三种联合术治疗胆总管结石的临床疗效及安全性比较

doi:10.3877/cma.j.issn.1674-3946.2020.03.026

目的

比较三种联合术治疗胆总管结石的临床疗效及安全性。

方法

回顾性分析2014年10月至2016年10月81例胆总管结石患者资料，根据手术方式不同分为三组，分别为A组(腹腔镜胆囊切除和经胆囊管胆道探查)；B组(腹腔镜胆囊切除＋胆总管切开探查＋胆管一期缝合)；C组(腹腔镜胆囊切除＋胆总管切开探查＋T管引流)，各27例。采用SPSS20.0软件进行统计分析，围术期各项指标等计量资料以(±s)描述，两组间t检验，三组间经方差齐性检验分析；治疗效果秩和检验；术后并发症情况等计数资料采用χ²检验。P<0.05差异有统计学意义。

结果

A组患者的手术时间、腹腔引流时间、住院时间、住院费用及恢复正常生活时间等指标均明显优于B组和C组，而B组的上述各项指标均优于C组(P<0.05)；三组患者的疗效经比较，A组的治疗总有效率明显高于C组患者(92.6% vs. 63.0%, P<0.05)，但A组与B组，B组与C组间的治疗总有效率差异无统计学意义(92.6% vs. 74.1%；74.1% vs. 63.0% P>0.05)；三组患者的胆道感染、胆汁渗漏、肺部感染、腹腔积液以及脓肿形成等术后并发症的发生率差异无统计学意义(P>0.05)。

结论

三种联合术治疗胆总管结石均有各自的适应证。综合来看，腹腔镜胆囊切除联合经胆囊管胆道探查术治疗胆总管结石患者的疗效最优，其次为腹腔镜胆囊切除联合胆总管切开探查并进行胆管一期缝合。

关键词: 胆总管结石, 腹腔镜, 胆囊切除术, 疗效比较研究, 安全

Objective

To compare the clinical efficacy and safety of three kinds of combined surgery for common bile duct stones.

Methods

A retrospective analysis was performed in 81 cases of common bile duct stones from October 2014 to October 2016, who were divided into three groups according to the surgical treatments. There were 27 cases in group A (laparoscopic cholecystectomy and cystic duct exploration); 27 cases in Group B (laparoscopic cholecystectomy+ common bile duct exploration+ bile duct primary suture) and 27 cases in Group C (laparoscopic cholecystectomy+ common bile duct exploration+ T tube drainage). The measurement data such as the perioperative indicatores were described as (±s), and were examined by using t test, while the three groups were analyzed by Homogeneity test of variance. Count data such as treatment effect and postoperative complications were analyzed by χ² test. A value of P<0.05 was considered as significant difference.

Results

Compare with group B and C, there were significant advantages in group A, in terms of the operation time, drainage time, hospital stay, medical cost and recovery time to normal life, while the above indicators in group B were all better than those in group C respectively (P<0.05); After comparing the efficacy of the three groups of patients, the total effective rate of treatment in group A was significantly higher than that in group C (92.6% vs. 63.0%, P<0.05). However, there was no significant difference in the total treatment efficiency between group A and group B, group B and group C (92.6% vs. 74.1%, 74.1% vs. 63.0% respectively, P>0.05). There were no significant difference between three groups in terms of the incidence of postoperative complications such as biliary tract infection, bile leakage, pulmonary infection, peritoneal effusion and abscess formation (P>0.05).

Conclusion

Three kinds of combined surgery for common bile duct stones have their own indications. Taken together, laparoscopic cholecystectomy combined with cystic duct exploration for the treatment of common bile duct stones was the best choice, followed by laparoscopic cholecystectomy combined with common bile duct exploration and primary bile duct suturing.

Key words: Choledocholithiasis, Laparoscopes, Cholecystectomy, Comparative effectiveness research, Safety

表1 81例胆总管结石患者不同术式三组患者的基本临床资料[(±s)，例]

组别	例数	年龄(岁)	性别	最大结石直径(cm)	胆总管内径(cm)
组别	例数	年龄(岁)	男/女	最大结石直径(cm)	胆总管内径(cm)
A组	27	57.4±5.2	13/14	0.8±0.2	1.2±0.1
B组	27	56.8±5.9	15/12	0.7±0.3	1.2±0.3
C组	27	57.1±5.8	14/13	0.8±0.3	1.3±0.1
F/χ²值	?	0.400	0.297	1.441	1.643
P值	?	0.691	0.862	0.156	0.106
组别	例数	总胆红素(mmol/L)	结石数量(枚)	黄疸
组别	例数	总胆红素(mmol/L)	结石数量(枚)	有/无
A组	27	25.3±16.4	2.2±2.1	4/23
B组	27	25.6±15.8	2.5±2.8	6/21
C组	27	25.5±16.1	2.9±2.4	5/22
F/χ²值	?	0.069	1.141	0.491
P值	?	0.946	0.259	0.782

表1 81例胆总管结石患者不同术式三组患者的基本临床资料[(±s)，例]

组别	例数	年龄(岁)	性别	最大结石直径(cm)	胆总管内径(cm)
组别	例数	年龄(岁)	男/女	最大结石直径(cm)	胆总管内径(cm)
A组	27	57.4±5.2	13/14	0.8±0.2	1.2±0.1
B组	27	56.8±5.9	15/12	0.7±0.3	1.2±0.3
C组	27	57.1±5.8	14/13	0.8±0.3	1.3±0.1
F/χ²值	?	0.400	0.297	1.441	1.643
P值	?	0.691	0.862	0.156	0.106
组别	例数	总胆红素(mmol/L)	结石数量(枚)	黄疸
组别	例数	总胆红素(mmol/L)	结石数量(枚)	有/无
A组	27	25.3±16.4	2.2±2.1	4/23
B组	27	25.6±15.8	2.5±2.8	6/21
C组	27	25.5±16.1	2.9±2.4	5/22
F/χ²值	?	0.069	1.141	0.491
P值	?	0.946	0.259	0.782

表2 81例胆总管结石患者不同术式三组患者手术情况比较(±s)

指标	例数	手术时间(min)	腹腔引流时间(d)	住院时间(d)	住院费用(万元)
A组	27	97.3±11.4	3.4±0.7	5.3±1.2	1.6±1.3
B组	27	103.2±10.2	4.3±0.8	6.0±1.3	1.8±1.3
C组	27	129.1±13.7	4.9±0.6	7.7±1.7	2.2±2.0
Ⅰ	?	t＝2.004	t＝4.399	t＝2.056	t＝4.525
Ⅰ	?	P＝0.050	P＝0.000	P＝0.045	P＝0.000
Ⅱ	?	t＝9.271	t＝8.454	t＝5.993	t＝13.014
Ⅱ	?	P＝0.000	P＝0.202	P＝0.000	P＝0.000
Ⅲ	?	t＝7.879	t＝3.118	t＝4.128	t＝9.621
Ⅲ	?	P＝0.000	P＝0.003	P＝0.001	P＝0.000

表2 81例胆总管结石患者不同术式三组患者手术情况比较(±s)

指标	例数	手术时间(min)	腹腔引流时间(d)	住院时间(d)	住院费用(万元)
A组	27	97.3±11.4	3.4±0.7	5.3±1.2	1.6±1.3
B组	27	103.2±10.2	4.3±0.8	6.0±1.3	1.8±1.3
C组	27	129.1±13.7	4.9±0.6	7.7±1.7	2.2±2.0
Ⅰ	?	t＝2.004	t＝4.399	t＝2.056	t＝4.525
Ⅰ	?	P＝0.050	P＝0.000	P＝0.045	P＝0.000
Ⅱ	?	t＝9.271	t＝8.454	t＝5.993	t＝13.014
Ⅱ	?	P＝0.000	P＝0.202	P＝0.000	P＝0.000
Ⅲ	?	t＝7.879	t＝3.118	t＝4.128	t＝9.621
Ⅲ	?	P＝0.000	P＝0.003	P＝0.001	P＝0.000

表3 81例胆总管结石患者不同术式三组患者的治疗效果比较[例(%)]

指标	例数	显效	有效	无效	总有效率
A组	27	21(77.8)	4(14.8)	2(7.4)	25(92.6)
B组	27	18(66.7)	2(7.4)	7(25.9)	20(74.1)
C组	27	15(55.6)	2(7.4)	10(37.0)	17(63.0)

表3 81例胆总管结石患者不同术式三组患者的治疗效果比较[例(%)]

指标	例数	显效	有效	无效	总有效率
A组	27	21(77.8)	4(14.8)	2(7.4)	25(92.6)
B组	27	18(66.7)	2(7.4)	7(25.9)	20(74.1)
C组	27	15(55.6)	2(7.4)	10(37.0)	17(63.0)

表4 81例胆总管结石患者不同术式三组患者术后并发症情况比较[例(%)]

指标	例数	胆道感染	胆汁渗漏	肺部感染	腹腔积液	脓肿形成
A组	27	1(3.7)	1(3.7)	0(0.0)	0(0.0)	0(0.0)
B组	27	2(7.4)	3(11.1)	2(7.4)	1(3.7)	1(3.7)
C组	27	3(11.1)	3(11.1)	2(7.4)	2(7.4)	1(3.7)
P	?	>0.05	>0.05	>0.05	>0.05	>0.05

表4 81例胆总管结石患者不同术式三组患者术后并发症情况比较[例(%)]

指标	例数	胆道感染	胆汁渗漏	肺部感染	腹腔积液	脓肿形成
A组	27	1(3.7)	1(3.7)	0(0.0)	0(0.0)	0(0.0)
B组	27	2(7.4)	3(11.1)	2(7.4)	1(3.7)	1(3.7)
C组	27	3(11.1)	3(11.1)	2(7.4)	2(7.4)	1(3.7)
P	?	>0.05	>0.05	>0.05	>0.05	>0.05

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Comparative study of clinical efficacy and safety of three kinds of combined surgery for common bile duct stones

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Comparative study of clinical efficacy and safety of three kinds of combined surgery for common bile duct stones