胆道镜联合术中胆道造影在困难腹腔镜胆囊切除术中的应用

目的 探讨胆道镜联合术中胆道造影（intraoperative cholangiography，IOC）在困难腹腔镜胆囊切除术（LC）中的应用价值，并分析影响术后并发症发生的相关因素。方法 前瞻性选取2019年6月至2020年9月温州市中西医结合医院收治的符合困难LC诊断的患者186例，随机分为对照组和观察组，每组各93例。对照组采用常规LC术，观察组采用胆道镜联合IOC的LC术。比较两组患者胆管损伤、手术时间、术中出血量、住院时间、中转开腹率及术后3个月并发症情况。采用单因素和多因素Logistic回归模型分析影响患者术后并发症发生的相关危险因素。结果 观察组与对照组手术时间（36.38±4.16）min vs（52.24±8.46）min]、术中出血量（67.35±6.22）mL vs（86.64±7.69）mL]、住院时间（5.72±0.36）d vs（8.45±1.42）d]、中转开腹率0 vs 8.60%（8/93）]以及并发症总发生率4.30%（4/93）vs 15.05%（14/93）]差异均有统计学意义（P＜0.05），观察组均低于对照组。多因素Logistic分析表明，年龄＞60岁（OR 2.128，95%CI 1.395～2.902）、合并糖尿病（OR 2.526，95%CI 1.682～3.427）、手术时间≥40 min（OR 2.318，95%CI 1.879～2.836）、术中出血量≥70 mL（OR 2.418，95%CI 1.389～3.523）、术中无胆道造影（OR 3.967，95%CI 2.184～4.853）是LC术后并发症发生的独立危险因素。结论 胆道镜联合IOC在困难LC治疗中可降低患者胆管损伤、手术时间、术中出血量、住院时间和中转开腹率，且术后并发症少。困难LC术后并发症与患者年龄、是否合并糖尿病、手术时间、术中出血量、术中有无胆道造影有关。

Application of choledochoscopy combined with intraoperative cholangiography in difficult laparoscopic cholecystectomy

Objective To investigate the application value of choledochoscopy combined with intraoperative cholangiography (IOC) in difficult laparoscopic cholecystectomy (LC), and to analyze the related factors affecting the occurrence of postoperative complications. Methods A total of 186 patients with difficult LC admitted to Wenzhou Hospital of Intergrated Traditional Chinese and Western Medicine from Jun. 2019 to Sep. 2020 were randomly divided into the control group (n=93) and the observation group (n=93). Patients in control group were treated with conventional difficult LC, and patients in observation group were treated with choledochoscopy combined with IOC in LC. Ratio of bile duct injury, operation time, intraoperative blood loss, time of hospitalization, conversion rate of laparotomy and complications 3 months after operation were compared between the two groups. Univariate analysis and multivariate Logistic regression models were employed to analyze the related factors of postoperative complications. Results There were statistical differences between two groups in terms of operation time (36.38±4.16)min vs (52.24±8.46)min], intraoperative blood loss (67.35±6.22)mL vs(86.64±7.69)mL], hospitalization time (5.72±0.36)d vs (8.45±1.42)d], conversion rate 0 vs 8.60% (8/93)], and the total incidence of postoperative complications 4.30% (4/93) vs 15.05% (14/93)] were all statistically significant (P<0.05), indicators in observation group were all lower than those in control group. Multivariate Logistic analysis showed that age>60 years old (OR 2.128, 95%CI 1.395~2.902), diabetes mellitus (OR 2.526, 95%CI1.682~3.427), operation time ≥40 min (OR 2.318, 95%CI 1.879~2.836), intraoperative blood loss ≥70 mL (OR 2.418, 95%CI 1.389~3.523), and non-intraoperative cholangiography (OR 3.967, 95%CI 2.184~4.853) were independent factors of postoperative complications. Conclusion For difficult LC, choledochoscopy combined with IOC can reduce bile duct injury, operation time, intraoperative blood loss, hospitalization time and conversion laparotomy rate, and postoperative complications. Complications after difficult LC are related to patient’s age, whether or not complicated with diabetes, operation time, intraoperative blood loss, and intraoperative cholangiography