三镜联合鼻胆管引流在胆总管结石急诊手术中的应用

Application of combined three endoscopes nasobiliary drainage in emergent operation on choledocholithiasis

目的 探讨三镜联合在胆总管结石胆道感染患者急诊手术中应用的可行性、适应证及优点.方法 回顾性分析2008年7月至2014年12月45例胆总管结石合并胆道梗阻感染患者的临床资料,均应用腹腔镜、胆道镜和十二指肠镜施行急诊手术.其中三镜联合,即腹腔镜下应用胆道镜胆总管探查取石,术中应用十二指肠镜协助放置鼻胆管引流,再将胆总管切口一期缝合（研究组）12例;胆道镜取石后放置T管引流（对照组）33例.两组病例都同时接受胆囊切除.比较两组手术时间、术后肠功能恢复时间、胆道带管引流时间、住院时间、术后感染消退时间与腹盆腔引流时间等情况.结果 研究组手术时间（56.56±5.64）min,术后肠道功能恢复时间（44.43 ±8.46）h,胆道引流时间（7.30±1.32）d,胆道引流带管时间（8.28±1.32）d,术后感染消退时间（4.74±0.77）d,腹盆腔引流时间（4.56±0.87）d,住院时间（9.94±1.19）d;对照组分别为（40.96 ±6.41）min、（53.16 ±9.64）h、（7.38±1.24）d、（30.40±1.95）d、（4.54±0.92）d、（4.49±0.91）d和（11.12±1.73）d.研究组肠道功能恢复时间、胆道引流带管时间及住院时间均明显优于对照组（P均＜0.01）,两组胆道引流时间、术后感染消退时间及腹盆腔引流时间比较差异未见统计学意义（P＞0.05）;研究组手术时间长于对照组（P＜0.01）.结论 三镜联合鼻胆管引流在肝外胆管结石急诊手术中应用比传统的腹腔镜胆总管探查T管引流手术胆道留管时间短,术后恢复快,如果术中患者生命体征平稳,仍然是一种急诊可选择的术式.

Objective To investigate the advantage, practicability and indications of combined three endoscopes nasobiliary drainage in laparoscopic choledocholithotomy on the choledocholithiasis and acute cholangitis. Methods The clinical data of 45 choledocholithiasis patients with acute cholangitis from July 2008 to December 2014 were analyzed retrospectively. Twelve cases in the group of primary closure of common bile duct after applied nasobiliary drainage by combined three endoscopes（the study group）, 33 cases in the group of T-tube drainage（the control group）. All patients had undergone laparoscopic cholecystectomy and choledocholithotomy. The mean operative time, intestinal effection restored time, biliary drainage time, hospital stay, duration of tube in biliary duct placement, infection disappeared and abdominal and pelvic cavity drainage of the two groups were compared. Results In the study group, the mean operative time was （56.56±5.64）min, intestinal effection restored time was （44.43±8.46）h, biliary drainage time was （7.30±1.32）d, duration of tube in biliary duct placement was （8.28±1.32）d, infection disappeared time was （4.74±0.77）d, abdominal and pelvic cavity drainage time was （4.56±0.87）d, mean hospital stay was （9.94±1.19 ）d; and those in the control group were（ 40.96±6.41）min, （53.16±9.64）h, （7.38±1.24）d, （30.40±1.95）d, （4.54±0.92）d, （4.49±0.91）d and （11.12±1.73）d, respectively. To compared with the control group, intestinal effection restored time, duration of tube in biliary duct placement and hospital stay of the study group were significantly decreased（P〈0.01）. There were no significantly differences on biliary drainage time, infection disappeared time and abdominal and pelvic cavity drainage time between the two groups（P〉0.05）. Nevertheless, mean operative time was significantly increased in the study group（P〈0.05） Conclusions Compare with the traditional laparoscopic choledocholithotomy combined with T-tube drainage, nasobiliary drainage by combined three endoscopies is practicable in emergent operation on common bile duct calculus, which has a short duration of tube in biliary duct placement and a fast postoperative restore.