腹腔镜术中逆行放置鼻胆管在治疗胆囊结石并胆总管结石中的临床价值

目的探讨腹腔镜术中放置鼻胆管一期缝合胆总管在治疗胆囊结石并胆总管结石的应用价值。方法55例胆总管结石合并胆囊结石，2010年1～12月24例采用经内镜下逆行胰胆管造影（ERCP）、乳头括约肌切开取石术（EST）后行腹腔镜胆囊切除术治疗（对照组），2011年1～6月31例行腹腔镜胆总管探查术中放置鼻胆管一期缝合治疗（观察组）。比较2组手术时间、术中出血量、术后肝功能恢复时间、近期并发症、住院时间和住院费用等指标。结果对照组24例中成功20例，行ERCP插管失败3例，EST取石失败1例，总体成功率83．3％（20／24）；观察组2例中转开腹，手术成功率93．5％（29／31）。2组总体手术成功率、术中出血量、术后胰腺炎和淀粉酶升高、术后肝功能异常和一过性胆漏的发生率差异无显著性（P〉0．05）。与对照组相比，观察组手术时间短[（128．6±18．9）rainvs．（170．8±25．2）min，t=-6．824，P=0．000]，总住院时间短[（8．7±2．4）dVS．（15．6±4．9）d，t=-6．715，P=0．000]，住院费低[（8723．6±1352．2）元vs．（14563．4±4285．9）元，t=-7．092，P=0．000]。2组均未出现严重并发症。术后随访6～12个月，观察组失访1例。观察组术后胆道感染[3．3％（1／30）]、肝功能异常[6．7％（2／30）]发生率明显低于对照组[25．0％（5／20），35．o％（7／20）]（χ^2=5．335、6．527，P=0．021、0．011）；2组术后结石残余、上腹不适发生率差异无显著性（P〉0．05），短期随访均无胆管狭窄。结论腹腔镜胆总管探查术中放置鼻胆管一期缝合胆总管，可一期完成手术，扩大一期缝合胆总管的适应证，安全，经济，技术设备要求低，易于开展。

The Clinical Value of Intraoperative Placed Nasobiliary Catheter in the Treatment of Choledocholithiasis under Laparoscopy

Objective To investigate the clinical value of intraoperatively placed nasobiliary catheter and primary suture of common bile duct in the treatment of cholecystolithiasis combined with choledocholithiasis under laparoscopy. Methods The data of 55 patients suffering from cholecystolithiasis combined with choledocholithiasis were divided into two groups. The 24 cases hospitalized from January 2010 to December 2010 （ control group） underwent ERCP ＋ EST preoperative LC and 31 cases hospitalized from January 2011 to June 2011 （observe group） underwent laparoscopic colecystectomy together with choledocholithotomy, nasobiliary drainage and primary suture of common bile duct. The operation time, intraoperative blood loss, short-term complications, hospital stay and hospital costs were compared between the two groups. Results In control group, the success rate of ERCP and EST was 83.3% （20/24） , with ERCP failure in 3 cases and EST failure in 1 case; in observe group,the success rate was 93.5% （29/31） , with 2 cases being converted to open cholecystectomy and common bile duct exploration. There were no statistical differences in success rate, operative blood loss, postoperative amylase increase and incidence of postoperative pancreatitis, abnormal liver function and transient bile leakage （P 〉 0.05）. Compared with control group, observe group had less operative time [ （128.6± 18.9） min vs. （170.8 ± 25.2） min, t= -6.824, P=0.000], shorter hospital stay [（8.7 ±2.4） d vs. （15.6 ±4.9） d, t = -6.715, P=0. 000] and lower hospital costs [ （8723.6 ± 1352.2） yuan vs. （ 14 563.4 ± 4285.9） yuan, t = - 7. 092, P = 0. 000]. No serious complications occurred in both groups. The patients were followed up for 6 - 12 months postoperatively, and 1 case in observe group was lost contact with. Compared with control group, there was lower incidence of biliary infection [ 3.3% （1/30） vs. 25.0% （5/20）, x^2 = 5. 335, P =0.021] and less abnormal liver function in observe group [6.7% （2/30） vs. 35.0% （7/20）, x^2 = 6. 527, P = 0. 011 ]. No obvious difference was found in the incidence of postoperative stone residual and epigastric discomfort （ P 〉 0.05 ）. No postoperative bile duct stricture was found in both groups. Conclusions Intraoperatively placing nasobiliary catheter under laparoscopy is safe, cost-effective and easy to perform. It can treat cholecystolithiasis combined with choledocholithiasis in one stage and expand the indications of primary suture of common bile duct.