经皮经肝胆道镜取石术治疗复杂肝胆管结石的应用分析

Percutaneous transhepatic choledochoscopic lithotripsy versus open hepatectomy for treatment of complicated hepatolithiasis-a propensity score matching study

目的探讨经皮经肝胆道镜取石术(PTCSL)治疗复杂肝胆管结石的效果。方法回顾分析2017年7月至2021年9月昆明医科大学第二附属医院收治的198例复杂肝胆管结石患者资料。其中48例行PTCSL纳入PTCSL组,150例行传统开腹肝切除术(OH)纳入OH组。利用倾向性评分按1∶1匹配,最终PTCSL组和OH组各纳入40例。PTCSL组中男性11例,女性29例,年龄(59.3±12.7)岁,年龄范围32~85岁;OH组中男性15例,女性25例,年龄(55.4±10.9)岁,年龄范围20~74岁。比较两组手术时间、术中出血量、住院时间、住院费用、并发症(包括胸腔积液、胆道出血等)发生率、结石残留率和结石复发率等。结果经倾向性评分匹配后,两组患者基线资料基本具备可比性。PTCSL组手术时间(135.8±42.6)min、术中出血量32.5(20.0,50.0)ml、住院时间13.5(11.0,18.0)d、住院费用3.4(2.9,5.0)万元,优于OH组的(350.7±113.8)min、475.0(200.0,900.0)ml、24.0(17.3,28.8)d、6.6(5.0,8.9)万元,差异均有统计学意义(均P<0.05)。PTCSL组1例(2.5%)、OH组9例(22.5%)发生术后并发症。OH组并发症发生率高于PTCSL组,差异有统计学意义(χ^(2)=7.31,P=0.007)。PTCSL组结石残留率20.0%(8/40)、结石复发率17.5%(7/40),OH组分别为27.5%(11/40)、12.5%(5/40),两组比较差异均无统计学意义(均P>0.05)。结论在复杂肝胆管结石的治疗中,PTCSL结石残留率与传统开腹肝切除手术相当,但PTCSL具有手术时间短、术中出血少、住院时间短、并发症发生率低和住院费用低的优点,值得应用推广。

Objective To study minimally invasive treatment using percutaneous transhepatic choledochoscopic lithotripsy(PTCSL)to treat complicated hepatolithiasis.Methods Patients with complicated hepatolithiasis who were treated at the Second Affiliated Hospital of Kunming Medical University from July 2017 to September 2021,were included into this study.There were 48 patients treated with PTCSL(the PTCSL group)and 150 patients treated with conventional open hepatectomy(the OH group).Propensity score matching(PSM)was used to match 40 patients in the PTCSL group with 40 patients in the OH group.There were 11 males and 29 females,aged 32 to 85(59.3±12.7)years in the PTCSL group and 15 males and 25 females,aged 20 to 74(55.4±10.9)years in the OH group.Theoperation time,intraoperative blood loss,hospitalization time,hospitalization cost,incidences of major complications(including pleural effusion,biliary bleeding),residual stone rates and recurrence rates were analyzed.Results Baseline data were comparable between groups after PSM.For the PTCSL group,the operation time was(135.8±42.6)minutes,intraoperative bleeding volume 32.5(20.0,50.0)ml,hospitalization time 13.5(11.0,18.0)days,and hospitalization expense 3.4(2.9,5.0)wanyuan compared with the corresponding figures in the OH group with operation time(350.7±113.8)minutes,intraoperative bleeding volume 475.0(200.0,900.0)ml,hospitalization time 24.0(17.3,28.8)days,and hospitalization expense 6.6(5.0,8.9)wanyuan.The differences between the two groups were statistically significant(all P<0.05).The overall complication rate was 2.5%(1/40)in the PTCSL group and 22.5%(9/40)in the OH group(χ^(2)=7.31,P=0.007).The residual stone rate of 20.0%(8/40),stone recurrence rate of 17.5%(7/40),compared with the OH group with the stone residual rate of 27.5%(11/40),stone recurrence rate of 12.5%(5/40).There was no significant difference between the two groups in both the stone residual rates and stone recurrence rates(both P>0.05).Conclusion In treatment of complex hepatolithiasis,the stone residual rate after repeated PTCSL was comparable to traditional open hepatectomy.PTCSL had the advantages of shorter operation time,less bleeding,lower hospitalization time,lower complication rate and lower hospitalization cost.PTCSL is worthy of wider application and popularization.