三镜联合行腹腔镜胆总管一期缝合术的疗效分析

目的 探讨三镜（腹腔镜+胆道镜+十二指肠镜）联合行腹腔镜胆总管一期缝合术治疗胆总管结石的临床疗效及其优缺点。 方法 采用回顾性分析方法收集行胆总管探查取石术的123例胆总管结石患者的临床资料。行三镜联合胆总管探查取石术+经腹置入鼻胆管引流术+一期缝合术62例（50.4%），以下简称三镜组；行腹腔镜胆总管探查取石术+T管引流术61例（49.6%），以下简称T管组。通过观察患者术前一般情况、术中手术情况、术后恢复及并发症情况、随访情况，对比分析三镜联合行腹腔镜胆总管一期缝合术和T管引流术各自的临床疗效及其优缺点。 结果 三镜组与T管组性别、年龄、术前伴有急性胰腺炎、术前慢性疾病率（高血压、糖尿病、心脏病）、结石数目、手术时间、术后1 d鼻胆管和T管引流情况、术后拔除腹腔引流管时间、术后漏胆率、术后出血、术后胰腺炎并发率差异均无统计学意义（P＞0.05）；在胆总管直径、术前总胆红素、术前胆管炎严重程度分度（应用2018版东京指南分级）、既往上腹部手术史情况、术中估计出血量、结石大小、腹腔引流管术后1 d引流量、术后残石率、手术治疗费用、住院时间方面差异有统计学意义（P＜0.05）。所有病例均成功手术且术后恢复良好，随访期间内无结石复发及胆道狭窄或其他相关并发症发生。 结论 在可靠的腔镜缝合技术支持下，三镜联合行腹腔镜胆总管一期缝合术安全可行，临床疗效满意。但不应盲目选择一期缝合，应根据患者自身情况和不同术式优缺点制定个体化的手术治疗方案。

Analysis of the efficacy of laparoscopic primary suture of common bile duct with three endoscopes

Objective To investigate the clinical efficacy and pros and cons of laparoscopic primary closure of common bile duct in patients with choledocholith-iasis by three endoscopes(laparoscopy + choledochoscopy + duodenoscope).Methods The clinical data of 123 patients with common bile duct stones who underwent choledocholithotomywere collected by retrospectively analysis method. Among the 123 cases, 62 cases(50.4%) underwent combination appliances of three endoscopes combined with choledocholithotomy and nasobiliary drainage through abdomen and primary closure of common bile duct，and hereinafter referred to as the three-endoscopes group. And 61 cases(49.6%) underwent choledocholithotomy plus T-tube drainage, and hereinafter referred to as the T-tube group. With observation on the general conditions before operation, situations at surgery, postoperative recovery situations and complications and follow-up situations of patients, we had a contrastive analysis of the pros and cons of primary suture of common bile duct with three endoscopes and T-tube drainage after choledocholithotomy.Results The differences of gender, age, preoperative with acute pancreatitis, preoperative chronic disease rate (hypertension, diabetes, heart disease), the number of stones, operation time, nasobiliary and T-tube drainage volume on the first day after operation, postoperative removal of abdominal drainage tube time, the rate of postoperative bile leakage, the postoperative hemorrhage, and the rate of complications of postoperative pancreatitis and hospitalization cost of patients all had no statistics significance(P＞0.05) between the three-endoscopes group and the T-tube group. But the differences of common bile duct diameter, preoperative total bilirubin, severe degrees of preoperative cholangitis(According to the 2018 version of the Tokyo Guideline classification), previous history of upper abdominal surgery, the estimated intraoperative bleeding volume, the size of stone, the abdominal drainage volume on the 1st postoperative day, the rate of postoperative residual stone, the cost of surgical treatment, and the hospitalization time of patients had statistics significance(P＜0.05) between the three-endoscopes group and the T-tube group. All 140 cases underwent operations successfully and recovered well. There were no stone recurrence, biliary stricture or other related complications occurred during the follow-up period.Conclusion With the support of reliable endoscopic suture technique, the laparoscopic primary suture of common bile duct with three endoscopes is safe and feasible, and the clinical effect is satisfactory. However, we should not blindly choose primary suture. Individualized surgical treatment should be formulated according to the patient′s own conditions and the advantages and disadvantages of different surgical.