老年单纯胆总管结石患者行腹腔镜胆总管探查取石术和内镜逆行胰胆管造影联合十二指肠乳头括约肌切开术的临床疗效与危险因素分析

doi:10.3877/cma.j.issn.1674-0793.2025.05.008

中华普通外科学文献(电子版) ›› 2025, Vol. 19 ›› Issue (05) : 325 -331. doi: 10.3877/cma.j.issn.1674-0793.2025.05.008

论著

老年单纯胆总管结石患者行腹腔镜胆总管探查取石术和内镜逆行胰胆管造影联合十二指肠乳头括约肌切开术的临床疗效与危险因素分析

祖力皮喀尔·图孙尼亚孜¹, 何荣东¹, 蒋铁民¹^,², 温浩¹^,²^,^†(

)

¹　830000　乌鲁木齐，新疆医科大学省部共建中亚高发病成因与防治国家重点实验室
²　830000　乌鲁木齐，新疆医科大学第一附属医院肝胆包虫病外科

收稿日期:2025-06-18 出版日期:2025-10-01
通信作者: 温浩
基金资助:
新疆维吾尔自治区重点研发项目(2022B03013-3); 新疆维吾尔自治区青年科学基金项目(2022D01C743)

Comparative efficacy and risk factors of laparoscopic common bile duct exploration versus endoscopic retrograde cholangiopancreatography combined with duodenal sphincterotomy for elderly patients with simple common bile duct stones

Rongdong He¹, Tiemin Jiang¹^,², Hao Wen¹^,²^,^†()

¹ State Key Laboratory of Pathogenesis, Prevention and Treatment of High Incidence Diseases in Central Asia, Urumqi 830000, China
² Department of Hepatobiliary & Hydatid Diseases, the First Affiliated Hospital of Xinjiang Medical University, Urumqi 830000, China

Received:2025-06-18 Published:2025-10-01
Corresponding author: Hao Wen

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引用本文：

祖力皮喀尔·图孙尼亚孜, 何荣东, 蒋铁民, 温浩. 老年单纯胆总管结石患者行腹腔镜胆总管探查取石术和内镜逆行胰胆管造影联合十二指肠乳头括约肌切开术的临床疗效与危险因素分析[J/OL]. 中华普通外科学文献(电子版), 2025, 19(05): 325-331.

Rongdong He, Tiemin Jiang, Hao Wen. Comparative efficacy and risk factors of laparoscopic common bile duct exploration versus endoscopic retrograde cholangiopancreatography combined with duodenal sphincterotomy for elderly patients with simple common bile duct stones[J/OL]. Chinese Archives of General Surgery(Electronic Edition), 2025, 19(05): 325-331.

目的

探讨腹腔镜胆总管探查取石术（LCBDE）与内镜逆行胰胆管造影联合内镜下十二指肠乳头括约肌切开术（ERCP+EST）治疗老年单纯胆总管结石的临床效果，分析术后并发症的独立危险因素。

方法

回顾性分析2017年1月至2024年12月新疆医科大学第一附属医院收治的240例老年单纯胆总管结石患者临床资料，按照手术方式分为LCBDE组（70例）和ERCP+EST组（170例）。采用卡钳值近邻匹配法（1∶2）对两组病例的一般资料进行倾向性评分匹配，其中LCBDE组47例，ERCP+EST组88例。比较两组患者手术操作相关指标以及术后并发症发生率、术后住院时间、住院总费用。通过多因素Logistic回归分析影响两种术式发生术后并发症的危险因素。

结果

ERCP+EST组在手术时长（40.00 min vs 190.00 min）、术中出血量（2.00 ml vs 50.00 ml）、住院时间（6 d vs 13 d）及住院总费用（24 768.53元 vs 35 699.11元）等方面均优于LCBDE组（均P<0.01）；转入ICU是LCBDE组术后并发症发生的独立危险因素（OR=8.59，95% CI：1.75~48.79，P<0.01），高龄、心血管疾病、胆总管直径较大显著增加ICU转入风险（P<0.05）。高血压（OR=2.90，95% CI：1.04~8.04）和糖尿病（OR=4.64，95% CI：1.16~17.73）是ERCP+EST组术后并发症发生的独立危险因素（均P<0.05）。

结论

老年胆总管结石患者的治疗术式中，LCBDE与ERCP+EST安全性良好，而ERCP+EST在手术时长、术中出血量、住院时间及住院总费用方面更优。对于伴有严重心血管疾病和胆管扩张的患者，应避免LCBDE而选择ERCP+EST；对于存在糖尿病或高血压的患者，行ERCP+EST时应慎重选择，同时围手术期应加强血糖和血压的管控。

关键词: 老年人, 胆总管结石病, LCBDE, ERCP+EST, 临床疗效, 危险因素

Objective

To investigate the clinical effectiveness of laparoscopic common bile duct exploration (LCBDE) versus endoscopic retrograde cholangiopancreatography combined with endoscopic duodenal sphincterotomy (ERCP+EST) in the treatment of elderly patients with simple common bile duct stones (CBDs), and to analyze the independent risk factors of postoperative complications.

Methods

The clinical data of 240 elderly patients with simple CBDs admitted to the First Affiliated Hospital of Xinjiang Medical University from January 2017 to December 2024 were retrospectively analyzed. The patients were divided into the LCBDE group (70 cases) and the ERCP+EST group (170 cases) according to the operation method. The general data of the two groups were matched by the propensity score matching method. Among them, there were 47 cases in the LCBDE group and 88 cases in the ERCP+EST group. The surgical operation-related indicators, including the incidence of postoperative complications, length of hospital stay, and total hospitalization costs, were compared between the two groups. Multivariate Logistic regression analysis was used to analyze the risk factors associated with postoperative complications following two surgical procedures.

Results

The ERCP+EST group had significantly better outcomes (all P<0.01), including shorter operation duration (40.00 min vs 190.00 min), less intraoperative blood loss (2.00 ml vs 50.00 ml), shorter hospitalization stay (6 days vs 13 days), and lower costs (24 768.53 yuan vs 35 699.11 yuan. ICU transfer emerged as an independent risk factor for postoperative complications in the LCBDE group (OR=8.59, 95% CI: 1.75-48.79, P<0.01). Elderly age, cardiovascular disease, and large diameter of common bile duct significantly increased the risk of ICU transfer (P<0.05). Hypertension (OR=2.90, 95% CI: 1.04-8.04) and diabetes mellitus (OR=4.64, 95% CI: 1.16-17.73) were independent risk factors for postoperative complications in the ERCP+EST group (both P<0.05).

Conclusions

In elderly patients with CBDs, LCBDE and ERCP+EST have good safety, while ERCP+EST is superior in terms of operation duration, intraoperative blood loss, hospitalization stay and costs. LCBDE should be avoided in patients with severe cardiovascular disease or bile duct dilation, while ERCP+EST is recommended. For patients with diabetes or hypertension, ERCP+EST should be carefully selected, and the control of blood glucose and blood pressure should be strengthened during the perioperative period.

Key words: Aged, Choledocholithiasis, LCBDE, ERCP+EST, Clinical efficacy, Risk factors

表1 两组患者术前一般资料比较

项目	总体(240例)	LCBDE组 (70例)	ERCP+EST组 (170例)	统计值	P值
性别^a				χ²=1.04	0.31
女	118 (49.17)	38 (54.29)	80 (47.06)
男	122 (50.83)	32 (45.71)	90 (52.94)
年龄(岁)^b	74.06±7.95	74.01±6.67	74.08±8.44	t=-0.07	0.95
体质指数(kg/m²)^b	23.87±3.99	24.83±5.07	23.47±3.39	t=2.06	0.04^e
高血压^a				χ²=18.64	<0.01^e
无	156 (65.00)	31 (44.29)	125 (73.53)
有	84 (35.00)	39 (55.71)	45 (26.47)
糖尿病^a				χ²=0.22	0.64
无	216 (90.00)	62 (88.57)	154 (90.59)
有	24 (10.00)	8 (11.43)	16 (9.41)
肺部疾病^c				χ²<0.001	1.00
无	231 (96.25)	67 (95.71)	164 (96.47)
有	9 (3.75)	3 (4.29)	6 (3.53)
心血管疾病^a				χ²=13.92	<0.01^e
无	196 (81.67)	47 (67.14)	149 (87.65)
有	44 (18.33)	23 (32.86)	21 (12.35)
肾功能不全^c				χ²=2.19	0.14
无	236 (98.33)	67 (95.71)	169 (99.41)
有	4 (1.67)	3 (4.29)	1 (0.59)
高热^a				χ²=2.41	0.12
无	115 (47.92)	39 (55.71)	76 (44.71)
有	125 (52.08)	31 (44.29)	94 (55.29)
黄疸^a				χ²=2.90	0.09
无	120 (50.00)	41 (58.57)	79 (46.47)
有	120 (50.00)	29 (41.43)	91 (53.53)
电解质紊乱^a				χ²=2.30	0.13
无	112 (46.67)	38 (54.29)	74 (43.53)
有	128 (53.33)	32 (45.71)	96 (56.47)
低蛋白血症^a				χ²=0.01	0.93
无	205 (85.42)	60 (85.71)	145 (85.29)
有	35 (14.58)	10 (14.29)	25 (14.71)
肝功能异常^a				χ²=0.09	0.76
无	223 (92.92)	64 (91.43)	159 (93.53)
有	17 (7.08)	6 (8.57)	11 (6.47)
感染性休克^c				χ²=0.47	0.50
无	234 (97.50)	67 (95.71)	167 (98.24)
有	6 (2.50)	3 (4.29)	3 (1.76)
化脓性胆管炎^a				χ²=1.99	0.16
无	177 (73.75)	56 (80.00)	121 (71.18)
有	63 (26.25)	14 (20.00)	49 (28.82)
胆源性胰腺炎^a				χ²=0.19	0.66
无	206 (85.83)	59 (84.29)	147 (86.47)
有	34 (14.17)	11 (15.71)	23 (13.53)
胆总管直径(cm)^b	1.56±0.47	1.45±0.46	1.60±0.47	t=-2.38	0.02^e
结石最大直径(cm)^d	1.20 (0.90, 1.50)	1.10 (0.80, 1.20)	1.30 (1.00, 1.50)	Z=-3.00	<0.01^e

表1 两组患者术前一般资料比较

项目	总体(240例)	LCBDE组 (70例)	ERCP+EST组 (170例)	统计值	P值
性别^a				χ²=1.04	0.31
女	118 (49.17)	38 (54.29)	80 (47.06)
男	122 (50.83)	32 (45.71)	90 (52.94)
年龄(岁)^b	74.06±7.95	74.01±6.67	74.08±8.44	t=-0.07	0.95
体质指数(kg/m²)^b	23.87±3.99	24.83±5.07	23.47±3.39	t=2.06	0.04^e
高血压^a				χ²=18.64	<0.01^e
无	156 (65.00)	31 (44.29)	125 (73.53)
有	84 (35.00)	39 (55.71)	45 (26.47)
糖尿病^a				χ²=0.22	0.64
无	216 (90.00)	62 (88.57)	154 (90.59)
有	24 (10.00)	8 (11.43)	16 (9.41)
肺部疾病^c				χ²<0.001	1.00
无	231 (96.25)	67 (95.71)	164 (96.47)
有	9 (3.75)	3 (4.29)	6 (3.53)
心血管疾病^a				χ²=13.92	<0.01^e
无	196 (81.67)	47 (67.14)	149 (87.65)
有	44 (18.33)	23 (32.86)	21 (12.35)
肾功能不全^c				χ²=2.19	0.14
无	236 (98.33)	67 (95.71)	169 (99.41)
有	4 (1.67)	3 (4.29)	1 (0.59)
高热^a				χ²=2.41	0.12
无	115 (47.92)	39 (55.71)	76 (44.71)
有	125 (52.08)	31 (44.29)	94 (55.29)
黄疸^a				χ²=2.90	0.09
无	120 (50.00)	41 (58.57)	79 (46.47)
有	120 (50.00)	29 (41.43)	91 (53.53)
电解质紊乱^a				χ²=2.30	0.13
无	112 (46.67)	38 (54.29)	74 (43.53)
有	128 (53.33)	32 (45.71)	96 (56.47)
低蛋白血症^a				χ²=0.01	0.93
无	205 (85.42)	60 (85.71)	145 (85.29)
有	35 (14.58)	10 (14.29)	25 (14.71)
肝功能异常^a				χ²=0.09	0.76
无	223 (92.92)	64 (91.43)	159 (93.53)
有	17 (7.08)	6 (8.57)	11 (6.47)
感染性休克^c				χ²=0.47	0.50
无	234 (97.50)	67 (95.71)	167 (98.24)
有	6 (2.50)	3 (4.29)	3 (1.76)
化脓性胆管炎^a				χ²=1.99	0.16
无	177 (73.75)	56 (80.00)	121 (71.18)
有	63 (26.25)	14 (20.00)	49 (28.82)
胆源性胰腺炎^a				χ²=0.19	0.66
无	206 (85.83)	59 (84.29)	147 (86.47)
有	34 (14.17)	11 (15.71)	23 (13.53)
胆总管直径(cm)^b	1.56±0.47	1.45±0.46	1.60±0.47	t=-2.38	0.02^e
结石最大直径(cm)^d	1.20 (0.90, 1.50)	1.10 (0.80, 1.20)	1.30 (1.00, 1.50)	Z=-3.00	<0.01^e

表2 倾向性评分匹配后两组患者术前一般资料比较

项目	总体(135例)	LCBDE组(47例)	ERCP+EST组(88例)	统计值	P值
性别^a				χ²=0.35	0.56
女	70 (51.85)	26 (55.32)	44 (50.00)
男	65 (48.15)	21 (44.68)	44 (50.00)
年龄^b	74.64±8.24	73.70±6.73	75.14±8.95	t=-1.05	0.30
体质指数(kg/m²)^c	23.79±4.03	23.89±4.56	23.73±3.74	t=0.23	0.82
高血压^a				χ²=0.20	0.66
无	81 (60.00)	27 (57.45)	54 (61.36)
有	54 (40.00)	20 (42.55)	34 (38.64)
糖尿病^a				χ²=0.02	0.90
无	120 (88.89)	42 (89.36)	78 (88.64)
有	15 (11.11)	5 (10.64)	10 (11.36)
肺部疾病^d				χ²=0.05	0.82
无	130 (96.30)	46 (97.87)	84 (95.45)
有	5 (3.70)	1 (2.13)	4 (4.55)
心血管疾病^a				χ²=0.16	0.69
无	106 (78.52)	36 (76.60)	70 (79.55)
有	29 (21.48)	11 (23.40)	18 (20.45)
肾功能不全^d				χ²=1.39	0.24
无	131 (97.04)	44 (93.62)	87 (98.86)
有	4 (2.96)	3 (6.38)	1 (1.14)
高热^a				χ²=1.16	0.28
无	69 (51.11)	27 (57.45)	42 (47.73)
有	66 (48.89)	20 (42.55)	46 (52.27)
黄疸^a				χ²=2.85	0.09
无	67 (49.63)	28 (59.57)	39 (44.32)
有	68 (50.37)	19 (40.43)	49 (55.68)
电解质紊乱^a				χ²=3.29	0.07
无	66 (48.89)	28 (59.57)	38 (43.18)
有	69 (51.11)	19 (40.43)	50 (56.82)
低蛋白血症^a				χ²=0.06	0.81
无	119 (88.15)	41 (87.23)	78 (88.64)
有	16 (11.85)	6 (12.77)	10 (11.36)
肝功能异常^d				χ²=0.05	0.83
无	127 (94.07)	45 (95.74)	82 (93.18)
有	8 (5.93)	2 (4.26)	6 (6.82)
感染性休克^d				χ²=0.31	0.58
无	132 (97.78)	45 (95.74)	87 (98.86)
有	3 (2.22)	2 (4.26)	1 (1.14)
化脓性胆管炎^a				χ²=0.12	0.73
无	101 (74.81)	36 (76.60)	65 (73.86)
有	34 (25.19)	11 (23.40)	23 (26.14)
胆源性胰腺炎^a				χ²=1.07	0.30
无	115 (85.19)	38 (80.85)	77 (87.50)
有	20 (14.81)	9 (19.15)	11 (12.50)
胆总管直径(cm)^e	1.50 (1.20, 1.70)	1.40 (1.20, 1.70)	1.50 (1.20, 1.70)	Z=-0.48	0.63
结石最大直径(cm)^e	1.10 (0.80, 1.50)	1.10 (0.80, 1.45)	1.15 (0.88, 1.50)	Z=-0.50	0.61

表2 倾向性评分匹配后两组患者术前一般资料比较

项目	总体(135例)	LCBDE组(47例)	ERCP+EST组(88例)	统计值	P值
性别^a				χ²=0.35	0.56
女	70 (51.85)	26 (55.32)	44 (50.00)
男	65 (48.15)	21 (44.68)	44 (50.00)
年龄^b	74.64±8.24	73.70±6.73	75.14±8.95	t=-1.05	0.30
体质指数(kg/m²)^c	23.79±4.03	23.89±4.56	23.73±3.74	t=0.23	0.82
高血压^a				χ²=0.20	0.66
无	81 (60.00)	27 (57.45)	54 (61.36)
有	54 (40.00)	20 (42.55)	34 (38.64)
糖尿病^a				χ²=0.02	0.90
无	120 (88.89)	42 (89.36)	78 (88.64)
有	15 (11.11)	5 (10.64)	10 (11.36)
肺部疾病^d				χ²=0.05	0.82
无	130 (96.30)	46 (97.87)	84 (95.45)
有	5 (3.70)	1 (2.13)	4 (4.55)
心血管疾病^a				χ²=0.16	0.69
无	106 (78.52)	36 (76.60)	70 (79.55)
有	29 (21.48)	11 (23.40)	18 (20.45)
肾功能不全^d				χ²=1.39	0.24
无	131 (97.04)	44 (93.62)	87 (98.86)
有	4 (2.96)	3 (6.38)	1 (1.14)
高热^a				χ²=1.16	0.28
无	69 (51.11)	27 (57.45)	42 (47.73)
有	66 (48.89)	20 (42.55)	46 (52.27)
黄疸^a				χ²=2.85	0.09
无	67 (49.63)	28 (59.57)	39 (44.32)
有	68 (50.37)	19 (40.43)	49 (55.68)
电解质紊乱^a				χ²=3.29	0.07
无	66 (48.89)	28 (59.57)	38 (43.18)
有	69 (51.11)	19 (40.43)	50 (56.82)
低蛋白血症^a				χ²=0.06	0.81
无	119 (88.15)	41 (87.23)	78 (88.64)
有	16 (11.85)	6 (12.77)	10 (11.36)
肝功能异常^d				χ²=0.05	0.83
无	127 (94.07)	45 (95.74)	82 (93.18)
有	8 (5.93)	2 (4.26)	6 (6.82)
感染性休克^d				χ²=0.31	0.58
无	132 (97.78)	45 (95.74)	87 (98.86)
有	3 (2.22)	2 (4.26)	1 (1.14)
化脓性胆管炎^a				χ²=0.12	0.73
无	101 (74.81)	36 (76.60)	65 (73.86)
有	34 (25.19)	11 (23.40)	23 (26.14)
胆源性胰腺炎^a				χ²=1.07	0.30
无	115 (85.19)	38 (80.85)	77 (87.50)
有	20 (14.81)	9 (19.15)	11 (12.50)
胆总管直径(cm)^e	1.50 (1.20, 1.70)	1.40 (1.20, 1.70)	1.50 (1.20, 1.70)	Z=-0.48	0.63
结石最大直径(cm)^e	1.10 (0.80, 1.50)	1.10 (0.80, 1.45)	1.15 (0.88, 1.50)	Z=-0.50	0.61

表3 两组患者术后并发症发生率的比较[例（%）]

组别	例数	术后胰胆道系统并发症^a		术后胰腺炎^a		术后胆漏^b		术后感染^c
组别	例数	无	有	无	有	无	有	无	有
总体	135	116 (85.93)	19 (14.07)	118 (87.41)	17 (12.59)	133 (98.52)	2 (1.48)	132 (97.78)	3 (2.22)
LCBDE组	47	40 (85.11)	7 (14.89)	42 (89.36)	5 (10.64)	45 (95.74)	2 (4.26)	44 (93.62)	3 (6.38)
ERCP+EST组	88	76 (86.36)	12 (13.64)	76 (86.36)	12 (13.64)	88 (100.00)	0 (0)	88 (100.00)	0 (0)
统计值		χ²=0.04		χ²=0.25		-		χ²=3.18
P值		0.84		0.62		0.12		0.07

表3 两组患者术后并发症发生率的比较[例（%）]

组别	例数	术后胰胆道系统并发症^a		术后胰腺炎^a		术后胆漏^b		术后感染^c
组别	例数	无	有	无	有	无	有	无	有
总体	135	116 (85.93)	19 (14.07)	118 (87.41)	17 (12.59)	133 (98.52)	2 (1.48)	132 (97.78)	3 (2.22)
LCBDE组	47	40 (85.11)	7 (14.89)	42 (89.36)	5 (10.64)	45 (95.74)	2 (4.26)	44 (93.62)	3 (6.38)
ERCP+EST组	88	76 (86.36)	12 (13.64)	76 (86.36)	12 (13.64)	88 (100.00)	0 (0)	88 (100.00)	0 (0)
统计值		χ²=0.04		χ²=0.25		-		χ²=3.18
P值		0.84		0.62		0.12		0.07

表4 两组患者术后住院时间与住院总费用比较[M(Q₁, Q₃)]

组别	例数	术后住院时间(d)	住院总费用(元)
总体	135	8.00 (5.00, 12.00)	26 669.27 (22 231.61, 33 375.15)
LCBDE组	47	13.00 (9.50, 17.00)	35 699.11 (29 294.64, 45 804.49)
ERCP+EST组	88	6.00 (5.00, 8.00)	24 768.53 (20 791.53, 28 913.79)
Z值		8.03	6.54
P值		<0.01	<0.01

表4 两组患者术后住院时间与住院总费用比较[M(Q₁, Q₃)]

组别	例数	术后住院时间(d)	住院总费用(元)
总体	135	8.00 (5.00, 12.00)	26 669.27 (22 231.61, 33 375.15)
LCBDE组	47	13.00 (9.50, 17.00)	35 699.11 (29 294.64, 45 804.49)
ERCP+EST组	88	6.00 (5.00, 8.00)	24 768.53 (20 791.53, 28 913.79)
Z值		8.03	6.54
P值		<0.01	<0.01

图1 LCBDE组多因素Logistic回归森林图　腹腔镜胆总管探查取石术（LCBDE）

图2 ERCP+EST组多因素Logistic回归森林图　内镜逆行胰胆管造影（ERCP）；十二指肠乳头括约肌切开术（EST）

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Comparative efficacy and risk factors of laparoscopic common bile duct exploration versus endoscopic retrograde cholangiopancreatography combined with duodenal sphincterotomy for elderly patients with simple common bile duct stones

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Comparative efficacy and risk factors of laparoscopic common bile duct exploration versus endoscopic retrograde cholangiopancreatography combined with duodenal sphincterotomy for elderly patients with simple common bile duct stones