腹腔镜胆总管探查取石术在既往有上腹部手术史患者中的应用

Application of laparoscopic exploration and choledocholithotomy in patients with a history of upper abdominal surgery

目的探讨既往有上腹部手术史患者行腹腔镜胆总管探查取石术的可行性、安全性及早期预后。方法回顾性分析2014年1月—2018年12月在鄂东医疗集团市中心医院肝胆胰腺外科既往有上腹部手术史患者行胆总管探查胆道镜取石术156例患者的临床资料,按手术方式不同分为腹腔镜组(n=84)和开腹组(n=72),腹腔镜组行腹腔镜胆总管探查取石术,开腹组行开腹胆总管探查取石术,腹腔镜组男50例、女34例,年龄(66.4±17.8)岁,年龄范围42~83岁;开腹组男40例、女32例,年龄(64.2±16.9)岁,年龄范围45~82岁。比较两组患者手术时间、术中出血量、术后首次排便时间、术后住院天数、术后疼痛评分情况及早期并发症(胆漏、腹胀、腹腔积液、上腹部疼痛、残余结石)发生率。符合正态分布的计量资料采用均数±标准差(Mean±SD)表示,组间比较采用独立样本t检验,计数资料的比较采用χ2检验。结果两组患者均成功实施手术,腹腔镜组中转开腹3例,无围手术期死亡病例。腹腔镜组手术时间、术中出血量、术后首次排便时间、术后住院天数分别为(122.8±28.1)min、(80.3±13.7)mL、(1.8±0.3)d、(7.7±0.8)d;开腹组分别为(146.6±33.5)min、(125.8±19.6)mL、(2.7±0.6)d、(9.1±1.2)d,腹腔镜组均显著低于开腹组,两组相比差异具有统计学意义(P<0.05);术后第2天和第4天,腹腔镜组患者腹部疼痛评分分别为(3.6±1.3)分、(2.3±0.7)分,开腹组评分分别为(5.5±1.6)分、(4.2±1.3)分,腹腔镜组均显著低于开腹组(P<0.05);腹腔镜组术后早期总并发症发生率32.1%(27/84)低于开腹组47.2%(34/72),但差异无统计学意义(P>0.05)。结论对于有上腹部手术史患者,行腹腔镜胆总管探查胆道镜取石是安全可行的,该术式具有微创、出血少等优势,能缓解术后疼痛、缩短术后住院时间,且不会增加术后并发症发生率,有利于快速康复,适合基层医院推广。

Objective To explore the feasibility,safety and early prognosis of laparoscopic choledocholithotomy in patients with previous history of upper abdominal surgery.Methods From January 2014 to December 2018,the clinical data of 156 patients with previous history of upper abdominal surgery in hepatobiliary and pancreatic surgery of Central Hospital of Edong Healthcare Group were analyzed retrospectively.Among them,84 cases with laparoscopic common bile duct exploration and stone extraction were allocated into laparoscopic group,72 cases with open common bile duct exploration and stone extraction were allocated into open group.In the laparoscopic group,there were 50 males and 34 females,aged 42-83(66.4±17.8)years;In the open group,there were 40 males and 32 females,aged 45-82(64.2±16.9)years.The operation time,intraoperative hemorrhage,first defecation time and postoperative hospital stay were compared between the two groups.The postoperative pain score and the incidence of early complications(bile leakage,abdominal distention,ascites,epigastric pain,residual stones)were compared between the two groups.The measurement data subject to normal distribution are represented by(Mean±SD),the independent sample t test was used for group comparison,and the chi-square test was used for counting data comparison.Results The laparoscopic group was converted to open surgery in 3 cases,and there was no perioperative death.In the laparoscopic group,the operation time,the intraoperative bleeding volume,the first defecation time,the postoperative hospital stay wee(122.8±28.1)min,(80.3±13.7)mL,(1.8±0.3)d,(7.7±0.8)d,and(146.6±33.5)min,(125.8±19.6)mL,(2.7±0.6)d,(9.1±1.2)d in the open group;The difference between the two groups was statistically significant(P<0.05);On the 2nd and 4th day after operation,the abdominal pain scores in laparoscopic group were(3.6±1.3)scores and(2.3±0.7)scores,and(5.5±1.6)scores,(4.2±1.3)scores in the open group,the laparoscopic group were significantly lower than those in the open group(P<0.05);The incidence of early postoperative complications in the laparoscopic group was 32.1%(27/84),and in the open group was 47.2%(34/72),but the difference was not statistically significant(P>0.05).Conclusions For patients with a history of upper abdominal surgery,laparoscopic common bile duct exploration and choledochoscopy are safe and feasible,The operation has the advantages of minimally invasive and less bleeding,which can relieve postoperative pain,shorten postoperative hospital stay,and will not increase the incidence of postoperative complications,It′s good for quick recovery.It is suitable for the promotion of grass-roots hospitals.