腹腔镜与开放胆肠内引流重建术治疗胆肠吻合口狭窄安全性与近期疗效观察:一项倾向性评分匹配研究

Safety and short-term clinical efficacy of laparoscopic and open biliary-enteric drainage reconstruction in the treatment of biliary-enteric anastomotic strictures:a propensity score-matched study

目的比较腹腔镜与开放胆肠内引流重建术治疗胆肠吻合口狭窄的安全性与近期临床疗效。方法回顾性分析2018年1月至2020年12月湖南省人民医院收治的250例吻合口狭窄病人的临床资料。根据手术方式分为腹腔镜手术(腹腔镜组,39例)和开放手术(开放组,211例)。通过术前基线资料及术中是否行输入袢重建按照最邻近匹配法进行倾向性评分匹配(卡钳值设置为0.01),评分匹配后分组为腹腔镜手术组(腹腔镜组,31例)和开放手术组(开放组,31例),比较两组术中情况(手术时间,术中失血量),术后情况[术后住院时间,术后肛门排气时间,术后炎性指标(第1天及第5天C-反应蛋白、术后第1天降钙素原),术后并发症(出血、胆漏、切口感染、结石残留)]及出院后随访近期并发症(反流性胆管炎、吻合口再狭窄等)等相关指标。结果腹腔镜组与开放组病人在手术时间[(332.58±118.77)min vs.(279.03±97.22)min,P=0.057]、术后住院时间[(12.00±5.16)d vs.(14.84±9.32)d,P=0.143]上差异无统计学意义,但腹腔镜组较开放组术中失血量较少[(107.10±101.99)mL vs.(212.90±225.09)mL,P=0.022],术后肛门排气时间较短[(2.06±0.57)d vs.(2.65±0.76)d,P=0.001],术后炎性指标较低:术后第1天C-反应蛋白[(103.92±34.02)mg/L vs.(129.07±29.37)mg/L,P=0.003],术后第5天C-反应蛋白[(12.09±9.35)mg/L vs.(21.42±14.03)mg/L,P=0.003],术后第1天降钙素原[(0.69±0.55)μg/L vs.(1.72±2.23)μg/L,P=0.017],差异有统计学意义。以上均无死亡病例及非计划再手术病例,腹腔镜组无中转开放手术病例。腹腔镜组术后发生胆瘘2例,切口感染2例,结石残留3例,无术后出血病例;开放组术后发生胆瘘2例,切口感染4例,结石残留3例,无术后出血病例,胆瘘、切口感染经保守治疗后好转出院,结石残留出院后经T管窦道胆道镜取石后治愈,两组间术后并发症发生率比较差异无统计学意义(P>0.05)。随访12~48个月,所有病例均未出现反流性胆管炎、吻合口再狭窄等症状。结论腹腔镜胆肠内引流重建术治疗胆肠吻合口狭窄未增加手术时间,具有创伤小、恢复快等优点,未增加术后并发症,且近期疗效确切。

Objective To compare and analyze the safety and short-term clinical efficacy of laparoscopy and open biliary-enteric drainage and reconstruction in the treatment of biliary-enteric anastomotic strictures.Methods The clinical data of 250 patients with anastomotic stenosis who were admitted to Hunan Provincial People's Hospital and underwent surgical treatment from January 2018 to December 2020 were retrospectively analyzed.According to the surgical method,they were divided into laparoscopic surgery(laparoscopic group,39 cases)and open surgery(open group,211 cases).Based on the preoperative baseline data and whether the input loop reconstruction was performed during the operation,propensity score matching was performed according to the nearest neighbor matching method(caliper value was set to 0.01),and after matching,they were divided into laparoscopic surgery group(laparoscopic group,31 cases)and open surgery group(open group,31 cases),and the intraoperative conditions(operation time,intraoperative blood loss),postoperative conditions(postoperative hospital stay,postoperative anal exhaust time,postoperative inflammatory markers[C-reactive protein on the first and fifth days,procalcitonin on the first postoperative day],postoperative complications[Bleeding,bile leakage,wound infection,residual stone]),and recent complications after discharge follow-up(reflux cholangitis,anastomotic restenosis,etc.)and other related indicators.Results The operative time[(332.58±118.77)min vs.(279.03±97.22)min,P=0.057],postoperative hospital stay[(12.00±5.16)d vs.(14.84±9.32)d in the laparoscopic group and the open group,P=0.143],in terms of intraoperative blood loss,postoperative anal exhaust time,and postoperative inflammatory indicators,the laparoscopic group had less intraoperative blood loss than the open group[(107.10±101.99)mL vs.(212.90±225.09)mL,P=0.022],shorter postoperative anal exhaust time[(2.06±0.57)d vs.(2.65±0.76)d,P=0.001],lower postoperative inflammatory indexes:C-reactive protein on the first postoperative day[(103.92±34.02)mg/L vs.(129.07±29.37)mg/L,P=0.003],C-reactive protein on the fifth postoperative day[(12.09±9.35)mg/L vs.(21.42±14.03)mg/L,P=0.003],procalcitonin on the first postoperative day[(0.69±0.55)μg/L vs.(1.72±2.23)μg/L,P=0.017],the difference was statistically significant.There were no deaths or unplanned reoperations,and there were no cases of conversion to open surgery in the laparoscopic group.In the laparoscopic group,2 cases of biliary fistula,2 cases of incision infection,3 cases of residual calculus,and no postoperative bleeding occurred;in the open group,2 cases of biliary fistula occurred,4 cases of incision infection,and 3 cases of residual calculus.No postoperative bleeding cases,biliary fistula and incision infection improved after conservative treatment and discharged,cases with residual stones were cured after discharge through the T-tube channel to remove stones with choledochoscope.There was no significant difference in the incidence of postoperative complications between the two groups(P>0.05).During the follow-up period of 12-48 months,no symptoms of reflux cholangitis and anastomotic restenosis occurred in all cases.Conclusion Laparoscopic biliaryenteric drainage reconstruction for the treatment of biliary-enteric anastomotic stenosis does not increase the operation time,has the advantages of less trauma,quick recovery,and does not increase postoperative complications,and the shortterm curative effect is accurate.