应用经皮经肝胆道镜技术治疗老年复杂性肝内外胆管结石患者的疗效及安全性

Efficacy and safety evaluation of percutaneous transhepatic cholangioscopic technique in the treatment of elderly patients with complex intra-and extrahepatic bile duct calculi

目的探讨在老年复杂肝内外结石患者中采用一期法经皮经肝胆道镜取石术的有效性及安全性。方法纳入2021年1月—2021年6月西安交通大学第一附属医院诊治的老年复杂性肝例内外胆管结石患者共65例,男性34例,女性31例;平均年龄为(67.2±10.3)岁。按照手术方式不同,随机分为观察组(n=36),采用一期经皮经肝胆道镜技术清除胆道结石;对照组(n=29),采用常规手术,即胆总管切开取石、T管引流或行胆肠吻合术。检测两组患者在术后6个月的肝功能及结石复发情况,记录围手术期相关指标。结果观察组手术后6个月ALT、AST、TBil、DBil分别为(24.7±11.4)U/L、(22.8±9.7)U/L、(21.8±2.6)mmol/L、(19.5±11.9)mmol/L,显著低于对照组[分别为(36.2±9.3)U/L、(31.5±10.3)U/L、(31.3±7.5)mmol/L、(28.6±11.9)mmol/L,P<0.05];观察组的手术时间、术中出血量、术后禁食时间、术后排气时间以及住院时间分别为(95.5±10.4)min、(45.1±9.3)mL、(15.2±6.6)h、(12.4±1.2)h、(4.5±0.6)d,均显著低于对照组[分别为(157.3±16.4)min、(92.3±10.8)mL、(27.3±5.9)h、(26.3±7.9)h、(6.8±1.0)d,P<0.05];观察组的手术并发症发生率显著低于对照组(8.3%对20.7%,P<0.05);观察组结石复发率显著低于对照组(5%对28%,P<0.05)。通过二元logistic回归模型分析,采用一期法经皮经肝胆道镜取石术(OR=0.21,P=0.036,95%CI:0.052~0.89)能减少结石复发,而术前胆红素升高(OR=1.12,P=0.002,95%CI:1.01~1.48)是结石复发的危险因素。结论在老年复杂肝内外结石患者中采用一期法经皮经肝胆道镜取石术是安全的,能够提高结石清除率、减少并发症、降低远期结石复发。

Objective To explore the effectiveness and safety of one-stage percutaneous transhepatic choledocholithotomy in elderly patients with complex intrahepatic and extrahepatic stones.Methods Between January 2021 and June 2021,there were 65 elderly patients with complicated liver diseases,including 34 males and 31 females.The average age was(67.2±10.3)years.According to the different surgical methods,they were randomly divided into observation group(n=36),and the bile duct stones were removed by one-stage percutaneous transhepatic cholangioscopy.In the control group(n=29),routine operations were performed,that is,choledocholithotomy,T-tube drainage or cholangioenterostomy.The liver function and stone recurrence of patients in the two groups were detected 6 months after operation,and the related indexes during perioperative period were recorded.Results 6 months after operation,the ALT,AST,TBil and DBil in the observation group were(24.7±11.4)U/L,(22.8±9.7)U/L,(21.8±2.6)mmol/L and(19.5±11.9)mmol/L/L,respectively,significantly lower than the control group[(36.2±9.3)U/L,(31.5±10.3)U/L,(31.3±7.5)mmol/L,(28.6±11.9)mmol/l,respectively,P<0.05].The operation time,intraoperative blood loss,postoperative fasting time,postoperative exhaust time and hospitalization time in the observation group were(95.5±10.4)min,(45.1±9.3)mL,(15.2±6.6)h,(12.4±1.2)h and(4.5±0.6)d,respectively,they were significantly lower than those in the control group[(157.3±16.4)min,(92.3±10.8)mL,(27.3±5.9)h,(26.3±7.9)h,(6.8±1.0)d,respectively,P<0.05].The recurrence rate of stones in the observation group was significantly lower than that in the control group(5%vs 28%,P<0.05).According to the analysis of binary logistic regression model,the one-stage percutaneous choledocholithotomy(OR=0.21,P=0.036,95%CI:0.052-0.89)can reduce the recurrence of stones,while the preoperative bilirubin is increased(OR=1.12,P=0.002,95%CI:1.01-1.48).Conclusion In elderly patients with complex intra-and extrahepatic stones,the single-stage percutaneous transhepatic cholangioscopic lithotripsy is safe,can improve stone clearance rate,reduce complications,and decrease the long-term recurrence of stones.