腹腔镜胆囊切除联合术中与术前内镜十二指肠乳头括约肌切开治疗胆石症

Laparoscopic cholecystectomy combined with intraoperative versus preoperative endoscopic sphincterotomy in the treatment of cholecystocholedocholithiasis

目的 评价腹腔镜联合顺行导丝引导术中内镜十二指肠乳头括约肌切开术（EST）治疗胆囊结石合并胆总管结石的临床价值.方法 应用前瞻对照方法对腹腔镜胆囊切除（LC）联合术前EST（POEST）与LC联合术中EST（IOEST）两种方案治疗胆石症进行研究.将我院2012年6月至2014年2月收治的胆囊结石合并胆总管结石病例分为POEST和IOEST两组,每组各50例.记录两组病例手术操作时间、单次EST胆管结石清除率、胆管残余结石发生率、EST相关急性胰腺炎发生率、治疗后住院时间及住院费用等指标并进行统计学分析.结果 POEST与IOEST两组患者性别年龄分布以及结石大小、数目、胆总管直径差异无统计学意义（P＞0.05）.两组治疗结果的比较：EST操作时间、LC联合EST总手术时间、单次EST胆管结石取净率、住院费用等四项指标,两组差异无统计学意义（P＞0.05）.胆管残余结石发生率,EST相关高淀粉酶血症发生率,EST相关急性胰腺炎发生率,治疗后住院时间等四项指标两组比较差异有统计学意义（P＜0.05）.IOEST组胆管残余结石发生率（分别为0和8％）显著降低,EST相关高淀粉酶血症发生率（分别为4％和18％）和急性胰腺炎发生率（分别为0和8％）显著降低,治疗后住院时间显著缩短.结论 LC联合顺行导丝引导IOEST技术治疗胆石症操作技术可行.与传统LC联合EST序贯性方案相比,LC联合术中EST技术能显著降低EST相关急性胰腺炎发生率,降低胆管残余结石发生率.其应成为LC联合EST治疗胆石症的推荐技术.

Objective To study the clinical application of laparoscopic cholecystectomy （LC） combined with intraoperative endoscopic sphincterotomy （IOEST） with the antegrade guidewire technique in the treatment of cholecystocholedocholithiasis.Methods This is a prospective controlled study comparing LC combined with preoperative endoscopic sphincterotomy （POEST） versus LC combined with IOEST in the treatment of cholecystocholedocholithiasis.Patients who were diagnosed to have cholecystocholedocholithiasis from June 2012 to February 2013 in our hospital were divided into the POEST group and the IOEST group.There were 50 patients in each group.The operation time,successful stone-extraction rate,residual stones rate,complication rate,postoperative stay and hospitalization cost between the groups were compared.Results The sex,age,stone size,number of stones and diameter of the common bile duct showed no significant difference between the two groups （P ＞ 0.05）.There were no differences between the two groups in surgical time of EST,surgical time of LC combined with EST,successful stone-extraction rate and hospitalization cost （P ＞ 0.05）.There were significant differences between the two groups in the residual stones rate,postoperative hyperamylasemia rate,postoperative acute pancreatitis rate and postoperative stay （P ＜0.05）.LC combined with IOEST using the antegrade insertion of guidewire technique significantly reduced the residual stones rate （0 vs 8％）,postoperative hyperamylasemia rate （4％ vs 18％）,postoperative acute pancreatitis rate （0 vs 8％） and postoperative stay.Conclusions LC combined with IOEST using the antegrade guidewire technique could be performed safely when compared with the traditional sequential technique,LC combined with IOEST using the antegrade guidewire technique significantly reduced the postoperative acute pancreatitis rate and the residual stones rate.LC combined with IOEST using the antegrade guidewire technique should be the recommended technique to treat patients with cholecystocholedocholithiasis.