腹腔镜下左半肝切除联合纤维胆道镜治疗肝内胆管结石

目的 探讨腹腔镜下左半肝切除联合纤维胆道镜取石术治疗肝内胆管结石患者的临床效果。方法 选取2016年1—12月手术治疗的148例肝内胆管结石患者的临床资料进行回顾性分析。148例患者中男82例,女66例;年龄43～78(65.3 ±10.7)岁。其中69例患者采用腹腔镜左半肝切除联合纤维胆道镜取石术治疗(微创组),79例患者采用传统开腹手术治疗(开腹组)。对比两组患者术中出血量、手术时间、取石时间、术后引流量、住院时间,对比不同时间点患者血清白蛋白(ALB)、丙氨酸氨基转移酶(ALT)、天门冬氨酸氨基转移酶(AST)、总胆红素(TBIL)、血清球蛋白(G)、白细胞(WBC)、中性粒细胞、皮质醇变化情况,对比患者术后并发症的发生率。结果 微创组的手术出血量、术后引流量、住院时间均低于开腹组,而取石时间长于开腹组,差异均有统计学意义(P值均<0.01)。组内不同时间点比较:两组患者的血清ALT、AST、TBIL以及WBC、中性粒细胞在术后第1天显著升高,此后逐渐降低,差异均有统计学意义(P值均<0.01);而血清ALB、G在手术前后差异均无统计学意义(P值均>0.05);而皮质醇在术后逐渐升高,在第3天达高峰,之后降低(P<0.05)。组间比较:术前两组患者的血清ALT、AST、TBIL、ALB、G、WBC、中性粒细胞、皮质醇测定值差异均无统计学意义(P值均>0.05);术后第1、3、7天,微创组患者的血清ALT、AST、TBIL、WBC、中性粒细胞、皮质醇均低于开腹组,差异均有统计学意义(P值均<0.05),而血清ALB、G两组间差异均无统计学意义(P值均>0.05)。微创组患者的手术并发症发生率为7.25%(5/69),低于开腹组患者的18.99%(15/79),差异有统计学意义(χ²=4.344, P<0.05)。结论 腹腔镜左半肝切除联合纤维胆道镜取石术治疗肝内胆管结石具有手术创伤小、术后恢复快、并发症少的优势。

Study on the effect of partial hepatectomy combined with choledochoscopy in the treatment of intrahepatic bile duct stones under laparoscopic left liver pedicle

Objective To explore the clinical effect of laparoscopic left hepatic pedicle block partial hepatectomy combined with choledochofiberscope in the treatment of intrahepatic bile duct stones.Methods A retrospective analysis of 148 patients with intrahepatic bile duct stones treated surgically from January 2016 to December 2016 was performed, there were 82 males and 66 females, range from 43 to 78 years, mea age was 65.3±10.7. Among them, 69 patients were treated with laparoscopic left hepatic pedicle occlusion, partial hepatectomy combined with fiber choledochoscope lithotripsy (minimally invasive group), and 79 patients with traditional open surgery (laparotomy group). The blood loss, operation time, lithotripsy time, postoperative drainage and hospital stay were compared between two groups. Serum albumin (ALB), alanine aminotransferase (ALT), aspartate amino (AST), total bilirubin (TBIL), serum globulin (G), white blood cells (WBC), neutrophils, cortisol changes in patients with postoperative complications compared the incidence.Results In the minimally invasive group, the amount of operative bleeding, postoperative drainage, and hospital stay were all lower than those in the laparotomy group, while the stone retrieval time was longer than that in the laparotomy group. The difference was statistically significant (all P values<0.01). There were no significant differences in the measured values of ALB, ALT, AST, TBIL, G, WBC, neutrophil and cortisol between the two groups before surgery (all P values>0.05). The levels of serum ALT, AST, TBIL, WBC, neutrophil and cortisol in patients in minimally invasive group were significantly lower than those in laparotomy group on the 1st, 3rd, 7th day after operation (all P values<0.05). However, there was no significant difference between ALB and G proteins (all P values>0.05). Serum levels of ALT, AST, TBIL, WBC and neutrophil in the two groups increased significantly on the first postoperative day and gradually decreased (all P values<0.01). Serum ALB in both groups decreased gradually after operation and recovered on the 7th day after operation (all P values<0.05). Cortisol in both groups gradually increased in the first 3 days after operation and then gradually decreased (all P values<0.05). The incidence of complications in the minimally invasive group was 7.25%(5/69), the laparotomy group was 18.99%(15/79), the difference was statistically significant (χ²=4.344, P<0.05).Conclusions Laparoscopic partial hepatic pedicle blockade combined with partial cholecystectomy and cholecystolithotomy for the treatment of intrahepatic bile duct stones has the advantages of small trauma, rapid postoperative recovery and less complications.