腹腔镜下经胆囊管胆管引流联合胆总管探查取石术治疗复杂胆管结石的临床效果

Clinical effect of laparoscopic transcystic drainage combined with common bile duct exploration for the patients with difficult biliary stones

目的:探讨腹腔镜下经胆囊管胆管引流联合胆总管探查取石术治疗复杂胆管结石的可行性及效果。方法:回顾性分析2020年4月至2021年12月因复杂胆管结石采用腹腔镜下经胆囊管胆管引流(C管技术)联合胆总管探查取石术治疗的18例患者的临床资料,分析此种治疗方式的安全性及有效性。结果:18例患者中,13例采用传统C管技术,5例采用改良C管技术,手术时间(161±59)min(82~279 min),术后经C管造影均无结石残留及胆道狭窄,C管最大引流量为(500±163)mL/d(180~820 mL/d),3例C管脱落患者早期拔除C管,其余15例患者拔除C管的中位时间为8 d(5~12 d),18例患者术后住院时间为(12±3)d(7~21 d)。5例患者出现C管相关不良事件,均发生在采用传统C管技术的患者中,包括C管位置异常2例、早期脱落3例,均未出现并发症。1例患者出现1级并发症,该例患者采用的是改良C管技术,患者拔管后出现一过性发热,拔管后保留的腹腔引流管无胆汁,进一步行CT检查亦无明显胆漏,保守观察后第2天平稳出院。患者的术后中位随访时间为9个月(1~20个月),所有患者的肝功能均于术后1个月恢复正常,彩超或磁共振胰胆管造影(magnetic resonance cholangiopan-creatography,MRCP)检查未见结石复发征象。结论:腹腔镜下C管引流联合胆总管探查取石术在复杂胆总管结石患者的治疗上安全可行,近期效果良好,改良C管技术可能会减少C管脱落及胆漏的风险。

Objective:To explore the feasibility and efficacy of laparoscopic transcystic drainage and common bile duct exploration in the treatment of patients with difficult biliary stones.Methods:Between April 2020 and December 2021,eighteen patients with difficult biliary stones received laparoscopic transcystic drainage(C-tube technique)and common bile duct exploration.The clinical characteristics and outcomes were retrospectively collected.The safety and effectiveness of laparoscopic transcystic drainage and common bile duct exploration were analyzed.Results:Among the eighteen patients with difficult biliary stones,thirteen patients received traditional laparoscopic transcystic drainage,and the remaining five received modified laparoscopic transcystic drainage.The mean surgical duration were(161±59)min(82-279 min),no bile duct stenosis or residual stone was observed in the patients receiving postoperative cholangiography via C-tube.The maximum volume of C-tube drainage was(500±163)mL/d(180-820 mL/d).Excluding three patients with early dislodgement of C-tube,among the fifteen patients with C-tube maintained,the median time of C-tube removal was 8 d(5-12 d).The duration of hospital stay was(12±3)d(7-21 d)for the 18 patients.Five C-tube related adverse events were observed,all of which occurred in the patients with traditional laparoscopic transcystic drainage,including two abnormal position of the C-tube,and three early dislocation of the C-tube.All the 5 adverse events caused no complications.Only one grade one complication occurred,which was in a patient with modified laparoscopic transcystic drainage.The patient demonstrated transient fever after C-tube removal,but there was no bile in the drainage tube and the subsequent CT examination confirmed no bile leakage.The fever spontaneously relieved with conservative observation,and the patient recovered uneventfully with discharge the next day.All the 18 patients were followed up for 1-20 months(median:9 months).Normal liver function and no recurrence of stone were detected with ultrasonography or magnetic resonance cholangiopancreatography(MRCP).Conclusion:Laparoscopic transcystic drainage combined with common bile duct exploration is safe and feasible in the treatment of patients with difficult biliary stones.The short-term effect is good.Modified laparoscopic transcystic drainage approach may reduce the incidence of C-tube dislocation and bile leak.