加速康复外科在腹腔镜联合胆道镜治疗胆总管结石胆道Ⅰ期缝合的临床应用研究

The application study of enhanced recovery after surgery(ERAS)in the laparoscopy combined with choledochoscopy in the treatment of choledocholithiasis

目的探讨腹腔镜联合胆道镜治疗胆总管结石胆道Ⅰ期缝合的可行性及安全性以及快速康复外科(ERAS)策略在胆道外科的临床应用价值。方法回顾性分析2019年7月至2020年12月腹腔镜联合胆道镜治疗胆囊合并胆总管结石Ⅰ期缝合36例患者,其中20例采用围手术期快速康复策略(ERAS组),16例行常规术前准备(常规组),所有手术由同一术者完成。比较两组患者术后恢复情况、并发症发生率、住院费用及手术前后的肝功、炎性及应激性指标。结果ERAS组术后肠功能恢复时间、腹腔引流管留置时间、术后住院天数、住院费用明显降低(P<0.05);两组并发症发生率差异无统计学意义(P>0.05);术前两组谷丙转氨酶(ALT)、直接胆红素(DBIL)、白细胞(WBC)、C反应蛋白(CRP)、血清皮质醇(Cor)、去甲肾上腺素(NE)、促肾上腺皮质激素(ACTH)比较,无统计学意义(P>0.05);术后第一天的ALT、WBC、CRP、Cor、NE、ACTH水平较术前升高,DBIL较术前降低,组间比较无统计学意义(P>0.05);术后第3天两组的ALT、DBIL、WBC、CRP、Cor、NE、ACTH较术前、术后第一天降低,ALT、DBIL指标组间无统计学意义(P>0.05),WBC、CRP、Cor、NE、ACTH组间对比有统计学意义(P<0.05)。结论在严格掌握适应证的情况下,腹腔镜联合胆道镜治疗胆总管结石胆道Ⅰ期缝合术安全、有效、可行,ERAS策略的应用可减轻机体炎症和应激反应,加速患者康复及降低治疗费用。

Objective To explore the feasibility and safety of laparoscopic combined with choledo⁃choscopy in the treatment of choledocholithiasis and the clinical value of ERAS strategy in biliary sur⁃gery.Methods A total of 36 cases with choledocholithiasis were treated by laparoscopy combined with choledochoscopy from July 2019 to Dec 2020 and the patients were divided into an ERAS group(n=20)and a routine group(n=16).All surgical procedures were performed by the same surgeon.The postopera⁃tive recovery,incidence of complications,hospitalization costs,and liver function,inflammatory and stress indicators were compared between the two groups.Results The recovery time of intestinal func⁃tion,the indwelling time of abdominal drainage tube,the days of postoperative hospital stay and hospital⁃ization cost in the ERAS group were less than those in the routine group(P<0.05).There were no signifi⁃cant difference in the incidence of complications between the two groups(P>0.05).There were no signifi⁃cant differences in the levels ALT,DBIL,WBC,CRP,Cor,NE and ACTH between the two groups before surgery and on the 1st day after surger(P>0.05).The levels of ALT,DBIL,WBC,CRP,Cor,NE and ACTH in both groups on the 3rd day after surgery were markedly lower than those on the 1st day after surgery(P<0.05).On the 3rd day after surgery,the indicators of WBC,CRP,Cor,NE and ACTH in the ERAS group were lower than those in the routine group(P<0.05).No significant change was revealed in the indicators of transaminase and bilirubin in the ERAS group compared with the routine group(P<0.05).Conclusion Under the strict operation indication,laparoscopic combined with choledochoscopy in the treatment of choledocholithiasis is safe,effective and feasible.The concept of ERAS can reduce body inflammation and stress response,accelerate patient rehabilitation and minimize the cost of treatment.