经T管扩张乳头括约肌清除结石与胆道镜取石的临床对比:附视频

doi:10.3877/cma.j.issn.1674-0793.2015.05.011

目的

比较经T管球囊导管扩张乳头括约肌并推出结石技术与胆道镜取石的临床效果。

方法

选择2008年2月至2014年6月收治的41例手术后留置T管的胆总管残石患者,20例采用十二指肠乳头扩张推石治疗(乳头扩张组),21例进行胆道镜窦道取石治疗(胆道镜组)。比较两组患者术前胆总管直径、留置T管时间、胆道结石情况、手术操作时间、术中结石彻底清除率以及术后近期并发症发生率、结石复发率、胆道狭窄发生率等。

结果

术前乳头扩张组患者T管放置时间为(24.2±9.7) d,明显短于胆道镜组的(65.4±14.6) d (t=16.422,P<0.01);乳头扩张组的T管直径(5.3±0.7) mm、胆总管直径(13±5) mm均较胆道镜组的(7.2±0.9) mm、(19±7) mm明显缩小,差异均有统计学意义(t=7.152,P<0.01; t= 3.144,P<0.01)。两组患者取石成功率、近远期并发症总发生率、手术早期的白细胞数量、C反应蛋白水平(CRP)、胆道结石复发率、并发症发生率差异无统计学意义。

结论

经T管球囊导管扩张乳头括约肌清除胆总管结石具有与胆道镜窦道取石类似的效果,较后者明显缩短T管放置时间,对于较细的胆总管及T管患者仍然适用。

关键词: 残留结石, 十二指肠乳头球囊扩张, 介入操作, 取石, 胆道镜

Objective

To compare dilated papillary sphincter via T-tube balloon catheter to extrude stones and calculus removal with choledochoscope.

Methods

Forty-one patients with residual common bile duct stones after common bile duct exploration with T-tube drainage were enrolled in the study from February 2008 to June 2014. Twenty patients were treated with balloon dilation of the papilla and the use of an occlusion balloon for clearance of bile duct calculi via T tube, and were allocated to balloon sphincteroplasty group. The other 21 patients, treated with choledochoscope through T tube sinus, were allocated to choledochoscope group. The size of common bile duct, retention time of T tube, the size and number of stones, operation time, clearance rate of bile duct stones, and postoperative complications between the two groups were compared.

Results

The preoperative T tube indwelling time in balloon sphincteroplasty group was significantly shorter than that in choledochoscope group [(24.2±9.7) d vs (65.4±14.6) d, t=16.4, P<0.01]. The size of common bile duct and the diameter of T tube in balloon sphincteroplasty group were significantly shorter than those in choledochoscope group [(13±5) mm vs (19±7) mm, t=3.144, P<0.01; (5.3±0.7) mm vs (7.2±0.9) mm, t=7.152, P<0.01]. There was no significant difference between the two groups in terms of clearance rate of bile duct calculi, overall postoperative morbidity rate, postoperative WBC count, C-reactive protein concentration, stone recurrence rate and bile duct stricture rate throughout the follow-up period after complete clearance of bile duct.

Conclusions

Common bile duct stone clearance by dilation of the papilla and evacuation of the residual stones with an occlusion balloon via T tube is as safe and effective as stone extraction with choledochoscope through T tube sinus. The technique can shorten T tube retention time and is still available to slim common bile duct and T tube.

Key words: Residual stone, Papillary balloon dilation, Interventional procedures, Stone extraction, Choledochoscope

表1 41例留置T管的胆总管结石患者术前临床资料

组别	例数	年龄(岁)	男/女(例)	T管放置时间(d)	结石大小(cm³)	结石数量(枚)	T管直径(mm)	T管体内长度(cm)	胆总管直径(mm)
乳头扩张组	20	69.8±14.8	7/13	24.2±9.7	1.1±0.3	1.7±0.5	5.3±0.7	16.3±6.4	13±5
胆道镜组	21	65.3±16.7	10/11	65.4±14.6	1.0±0.4	1.5±0.4	7.2±0.9	12.1±4.2	19±7
统计值	?	0.911	0.808	16.422	0.902	1.418	7.152	2.496	3.144
P值	?	>0.20	>0.25	<0.01	>0.20	>0.10	<0.01	<0.02	<0.01

表1 41例留置T管的胆总管结石患者术前临床资料

组别	例数	年龄(岁)	男/女(例)	T管放置时间(d)	结石大小(cm³)	结石数量(枚)	T管直径(mm)	T管体内长度(cm)	胆总管直径(mm)
乳头扩张组	20	69.8±14.8	7/13	24.2±9.7	1.1±0.3	1.7±0.5	5.3±0.7	16.3±6.4	13±5
胆道镜组	21	65.3±16.7	10/11	65.4±14.6	1.0±0.4	1.5±0.4	7.2±0.9	12.1±4.2	19±7
统计值	?	0.911	0.808	16.422	0.902	1.418	7.152	2.496	3.144
P值	?	>0.20	>0.25	<0.01	>0.20	>0.10	<0.01	<0.02	<0.01

图1 患者73岁,6年前行胆囊切除术,1个月前诊断胆总管结石并重症胆管炎症而行胆总管切开取石T管引流,经T管胆道造影显示结石负性影(白色箭头所示)

图2 给予患者球囊扩张胆道口括约肌(白色箭头所示)

图3 球囊推送胆总管结石,结石被球囊推至近胆总管壁内段(白色箭头所示)

图4 胆总管结石已被推入十二指肠内(白色箭头所示结石)

表2 两组患者术后血液检测指标比较( ± s)

组别	例数	术后1 h		术后24 h		术后72 h
组别	例数	WBC(×10⁹/L)	CRP(g/L)	WBC(×10⁹/L)	CRP(g/L)	WBC(×10⁹/L)	CRP(g/L)
乳头扩张组	20	11.2±2.3	9.6±2.2	8.9±2.6	7.5±2.1	7.1±2.5	5.9±1.4
胆道镜组	21	11.9±3.1	9.9±3.1	9.3±3.3	7.8±2.5	6.7±2.3	5.6±1.5
t值	?	0.818	0.356	0.430	0.415	0.534	0.661
P值	?	>0.05	>0.50	>0.50	>0.50	>0.50	>0.50

表2 两组患者术后血液检测指标比较( ± s)

组别	例数	术后1 h		术后24 h		术后72 h
组别	例数	WBC(×10⁹/L)	CRP(g/L)	WBC(×10⁹/L)	CRP(g/L)	WBC(×10⁹/L)	CRP(g/L)
乳头扩张组	20	11.2±2.3	9.6±2.2	8.9±2.6	7.5±2.1	7.1±2.5	5.9±1.4
胆道镜组	21	11.9±3.1	9.9±3.1	9.3±3.3	7.8±2.5	6.7±2.3	5.6±1.5
t值	?	0.818	0.356	0.430	0.415	0.534	0.661
P值	?	>0.05	>0.50	>0.50	>0.50	>0.50	>0.50

表3 两组患者术后近期并发症及远期随访结果

组别	近期并发症(例)					远期并发症(例)
组别	例数胆瘘	胆管炎	胰腺炎	胆道出血	发生率(%)	例数	结石复发	胆道炎症	胆道狭窄	发生率(%)
乳头扩张组	200	1	1	1	15.0	18	1	3	1	27.8
胆道镜组	211	1	1	1	19.0	19	2	2	1	26.3

表3 两组患者术后近期并发症及远期随访结果

组别	近期并发症(例)					远期并发症(例)
组别	例数胆瘘	胆管炎	胰腺炎	胆道出血	发生率(%)	例数	结石复发	胆道炎症	胆道狭窄	发生率(%)
乳头扩张组	200	1	1	1	15.0	18	1	3	1	27.8
胆道镜组	211	1	1	1	19.0	19	2	2	1	26.3

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Clinical comparison between dilated papillary sphincter via T tube and via choledochoscope in the treatment of bile duct stones: video attached

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Clinical comparison between dilated papillary sphincter via T tube and via choledochoscope in the treatment of bile duct stones: video attached