腹腔镜下套管乳头扩张术与内镜下乳头微切开术治疗细径胆总管结石合并Oddi括约肌狭窄的疗效对比

Comparison of laparoscopic papillary dilation and Endoscopic sphincterotomy with small incision treating fine stones in common bile duct with stricture of oddi sphincter

目的分析比较腹腔镜下经肝穿刺套管行十二指肠乳头扩张术与十二指肠镜下行乳头微切开术处理胆总管结石合并胆道良性狭窄及Oddi括约肌狭窄患者的临床资料,探讨细径胆总管结石合并Oddi括约肌狭窄的临床治疗经验;腹腔镜下经导管乳头扩张术的安全性、优越性及在扩大一期缝合范围上的临床价值。方法回顾性分析该科2016年1月-2017年1月收治的细径胆总管结石合并Oddi括约肌狭窄患者60例。其中腹腔镜下套管乳头扩张术30例,十二指肠镜下行乳头微切开术30例。对比分析腹腔镜下套管乳头扩张术组(以下简称套管扩张组)及十二指肠镜下行乳头微切开术组(以下简称乳头微切开组)的临床治疗情况。结果 60例手术均成功,围手术期无死亡发生。两组资料对比,手术前后谷丙转氨酶(ALT)及谷草转氨酶(AST)差异值、直接胆红素(DBIL)差异值以及术后并发胆道出血情况差异无统计学意义(P>0.05),而手术时间、手术前后血淀粉酶差异值、脂肪酶差异值、术后消化道症状、并发胰腺炎和胃肠功能恢复时间等,差异均具有统计学意义(P<0.05)。其中套管扩张组出现1例胆漏,经术中常规放置腹腔引流管引流自愈。而因其未切开乳头括约肌,术后胃肠功能恢复快,不易并发胰腺炎。结论腹腔镜下套管乳头扩张术并未增加术后肝功能损害、DBIL异常、结石残留、胆道出血和胆道狭窄等,同时能有效减少术后胰腺炎、胆汁反流和消化道症状等并发症的发生率,体现出了其在微创技术方面的优越性。在合适的应用范围(术者操作熟练)内选择该术式治疗细径胆总管结石伴Oddi括约肌狭窄安全有效且术后并发症相对减少。

Objective Analyze and compare the clinical data of patients with choledocholithiasis combined with benign biliary stricture and Oddi sphincter received laparoscopic percutaneous endoscopic dilation of duodenal papilla and endoscopic sphincterotomy,to explore the clinical experience and investigate the safety and superiority of laparoscopic papillary dilatation and the clinical value in extending the first phase suturing..Methods From January2016to January2017,60patients with choledocholithiasis combined with Oddi sphincter received laparoscopic nipple expansion(30cases,Group L)and the others received endoscopic sphincterotomy(30cases,Group E).All the patients clinical data was retrospectively compared and analyzed to explore the clinical experience.Results All operation were successfully performed with no perioperative deaths occurred..By comparison of the clinical data before and after surgery,we learned that the changes of alanine aminotransferase(ALT),aspartate transaminase(AST),direct bilirubin and postoperative biliary tract bleeding has no statistically significant difference(P>0.05),while the operation time,the changes of blood amylase and lipase,postoperative gastrointestinal symptoms,postoperative pancreatitis,gastrointestinal function recovery time has statistically significant differences(P<0.05).There has one self-healing bile leakage case in Group L thanks to routine placement of abdominal drainage tube intraoperatively.The patients gastrointestinal function recovered quick and not suffered pancreatitis because of there’s no incision of nipple sphincter.Conclusion Laparoscopic papillary dilation reflects its superiority for not increase postoperative liver function damage,DBIL abnormalities,residual stones,biliary tract bleeding and biliary stricture,while can effectively decrease the incidence of complications such as postoperative pancreatitis,bile reflux and gastrointestinal symptoms.It is safe and effective with less postoperative complications in appropriately application in treatment of fine diameter common bile duct stones with sphincter of Oddi stenosis.