经内镜逆行胰胆管造影联合腹腔镜胆囊切除术后胆囊结石合并胆总管结石复发的危险因素分析

Risk factors of recurrence after endoscopic retrograde cholangiopancreatography combined with laparoscopic cholecystectomy for gallbladder and choledocholithiasis

目的探讨经内镜逆行胰胆管造影(ERCP)联合腹腔镜胆囊切除术(LC)治疗胆囊结石合并胆总管结石复发的危险因素。方法回顾性分析2012年1月至2015年3月沭阳县人民医院诊断为胆囊结石合并胆总管结石患者87例,均行ERCP联合LC术治疗。根据患者术后结石复发情况分为复发组与非复发组,对比两组患者一般情况、术者经验、胆道情况、结石情况。单因素分析以及多因素Logistic回归分析术后结石复发的危险因素。结果87例患者术后随访32~60个月,中位随访时间为48个月,未复发组66例,复发组21例,中位复发时间15.0(95%CI=12.5~20.0)个月,术后1、2、3年复发率分别为8.0%、23.0%、24.1%,复发主要集中于术后2年内。单因素分析显示,胆道感染、胆道狭窄、胆总管夹角、结石数量、结石大小、乳头旁憩室情况影响胆囊结石合并胆总管结石复发(均P<0.05)。多因素分析显示,胆总管夹角(OR=0.196,95%CI=0.044~0.877)、胆道感染(OR=6.894,95%CI=1.698~27.984)、乳头旁憩室(OR=10.554,95%CI=2.134~52.197)、胆道口括约肌切开(OR=17.803,95%CI=3.342~94.845)是胆囊并胆总管结石术后复发的独立危险因素。结论合并胆总管夹角过小、胆道感染、乳头旁憩室及术中括约肌切开的患者,ERCP联合LC术后结石更容易复发,对临床的预防和治疗有一定借鉴意义。

Objective To explore the risk factors of recurrence of gallbladder and common bile duct stones by endoscopic retrograde cholangiopancreatography (ERCP) combined with laparoscopic cholecystectomy (LC).Methods From January 2012 to March 2015,eighty-seven cases with cholecystolithiasis complicated with choledocholithiasis diagnosed in Shuyang People's Hospital were analyzed retrospectively, all of whom were treated with ERCP combined with LC.Clinical data were collected and the patients were divided into recurrence group and non-recurrence group,according to recurrence of stones.Univariate factor analysis and multivariate Logistic regression analysis were performed to identify the risk factors for postoperative stone recurrence.Results Sixty-six cases of non-recurrence group and twenty-one cases of recurrence group were followed up for 32-60 months with a median of 48 months.The median recurrence time was 15.0 months (95% CI=12.5-20.0).The recurrence rates were 8.0%,23.0% and 24.1% at 1,2, and 3 years after operation,respectively,the recurrence mainly occurred within 2 years after operation. Univariate analysis showed that biliary tract infection,biliary stricture,common bile duct angle,the number of stones,stone size,nipple diverticula affected the recurrence of cholecystolithiasis with common bile duct stones (all P<0.05).Multivariate analysis showed that common bile duct angle (OR=0.196,95% CI=0.044- 0.877),biliary tract infection (OR=6.894,95% CI=1.698-27.984),peripapillary diverticulum (OR=10.554, 95% CI=2.134-52.197),and Oddi sphincterotomy (OR=17.803,95% CI=3.342-94.845) were independent risk factors for recurrence of cholecystolithiasis after cholecystectomy.Conclusions Patients with small common bile duct angle,biliary tract infection,peripapillary diverticulum,and intraoperative oddi sphincterotomy are more likely to recur after ERCP combined with LC.It can be used for reference in further clinical prevention and treatment.