内镜下胆总管取石术后胆总管结石复发的危险因素及择期胆囊切除术对复发的影响

Risk factors for recurrence of common bile duct stones after endoscopic common bile duct stone extraction and the influence of elective cholecystectomy on recurrence of common bile duct stones

摘要:

分析经内镜逆行胰胆管造影术（ERCP）联合内镜下十二指肠乳头括约肌切开术（EST）的胆总管取石术后胆总管结石复发的危险因素，探讨择期行腹腔镜胆囊切除术（LC）对胆总管结石复发的影响。方法 选取2008年9月－2012年9月ERCP联合EST胆总管取石术289例患者，其合并胆囊结石，择期行LC。按胆总管结石是否复发分为复发组和无复发组，按是否行LC分为LC组和无LC组。均记录性别、年龄、体质指数（BMI）、胆囊切除史、总胆红素水平、黄疸和壶腹周围憩室情况；使用熊去氧胆酸（UDCA）药物情况；胆道狭窄、胆管成角、胆总管直径；结石的性质、数量和大小；机械碎石、鼻胆管引流情况。跟踪随访5年。结果 胆总管结石复发时间（27.1±14.6）个月。复发组与无复发组相比：胆总管直径分别为（17.7±3.7）和（15.5±4.4）mm；胆总管结石直径≥15 mm例数分别占41.3%和16.8%；壶腹周围憩室例数分别占61.9%和13.7%，差异均有统计学意义（P =0.007～0.011）。胆总管直径≥15 mm和存在壶腹周围憩室是胆总管结石复发的危险因素（OR=1.789～1.941，均P <0.05），择期LC不是复发的危险因素（P >0.05）。LC组与无LC组5年累计胆总管结石复发率分别为24.5%和26.1%，差异无统计学意义（P >0.05）。结论 胆总管直径≥15 mm，存在壶腹周围憩室是ERCP+EST胆总管取石术后胆总管结石复发的危险因素；择期行LC并不能降低胆总管结石的复发率。

Abstract:

To study the risk factors for recurrence of common bile duct stones after endoscopic common bile duct stone extraction by endoscopic retrograde cholangiopancreatography (ERCP) combined with endoscopic biliary sphincterotomy (EST), and investigate the effect of laparoscopic cholecystectomy (LC) on the recurrence of common bile duct stones. Methods 289 patients diagnosed as common bile duct stones underwent ERCP combined with EST, those patients who merged with cholecystolithiasis were elected to undergo LC. Patients were divided into two groups according to whether the common bile duct stones recurrence: recurrence group and no recurrence group. And the patients were divided into group LC and group no-LC according to whether LC was performed or not. The recorded indexes included: gender, age and body mass index (BMI); the history of cholecystectomy, total bilirubin and jaundice, periampullary diverticulum; whether used ursodeoxycholic acid (UDCA) or not; biliary stricture, biliary angle, the diameter of common bile duct; the nature, number and size of stones; mechanical lithotripsy, and drainage situation of nasal biliary. All the patients were followed up for 5 years. Results The mean time of recurrence of common bile duct stones was (27.1 ± 14.6) months. The recurrence group compared with the group without recurrence: the diameter of the common bile duct were (17.7 ± 3.7) vs (15.5 ± 4.4) mm; the number of cases of the diameter of common bile duct ≥15 mm accounted for 41.3% vs 16.8%, respectively; the number of cases of periampullary diverticula accounted for 61.9% vs 13.7%, respectively; the differences were statistically significant (P = 0.007 ~ 0.011). The diameter of the common bile duct ≥15 mm and periampullary diverticula were risk factors of recurrence of common bile duct (OR value, from 1.789 to 1.941, P < 0.05), selective LC was not the risk factors of recurrence of common bile duct (P > 0.05). The recurrence rate of common bile duct in the group of LC and the group of no LC was 24.5% and 26.1% respectively, and there was no significant difference (P > 0.05).?Conclusion?The diameter of the common bile duct ≥15 mm and periampullary diverticula are risk factors of recurrence of common bile duct stones after endoscopic common bile duct stone extraction by ERCP + EST. Elective LC does not reduce the recurrence rate of common bile duct stones.