经内镜逆行胰胆管造影术与腹腔镜胆道手术在肝内外胆管结石治疗中的疗效评价

Evaluation of effect of endoscopic retrograde cholangiopancreatography and laparoscopic bile duct exploration lithotomy in treatment of intra/extra-hepatic duct stones

摘要:

目的 探讨经内镜逆行胰胆管造影术（ERCP）与腹腔镜胆道手术在肝内外胆管结石治疗中的 疗效。方法 对110 例肝内胆管结石位于Ⅰ和Ⅱ级肝管与378 例单纯胆总管结石患者行ERCP+ 内镜下十二 指肠乳头括约肌切开术（EST）+ 经内镜鼻胆管引流术（ENBD），或腹腔镜胆道探查取石术（LBDEL）联合 激光碎石术，术中胆管一期缝合或放置T 管，比较两种术式的围手术期并发症及术后恢复情况。结果 110 例肝内胆管结石患者结石残余率为31.82%，其中ERCP 组（51.06%）残余结石率高于LBDEL 组（17.46%） （P <0.05），术后恢复LBDEL 组优于ERCP 组。378 例单纯胆总管结石患者结石残余率为8.20%，其中ERCP 组（3.68%）残余结石率低于LBDEL 组（11.63%）（P <0.05）；术后恢复情况两组差异无统计学意义（P >0.05）。 术后并发症中LBDEL 组胆漏与肺部感染发生率高于ERCP 组；腹腔感染、急性胰腺炎、消化道出血及消化 道穿孔方面ERCP 组发生率高于LBDEL 组。单纯胆总管结石患者ERCP 治疗时出现2 例消化道穿孔导致死 亡。结论 LBDEL 和ERCP 治疗胆总管结石具有相同的临床疗效，但在肝内胆管结石治疗中ERCP 优势不 明显，术后并发症发生率高。LBDEL 治疗肝内外胆管结石疗效显著，可保持Oddi 括约肌的完整性，该项技术 易于普及到基层医院，令广大患者受益。

Abstract:

Objective To investigate the therapeutic effects of endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic bile duct exploration lithotomy (LBDEL) in treatment of intra/extra-hepatic duct stones. Methods There were 110 patients whose intrahepatic stones located in Ⅰ , Ⅱ hepatic duct and 378 patients whose stones only located in the common bile duct. These patients respectively underwent LBDE combined with choledochoscope laser lithotripsy or ERCP combined with endoscopic sphincterotomy (EST) and endoscopic nasobiliary drainage (ENBD) to remove the stones. Common bile ducts were performed primary suture or T tube placement in the LBDEL cases. The evaluation was carried out for perioperative complications and postoperative recovery of the surgical methods. Results The residual stone rate was 31.82% in 110 cases. The rate was higher in ERCP group (51.06%) than that in LBDEL group (17.46%) (P < 0.05). Postoperative recovery was better in LBDEL group than that in ERCP group. The residual stone rate was 8.20% in 378 cases. The rate was lower in ERCP group (3.68%) than that in LBDEL group(11.63%) (P < 0.05). Between the two groups, there had no statistical significance in postoperative recovery. The incidences of bile leakage and pulmonary infection were higher in LBDEL group than in ERCP group. The incidences of abdominal cavity infection, acute pancreatitis, digestive tract perforation and gastrointestinal bleeding were higher in ERCP group than that in LBDEL group. 2 of the 378 patients occurred death were happened digestive tract perforation which were induced during ERCP procedure. Conclusion LBDEL and ERCP demonstrated the same therapeutic effects in the treatment of common bile duct stones. However, ERCP has no large advantages in the treatment of hepatolithiasis, and shows higher complication rates. LBDEL has a significant curative effect for intra-and extrahepatic bile duct calculi and can maintain the integrity of Oddi sphincter. This technology is easy to spread to the basic-level hospital to benefit the majority of patients.