经皮经肝胆道镜硬镜碎石术治疗肝内胆管结石患者临床疗效研究*

目的 探讨经皮经肝胆道镜（PTCL）硬镜碎石术治疗肝内胆管结石患者的临床疗效。方法 2013年3月~2015年3月我院诊治的肝内胆管结石患者200例,随机分为两组,每组100例,分别采取经皮经肝胆道镜硬镜手术取石治疗或常规开腹手术治疗。比较两组患者疗效和并发症发生率情况。结果 PTCL治疗组患者体质指数为（24.2±2.2） kg/m²,结石直径为（4.3±0.5） mm,结石位于左肝管、右肝管和左右肝管比例分别为56.0%、37.0%和7.0%,与开腹组【分别为（24.0±3.0） kg/m²、（4.4±0.6） mm、55.0%、39.0%和6.0%】比,差异均无统计学意义（P>0.05）;两组均顺利完成手术,取净结石;PTCL组手术时间为（154.3±21.8） min,术中出血量为（96.3±15.8） ml,肛门排气时间为（1.1±0.5） d,术后住院日为（7.7±0.9） d,均显著短于或少于开腹组【分别为（247.6±30.5） min、（190.0±10.5） ml、（1.9±0.4） d和（10.0±1.2） d,P<0.05】;术后,PTCL组发生切口感染、腹腔感染、肺部感染或胆汁漏等并发症3例（3.0%）,显著少于开腹组的11例（11.0%,x²=4.902,P<0.05）;术后2 w,PTCL组血清ALT和AST水平为（43.9±9.5） u/l和（40.3±8.9） u/l,与开腹组的（42.3±10.2） u/l和（43.4±10.5） u/l比,无显著性差异（P>0.05）,而血清TBIL水平为（18.9±3.2） μmol/l,显著低于开腹组的（23.0±3.1） μmol/l（P<0.05）;术后1年末,经B超复查,PTCL治疗患者结石复发2例（2.0%）,显著少于开腹组的9例（9.0%,x²=8.901,P<0.01）;术后2年末,经B超复查,PTCL治疗患者结石累计复发3例（3.0%）,显著低于开腹组的15例（15.0%,x²=11.071,P<0.01）。结论 采用经皮经肝胆道镜硬镜碎石术治疗肝内胆管结石患者能够加快患者康复进程,降低术后并发症的发生,在两年观察期间,结石复发率较低,值得临床进一步研究。

Two-year follow up of patients with intrahepatic cholelithiasis after percutaneous transhepatic choledochoscopic lithotripsy

Objective To investigate the efficacy of percutaneous transhepatic choledochoscopic lithotripsy （PTCL） in patients with intrahepatic cholelithiasis after two-year follow-up.Methods 200 patients with intrahepatic cholelithiasis were enrolled in our hospital between March 2013 and March 2015,and were randomly divided into two groups with 100 in each,receiving PTCL or conventional open laparotomy. The operation parameters,complications and relapse of stone after two-year follow-up in the two groups were compared.Results The body mass index （BMI） was （24.2±2.2） kg/m²,the diameter of stone was （4.3±0.5） mm,and the percentages of stone location in the left,right and both hepatic ducts in PTCL-treated group were 56.0%,37.0% and 7.0%,not significantly different as compared to （24.0±3.0） kg/m²,（4.4±0.6） mm,55.0%,39.0% and 6.0% （P>0.05） in patients receiving open laparotomy;the operation finished in both groups and the stones were cleared out;the operation time was （154.3±21.8） min,bleeding volume was （96.3±15.8） ml,first exhaust was （1.1±0.5） d,and hospitalization time after operation was（7.7±0.9） d in PTCL-treated patients,all significantly shorter or less than（247.6±30.5） min,（190.0±10.5） ml,（1.9±0.4） d and （10.0±1.2） d,respectively,in the open laparotomy （P<0.05）;after operation,the incidence of complications,such as incision infection,peritonitis,pulmonary infection or bile leak in PTCL-treated group was 3.0%,significantly less than 11.0% （x²=4.902,P<0.05） in patients receiving open laparotomy;two weeks after operation,serum ALT and AST levels in PTCL-treated group were （43.9±9.5） u/l and （40.3±8.9） u/l,not significantly different as compared to （42.3±10.2） u/l and （43.4±10.5） u/l in open laparotomy （P>0.05）,while serum bilirubin level was （18.9±3.2） μmol/l,significantly lower than （23.0±3.1） μmol/l（P<0.05） in open laparotomy;at the end of one year follow-up,the stone relapse as showed by ultrasound examination in PTCL-treated patients was 2.0%,significantly lower than 9.0% （x²=8.901,P<0.01） in open laparotomy;at the end of two year follow-up,the cumulated stone relapse in PTCL group was 3.0%,significantly lower than 15.0% （x²=11.071,P<0.01） in open laparotomy. Conclusion The application of percutaneous transhepatic choledochoscopic lithotripsy for treatment of patients with intrahepatic cholangiolithiasis might accelerate the rehabilitation and reduce postoperative complications and stone relapse,which warrants further investigation.