摘要
目的探讨内置J管引流并一期缝合胆管在临床中治疗胆囊结石合并胆总管结石的应用价值。方法采用回顾性队列研究的方法分析2021年1月-2023年9月收住于山西医科大学附属山西省人民医院肝胆胰外科179例胆囊结石合并胆总管结石患者的病例资料, 按手术方式分为J管组(n=45)、ERCP组(n=59)和T管组(n=75), J管组采用腹腔镜胆囊切除术(LC)+腹腔镜胆总管探查术(LCBDE)+内置J管引流并一期缝合, ERCP组采用LC+内镜逆行胰胆管造影(ERCP)+内镜下乳头括约肌切开术(EST)+鼻胆管引流, T管组采用LC+LCBDE+T管引流。对比三组患者术前基线资料、术前术后实验室检查指标、手术及术后相关指标和术后短期及远期并发症的差异。正态分布的计量资料以均数±标准差(x±s)表示, 三组资料同时满足正态性和方差齐性时, 三组间比较采用单因素方差分析, 组间两两比较采用LSD-t检验。非正态分布的计量资料采用M(Q_(1), Q_(3))表示, 三组间比较采用非参数检验, 三组间两两比较采用Kruskal-Wallis单因素ANOVA检验(k个样本), 以Bonferroni校正后的显著性为准。计数资料组间比较采用χ^(2)检验或Fisher确切概率法。结果三组患者术前及术后实验室检查指标对比差异均无统计学意义(P>0.05);三组患者术后实验室检查指标与术前比较均明显下降, 差异有统计学意义(P<0.05)。在手术时间、术中出血量、胆道和腹腔引流时间、术后住院时间及住院费用方面, 三组之间比较差异均有统计学意义(P<0.05), 三组间各指标行两两比较, J管组、ERCP组和T管组手术时间分别为1.75(1.50, 2.13) h、2.00(1.83, 2.50) h和2.50(2.00, 3.00) h, J管组少于ERCP组和T管组, 差异有统计学意义(P<0.05);J管组、ERCP组和T管组术中出血量分别为15(10, 20) mL、20(10, 20) mL和30(20, 50) mL, J管组小于T管组, 差异有统计学意义(P<0.05), J管组与ERCP组差异无统计学意义(P>0.05);J管组、ERCP组和T管组胆道引流时间分别为13(12, 15) d、3(3, 4) d和55(38, 63) d, J管组小于T管组, J管组大于ERCP组, 差异均有统计学意义(P<0.05);J管组、ERCP组和T管组腹腔引流时间分别为4(3, 5) d、4(3, 4) d和5(4, 7) d, J管组小于T管组, 差异有统计学意义(P<0.05), J管组与ERCP组差异无统计学意义(P>0.05);J管组、ERCP组和T管组术后住院时间分别为4(4, 5) d、4(3, 5) d和6(4, 8) d, J管组小于T管组, 差异有统计学意义(P<0.05), J管组与ERCP组差异无统计学意义(P>0.05);J管组、ERCP组和T管组住院费用分别为(25 005.70±5 081.95)元、(40 270.59±5 785.39)元和(29 485.25±5 883.66)元, J管组少于ERCP组和T管组, 差异均有统计学意义(P<0.05)。在术后胆道出血、胆漏、胆道感染、消化道穿孔、切口感染、结石残余、结石复发和胆道狭窄方面, 三组之间比较差异无统计学意义(P>0.05);三组患者术后胰腺炎的发生率对比差异有统计学意义(P<0.05), J管组、ERCP组和T管组术后胰腺炎的例数分别为3例、10例和2例, J管组小于ERCP组, 差异有统计学意义(P<0.05), J管组与T管组差异无统计学意义(P>0.05)。结论 LC+LCBDE+内置J管引流并一期缝合与LC+ERCP+EST和LC+LCBDE+T管引流两种手术方式相比, 同样可有效的、安全地处理胆囊结石合并胆总管结石, 且术后无需带管、手术时间短、住院费用低、并发症相对较少, 性价比高, 值得在临床推广应用。
Objective To explore the application value of built-in J tube drainage and primary suture in the clinical treatment of gallbladder stones complicated with common bile duct stones.Methods A retrospective cohort study was conducted to analyze the case data of 179 patients admitted to the Department of Hepatobiliary and Pancreatic Surgery of Shanxi Provincial People's Hospital Affliated to Shanxi Medical University with gallbladder stones combined with choledocholithiasis from January 2021 to September 2023,which were divided into J-tube group(n=45),ERCP group(n=59),and T-tube group(n=75)according to the surgical methods,and the J-tube group was treated with laparoscopic cholecystectomy(LC)+laparoscopic choledochotomy exploration(LCBDE)+built-in J-tube drainage with one-stage suture,LC+endoscopic retrograde cholangiopancreatography(ERCP)+endoscopic sphincterotomy of the papilla(EST)+nasobiliary drainage in the ERCP group,and LC+LCBDE+T-tube drainage in the T-tube group.Compared the differences of preoperative baseline data,preoperative and postoperative laboratory examination indexes,surgical and postoperative related indexes,and postoperative short-term and long-term complications among the three groups.The measurement data of normal distribution were expressed as mean±standard deviation(x±s),and when the three groups of data met both normality and homogeneity of variance,one-way ANOVA was compared among the three groups,and the LSD-t test was used for ptwo comparison between the groups.Measurement data with non-normal distribution were represented by M(Qi,Qs),non-parametric test was used for comparison among the three groups,and Kruskal-Wallis single factor ANOVA test(k samples)was used for pair-to-group comparison,with Bonferroni's corrected significance as the criterion.The count data were expressed as relative numbers,and the comparison between groups was performed using chi-square test or Fisher exact probability method.Results There was no statistical significance in the comparison of preoperative and postoperative laboratory examination indexes among the three groups(P>0.05).The postoperative laboratory examination indexes of the three groups decreased significantly compared with the preoperative period,and the diference was statistically significant(P<0.05).In terms of operation time,intraoperative bleeding,biliary and abdominal drainage time,postoperative hospitalization days and hospitalization costs,the difference between the three groups was statistically significant(P<0.05),and a two-by-two comparison was made between the three groups,the operation time of the J-tube group,the ERCP group,and the T-tube group were 1.75(1.50,2.13)h,2.00(1.83,2.50)h and 2.50(2.00,3.00)h,respectively,the J-tube group was less than the ERCP group and the T-tube group,and the difference was statistically significant(P<0.05).The intraoperative bleeding in the J-tube group,ERCP group and T-tube group were 15(10,20)mL,20(10,20)mL and 30(20,50)mL,respectively,the J-tube group was smaller than the T-tube group,and the difference was statistically significant(P<0.05),and there was no statistically significant difference between the J-tube group and the ERCP group(P>0.05);The time of biliary drainage in J-tube group,ERCP group and T-tube group were 13(12,15)d,3(3,4)d and 55(38,63)d,respectively,and the J-tube group was smaller than the T-tube group,while the J-tube group was larger than the ERCP group,and the differences were statistically significant(P<O.05).The time of abdominal drainage in J-tube group,ERCP group and T-tube group were 4(3,5)d,4(3,4)d and 5(4,7)d,respectively,and the J-tube group was smaller than the T-tube group,and the dfferences were statistically significant(P<0.05).There was statistical significance(P<0.05),and the difference between the J-tube group and the ERCP group was not statistically significant(P>0.05).The postoperative hospitalization time in the J-tube group,the ERCP group,and the T-tube group was 4(4,5)d,4(3,5)d,and6(4,8)d,respectively,and the J-tube group was smaller than the T-tube group,with a statistically significant difference(P<0.05),and the difference between the J-tube group and the ERCP group was not statistically significant(P>0.05).The hospitalization costs of J-tube group,ERCP group and T-tube group were(25005.70±5081.95)yuan,(40270.59±5785.39)yuan and(29485.25±5883.66)yuan,respectively,and the J-tube group was less than ERCP group and T-tube group,and the difference was statistically significant(P<0.05).In terms of postoperative biliary bleeding,bile leakage,biliary tract infection,digestive tract perforation,incision infection,stone remnants,stone recurrence and biliary tract stenosis,the difference between the three groups was not statistically significant when compared with each other(P>0.05).However,the difference in the comparison of the incidence rates of postoperative pancreatitis among the patients in the three groups was statistically significant(P<0.05),and the cases of postoperative pancreatitis in the J-tube group,ERCP group and T-tube group were 3 cases,10 cases and 2 case,respectively.The J-tube group was smaller than the ERCP group,the difference was statistically significant(P<0.05),while the difference between the J-tube group and T-tube group was not statistically significant(P>0.05).Conclusion Compared with LC+ERCP+EST and LC+LCBDE+T tube drainage,LC+LCBDE+built-in J tube drainage and primary suture can also effectively and safely deal with gallbladder stones combined with common bile duct stones,and LC+LCBDE+builtin J-tube drainage with primary suture have the advantages of no tube,short operation time,low hospitalization cost,relatively few complications,and high cost performance,which is worthy of clinical promotion and application.
作者
张磊
黄博
Zhang Lei;Huang Bo(Department of Hepatobiliary and Pancreatic Surgery,Shanxi Provincial People's Hospital Affiliated to Shanxi Medical University,Taiyuan030012,China)
出处
《国际外科学杂志》
2024年第8期534-541,共8页
International Journal of Surgery
关键词
引流术
胆囊结石病
胆总管结石
治疗应用
Drainage
Cholecystolithiasis
Choledocholithiasis
Therapeutic uses
作者简介
通信作者:黄博,Email:huangbol408@sina.com。
