经皮肾镜与纤维胆道镜用于腹腔镜胆总管切开取石对比研究

Rigid nephroscopy vs flexible cholangioscopy in laparoscopic common bile duct exploration for patients with choledocholithiasis

目的：探讨经皮肾镜（硬镜）和纤维胆道镜（软镜）联合腹腔镜处理胆总管结石的应用价值。方法回顾性分析本院2014年1月至2016年1月间接受腹腔镜胆总管切开取石术的47例患者临床资料。所有患者术前均行CT及彩超检查确诊为胆总管结石，按照术中使用的内镜不同分成软镜组（23例，直接置入纤维胆道镜）和硬镜组（24例，置入18~20号外鞘，再于鞘内置入经皮肾镜），统计分析两组患者在手术时间、术中出血量、术后出血、胆漏、结石残留等情况的差异。结果硬镜组均顺利完成手术，而软镜组则有3例术中需协同使用硬镜来取出结石，结石取出率差异无统计学意义（100.0%vs 87.0%，χ^2=3.344，P=0.067）。硬镜组和软镜组的手术时间差异有统计学意义[（124.2±20.4）min vs（152.8±29.0）min，t=-3.924，P〈0.05]，术中出血量[（28.70±8.69）ml vs （26.67±8.17）ml，t=-0.825，P=0.414）]、术后出血（4.2%vs 0，χ^2=0.979，P=0.322）、术后胆漏（8.3%vs 13.0%，χ^2=0.274，P=0.601）及结石残留率（0 vs 8.7%，χ^2=2.180，P=0.140）差异均无统计学意义。结论对于单纯胆总管结石患者，硬镜及鞘管在腹腔镜胆总管切开取石术中的应用可极大地减少取石、碎石时间，缩短手术时间，较软镜优势明显。

Objective To explore the clinical value of rigid nephroscopy and flexible cholangioscopy in laparoscopic common bile duct exploration in the treatment of choledocholithiasis. Methods A retrospective analysis of forty seven cases of choledocholithiasis undergoing laparoscopic common bile duct exploration in our hospital from January 2014 to January 2016 was carried out. All the cases were diagnosed with choledocholithiasis by CT and ultrasonography before operations. According to the different endoscopic surgeries, they were divided into flexible cholangioscopy group （23 cases, directly inserting the flexible cholangioscopy into common bile duct） and rigid nephroscopy group （24 cases, firstly inserting the external sheath sized 18-20 into common bile duct, and then putting the rigid nephroscopy from the external sheath）. The operation time, operative bleeding, postoperative bleeding, bile leakage, and rates of residual stones was compared between the two groups. Results The difference of operation time between two groups was of statistical significance [（124.2 ± 20.4） min vs （152.8 ± 29.0） min, t=3.924, P〈0.05]. The differences of surgical completion rate （100.0%vs 87.0%,χ^2=3.344,P=0.067）, operative bleeding [（28.70 ± 8.69） ml vs （26.67 ± 8.17） ml, t=0.825,P=0.414）], rate of postoperative bleeding （4.2%vs 0, χ^2=0.979, P=0.322）, bile leakage （8.3%vs 13.0%, χ^2=0.274, P=0.601）, and rate of residual stones （0 vs 8.7%, χ^2=2.180, P=0.140） between two groups was of no statistical significance. Conclusion For patients with simple choledocholithiasis, it can reduce the operation time using rigid nephroscopy and sheath, and has obvious advantages compared with flexible cholangioscopy in the laparoscopic common bile duct exploration.