双镜联合治疗胆囊结石合并肝外胆管结石患者疗效及安全性分析

∗基金项目:2022年度重庆市卫生健康委医学科研项目(编号:2022WSJK044)
作者单位:400060重庆市重庆医药高等专科学校附属第一医院普通外科(古乾权,邓开);重庆市丰都县人民医院胃肠外科(陈杰)
第一作者:古乾权,男,41岁,大学本科,主治医师㊂E-mail: wy13960936@ ㊃胆石症㊃
双镜联合治疗胆囊结石合并肝外胆管结石患者
疗效及安全性分析∗
古乾权,陈杰,邓开
㊀㊀ʌ摘要ɔ㊀目的㊀探讨采取双镜联合治疗胆囊结石(GS)合并肝外胆管结石(EBDS)患者的疗效及安全性㊂方法㊀2020年1月~2022年12月我院收治的GS合并EBDS患者76例,其中观察组42例接受内镜下逆行胰胆管造影术(ERCP)治疗,5d后进行腹腔镜下胆囊切除术(LC)治疗,对照组34例接受传统开腹手术治疗㊂采用视觉模拟评分法(VAS)评估疼痛程度,采用ELISA法检测血清肿瘤坏死因子-α(TNF-α)㊁白细胞介素-6(IL-6)㊁C反应蛋白(CRP)和皮质醇(Cor)㊂结果㊀两组结石清除率均为100.0%,观察组手术时间㊁术中出血量和术后3d VAS评分分别为(96.8ʃ7.4) min㊁(25.7ʃ5.3)ml和(2.8ʃ0.7)分,显著短于或少于对照组ʌ分别为(120.1ʃ9.6)min㊁(46.0ʃ6.8)ml和(3.5ʃ0.6)分, P<0.05ɔ;在术后7d,观察组血清AST和ALT水平分别为(40.5ʃ3.9)U/L和(43.1ʃ4.9)U/L,显著低于对照组ʌ分别为
(50.2ʃ5.0)U/L和(56.9ʃ6.0)U/L,P<0.05ɔ;观察组血清TNF-α㊁IL-6㊁CRP㊁Cor和外周血WBC计数分别为(1.5ʃ0.3)
ng/L㊁(10.8ʃ2.0)ng/L㊁(13.4ʃ2.5)mg/L㊁(224.7ʃ28.1)mmol/L和(9.8ʃ1.3)ˑ109/L,均显著低于对照组ʌ分别为(2.7ʃ
0.5)ng/L㊁(16.1ʃ2.5)ng/L㊁(22.0ʃ4.9)mg/L㊁(262.4ʃ31.8)mmol/L和(12.0ʃ1.5)ˑ109/L,P<0.05ɔ;术后,观察组并发
症发生率为7.2%,显著低于对照组的23.5%(P<0.05)㊂结论㊀采用双镜联合治疗GS合并EBDS患者能有效改善围术期指标,促进术后恢复,缓解应激反应,减少并发症㊂
㊀㊀ʌ关键词ɔ㊀胆囊结石;肝外胆管结石;内镜下逆行胰胆管造影术;腹腔镜胆囊切除术;治疗
㊀㊀DOI:10.3969/j.issn.1672-5069.2023.06.038
㊀㊀Double endoscopic surgery in the treatment of patients with gallbladder stones and extrahepatic bile duct stones㊀Gu Qianquan,Chen Jie,Deng Kai.Department of General Surgery,First Affiliated Hospital,Medical Pharmaceutical Vocational School,Chongqing400060,China
㊀㊀ʌAbstractɔ㊀Objective㊀This study was conducted to investigate double endoscopic surgery in the treatment of patients with gallbladder stones(GS)and extrahepatic bile duct stones(EBDS).Methods㊀76patients with GS and EBDS were encountered in our hospital between January2020and December2022,42patients in the observation group received laparoscopic cholecystectomy (LC)five days after endoscopic retrograde cholangiopancreatography(ERCP)for the removal of common bile duct stones,and34 patients in the control underwent traditional open surgery.The pain was evaluated by visual analogue scale(VAS),and serum tumor necrosis factor-α(TNF-α),interleukin-6(IL-6),C-reactive protein(CRP)and cortisol(Cor)levels were detected by ELISA.The white blood cell counts(WBC)were detected by full-automatic blood cell analyzer.Results㊀The stone clearance rates in the two groups were both100.0%;the operation time,intraoperative blood loss and VAS score at day3after surgery in the observation were(96.8ʃ7.4)min,(25.7ʃ5.3)ml and(2.8ʃ0.7),significantly shorter or less than[(120.1ʃ9.6)min,(46.0ʃ6.8)ml and(3.5ʃ0.6),respectively,P<0.05]in the control;seven days after operation,serum AST and ALT levels were (40.5ʃ3.9)U/L and(43.1ʃ4.9)U/L,both significantly lower than[(50.2ʃ5.0)U/L and(56.9ʃ6.0)U/L,P<0.05]in the control;serum TNF-α,IL-6,CRP,Cor levels and WBC counts were(1.5ʃ0.3)ng/L,(10.8ʃ2.0)ng/L,(13.4ʃ2.5)mg/L, (224.7ʃ28.1)mmol/L and(9.8ʃ1.3)ˑ109/L,all significantly lower than[(2.7ʃ0.5)ng/L,(16.1ʃ2.5)ng/L,(22.0ʃ4.9) mg/L,(262.4ʃ31.8)mmol/L and(12.0ʃ1.5)ˑ109/L,respectively,P<0.05]in the control;post-operationally,the incidence
of complications in the observation group was7.2%,much lower
than23.5%(P<0.05)in the control.Conclusion㊀The double
endoscopic surgery could effectively improve perioperative
indexes,promote postoperative recovery,relieve stress response
and reduce the complications in patients with GS and EBDS.
㊀㊀ʌKey wordsɔ㊀Gallstone stone;Extrahepatic bile duct
stone;Endoscopic retrograde cholangiopancreatography;
Laparoscopic cholecystectomy;Treatment
㊀㊀胆石症是临床常见的多发性胆道疾病,发病率随人口老龄化和生活方式改变而不断升高,其中胆囊结石(gallbladder stones,GS)合并肝外胆管结石(extrahepatic bile duct stones,EBDS)占10%~ 15%[1,2]㊂GS合并EBDS具有个体差异大㊁病情复杂㊁易复发等特点㊂若治疗不及时,易导致梗阻性黄疸㊁胆源性胰腺炎等疾病,增加不良预后风险[3]㊂手术是现阶段临床治疗GS合并EBDS的主要手段,在手术治疗过程中需处理胆囊结石和解除胆总管梗阻,手术操作较为复杂[4]㊂因此,临床需选择合适的术式治疗GS合并EBDS患者,以减轻手术损伤㊁提高结石清除率㊂既往临床多采用传统开腹手术治疗GS合并EBDS患者,但手术易损害胆管系统功能,存在较多的并发症,不利于术后恢复[5]㊂随着微创理念发展和内镜技术的完善,胆道镜和腹腔镜等内镜治疗广泛应用于GS合并EBDS的治疗,双镜联合治疗能有效清除结石㊁减少并发症,具有创伤小㊁精确度高和安全性高等特点[6,7]㊂本研究观察了采用双镜联合治疗GS合并EBDS患者的效果和安全性,为临床治疗提供参考经验㊂
1㊀资料与方法
1.1一般资料㊀2020年1月~2022年12月我院收治的GS合并EBDS患者76例,男性46例,女性30例;年龄为37~67岁,平均年龄为(51.6ʃ6.9)岁㊂符合‘实用肝胆外科学“[8]中关于GS合并EBDS的诊断标准,经超声㊁CT或MRI等影像学检查确诊,结石数量为(3.6ʃ0.7)个,胆囊结石直径为(8.9ʃ
2.4) mm,肝外胆管结石直径为(9.0ʃ2.8)mm,胆总管内径为(10.1ʃ1.4)mm㊂排除标准:急性胆囊炎㊁重度萎缩性胆囊炎㊁急性化脓性胆管炎㊁急性重症胆管炎㊁胆道畸形或狭窄㊁胆囊恶性肿瘤;有肝胆系统手术史或腹部重大手术史;存在脑㊁肾㊁心㊁肺等脏器严重疾病;存在造血㊁凝血㊁认知和视听功能损伤;存在手术禁忌证;腹腔严重粘连㊂将患者分为观察组和对照组,分别采用双镜联合治疗或传统开腹手术治疗,两组基线资料比较无显著性差异(P>0.05)㊂本研究经我院医学伦理委员会批准,患者及其家属签署知情同意书㊂
1.2手术方法㊀在对照组,行传统开腹手术㊂全身麻醉㊁气管插管㊂经胆道造影,确定结石位置㊂于患者上腹正中处作一切口,进腹后使用取石钳取出结石㊂经胆道镜或胆道造影检查,确认取尽结石㊂留置腹腔和胆总管引流管;在观察组,采用双镜联合治疗,先行内镜下逆行胰胆管造影术(ERCP):采用静脉麻醉,置入十二指肠镜后行乳头括约肌切开术,用小切刀于乳头隆起部位切开乳头,使切线位于乳头11点方向,切开深度不超过隆起部位的1/3,经造影确认结石位置㊂对于直径<15mm的结石,采用取石网篮或气囊取出或拖出,对于直径ȡ15mm的结石,使用碎石机或碎石网篮碎石再取出结石㊂经胆道镜检查或胆道造影确认无结石残留㊂对发现的残留结石,则冲洗胆管,常规留置鼻胆管㊂在术后5d,采用腹腔镜胆囊切除术(LC)治疗:全身麻醉和气管插管,保持头高脚低体位,于脐下常规构建气腹,保持腹腔压力为13mmHg㊂以右侧腋前线肋缘和右锁骨中线上切口为辅助操作孔和观察孔,充分暴露胆囊动脉和胆囊管,使用可吸收生物夹结扎胆囊动脉㊁离断,切除胆囊㊂撤出器械,缝合切口㊂术后,常规给予两组预防感染㊁对症处理㊂
1.3指标检测㊀使用Beckman Coulter公司生产的AU680型全自动生化分析仪检测血生化指标;采用ELISA法检测血清白细胞介素-6(IL-6)㊁C反应蛋白(CRP)㊁皮质醇(Cor)和肿瘤坏死因子-α(TNF-α,上海酶联生物);使用Bechman Coulter公司生产的LH750型全自动血球分析仪检测血常规㊂1.4疼痛程度评估㊀采用视觉模拟评分法(VAS)评估疼痛程度㊂VAS评分为0~10分,分值越高,疼痛感越强烈[9]㊂
1.5统计学方法㊀应用SPSS25.0软件进行统计学分析,应用Shapiro-Wilk进行正态性检验,对符合正态分布的计量资料以(xʃs)表示,采用t检验;计数资料以%表示,采用x2检验或Fisher精确概率计算㊂P<0.05为差异有统计学意义㊂
2㊀结果
2.1两组围术期指标比较㊀两组结石清除率均为100.0%,但观察组手术时间㊁术中出血量和术后3d VAS评分显著短于或少于对照组(P<0.05,表1)㊂2.2两组肝功能指标比较㊀在术后7d,观察组血清AST和ALT水平显著低于对照组(P<0.05,表2)㊂2.3两组血清应激指标比较㊀在术后7d,观察组血清TNF-α㊁IL-6㊁CRP和Cor水平及外周血WBC计数显著低于对照组(P<0.05,表3)㊂
2.4两组并发症发生率比较㊀术后,观察组并发症发生率显著低于对照组(P<0.05,表4)㊂
表1㊀两组围术期指标(%,ʃs)比较
例数手术时间(min)出血量(ml)结石清除VAS(分)住院日(d)观察组4296.8ʃ7.4①25.7ʃ5.3①42(100.0) 2.8ʃ0.7①9.3ʃ1.1对照组34120.1ʃ9.646.0ʃ6.834(100.0) 3.5ʃ0.67.4ʃ2.0㊀㊀与对照组比,①P<0.05
表2㊀两组肝功能指标(xʃs)比较
例数TBIL(μmol/L)ALT(U/L)AST(U/L)GGT(U/L)观察组术前4267.8ʃ7.376.6ʃ6.455.2ʃ5.6248.9ʃ28.3
㊀㊀术后4221.1ʃ5.243.1ʃ4.9①40.5ʃ3.9①186.4ʃ25.1对照组术前3468.4ʃ7.675.3ʃ6.854.7ʃ6.3251.2ʃ30.7
㊀㊀术后3423.0ʃ5.556.9ʃ6.050.2ʃ5.0192.3ʃ27.0㊀㊀与对照组比,①P<0.05
表3㊀两组血清应激指标(xʃs)比较
例数TNF-α(ng/L)IL-6(ng/L)CRP(mg/L)Cor(mmol/L)WBC(ˑ109/L)观察组术前42 1.1ʃ0.2 5.9ʃ1.437.8ʃ8.9181.3ʃ24.610.2ʃ0.9㊀㊀㊀术后42 1.5ʃ0.3①10.8ʃ2.0①13.4ʃ2.5①224.7ʃ28.1①9.8ʃ1.3①对照组术前34 1.0ʃ0.3 6.3ʃ1.137.5ʃ10.7183.5ʃ23.211.5ʃ1.0㊀㊀㊀术后34 2.7ʃ0.516.1ʃ2.522.0ʃ4.9262.4ʃ31.812.0ʃ1.5㊀㊀与对照组比,①P<0.05
表4㊀两组并发症发生率(%)比较
例数切口感染胆道出血急性胰腺炎腹腔感染小计观察组421(2.4)1(2.4)1(2.4)0(0.0)3(7.2)①对照组342(5.9)2(5.9)3(8.8)1(2.9)8(23.5)
㊀㊀与对照组比,①P<0.05
3㊀讨论
GS合并EBDS是临床常见的急腹症,以右上腹疼痛㊁持续胀痛或胆绞痛等表现为主,可累及胰腺㊁肝脏等多个脏器,影响患者生命安全[10,11]㊂虽然传统开腹手术能清除结石,但患者术后疼痛感相对强烈,且存在较多的并发症,易延长恢复时间[12,13]㊂近年来,微创治疗理念不断发展,利用内镜微创手术治疗GS合并EBDS逐渐成为临床的重要选择[14,15]㊂相较于传统开腹手术,内镜下微创手术具有创伤小㊁术后恢复快等特点㊂ERCP联合LC是临床常用的双镜治疗方法㊂ERCP能显示胆管病变,明确胆管走行和结石分布,治疗损伤胆总管的机会小[16,17]㊂
本研究两组结石清除率无显著性差异,提示双镜联合治疗与传统开腹手术治疗的疗效相当,均能有效清除胆结石㊂但进一步研究显示,观察组手术时间㊁术后3d VAS评分和术中出血量显著短于或少于对照组,提示双镜联合治疗能改善GS合并EBDS患者围术期指标,减轻术后疼痛㊂国内研究发现,双镜联合治疗能缩短手术操作时间,降低术中操作对机体的影响,减轻医源性损伤,有利于术后恢复[18]㊂传统开腹手术治疗的创口较大,术中出血量明显增加,手术创伤较大,会严重影响胆管系统功能,增加术后发生并发症的风险,导致恢复缓慢㊂相较于传统开腹手术,双镜联合治疗通过内镜能明确胆管狭窄部位和胆管结石分布情况,从而确定手术范围,避免术中切开胆管,有利于快速完成手术,且对腹腔的干扰较少,有利于缓解术后疼痛㊂双镜联合治疗的创伤较小,不会对胃肠道蠕动节律造成严重的影响,有利于降低术后肠内容物淤积风险,促进肠道功能恢复㊂
国内外研究发现,双镜联合治疗创伤远低于传统开腹手术治疗,能有效减轻术中操作对肝功能的损伤[19,20]㊂本研究术后7d观察组血清AST和ALT 水平显著低于对照组,表明双镜联合治疗能改善GS 合并EBDS患者肝功能㊂双镜联合治疗能准确发现和取出结石,避免传统开腹手术中反复钳夹结石可能所致的胆管损伤,通过高效取石能缓解胆汁外流引起的水电解质紊乱,减少代谢产物损伤肝组织,有利于保护肝功能㊂临床研究显示,手术操作属于应激源,GS合并EBDS患者在双镜联合治疗或传统开腹手术治疗后,术中刺激及疼痛会促进大量促炎因
子的释放,引起机体应激反应[21,22]㊂本研究发现,在术后7d,观察组血清IL-6㊁CRP㊁Cor㊁TNF-α和外周血WBC计数显著低于对照组,表明双镜联合治疗诱发的应激反应相对较轻㊂双镜联合治疗的创伤程度较轻,能避免大量炎性因子释放所致的炎症反应,从而减轻应激损伤对机体的影响㊂为探寻双镜联合治疗的安全性,本研究对比分析术后并发症发现观察组显著低于对照组,提示双镜联合治疗能降低EBDS患者术后并发症发生风险,具有较高的安全性㊂双镜联合治疗无需留置T形管,保证了胆管的完整性,有利于降低胆道出血㊁急性胰腺炎和感染风险[23]㊂
综上所述,在GS合并EBDS患者,采用双镜联合治疗能改善围术期指标,加快术后恢复,改善肝功能,缓解应激反应,减少并发症,安全性较高㊂本研究尚存在一些不足,比如系单中心研究,样本量相对偏少,可能存在选择偏倚㊂由于胆石症患者可能存在高脂血症㊁高血压和糖尿病的基础疾病,对手术治疗提出了很高的要求,这些都需要认真控制和处理㊂ʌ参考文献ɔ
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(收稿:2023-06-06)
(本文编辑:张骏飞)。