选择性术中胆道造影在胆系手术中的应用价值

Clinical application of selective intraoperative cholangiography in biliary system surgery

目的探讨选择性术中胆道造影（IOC）在胆系手术中的应用价值。方法回顾性分析2010年5月-2015年5月于平顶山市第一人民医院住院的112例行选择性IOC患者的临床资料及随访情况;另选取同期或早期符合选择性IOC标准但未行IOC或造影失败的84例患者作为对照。比较两组患者的临床资料及随访情况。计量资料组间比较采用t检验,计数资料组间比较采用χ^2检验。结果选择性IOC组中,腹腔镜下IOC 82例（造影后中转开腹手术19例）,开腹IOC 30例;其中IOC阳性40例,包括胆道结石24例,胆道狭窄4例,胆管下端占位1例,胆道损伤5例,胆道阴性探查6例。对照组中,术中胆道探查53例,其中胆道结石26例,胆总管下端炎性狭窄2例,阴性探查25例。选择性IOC组胆道阴性探查率为15.00%（6/40）,对照组为47.17%（25/53）,两组比较差异有统计学意义（χ^2=10.616,P=0.001）。选择性IOC组中胆管损伤致术后胆漏1例（0.89%）,术中及时发现并行一期胆管修补T管引流,2周后自愈;对照组中术后发现胆道损伤7例（8.33%）,均需短期内再次手术或内镜下治疗,两组间胆道损伤发生率差异有统计学意义（χ^2=6.787,P=0.009）。选择性IOC组患者术后半年内发现胆道结石2例（1.79%）,对照组术后半年内发现12例（14.29%）,两者比较差异有统计学意义（χ^2=11.308,P=0.001）。结论选择性IOC能有效减少不必要的胆道探查,降低胆道损伤几率,减少术后残石的发生,并可在术中帮助术者较早地发现胆管损伤,减少再次手术的几率,减轻患者的痛苦及花费,为胆道探查手术提供有力的帮助。

Objective To investigate the value of selective intraoperative cholangiography（ IOC） in biliary system surgery. Methods A retrospective analysis was performed on the clinical data and follow- up data of 112 patients who were hospitalized in The First People＇s Hospital of Pingdingshan and underwent selective IOC from May 2010 to May 2015. Another 84 patients who met the criteria for selective IOC but underwent no IOC or failed IOC were enrolled as controls. The clinical data and follow- up data were compared between the two groups.The t- test was used for comparison of continuous data between groups,and the chi- square test was used for comparison of categorical data between groups. Results In the selective IOC group,82 patients underwent laparoscopic IOC（ 19 were converted to open surgery after IOC） and 30 underwent open IOC; 40 patients had positive results on IOC,among whom 24 had biliary calculi,4 had biliary stricture,1had space- occupying lesions at the lower end of bile duct,5 had bile duct injury,and 6 had negative bile duct exploration. In the control group,53 patients underwent intraoperative bile duct exploration,among whom 26 had biliary calculi,2 had inflammatory stricture at the lower end of bile duct,and 25 had negative results. The negative exploration rate showed a significant difference between the selective IOC group and the control group [15. 00%（ 6 /40） vs 47. 17%（ 25 /53）,χ^2= 10. 616,P = 0. 001]. In the selective IOC group,1 patient（ 0. 89%） experienced postoperative bile leakage caused by bile duct injury,which was noticed during the surgery and treated with bile duct repair and T- tube drainage,and the patient was cured 2 weeks later. In the control group,7 patients（ 8. 33%） experienced postoperative bile duct injury and required reoperation or endoscopic treatment. The incidence rate of bile duct injury showed a significant difference between the two groups（ χ^2= 6. 787,P = 0. 009）. Within half a year after surgery,2 patients（ 1. 79%） in the selective IOC group and 12 patients（ 14. 29%） in the control group experienced biliary calculi,and the incidence rate of biliary calculi showed a significant difference between the two groups（ χ^2= 11. 308,P = 0. 001）. Conclusion Selective IOC can effectively reduce unnecessary bile duct exploration,the probability of bile duct injury,and the incidence of postoperative residual calculi,identify bile duct injury as early as possible during surgery,reduce the probability of reoperation,relieve pain,and reduce costs; therefore,it helps with bile duct exploration.