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

1	Karsenti D. Endoscopic management of bile duct stones: residual bile duct stones after surgery, cholangitis, and "difficult stones"[J]. J Visc Surg, 2013, 150(3 Suppl): S39-46.
2	Ozcan N, Kahriman G, Mavili E. Percutaneous transhepatic removal of bile duct stones: results of 261 patients[J]. Cardiovasc Intervent Radiol, 2012, 35(3): 621-627.
3	Kint JF, van den Bergh JE, van Gelder RE, et al. Percutaneous treatment of common bile duct stones: results and complications in 110 consecutive patients[J]. Dig Surg, 2015, 32(1): 9-15.
4	Szulman C, Gimenez M, Sierre S. Antegrade papillary balloon dilation for extrahepatic bile duct stone clearance: lessons learned from treating 300 patients[J]. J Vasc Interv Radiol, 2011, 22(3): 346-353.
5	郑强, 温子龙, 薛平, 等. 腹腔镜十二指肠镜联合治疗胆囊胆总管结石的两种术式临床分析[J/CD]. 中华普通外科文献:电子版, 2014, 8(5): 383-383.
6	Sakai Y, Tsuyuguchi T, Sugiyama H, et al. Current situation of endoscopic treatment for common bile duct stones[J]. Hepatogastroenterology, 2012, 59(118): 1712-1716.
7	Szulman C, Giménez M, Sierre S. Antegrade papillary balloon dilation for extrahepatic bile duct stone clearance: lessons learned from treating 300 patients[J]. J Vasc Interv Radiol, 2011, 22(3): 346-353.
8	Kong J, Wu SD, Xian GZ, et al. Complications analysis with postoperative choledochoscopy for residual bile duct stones[J]. World J Surg, 2010, 34(3): 574-580.
9	李玉亮, 耿建利, 贾云明, 等. 经皮穿肝十二指肠乳头肌扩张术治疗胆总管结石[J]. 中华医学杂志, 2013, 93(45): 3586-3589.

[1]	李博, 贾蓬勃, 李栋, 李小庆. ERCP与LCBDE治疗胆总管结石继发急性重症胆管炎的效果[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 60-63.
[2]	陈燕. LCBDE和ERCP+EST治疗胆囊结石合并胆总管结石的疗效观察[J/OL]. 中华普外科手术学杂志(电子版), 2024, 18(04): 385-388.
[3]	张翼翔, 马明, 田金龙, 杨珊珊, 尚程程, 张景欣. 腹腔镜肝叶切除联合胆道镜取石治疗肝内胆管结石的临床观察[J/OL]. 中华普外科手术学杂志(电子版), 2024, 18(04): 381-384.
[4]	张立一, 徐春晓, 单玉玺. sEST联合不同扩张时间EPBD治疗胆总管结石的随机临床试验[J/OL]. 中华普外科手术学杂志(电子版), 2024, 18(03): 295-298.
[5]	张飞, 许陈祥, 邵涛, 王伟, 周红庆. 二期局麻下应用膀胱软镜处理复杂性肾结石经皮肾镜术后残石的研究[J/OL]. 中华腔镜泌尿外科杂志(电子版), 2024, 18(01): 69-73.
[6]	胡金科, 钟文. 妊娠期输尿管结石的处理与转归[J/OL]. 中华腔镜泌尿外科杂志(电子版), 2023, 17(04): 377-381.
[7]	朱兆璧, 陈伟, 谢佳明, 高嘉伟, 徐相蓉, 张超, 庄林俊, 何晨馨. 腹腔镜联合胆道镜在胰管结石治疗中的应用[J/OL]. 中华腔镜外科杂志(电子版), 2023, 16(03): 171-174.
[8]	王庆亮, 党兮, 师凯, 刘波. 腹腔镜联合胆道子镜经胆囊管胆总管探查取石术[J/OL]. 中华肝脏外科手术学电子杂志, 2025, 14(02): 313-313.
[9]	聂云贵, 肖广发. 胆管内乳头状黏液瘤三例诊治及文献复习[J/OL]. 中华肝脏外科手术学电子杂志, 2024, 13(01): 72-77.
[10]	周标, 陈达伟, 汤晓东, 陈胜, 刘双海, 邓志成. 腹腔镜下经胆囊管汇入部微切开取石在细径胆总管结石合并胆囊结石中的应用[J/OL]. 中华肝脏外科手术学电子杂志, 2023, 12(04): 422-426.
[11]	涂建华, 史亚波, 李杨, 刘华兵, 黄长文, 饶雪峰. 一期与二期经皮经肝胆道镜取石术治疗中国肝内胆管结石患者安全性与疗效比较Meta分析[J/OL]. 中华肝脏外科手术学电子杂志, 2023, 12(02): 201-205.
[12]	张曦才, 曹先德. 经皮肾镜取石术治疗无积水肾结石中皮肾通道建立的应用研究进展[J/OL]. 中华临床医师杂志(电子版), 2023, 17(08): 911-915.
[13]	张曦才, 曹先德, 高建萍, 沈大庆, 曹现祥, 郭诗杰, 李凤岳, 肖琳. 免人工肾积水在超声引导经皮肾镜取石术中的应用[J/OL]. 中华临床医师杂志(电子版), 2023, 17(07): 798-803.
[14]	张波, 姚怡, 张文刚, 柴宁莉, 令狐恩强. 胆道镜直视系统在胆胰"超级微创理念"中的诊疗价值[J/OL]. 中华胃肠内镜电子杂志, 2023, 10(04): 264-266.
[15]	董浩, 张文刚, 刘圣圳, 李笑, 冯宇杰, 王佳凤, 赵晨怡, 柴宁莉, 令狐恩强. 胆道镜直视下胆总管结石取出术的初步探索[J/OL]. 中华胃肠内镜电子杂志, 2023, 10(02): 92-96.

阅读次数

全文

摘要

选择文件类型/文献管理软件名称

选择包含的内容

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

模态框（Modal）标题

选择文件类型/文献管理软件名称

选择包含的内容

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