胆道镜下放置胆道支架在胆总管结石并急性胆管炎中的应用

doi:10.3877/cma.j.issn.1674-0793.2023.02.005

目的

对比胆囊结石合并胆总管结石、急性胆管炎患者行腹腔镜胆总管探查（LCBDE）一期缝合术中应用改良胆道支架与行内镜逆行胰胆管造影（ERCP）+腹腔镜胆囊切除术（LC）的差异。

方法

回顾性分析2021年6月至2022年7月收治的66例胆囊结石合并胆总管结石、急性胆管炎患者资料，其中33例行LCBDE一期缝合术中应用改良胆道支架（LCBDE组），33例行ERCP+LC术（ERCP组）。

结果

两组患者术后3 d内炎性指标下降趋势差异无统计学意义。LCBDE组患者术后胰腺炎发生率低于ERCP组（P=0.009），住院总费用更低（t=38.970，P=0.008）。随访6个月，LCBDE组术后出现胆漏、胆道感染、切口感染各1例，两组总并发症发生率均为9.09%（3/33），差异无统计学意义（P=0.500）。

结论

对于胆总管结石合并急性胆管炎患者，行LCBDE一期缝合术中应用改良胆道支架是安全有效的。

关键词: 急性胆管炎, 胆总管探查, 一期缝合, 胆道支架, 内镜逆行胰胆管造影, 腹腔镜, 胆囊切除术

Objective

To compare the difference between modified biliary stent placement in laparoscopic common bile duct exploration (LCBDE) and primary suture and endoscopic retrograde cholangiopancreatography (ERCP)+laparoscopic cholecystectomy (LC) for gallstone with choledocholithiasis and acute cholangitis.

Methods

From June 2021 to July 2022, the clinical data of 66 patients with gallstone, choledocholithiasis and acute cholangitis were retrospectively analyzed. Among them, 33 cases were treated with LCBDE and primary suture with modified biliary stent (LCBDE group), and 33 cases with ERCP+LC (ERCP group).

Results

There was no statistically significant difference between the two groups in the change trend of postoperative inflammatory indexes within 3 days after surgery. The incidence of postoperative pancreatitis in LCBDE group was lower than that in ERCP group (P=0.009), and the total cost of hospitalization was lower (t=38.970, P=0.008). Following up for 6 months, there was 1 case of bile leakage, 1 case of biliary tract infection and 1 case of incision infection in the LCBDE group, with no statistically significant difference in the total complication rate with ERCP group (9.09% vs 9.09%, P=0.500).

Conclusion

The application of modified biliary stent placement in LCBDE and primary suture is safe and effective for patients with choledocholithiasis and acute cholangitis.

Key words: Acute cholangitis, Choledochal exploration, Primary suture, Biliary stent, Endoscopic retrograde cholangiopancreatography, Laparoscopes, Cholecystectomy

图1 手术过程　术中可见炎性水肿的胆囊（A）；胆总管扩张，直径大于8 mm（B）；切开胆总管取石后，导丝探查可通过胆总管开口（C）；胆道镜下置入胆道支架（D）；支架侧翼完全进入胆道（E）；胆总管一期缝合（F）

表1 两组胆总管结石并急性胆管炎患者围手术期一般临床资料比较

组别	LCBDE组	ERCP组	统计值	P值
例数	33	33
性别			0.243	0.622
男	16(48.48)	18(54.55)	0.154	0.132
女	17(51.52)	15(45.45)	0.176	0.098
年龄(岁)^a	53.27±8.06	49.30±7.05	0.235	1.021
白细胞计数(×10⁹/L)^a
术前	7.82±1.05	10.77±1.34	0.012	0.986
术后3 d	7.83±1.03	9.83±1.21	0.321	0.635
C反应蛋白(mg/L)^a
术前	15.22±1.89	17.17±2.01	0.123	0.874
术后3 d	33.72±3.12	33.39±5.31	0.456	0.352
降钙素原(μg/L)^a
术前	2.34±0.15	0.12±0.01	0.056	0.098
术后3 d	1.02±0.02	1.20±0.03	0.253	1.650
丙氨酸转氨酶(U/L)^a
术前	284.70±50.12	35.91±5.20	1.324	0.051
术后3 d	93.75±10.23	108.94±11.23	0.698	0.210
γ-谷氨酰转肽酶(U/L)^a
术前	422.97±89.03	320.54±56.21	2.698	0.064
术后3 d	222.85±12.31	181.70.81±13.12	0.985	0.098
总胆红素(μmol/L)^a
术前	86.7±3.42	47.84±5.15	1.874	0.078
术后3 d	31.01±5.31	30.12±5.23	0.321	1.256
淀粉酶(U/L)^a
术前	144.38±8.56	564.03±101.10	3.685	0.053
术后3 d	87.91±15.63	94.11±18.53	1.365	0.035
合并疾病
高血压	8(24.24)	7(21.21)	0.986	0.875
心脑血管病	5(15.15)	2(6.06)	0.236	0.062
糖尿病	0(0)	1(3.03)	0.025	0.058
ASA分级
Ⅰ	10(30.30)	11(33.33)	0.984	0.867
Ⅱ	14(42.42)	21(63.64)	0.754	0.587
Ⅲ	9(27.27)	0(0)	1.265	0.012^b
Ⅳ	0(0)	1(3.03)	0.635	0.514
结石直径(cm)	1.40±0.12	0.66±0.03	0.521	0.060
结石数量(个)	1.96±0.65	1.30±0.08	0.765	0.124
结石嵌顿	3(9.09)	1(3.03)	0.241	0.071

表1 两组胆总管结石并急性胆管炎患者围手术期一般临床资料比较

组别	LCBDE组	ERCP组	统计值	P值
例数	33	33
性别			0.243	0.622
男	16(48.48)	18(54.55)	0.154	0.132
女	17(51.52)	15(45.45)	0.176	0.098
年龄(岁)^a	53.27±8.06	49.30±7.05	0.235	1.021
白细胞计数(×10⁹/L)^a
术前	7.82±1.05	10.77±1.34	0.012	0.986
术后3 d	7.83±1.03	9.83±1.21	0.321	0.635
C反应蛋白(mg/L)^a
术前	15.22±1.89	17.17±2.01	0.123	0.874
术后3 d	33.72±3.12	33.39±5.31	0.456	0.352
降钙素原(μg/L)^a
术前	2.34±0.15	0.12±0.01	0.056	0.098
术后3 d	1.02±0.02	1.20±0.03	0.253	1.650
丙氨酸转氨酶(U/L)^a
术前	284.70±50.12	35.91±5.20	1.324	0.051
术后3 d	93.75±10.23	108.94±11.23	0.698	0.210
γ-谷氨酰转肽酶(U/L)^a
术前	422.97±89.03	320.54±56.21	2.698	0.064
术后3 d	222.85±12.31	181.70.81±13.12	0.985	0.098
总胆红素(μmol/L)^a
术前	86.7±3.42	47.84±5.15	1.874	0.078
术后3 d	31.01±5.31	30.12±5.23	0.321	1.256
淀粉酶(U/L)^a
术前	144.38±8.56	564.03±101.10	3.685	0.053
术后3 d	87.91±15.63	94.11±18.53	1.365	0.035
合并疾病
高血压	8(24.24)	7(21.21)	0.986	0.875
心脑血管病	5(15.15)	2(6.06)	0.236	0.062
糖尿病	0(0)	1(3.03)	0.025	0.058
ASA分级
Ⅰ	10(30.30)	11(33.33)	0.984	0.867
Ⅱ	14(42.42)	21(63.64)	0.754	0.587
Ⅲ	9(27.27)	0(0)	1.265	0.012^b
Ⅳ	0(0)	1(3.03)	0.635	0.514
结石直径(cm)	1.40±0.12	0.66±0.03	0.521	0.060
结石数量(个)	1.96±0.65	1.30±0.08	0.765	0.124
结石嵌顿	3(9.09)	1(3.03)	0.241	0.071

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Application of biliary stent placement under choledochoscope for gallstone with choledocholithiasis and acute cholangitis

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Application of biliary stent placement under choledochoscope for gallstone with choledocholithiasis and acute cholangitis