继发性胆总管结石外科治疗策略研究

摘要：目的　探讨继发性胆总管结石的外科治疗策略，比较并分析腹腔镜下一期缝合手术及内镜治疗方法的优缺点及适应证。方法　收集接受腹腔镜下一期缝合手术及内镜治疗的188例继发性胆总管结石患者的临床资料并随访，所有患者均合并胆囊结石，65例患者（一期缝合组）接受了腹腔镜下胆总管切开取石（LCBDE）一期缝合联合胆囊切除术（LC），123例患者（内镜取石组）施行了内镜下逆行胰胆管造影检查（ERCP）联合十二指肠乳头肌切开取石术（EST）并二期行LC。对2组患者手术适应证、结石大小、结石分布、胆道感染情况、合并基础疾病及住院时间、术后近远期并发症、费用等进行比较分析。结果　2组患者的胆总管直径、结石数量及大小差异无统计学意义。一期缝合组住院时间、住院费用均低于内镜取石组（P＜0.05）。一期缝合组术后轻微胆瘘2例，内镜取石组术后高淀粉酶血症21例。术后1年随访2组均无胆道狭窄及结石复发。结论　在同时满足适应证的情况下，胆总管一期缝合手术治疗继发性胆总管结石相较内镜取石住院时间更短、费用更低且不破坏正常生理结构。

Study on surgical treatment strategy for secondary choledocholithiasis

Abstract: Objective　To explore the surgical treatment strategies for secondary choledocholithiasis, and to compare and analyze the advantages and disadvantages of laparoscopic primary suture and endoscopic treatment. Methods　The clinical data of 188 patients with secondary common bile duct stones who underwent laparoscopic primary suture and endoscopic treatment were collected. All these patients were with gallbladder stones, 65 patients (primary suture group) underwent laparoscopic choledocholithotomy (LCBDE) and primary suture combined with cholecystectomy (LC), and 123 patients (endoscopic lithotomy group) who underwent endoscopic retrograde cholangiopancreatography (ERCP) combined with twelve papillary muscle incision and stone extraction (EST), and LC was performed in the second stage. The stone size, distribution, biliary tract infection, combined underlying diseases and length of hospitalization, postoperative complications, costs and other data were compared and analyzed between the two groups. Results　There were no significant differences in the diameter of the common bile duct, the number and the size of stones between the two groups. The length of hospitalization and hospitalization expenses were lower in the primary suture group than those in the endoscopic lithotomy group (P＜0.05). There were 2 cases of minor biliary fistula in the primary suture group and 21 cases of postoperative hyperamylase in the endoscopic lithotomy group. After 1 year follow-up, there was no biliary stricture or recurrence of stones in the two groups. Conclusion　Both treatment methods have merit and demerit, and under the condition of satisfying the indications, the primary suture of common bile duct for the treatment of secondary common bile duct stones has shorter hospital stay, lower cost and no damage to the normal physiological structure compared with the endoscopic lithotomy.