内镜与腹腔镜同期治疗胆囊结石合并胆管结石的应用体会

Application of concurrent endoscopy and laparoscopy in the treatment of cholecystolithiasis combined with bile duct calculi

目的:比较内镜逆行胰胆管造影(ERCP)同期联合腹腔镜胆囊切除术(LC)、腹腔镜胆总管探查取石术(LCBDE)两种方式治疗胆囊结石合并胆管结石的临床疗效。方法:收集2018年9月至2022年1月收治的符合入选标准的146例胆囊结石合并肝外胆管结石患者的临床资料,其中ERCP+LC组60例,LCBDE组86例,回顾分析两组患者一般情况、手术成功率、并发症发生率、结石残留率等。结果:ERCP+LC组中58例成功施行ERCP,腹腔引流管留置率低于LCBDE组(41.7%vs.95.3%),两组中转开腹率、手术时间、术中出血量差异无统计学意义;术后6 h疼痛评分低于LCBDE组[(3.9±1.6)vs.(6.5±2.4),P<0.05],住院时间短于LCBDE组[(5.1±2.3)d vs.(7.9±3.7)d,P<0.05],手术费用高于LCBDE组[(48839.9±8549.5)元vs.(34635.9±5893.7)元,P<0.05]。ERCP+LC组发生4例(6.7%)ERCP术后胰腺炎,经保守治疗痊愈;两组胆漏(1.7%vs.4.7%)、术后胆管炎(5.0%vs.5.8%)、切口感染(3.3%vs.3.5%)、胆管残石率(5.0%vs.3.5%)差异无统计学意义,均无重症胰腺炎、二次手术及死亡病例。结论:两种术式治疗胆囊结石合并肝外胆管结石均是安全、有效的,ERCP同期行LC在患者舒适度、快速康复方面具有一定优势,可在有条件的医院适时推广。

Objective:To compare the clinical efficacy of endoscopic retrograde cholangiopancreatography(ERCP)combined with concurrent laparoscopic cholecystectomy(LC)and laparoscopic common bile duct exploration(LCBDE)in the treatment of cholecystolithiasis complicated with bile duct stones.Methods:The clinical data of 146 patients with cholecystolithiasis complicated with e xtrahepatic bile duct stones who met the inclusion criteria from Sep.2018 to Jan.2022 were collected,including 60 cases in ERCP combined with LC group and 86 cases in LCBDE group.The general conditions,operation success rate,complications and residual stone rate of the two groups were analyzed retrospectively.Results:ERCP was successfully performed in 58 patients in the ERCP combined with LC group.The retention rate of abdominal drainage tube was significantly lower than that of LCBDE group(41.7%vs 95.3%).There was no significant difference in conversion to laparotomy rate,operation time and intraoperative blood loss between the two groups;the pain score at 6 h after operation was significantly lower than that in LCBDE group[(3.9±1.6)vs.(6.5±2.4)].T he hospital stay in ERCP combined with LC group was shorter[(5.1±2.3)d vs.(7.9±3.7)d,P<0.05],but the operation cost was significantly higher than that in LCBDE group[(48839.9±8549.5)vs.(34635.9±5893.7)yuan,P<0.05].4 patients(6.7%)suffered from pancreatitis in ERCP combined with LC group,which was cured by conservative treatment.There was no significant diffe-rence between the two groups in bile leakage(1.7%vs.4.7%),postoperative cholangitis(5.0%vs.5.8%),incision infection(3.3%vs.3.5%),bile duct residual stone rate(5.0%vs.3.5%),and there were no cases of severe pancreatitis,secondary surgery and death.Conclusions:ERCP combined with LC,like LCBDE,is a safe and effective method to treat cholecystolithiasis complicated with extrahepatic bile duct stones.ERCP combined with LC has certain advantages in patients’comfort and rapid rehabilitation,and can be popularized in conditional hospitals in due time.