2364例肝外胆管结石三镜联合微创外科治疗的临床疗效

Clinical efficacy of combined three-endoscopic minimally invasive surgical treatment of extrahepatic cholangiolithiasis in 2 364 patients

目的探讨腹腔镜、胆道镜及十二指肠镜联合应用治疗肝外胆管结石的适应证及临床疗效。方法采用回顾性队列研究方法。收集2008年1月至2015年12月吉林大学第一医院收治的2364例肝外胆管结石患者（胆总管直径1〉8mm的胆囊结石合并肝外胆管结石861例，胆总管直径〈8mm的胆囊结石合并肝外胆管结石720例，单纯肝外胆管结石或胆囊切除术后的肝外胆管结石783例）的临床资料。胆囊结石合并肝外胆管结石且胆总管直径≥8mm者，行LC＋腹腔镜胆总管探查术（LCBDE），术中根据患者具体情况选择留置T管或一期缝合。胆囊结石合并肝外胆管结石且胆总管直径〈8mm者行内镜下乳头括约肌切开术（EST）或内镜下乳头气囊扩张术（EPBD）＋Lc。单纯肝外胆管结石或胆囊切除术后复发结石行EST或EPBD；结石多发且最大直径〉2cm，无法行EST或EPBD者行LCBDE；LCBDE术后残余结石有T管则行胆道镜取石，无T管测行EST或EPBD取石。观察患者治疗结果（治疗方式、微创取石成功率、手术时间、并发症发生率、术后住院时间及治疗费用），随访结果（术后1、3年结石复发率）。采用门诊及电话方式随访。所有患者术后1个月、3个月、6个月、1年、3年复查血常规、肝功能及腹部彩色多普勒超声，超声检查发现疑似残余胆管结石者以CT或MRCP等影像学检查确诊；留置T管患者术后2～3个月行肝胆cT及胆道造影检查确定无残余结石后拔除T管。随访时间截至2016年1月。计量资料采用平均数（范围）表示。结果（1）治疗结果：2364例患者中，2271例微创取石成功。861例胆总管直径≥8mm的胆囊结石合并肝外胆管结石患者中，836例行LC＋LCBDE微创取石成功，微创取石成功率为97．10％（836／861），其余25例中转开腹手术。836例患者中703例术中留置T管，平均手术时间为97min（41～167min），并发症发生率为3．70％（26／703），平均术后住院时间为6．7d（3．0～32．0d），平均治疗费用为3．4万元（1．5～6．7万元）。836例患者中133例行一期缝合，平均手术时间为89min（39～123min），并发症发生率为3．01％（4／133），平均术后住院时间为4．1d（2．0～17．0d），平均治疗费用为2．1万元（1．6～3．4万元）。720例胆总管直径〈8mm的胆囊结石合并肝外胆管结石患者中，687例行EST或EPBD＋LC，微创取石成功率为95．42％（687／720），其余33例中转开腹手术。687例患者平均手术时间为101min（69～163min），并发症发生率为2．91％（20／687），平均术后住院时间为5．6d（2．0～15．0d），平均治疗费用为2．8万元（2．0～6．4万元）。783例单纯肝外胆管结石或胆囊切除术后复发结石患者中，725例采用EST或EPBD取石，成功率为96．69％（701／725）。701例患者平均手术时间为47min（11～79min），并发症发生率为2．28％（16／701），平均术后住院时间为3．7d（2．0～19．0d），平均治疗费用为1．7万元（1．3～5．5万元）。783例患者中58例采用LCBDE取石，成功率为81．03％（47／58）。47例患者平均手术时间为124min（94～170min），并发症发生率为8．51％（4／47），平均术后住院时间为7．9d（5．0～21．0d），平均治疗费用为3．8万元（2．3～7．9万元）。（2）随访结果：2364例患者中，2207例获得随访，平均随访时间为38个月（1～72个月）。行LC＋LCBDE患者1、3年结石复发率分别为2．74％（19／693）和5．08％（24／472）；行EST或EPBD＋Lc患者1、3年结石复发率分别为3．10％（21／677）和5．69％（30／527）。单纯肝外胆管结石或胆囊切除术后复发结石患者中，行EST或EPBD取石患者1、3年结石复发率分别为3．22％（20／621）和6．11％（25／409）；行LCBDE取石患者1、3年结石复发率分别为7．32％（3／41）和11．11％（2／18）。结论三镜联合治疗肝外胆管结石安全、有效，三镜互为补充，恰当合理地选择适应证是提高疗效的关键。LCBDE术中一期缝合可使部分患者免受T管之苦，值得推广使用。

Objective To investigate the indications and clinical efficacy of combined application of laparoscope, choledochoscope and duodenoscope in the treatment of extrahepatic cholangiolithiasis. Methods The retrospective cohort study was adopted. The clinical data of 2 364 patients with extrahepatic eholangiolithiasis who were admitted to the First Hospital of Jilin University from January 2008 to December 2015 were collected. Of the 2 364 patients, 861 patients had cholecystolithiasis combined with extrahepatic cholangiolithiasis and the diameter of common bile duct ≥ 8 mm, 720 patients had cholecystolithiasis combine with extrahepatic cholangio- lithiasis and the diameter of common bile duct 〈 8 mm, 783 patients bad only extarhepatic cholangiolithiasis. In the patients diagnosed as cholecystolithiasis combined with extrahepatie changiolithiasis, laparoscopie cholecys- tectomy （LC） ＋ laparoscopie common bile duct exploration （LCBDE） were applied to patients with the diameter of common bile duct≥8 ram, and the T-tube placement or primary suture was used intraoperatively according to the status of individualized patients; endoscopic sphincterotomy （EST） or endoscopic papillary balloon dilation （EPBD） ＋ LC were applied to patients with the diameter of common bile duct 〈 8 mm. For patients with only extrahepatic cholangiolithiasis or recurrent stones after cholecystectomy, EST or EPBD was applied, and LCBDE was applied to patients with multiple stones and maximum diameter 〉 2 cm and unsuitable for EST or EPBD. If residual stones were found after operation in patients with T-tube placement, choledocboscope was used to extract stone; otherwise, EST or EPBD was used. Treatment outcomes including treatment method, success rate of minimally invasive lithotomy, operation time, incidence of complication, duration of postoperative hospital stay and treatment expenses, and the results of follow-up including 1-, 3-year recurrence rate of stones were recorded. The follow-up was done by outpatient examination and telephone interview till January 2016. All the patients were reexamined blood routine, liver function and color doppler uhrasonography of the abdomen at 1 month, 3 months, 6 months, 1 year and 3 years after operation. Suspected residual cholangiolithiasis found by ultrasound was varified by computer tomography （CT） or magnetic resonanced cholangiopancreatography （MRCP） imaging examination. For patients with T-tube placement, CT scan and biliary photography were performed at 2-3 months postoperatively to determine whether residual stones existed and T tube could be pulled out. Measurement data were presented as mean （range）. Results Of 2 364 patients, 2 271 patients received minimally invasive lithotomy successfully. Of 861 patients of cholecystolithiasis combined with extrahepatic eholangiolithiasis and the diameter of common bile duct≥8 mm, 836 succeeded in minimally invasive lithotomy, with a success rate of 97. 10% （ 836/861 ） , the other 25 patients were converted to open surgery. Seven hundred and three patients of 836 patients received T-tube placement in LCBDE, and the mean operation time, incidence of complications, duration of postoperative hospital stay and treatment expenses were 97 minutes （ range, 41 - 167 minutes ）, 3.70% （ 26/703 ）, 6. 7 days （ range, 3. 0-32. 0 days） and 3.4 ×104 yuan （range, 1.5 ×104-6. 7 × 104 yuan）, respectively. One hundred and thirty- three patients of 836 patients received primary suture, and the mean operation time, incidence of complications, duration of postoperative hospital stay and treatment expenses were 89 minutes （range, 39-123 minutes）, 3.01% （4/133）, 4.1 days （range, 2.0-17.0 days）, 2.1 × 104 yuan （range, 1.6 × 104-3.4× 104 yuan）, respectively. Of 720 patients with the diameter of common bile duet 〈 8 mm who underwent EST or EPBD ＋ LC, 687 succeeded in minimally invasive lithotomy, with a success rate of 95.42% （687/720）, the other 33 patients were converted to open surgery. The mean operation time, incidence of complications, duration of postoperative hospital stay and treatment expenses of 687 patients were 101 minutes （ range, 69-163 minutes）, 2. 91% （20/687）, 5.6 days （range, 2.0-15.0 days） and 2.8 × 104 yuan （range, 2. 0×104-6. 4 × 104 yuan） , respectively. In 783 patients with only extrabepatie cholangiolithiasis or recurrent stones after cholecystectomy, 701 of 725 patients who were treated with EST or EPBD succeeded in minimally invasive lithotomy, with a success rate of 96. 69% （701/ 725 ）, and the mean operation time, incidence of complications, duration of postoperative hospital stay and treatment expenses of 701 patients were 47 minutes （ range, 11 -79 minutes） , 2. 28% （ 16/701 ）, 3.7 days （range, 2. 0- 19. 0 days）, 1.7 × 104 yuan （ range, 1.3 × 104-5. 5× 104 yuan）, respectively; 47 of 58 patients who were treated with LCBDE succeeded in lithotomy, with a success rate of 81.03% （47/58）, and the mean operation time, incidence of complications, duration of postoperative hospital stay and treatment expenses were 124 minutes （range, 94-170 minutes）, 8.51% （4/47）, 7.9 days （range, 5.0-21.0 days） and 3.8 × 104 yuan （range, 2. 3 × 104-7. 9 × 104 yuan） , respectively. Of 2 364 patients, 2 207 were followed up for a mean time of 38 months （range, 1-72 months）. The 1-, 3-year recurrence rates were 2. 74% （19/693） and 5.08% （24/472） in patients receiving LC ＋ LCBDE, 3. 10% （21/677） and 5.69% （30/527）in patients receiving EST or EPBD ＋ LC for choleeystolithiasis combined with extrahepatie cholangiolithiasis. The 1-, 3- year recurrence rates were 3.22% （20/621） and 6. 11% （25/409）in patients receiving EST or EPBD ＋ LC, 7.32% （3/41） and 11.11% （2/18） in patients receiving LCBDE for only extrahepatie cholangiolithiasis or recurrent stones after choleeystectomy. Conclusions It is safe and effective to treat extrahepatic eholangiolithiasis based on combined application of laparoscope, choledochoscope and duodenoscope, with choosing appropriate indications as the key to improve the therapeutic effect. Primary suture in the LCBDE is recommended because it can protect patients from T-tube placement.