腹腔镜胆总管切开取石术中胆总管不同缝合方式效果比较

Comparison of the effect of different suture methods of common bile duct in laparoscopic choledocholithotomy

目的比较腹腔镜胆总管切开取石术中胆总管不同缝合方式的临床应用效果。方法选择2016年7月至2018年7月汝州市第一人民医院收治的274例胆总管结石患者为研究对象,所有患者行腹腔镜胆总管切开取石术,根据术中胆总管缝合方式分为A组(n=86)、B组(n=84)和C组(n=104),A组患者术中使用可吸收缝线间断缝合胆总管,B组患者术中使用可吸收缝线连续缝合胆总管,C组患者术中使用V-lock缝线连续缝合胆总管;术中胆道镜探查后使用测压表进行胆总管测压,记录胆总管初始压力、注水最大压力和回复末压力;术后第1、3、7天使用测压表直接连接T型管检测胆总管压力。分别于术前和术后24 h检测患者血清丙氨酸转氨酶(ALT)、天冬氨酸转氨酶(AST)、总胆红素(TBIL)、丝裂原活化蛋白激酶(MAPK)水平;记录3组患者术后肠鸣音恢复时间、首次肛门排气时间、住院时间及术后7 d内胆瘘发生情况。结果3组患者的胆总管初始压力、回复末压力比较差异无统计学意义(P>0.05);C组患者胆总管注水最大压力高于A组和B组(P<0.05),A组与B组患者胆总管注水最大压力比较差异无统计学意义(P>0.05)。3组患者术后第7天胆总管压力显著低于术后第1、3天(P<0.05),3组患者术后第3天胆总管压力显著低于术后第1天(P<0.05);术后第1、3、7天,C组患者的胆总管压力显著低于A组和B组(P<0.05),A组与B组患者的胆总管压力比较差异无统计学意义(P>0.05)。术后7 d内,A组、B组和C组患者胆漏发生率分别为17.44%(15/86)、16.67%(14/84)、2.88%(3/104);C组患者胆漏发生率显著低于A组和B组(χ2=11.632、10.731,P<0.05),A组和B组患者胆漏发生率比较差异无统计学意义(χ2=0.018,P>0.05)。3组患者术前血清ALT、AST、TBIL、MAPK水平比较差异无统计学意义(P>0.05),3组患者术后24 h血清ALT、AST、TBIL、MAPK水平显著低于术前(P<0.05);术后24 h,C组患者血清ALT、AST、TBIL、MAPK水平显著低于A组和B组(P<0.05),A组和B组患者血清ALT、AST、TBIL、MAPK水平比较差异无统计学意义(P>0.05)。C组患者术后肠鸣音恢复时间、首次肛门排气时间、住院时间显著短于A组和B组(P<0.05),A组和B组患者术后肠鸣音恢复时间、首次肛门排气时间、住院时间比较差异无统计学意义(P>0.05)。结论腹腔镜胆总管切开取石术中采用V-lock缝线连续缝合胆总管可降低术后胆总管压力和胆漏发生率,有利于患者术后快速康复。

Objective To compare the clinical application effect of different suture methods of the common bile duct in laparoscopic choledocholithotomy.Methods A total of 274 patients with common bile duct calculi admitted to the First People′s Hospital of Ruzhou City from July 2016 to July 2018 were selected as the research subjects.All patients underwent laparoscopic choledocholithotomy and were divided into group A(n=86),group B(n=84)and group C(n=104)according to the suture mode of common bile duct.The interrupted suture of common bile duct with absorbable suture was performed in the patients of the group A,the continuous suture of common bile duct with absorbable suture was performed in the patients of the group B,while the continuous suture of common bile duct with V-lock suture was performed in the patients of the group C.The intraoperative common bile duct pressure was measured by pressure gauge after choledochoscopy,and the initial pressure,the maximum pressure of water injection and the pressure at the end of recovery of the common bile duct were recorded.The pressure of common bile duct was measured by pressure gauge connecting T-tube on the 1 st,3 rd and 7 th day after operation.The levels of serum alanine transarninase(ALT),aspartate aminotransferase(AST),total bilirubin(TBIL)and mitogen activated protein kinase(MAPK)were detected before and 24 hours after operation.The peristaltic sound recovery time,the first anal exhaust time,hospitalization time and the incidence of bile leakage within 7 days after operation were recorded.Results There was no significant difference in the initial pressure and the pressure at the end of recovery of the common bile duct among the three groups(P>0.05).The maximum pressure of water injection of common bile duct in the group C was higher than that in the group A and group B(P<0.05),but there was no significant difference in the maximum pressure of water injection between the group A and group B(P>0.05).The pressure of common bile duct on the 7 th day was significantly lower than that on the 1 st and 3 rd day after operation(P<0.05),and the pressure of common bile duct on the 3 rd day was significantly lower than that on the 1 st day after operation in the three groups(P<0.05).On the 1 st,3 rd and 7 th day after operation,the pressure of common bile duct in the group C was significantly lower than that in the group A and group B(P<0.05),but there was no significant difference in the pressure of common bile duct between the group A and group B(P>0.05).Within 7 days after operation,the incidence of bile leakage in the group A,group B and group C was 17.44%(15/86),16.67%(14/84)and 2.88%(3/104),respectively.The incidence of bile leakage in the group C was significantly lower than that in the group A and group B(χ2=11.632,10.731;P<0.05),but there was no significant difference in the incidence of bile leakage between the group A and group B(χ2=0.018,P>0.05).There was no significant difference in serum ALT,AST,TBIL and MAPK levels among the three groups before operation(P>0.05).The levels of serum ALT,AST,TBIL and MAPK at 24 hours after operation were significantly lower than those before operation(P<0.05).At 24 hours after operation,the levels of serum ALT,AST,TBIL and MAPK in the group C were significantly lower than those in the group A and group B(P<0.05),but there was no significant difference in the levels of serum ALT,AST,TBIL and MAPK between the group A and group B(P>0.05).The peristaltic sound recovery time,the first anal exhaust time and hospitalization time in the group C were significantly shorter than those in the group A and group B(P<0.05).There was no significant difference in the peristaltic sound recovery time,the first anal exhaust time and hospitalization time between the group A and group B(P>0.05).Conclusion The continuous suture of common bile duct with V-lock suture in laparoscopic choledocholithotomy can reduce the postoperative common bile duct pressure and the incidence of bile leakage,which is conducive to the rapid recovery of patients after operation.