老年继发性胆总管结石患者的外科治疗和微创手术分析

Surgery Strategy and Minimally Invasive Operation of Common Bile Duct Exploration in Elderly Patients with Choledocholithiasis

目的通过对比分析老年患者和非老年胆囊结石继发胆总管结石患者治疗情况,特别是外科手术和微创手术的疗效和安全性,探索老年患者继发胆总管结石外科治疗的策略和微创手术方式的选择。方法回顾2010年1月1日~2014年12月31日间,首都医科大学北京宣武医院普通外科胆囊结石合并继发性胆总管结石的住院患者,建立数据库,录入所有诊疗相关数据。分组分析不同年龄(70岁上下)继发胆总管结石患者的治疗措施分布情况及治疗效果,分组分析不同年龄(70岁上下)继发胆总管结石患者LCBDE手术治疗,特别是微创手术疗效和安全性。结果纳入胆囊结石合并胆总管结石患者622例,患者年龄25~93岁。≥70岁患者281例,占45.2%,非手术治疗114例,EST或ENBD治疗11例(4%),手术治疗156例(55.5%)。<70岁患者341例,占54.8%,非手术治疗132例,EST或ENBD2例(0.58%);接受手术患者207例(60.7%)。更多≥70岁老年患者伴发多种全身性疾病,更多老年患者接受了内镜引流或取石治疗。≥70岁手术患者中腹腔镜手术109例(69.9%),中转开腹手术18例,完成LCBDE手术91例,开腹胆总管探查手术(OCBDE)47例。<70岁手术患者中腹腔镜手术138例(66.7%),中转开腹手术3例,完成LCBDE135例,OCBDE手术69例。老年和非老年患者采取外科手术治疗和微创手术治疗比例差异无统计学意义(P>0.05),但老年患者具有更高的腹腔镜中转开腹率,可能与老年患者既往有腹部手术病史的比例明显增加有关。老年手术患者住院时间延长,住院花费增高。微创手术并发症,主要是全身外科并发症发生率增高。老年患者病死率随着年龄增长而升高。结论年龄是影响治疗胆囊结石继发胆总管结石预后的重要因素。老年患者,特别是伴发急性梗阻性胆管炎的患者,治疗效果差,手术风险高,住院时间长,住院花费高。更多老年患者伴发多种全身性疾病和腹部手术病史,可能会影响选择治疗方式的选择。更多的老年患者选择了内镜治疗的方法,采取腹腔镜胆总管探查微创手术治疗时,应当全面评估患者情况,注意减少术后并发症。

Objective To explore the treatment strategies and minimally invasive surgery option in elderly patients with common bile duct stones （ CBDS）. Methods From December 31, 2014 to January 1,2010, we collected the date of gallstone inpatients with seconda- ry CBDS from the Gerenaral Department of Xuanwu Hospital, Capital Medical University. We divided these patients into two groups by age （group age I〉 70 and group age 〈 70） and conducted a retrospective analysis： treatment distribution and effect analysis between two groups; operative treatment feasibility and safety analysis for patients between two groups. Results We included 622 patients with gall- stone inpatients with secondary CBDS, aging from 25 to 93 years old. The elderly group included patients who were 70 years old or older （ n = 281 , 45.2% ）. Among them, 114 patients received non - surgical therapy, 11 received EST or ENBD（4% ） , and 156 received sur- gical treatment（55.5% ）. The younger group included patients who were younger than 70 years old （n = 341, 54.8% ）. 132 patients re- ceived non -surgical therapy,2 received EST or ENBD（0.58% ） , and 207 received surgical treatment（60.7% ）. Compared with younger patients, elder patients were more likely to have with multiple systemic diseases. There was no significant difference in the proportion of surgical treatment. In the ederly group（ n = 156, 109 patients underwent Laparoscopic operation（69.9% ）, including 18 cases of conver- sion to open cholecystectomy and 91 cases of LCBDE,and 47 patients underwent OCBDE. As the younger group, 138 patients underwent Laparoscopic operation（66.7% ） , including 3 cases of conversion to open cholecystectomy and 135 cases of LCBDE, and 69 patients un- derwent OCBDE. There were no significant defferenees in the option of surgical treatment and proportion of minimally - invasive treatment in both groups. But the elderly group had a lower successful completion rate of minimally invasive surgery and a higher rate of laparoscopic conversion to open surgery. The elderly group had higher rate in the selection of laparoscope and laparoscopie conversion to open surgery, and this may relate to the larger proportion of previous abdominal surgery. The elderly group had longer hospitalization time and higher hos- pitalization cost, Elderly patients underwentlng surgery had [onger hospitalization time and higher hospitalization cost, The mortality rate of the elderly patients increased with age, and the major increase was general surgical complications rate. Five patients died and they all had acute obstructive cholangitis. Four patients were over 70 years old, including two patients undertaken non - operative treatment, one pa- tient underwent emergency EST, one patient underwent emergency laparotomy common bile duct exploration. One patient was 69 years old and she was underwent laparotomy common bile duct exploration. No patient with LCBDE was died. Conclusion Age is an imporatant factor of prognosing the treatment of cholelithiasis with secondary CBDS. The old patients, especially with acute obstructive cholangitis, have the following charateristics ： higher mortality rate increasing with age, poorer treatment effect, higher risk of surgery, longer hospitali- zation time, and larger hospitalization cost, compared with the non - elderly group. More old patients are coexisting with multiple systemic diseases and abdominal surgery history, which may affect the treatment options. More elderly patients choose the method of endoscopic treatment. When taking the laparoscopic common bile duct exploration as the minimally invasive surgery, comprehensive assessment of the patient＇s condition is needed to lower the postoperative complications rate.