内镜保胆取石术后的复发规律及相关因素分析

Regularity and related factors analysis of recurrence after endoscopic gallbladder-preserving cholelithotomy

目的:探讨内镜保胆取石术后胆囊结石的复发规律及其相关因素。方法:采用回顾性队列研究方法,整理2009年3月至2016年9月973例成功完成内镜取石术的胆囊结石患者的临床资料,术后随访3~60个月。观察指标:(1)内镜取石术后每年的非累计复发率之间是否存在明显规律;(2)内镜取石术后复发与胆囊壁厚度、胆囊壁光滑、胆囊壁胆固醇沉积、胆囊壁间结石、胆囊内分隔、结石数量、胆囊颈部结石嵌顿、胆囊泥沙样结石、胆绞痛的相关性。结果:随访截至2016年12月,中位随访时间41个月。共135例(13.87%)失访,59例(7.04%)复发。每年失访率为0.93%、1.66%、2.53%、3.46%、6.05%;排除失访后,第1、2、3、4、5年的非累计复发率为0.31%、0.84%、1.52%、1.35%、2.63%,统计分析提示术后每年间的复发无明显规律。术后随访5年:(1)胆囊壁厚度2~3 mm的患者复发率为4.69%(16/341),厚度4~5 mm时复发率为8.65%(43/497),胆囊壁不光滑复发率为8.07%(54/669),胆囊壁胆固醇沉积复发率为11.11%(6/54),胆囊壁间结石复发率为11.39%(9/79),胆囊内分隔复发率为7.02%(4/57),多发结石复发率为8.39%(47/560),胆囊颈部结石嵌顿复发率为13.89%(5/36),胆囊泥沙样结石复发率为22.22%(4/18),胆绞痛复发率为17.50%(7/40);(2)单因素分析提示相关因素包括术前胆囊壁厚度、光滑、结石数量、泥沙样结石、胆绞痛(P<0.05);(3)多因素回归分析显示独立危险因素为结石数量(β=0.702,P=0.040,95%CI=1.034~3.938)。结论:内镜保胆取石术后复发无明显规律,结石数量是复发的独立危险因素,伴有胆囊颈部结石嵌顿、泥沙样结石、胆绞痛的多发结石患者保胆应慎重。

Objective： To explore the regularity and related factors of recurrence after endoscopic gallbladder-preserving cholelithotomy. Methods： A retrospective cohort study method was used. The clinical data of 973 patients who successfully completed endoscopic gallstone removal from Mar. 2009 to Sep. 2016 were collected and the patients were followed up for 3 to 60 months. Observed indicators included（ 1） whether there is obvious regularity among the non-accumulated recurrence rate each year after the surgery or not;（ 2） the relevance between recurrence and gallbladder wall thickness,gallbladder wall smoothness,gallbladder wall cholesterol deposition,gallbladder interlaminar calculi,gallbladder separation,number of calculi,gallbladder neck calculi incarceration,gallbladder silt calculi,biliary colic. Results： Follow-up time ended in Dec. 2016,the median follow-up time was 41 months. A total of 59（ 7. 04%）patients had relapsed,and a total of 135（ 13. 87%） patients were lost. The rate of lost follow-up was 0. 93%,1. 66%,2. 53%,3. 46%and 6. 05% each year. Excluding missed visits,the non-accumulative recurrence rates in the first,second,third,fourth and fifth year was0. 31%,0. 84%,1. 52%,1. 35% and 2. 63%. Statistical analysis showed that there was no obvious regular pattern of recurrence each year. Within 5 years follow-up：（ 1） the recurrence rate of gallbladder wall thickness between 2-3 mm,gallbladder wall thickness between 4-5 mm,non-smooth gallbladder wall,gallbladder wall cholesterol deposition,gallbladder interlaminar calculi,gallbladder separation,multiple calculi,gallbladder neck calculi incarceration,gallbladder silt calculi,biliary colic was 4. 69%（ 16/341）,8. 65%（ 43/497）,8. 07%（ 54/669）,11. 11%（ 6/54）,11. 39%（ 9/79）,7. 02%（ 4/57）,8. 39%（ 47/560）,13. 89%（ 5/36）,22. 22%（ 4/18）,17. 50%（ 7/40）.（ 2） univariate analysis showed that related factors were preoperative gallbladder wall thickness,gallbladder wall smoothness,number of calculi,gallbladder silt-like calculi and biliary colic（ P〈0. 05）.（ 3） multi-factor regression analysis showed that independent risk factor was number of calculi（ β = 0. 702,P = 0. 040,95% CI = 1. 034 to 3. 938）. Conclusions： There is no obvious regularity of recurrence after endoscopic gallbladder-preserving cholelithotomy. The number of calculi is an independent factor for recurrence. Patients with multiple calculi and gallbladder neck calculi incarceration,gallbladder silt calculi and biliary colic should be cautious to receive the surgery.