length of hospital stay, compared with the two-stage treatment. Its promotion and application still needs a large sample of clinical studies and long-term follow-up evaluation.