全腹腔镜与内镜联合腹腔镜治疗胆总管结石并胆囊良性疾病的对比研究

[摘 要] 目的 对比分析全腹腔镜与内镜联合腹腔镜治疗胆总管结石合并胆囊良性疾病的临床疗效，探讨最佳微创治疗方案。方法 回顾性分析四川绵阳四〇四医院2014年5月至2017年5月收治的122例胆总管结石合并胆囊良性疾病患者的临床资料，根据手术方案分为腹腔镜胆囊切除+胆总管探查取石组（LC+LCBDE，n=75），和十二指肠镜下乳头切开术（EST）+LC组（EST+LC，n=47）。其中LC+LCBDE组又分为经胆囊管胆总管探查组（LTCBDE，n=30）、胆道一期缝合组（n=21）、T管引流组（n=24）。对比分析各组围手术期结果。结果 LC+LCBDE组与EST+LC组比较，手术时间、术后禁食时间及术后并发症发生率无统计学差异（P＞0.05）；LC+LCBDE组术中失血量更多[（22.36±5.89）mL vs （18.74±6.58）mL]、术后住院时间更长[ （7.90±2.91）d vs （5.40±2.51）d]、但总费用更少[ （19 467.72±1 916.39）元 vs （24 882.89±2 477.21）元]，差异均有统计学意义（P＜0.05）。LC+LCBDE组内比较，LTCBDE组、胆道一期缝合组手术时间和术中失血量与T管引流组比较无统计学差异（P＞0.05）；LTCBDE组、胆道一期缝合组术后禁食时间[ （28.44±10.69）h、 （32.67±12.61）h vs （33.94±11.75）h]、腹腔引流时间[（2.02±0.64）d、 （2.19±0.71）d vs （3.68±0.94）d]、术后住院时间[（5.10±1.04）d、 （6.61±1.16）d vs （9.81±1.26）d]短于T管引流组（P＜0.05），住院费用[（18 743.57±1 952.64）元、 （21 035.94±2 268.68）元 vs （19 242.90±1 549.71）元]少于T管引流组（P＜0.05）；术后并发症发生率（0、19% vs 25.0%）也均低于T管引流组，且LTCBDE组与T管引流组比较有统计学差异（P＜0.05）。结论 （1）相对于内镜联合腹腔镜，全腹腔镜避免了分次手术，适应证更宽，术后并发症更轻且住院费用更少，值得推荐；（2）全腹腔镜中，LTCBDE及胆道一期缝合均能达到一次性封闭胆管的目的，能让患者获得更大的治疗收益，临床上应根据胆囊管或胆总管的具体情况优先选择。

Comparative study of full laparoscopy and endoscopy combined with laparoscopy in the treatment of choledocholithiasis with benign gallbladder diseases

Abstractobjective To compare and analyze the effect of full laparoscopy and endoscopy combined with laparoscopy for choledocholithiasis with benign gallbladder diseases, and to explore the best minimally invasive treatment. Methods The clinical data of 122 patients with choledocholithiasis and benign gallbladder diseases treated in Sichuan Mianyang 404 Hospital during the period of May 2014 to May 2017 was retrospectively analyzed. According to the operative method, patients were divided into laparoscopic cholecystectomy combined with common bile duct exploration group (LC+LCBDE, n=75) and endoscopic sphincterotomy combined with LC group (EST+LC, n=47). LC+LCBDE group was further divided into transcystic common bile duct exploration group (LTCBDE, n=30), biliary primary suture group (n=21), and T-tube drainage group (n=24). The perioperative results of each group were compared and analyzed. Results Compared with EST+LC group, LC+LCBDE group had no statistical difference (P>0.05) in operation duration, postoperative fasting time and incidence of postoperative complications, but the intraoperative blood loss [(22.36±5.89) mL vs (18.74±6.58) mL],the postoperative hospitalization time [(7.90±2.91) d vs (5.40±2.51) d], and the total cost [(19 467.72±1 916.39) yuan vs (24 882.89±2 477.21) yuan] between two groups were statistically significant different (P<0.05). In LC+LCBDE group, the operation duration and intraoperative blood loss in LTCBDE group and biliary primary suture group were not significantly different from that in T-tube drainage group (P>0.05); the postoperative fasting time [(28.44±10.69) h, (32.67±12.61) h vs (33.94±11.75) h], abdominal drainage time [(2.02±0.64) d,(2.19±0.71) d vs (3.68±0.94) d], postoperative hospitalization time [(5.10±1.04) d, (6.61± 1.16) d vs (9.81±1.26) d] in group LTCBDE and biliary primary suture group were shorter than those in T-tube drainage group (P<0.05), the hospitalization cost [(18 743.57±1 952.64) yuan, (21 035.94±2 268.68) yuan vs (19 242.90±1 549.71) yuan] were less than that in T-tube drainage group (P<0.05); the incidence of postoperative complications (0, 19% vs 25.0%) were also lower than that in T-tube drainage group, and there was a statistically significant difference between LTCBDE group and T-tube drainage group (P<0.05). Conclusion (1)Compared with the endoscopy combined with laparoscopy, full laparoscopy avoids sub-surgery, with wider indications, less postoperative complications, and less hospitalization costs, which is worth recommending; (2)In full laparoscopy, LTCBDE and primary suture of bile duct can achieve the purpose of one-time closure of the bile duct, allowing patients to obtain greater treatment benefits, clinically, preference should be given to the specific conditions of cystic duct orcommon bile duct.