同步多镜联合技术在肝胆管结石病中的应用

Application of synchronous multi-mirror combination technique for hepatobiliary cholithiasis

目的探讨同步多镜联合技术在肝胆管结石病中的应用价值。方法回顾性分析昆明医科大学第二附属医院自2018年1月至2021年10月收治的159例肝胆管结石病人的临床资料,按治疗方法的不同分为肝外胆管结石组[A组:腹腔镜+十二指肠镜组(A1组,55例)、腹腔镜+胆道镜组+十二指肠镜/胃镜组(A2组,40例)]和肝内外胆管结石组[B组:腹腔镜+胆道镜+十二指肠镜组/胃镜组(B1组,32例)、腹腔镜+胆道镜+T管引流组(B2组,32例)],分别比较各组内肝外胆管直径、手术时间、出血量、术后住院时间、总住院时间、术后并发症严重程度、残石率等指标,并进行统计学分析。结果所有病例均顺利完成手术,A组和B组由于病种不同,组间比较无意义,但组内比较有意义。A组中,术中出血量A1组少于A2组[(25.5±21.1)mL比(48.8±50.2)mL],差异有统计学意义(P<0.05),术后Ⅲ级以上近期并发症发生率(3.6%比5.0%)、远期并发症发生率(3.6%比2.5%)及残石率(1.8%比2.5%)比较差异均无统计学意义(均P>0.05)。B组中,B1组总住院时间短于B2组[(15.4±3.0)d比(19.0±6.2)d],术后住院时间短于B2组[(7.8±2.1)d比(10.2±3.7)d],差异均有统计学意义(均P<0.05);近期并发症发生率(6.3%比9.4%)、远期并发症发生率(3.1%比6.3%)及残石率(6.3%比6.3%)比较,差异均无统计学意义(均P>0.05)。结论对于肝外胆管结石,根据胆总管直径选择同步腹腔镜和十二指肠镜或同步腹腔镜、胆道镜和十二指肠镜/胃镜的手术方式有较好的微创手术效果;对于肝内外胆管结石的病人,同步腹腔镜下解剖性肝叶切除、胆道镜取石和十二指肠镜/胃镜下内引流的手术方式能够保证病灶切除、取净结石、通畅引流的同时免T管留置,减少了住院时间,获得了最大化微创效果,有较好的推广应用价值。

Objective To explore the value of synchronous multi-mirror combination technique for hepatobiliary cholithiasis.Methods From January 2018 to October 2021,retrospective review was performed for clinical data of 159 patients with hepatobiliary cholithiasis.According to different treatments,they were divided into group A of extrahepatic bile duct cholithiasis[laparoscopic+duodenal mirror group(A1,n=55)and laparoscopic+biliary mirror group(A2,n=40)]and group B of intra/extra-hepatic bile duct cholithiasis[laparoscopy+choledotoscopy+duodenoscopy group/gastroscopy group(B1,n=32)and laparoscopic+choledotoscopy+T tube drainage group(B2,n=32)].Mean T tube diameter,operative duration,bleeding volume,postoperative hospitalization time,total hospitalization time,severity of postoperative complications and residual stone rate were analyzed statistically.Results All procedures were successfully completed.Groups A and B were meaningless due to different disease types,but within meaningful.In group A,intraoperative blood loss was less in group A1 than that in group A2[(25.5±21.1)vs.(48.8±50.2)mL]and the difference was statistically significant(P<0.05).No significant differences existed in incidence of grade Ⅲ recent complication rate(3.6%vs.5.0%),long-term complication rate(3.6%vs.2.5%)or residual rate(1.8%vs.2.5%)(P>0.05);In group B,total length of hospital stay was shorter in group B1 than that in group B2[(15.4±3.0)vs.(19.0±6.2)days]and postoperative hospital stay shorter than B2 group[(7.8±2.1)vs.(10.2±3.7)days].The differences were statistically significant(P<0.05).No significant differences existed in recent complication rate(6.3%vs.9.4%),long-term complication rate(3.1%vs.6.3%)or residual rate(6.3%vs.6.3%)(P>0.05).Conclusion For extrahepatic bile duct cholithiasis,synchronous laparoscopy and duodenoscopy or syntaneous laparoscopy,choloscopy and duodenoscopy/gastroscopy based upon common bile duct diameter offer excellent mini-invasive outcomes.For hepatic and extrahepatic bile duct cholithiasis,synchronous laparoscopy anatomical hepatic lobectomy,calculus choledochoscopic removal and internal drainage followed by duodenoscopy/gastroscopy may ensure lesion resection,stone removal and smooth drainage of without T tube,shorten hospital stay and achieve maximal mini-invasiveness.Wider popularization is worthwhile.