腹腔镜胆总管一期缝合与内镜取石治疗继发性胆总管结石的临床疗效比较

Comparison of clinical efficacy of laparoscopic primary closure of the common bile duct and endoscopic stone extraction for secondary choledocholithiasis

背景与目的:腹腔镜胆总管探查术与内镜下取石术在治疗继发性胆总管结石方面仍存在争议,但文献报道多倾向于腹腔镜胆总管探查术一期缝合术联合胆囊切除术的单阶段治疗策略。因此,本研究比较腹腔镜胆总管一期缝合与内镜取石治疗继发性胆总管结石的临床疗效。方法:回顾性分析2019年1月—2020年2月天津市南开医院肝胆胰第二外科治疗的183例继发性胆总管结石患者临床资料,其中,60例行腹腔镜胆总管探查术+胆总管一期缝合+胆囊切除术(一期缝合组),123例行内镜逆行胰胆管造影术/内窥镜括约肌切开术+腹腔镜胆囊切除术(内镜取石组)。采用倾向性评分匹配(PSM)方法对两组病例进行1∶1匹配,共59对匹配成功,比较匹配后两组患者手术疗效、术后并发症、住院时间等指标,并分析术后住院时间及术后相关并发症的影响因素。结果:PSM前,两组患者性别差异有统计学意义(P=0.007),经PSM后两组基线数据差异均无统计学意义(均P>0.05)。内镜取石组术后总体并发症发生率高于一期缝合组(P<0.05),主要原因是前者较高的术后高淀粉酶血症发生率(20.3%vs.0),其他并发症发生率两组间差异均无统计学意义(均P>0.05);一期缝合组术后住院时间明显短于内镜取石组,住院费用也明显低于内镜取石组(均P<0.05)。高龄(OR=0.396,95%CI=0.182~0.864,P=0.020)、高淀粉血症(OR=0.057,95%CI=0.007~0.468,P=0.008)、内镜取石术(OR=0.084,95%CI=0.040~0.179,P=0.000)是术后住院时间延长的危险因素;手术方式是术后高淀粉酶血症的影响因素(P<0.05)。两组患者获至少1年随访,均无发生结石复发及胆道狭窄。结论:腹腔镜胆总管一期缝合治疗继发性胆总管结石相较内镜取石住院时间更短、费用更低,且不破坏Oddi括约肌正常生理结构。

Background and Aims:Laparoscopic common bile duct exploration and endoscopic choledochectomy are still controversial in the treatment of secondary choledocholithiasis,but reports in the literature tend to be a single-stage treatment strategy of primary closure following laparoscopic common bile duct exploration combined with cholecystectomy.Therefore,this study was conducted to compare the clinical efficacy of primary suture of laparoscopic common bile duct and endoscopic stone extraction in the treatment of secondary choledocholithiasis.Methods:The clinical data of 183 patients with secondary choledocholithiasis treated in the Second Department of Hepatopancreatobiliary Surgery of Tianjin Nankai Hospital from January 2019 to February 2020 were retrospectively analyzed.Of the patients,60 cases underwent laparoscopic common bile duct exploration with primary closure plus cholecystectomy(primary closure group),and 123 cases underwent endoscopic retrograde cholangiopancreatography/endoscopic lithotomy plus laparoscopic cholecystectomy(endoscopic stone extraction group).The two groups of patients were matched using 1∶1 propensity score matching(PSM),with a total of 59 pairs successfully matched.The surgical efficacy,postoperative complications,length of hospitalization and other clinical variables after matching were compared between the two groups,and the influencing factors for length of postoperative hospital stay and associated postoperative complications were also analyzed.Results:Before PSM,there was a statistical difference in sex between the two groups(P=0.007).After PSM,all differences in the baseline data of the two groups had no statistical significance(all P>0.05).The overall incidence of postoperative complication in endoscopic stone extraction group was higher than that in primary closure group(P<0.05),which was mainly due to the higher incidence rate of postoperative hyperamylasemia in the former(20.3%vs.0).There were no statistical differences in the incidence rates of other specific complications between the two groups(all P>0.05).The length of postoperative hospital stay was shorter and the hospitalization cost was lower in primary closure group than those in endoscopic stone extraction group(both P<0.05).The old age(OR=0.396,95%CI=0.182-0.864,P=0.020),hyperamylasemia(OR=0.057,95%CI=0.007-0.468,P=0.008)and endoscopic stone extraction(OR=0.084,95%CI=0.040-0.179,P=0.000)were risk factors for prolonged postoperative hospital stay,and the surgical method was an influencing factor for postoperative hyperamylasemia(P<0.05).Followed up was conducted for at least 1 year in the two groups of patients,and no stone recurrence and biliary stenosis occurred.Conclusion:Compared with endoscopic stone removal,the primary closure of the laparoscopic common bile duct for the treatment of secondary common bile duct stones has the advantages of shorter hospital stay and lower cost,with no damage to the normal physiological structure of the sphincter of Oddi.