腹腔镜胆总管切开取石一期缝合治疗胆总管结石术后胆漏发生的危险因素研究

The risk factors of bile leakage after primary closure following laparoscopic choledochotomy for choledocholithiasis

目的研究腹腔镜胆总管切开取石一期缝合治疗胆总管结石术后胆漏发生的危险因素。方法收集2017年1月至2019年6月因胆总管结石在滁州市第一人民医院行腹腔镜联合胆道镜胆总管探查取石一期缝合病人的临床资料,包括:年龄,体质量指数,术前病程,基础疾病,结石数目,胆总管直径,术前丙氨酸转氨酶、肌酐、总胆红素、白细胞计数、血小板计数、血清白蛋白、血淀粉酶水平,手术时间,术中出血量,胆汁培养结果及术后胆漏治愈情况。结果200例病人中44例(22%)出现胆漏,对比胆漏组与非胆漏组病人的临床资料,单因素分析结果显示:胆漏组较非胆漏组术前病程时间长[(6.8±1.9)d比(3.7±2.3)d],丙氨酸转氨酶高[265.0(212.0,300.0)U/L比73.2(54.0,203.0)U/L][数据采用中位数(四分位数间距)表示,以下同],肌酐值高[151(78.0,177.0)μmol/L比90.0(66.0,171.0)μmol/L],总胆红素高[63.8(30.4,68.4)μmol/L比43.2(27.4,52.6)μmol/L],血清白蛋白低[27.2(26.3,28.2)g/L比36.5(29.0,41.6)g/L],差异均有统计学意义(均P<0.05)。多因素Logistic回归分析结果显示术前病程时间长,丙氨酸转氨酶水平升高是胆漏发生的独立危险因素(OR>1,P<0.05),血清白蛋白水平高是胆漏发生的保护因素(OR=0.764,P<0.05)。受试者工作特征(ROC)曲线分析结果:术前病程时间的界值是5.5 d,丙氨酸转氨酶界值为208.5 U/L,术前白蛋白水平界值为28.25 g/L,均P<0.05。结论术前病程时间超过5.5 d、丙氨酸转氨酶超过208.5 U/L、血清白蛋白水平低于28.25 g/L可作为预测胆总管结石行胆总管一期缝合术后发生胆漏的重要依据。

Objective To explore the risk factors of bile leakage after laparoscopic choledocholithotomy and primary closure for choledocholithiasis.Methods The clinical data of patients with choledocholithiasis who underwent laparoscopy combined with choledochoscopy for primary suture of common bile duct exploration in the First People′s Hospital of Chuzhou from Jan.2017 to Jun.2019 were collected,including age,BMI,onset time,gallstone number,common bile duct diameter,preoperative alanine transaminase,creatinine,total bilirubin,white blood cells,platelets,serum albumin,serum amylase,operation time,intraoperative blood loss,positive bile culture during surgery and the cure of postoperative bile leakage.Results Of the 200 patients,44(22%)had bile leakage.the clinical data of patients with bile leakage and those without bile leakage were compared.Univariate analysis showed that the onset time[(6.8±1.9)d vs.(3.7±2.3)d],preoperative alanine transaminase[265.0(212.0,300.0)U/L vs.73.2(54.0,203.0)U/L],creatinine[151(78.0,177.0)μmol/L vs.90.0(66.0,171.0)μmol/L],total bilirubin[63.8(30.4,68.4)μmol/L vs.43.2(27.4,52.6)μmol/L]in the bile leakage group were higher than those in the non-bile leakage group,and the differences were statistically significant(P<0.05).long preoperative course of disease and high level of alanine transaminase were independent risk factors for bile leakage(OR>1,P<0.05),High level of serum albumin is a protective factor for bile leakage(OR=0.764,P<0.05).The ROC curve analysis of the working characteristics of the subjects showed that the cut-off value of the onset time was 5.5 days,the cut-off value of alanine transaminase was 208.5 U/L and the cut-off value of serum albumin was 28.25 g/L(P<0.05).Conclusion Preoperative course of disease more than 5.5 d,alanine aminotransferase more than 208.5 U/L and serum albumin level less than 28.25 g/L can be used as an important basis for predicting bile leakage after primary suture of common bile duct for choledocholithiasis.