腹腔鏡膽道再手術(shù)治療60歲以上肝外膽管結(jié)石患者的效果觀察

段仁全，王 偉，張慧慧，梁晶晶，唐露露

(棗陽(yáng)市第一人民醫(yī)院 普外科，湖北 棗陽(yáng) 441200 )

腹腔鏡膽道再手術(shù)治療60歲以上肝外膽管結(jié)石患者的效果觀察

段仁全，王 偉，張慧慧，梁晶晶，唐露露

(棗陽(yáng)市第一人民醫(yī)院 普外科，湖北 棗陽(yáng) 441200 )

目的 探討腹腔鏡膽道再手術(shù)治療老年肝外膽管結(jié)石的臨床療效。方法 回顧性分析2013年1月-2015年6月棗陽(yáng)市第一人民醫(yī)院收治的86例行腹腔鏡膽道手術(shù)的60歲以上肝外膽管結(jié)石患者的臨床資料，根據(jù)入選患者手術(shù)情況分為初次手術(shù)組(n=54)和再次手術(shù)組(n=32)，比較2組患者手術(shù)相關(guān)情況及隨訪情況。計(jì)量資料組間比較采用t檢驗(yàn)，計(jì)數(shù)資料組間比較采用χ2檢驗(yàn)。結(jié)果 2組患者均順利完成手術(shù)，無(wú)圍手術(shù)期死亡病例，且術(shù)后結(jié)石清除率均為100%。2組患者的手術(shù)方式(一期縫合/T管引流)差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。再次手術(shù)組的中轉(zhuǎn)開腹率、手術(shù)時(shí)間、手術(shù)出血量、住院時(shí)間、術(shù)中結(jié)石清除率、術(shù)中及術(shù)后并發(fā)癥發(fā)生率均高(長(zhǎng))于初次手術(shù)組，但僅在手術(shù)時(shí)間方面差異有統(tǒng)計(jì)學(xué)意義(t=2.126，P=0.036)。初次手術(shù)組術(shù)中膽囊動(dòng)脈損傷1例，予結(jié)扎止血；再次手術(shù)組術(shù)中胃腸道漿膜損傷2例，予漿肌層包埋處理。初次手術(shù)組術(shù)后出現(xiàn)膽漏1例，肺部感染1例，泌尿系感染1例，均經(jīng)保守治療后治愈；再次手術(shù)組術(shù)后出現(xiàn)膽漏1例，肺部感染2例，均經(jīng)保守治療后治愈。總隨訪率為94.19%，其中初次手術(shù)組50例，隨訪率為92.59%；再次組31例，隨訪率為96.88%。經(jīng)影像學(xué)檢查證實(shí)均無(wú)膽道狹窄、膽道殘留結(jié)石或結(jié)石復(fù)發(fā)等并發(fā)癥。結(jié)論 腹腔鏡膽道再手術(shù)治療老年肝外膽管結(jié)石安全、有效，但存在一定的中轉(zhuǎn)開腹率和并發(fā)癥發(fā)生率，應(yīng)注意提升操作水平，避免術(shù)中副損傷，并合理把握手術(shù)適應(yīng)證和優(yōu)化圍手術(shù)期處理。

腹腔鏡檢查； 膽管,肝外； 膽囊結(jié)石病； 治療結(jié)果； 老年人

隨著社會(huì)的老齡化，老年人群中膽囊結(jié)石合并膽總管結(jié)石的患病率逐年增高。腹腔鏡膽道探查術(shù)已成為肝外膽管結(jié)石的首選治療方式[1]。既往研究[2-3]表明，腹腔鏡膽道探查術(shù)治療老年患者較開腹手術(shù)具有明顯的微創(chuàng)優(yōu)勢(shì)，更利于術(shù)后恢復(fù)。但對(duì)于腹腔鏡膽道再手術(shù)的療效仍存在爭(zhēng)議。有文獻(xiàn)[4]報(bào)道腹腔鏡膽道再手術(shù)治療老年肝外膽管結(jié)石的臨床療效較好，但其內(nèi)容為經(jīng)驗(yàn)性總結(jié)。本研究回顧性比較了腹腔鏡膽道再手術(shù)與首次膽道手術(shù)治療老年肝外膽管結(jié)石的臨床療效，探討其可行性。

1 資料與方法

1.1 研究對(duì)象 回顧性分析2013年1月-2015年6月本院收治的行腹腔鏡膽道手術(shù)的老年肝外膽管結(jié)石患者的臨床資料。納入標(biāo)準(zhǔn)：(1)術(shù)前影像學(xué)檢查證實(shí)為肝外膽管結(jié)石患者；(2)年齡≥60歲；(3)未合并膽胰系統(tǒng)腫瘤者。排除標(biāo)準(zhǔn)：(1)合并嚴(yán)重內(nèi)科疾病者；(2)急性化膿性膽管炎患者；(3)既往有除膽道手術(shù)外的上腹部手術(shù)史者；(4)病例資料不全者；(5)合并精神疾病、吸毒或藥物成癮者。所有入選患者根據(jù)手術(shù)情況分為初次手術(shù)組和再次手術(shù)組。

1.2 手術(shù)方法 所有患者均采用全麻-氣管插管，取頭高腳低左傾位，常規(guī)四孔法操作。初次手術(shù)組：分離膽囊三角，結(jié)扎膽囊動(dòng)脈及膽囊頸管，順行或逆行將膽囊從膽囊床上剝離下來。暴露膽總管前壁，經(jīng)穿刺抽出膽汁證實(shí)為膽總管后，切開膽總管前壁約1～1.5 cm。抓鉗取出切口附近結(jié)石，置入膽道鏡檢查。對(duì)于較大結(jié)石或嵌頓結(jié)石，配合使用術(shù)中激光碎石，盡量取凈結(jié)石。對(duì)于結(jié)石取凈、膽總管直徑≥0.8 cm、無(wú)膽道狹窄的患者可行一期縫合。若不能滿足一期縫合條件，則行T管引流。T管引流術(shù)后若有殘留結(jié)石，于術(shù)后4～8周再行經(jīng)T管膽道鏡取石。再次手術(shù)組：建立觀察孔后，觀察腹腔黏連情況，根據(jù)腹腔黏連情況邊分離邊依次建立各操作孔。余膽總管探查相關(guān)手術(shù)操作同初次手術(shù)組，行一期縫合或T管引流。

1.3 觀察指標(biāo)

1.3.1 手術(shù)相關(guān)情況 記錄患者圍手術(shù)期病死率、手術(shù)方式、中轉(zhuǎn)開腹率、手術(shù)時(shí)間、手術(shù)出血量、術(shù)后住院時(shí)間、術(shù)中結(jié)石清除率、術(shù)后結(jié)石清除率、術(shù)中和術(shù)后并發(fā)癥發(fā)生率。術(shù)中并發(fā)癥包括損傷周圍臟器(胃腸道、肝臟等)及血管導(dǎo)致穿孔、出血等。術(shù)后并發(fā)癥是指術(shù)后30 d內(nèi)發(fā)生的與手術(shù)相關(guān)的并發(fā)癥，包括膽漏、膽道出血、急性胰腺炎、切口感染等。

1.3.2 隨訪結(jié)果 患者術(shù)后3、6、12個(gè)月定期于門診復(fù)查，包括肝功能、肝膽B(tài)超，必要時(shí)行CT、磁共振胰膽管造影檢查。

2 結(jié)果

2.1 一般資料 共納入老年肝外膽管結(jié)石患者86例，其中初次手術(shù)組54例，再次手術(shù)組32例。再次手術(shù)組中初次手術(shù)為腹腔鏡膽囊切除術(shù)18例、開腹膽囊切除+膽總管探查術(shù)10例、腹腔鏡膽囊切除+膽總管探查術(shù)4例。再次手術(shù)距首次手術(shù)時(shí)間間隔為2～8年，平均(4.2±1.1)年。2組患者在性別、年齡、結(jié)石大小等方面的差異無(wú)統(tǒng)計(jì)學(xué)意義(P值均>0.05)(表1)，具有可比性。

2.2 手術(shù)相關(guān)情況 2組患者均順利完成手術(shù)，無(wú)圍手術(shù)期死亡病例，且術(shù)后結(jié)石清除率均為100%。2組患者的手術(shù)方式差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。再次手術(shù)組的中轉(zhuǎn)開腹率、手術(shù)時(shí)間、手術(shù)出血量、住院時(shí)間、術(shù)中結(jié)石清除率、術(shù)中及術(shù)后并發(fā)癥發(fā)生率均高(長(zhǎng))于初次手術(shù)組，但僅在手術(shù)時(shí)間方面差異有統(tǒng)計(jì)學(xué)意義(t=2.126，P=0.036)。初次手術(shù)組術(shù)中膽囊動(dòng)脈損傷1例，予結(jié)扎止血；再次手術(shù)組術(shù)中胃腸道漿膜損傷2例，予漿肌層包埋處理。初次手術(shù)組術(shù)后出現(xiàn)膽漏1例，肺部感染1例，泌尿系感染1例，均經(jīng)保守治療后治愈；再次手術(shù)組術(shù)后出現(xiàn)膽漏1例，肺部感染2例，均經(jīng)保守治療后治愈(表2)。

表1 2組患者的一般資料比較

表2 2組患者手術(shù)相關(guān)情況的比較

組別例數(shù)術(shù)中結(jié)石清除率[例(%)]術(shù)后結(jié)石清除率[例(%)]術(shù)中并發(fā)癥[例(%)]術(shù)后并發(fā)癥[例(%)]初次手術(shù)組5447(87.04)54(100)1(1.85)3(5.56)再次手術(shù)組3228(87.50)32(100)2(6.25)3(9.38)統(tǒng)計(jì)值χ2=0.07χ2=0.22χ2=0.05P值0.7860.6410.815

2.3 隨訪結(jié)果 86例患者總隨訪率為94.19%，其中初次手術(shù)組50例，隨訪率為92.59%；再次手術(shù)組31例，隨訪率為96.88%。經(jīng)影像學(xué)檢查證實(shí)均無(wú)膽道狹窄、膽道殘留結(jié)石或結(jié)石復(fù)發(fā)等并發(fā)癥。

3 討論

臨床上，復(fù)發(fā)性老年肝外膽管結(jié)石并不少見，但其治療方式仍存在一定的爭(zhēng)議。高齡患者因存在免疫力低下且常伴有多種內(nèi)科疾病，故傳統(tǒng)的開腹手術(shù)術(shù)后易出現(xiàn)多種并發(fā)癥，部分患者預(yù)后欠佳。內(nèi)鏡下十二指腸乳頭括約肌切開術(shù)雖手術(shù)創(chuàng)傷小，但卻破壞了Oddi括約肌的正常生理功能，術(shù)后有并發(fā)急性胰腺炎、反流性膽管炎等的風(fēng)險(xiǎn)，而且對(duì)膽管大結(jié)石、多發(fā)結(jié)石的療效有限，甚至可能治療失敗。隨著腹腔鏡技術(shù)的發(fā)展，高齡已經(jīng)不再是腹腔鏡手術(shù)的禁忌證[5]。對(duì)于高齡患者，腹腔鏡手術(shù)較開腹手術(shù)具有創(chuàng)傷小、術(shù)后并發(fā)癥少、保留Oddi括約肌的功能、對(duì)機(jī)體的免疫功能影響小等優(yōu)勢(shì)[6-7]。但既往膽道手術(shù)引起的腹腔黏連又給腹腔鏡手術(shù)帶來一定的困難。

本研究結(jié)果顯示，初次、再次手術(shù)組患者的中轉(zhuǎn)開腹率、手術(shù)出血量、住院時(shí)間、術(shù)中結(jié)石清除率、術(shù)中及術(shù)后并發(fā)癥發(fā)生率比較差異均無(wú)統(tǒng)計(jì)學(xué)意義，表明腹腔鏡手術(shù)安全可行。其中，再次手術(shù)組的中轉(zhuǎn)開腹率為6.25%，高于初次手術(shù)組的3.70%及國(guó)外系統(tǒng)性綜述[8]報(bào)道的2.0%，可能與再次手術(shù)組樣本量較少及早期技術(shù)不成熟等因素有關(guān)。再次手術(shù)組手術(shù)時(shí)間明顯長(zhǎng)于初次手術(shù)組，主要原因在于術(shù)中分離腹腔黏連及找尋膽總管所致，二者也是腹腔鏡膽道再手術(shù)的難點(diǎn)，要求術(shù)者必須具備成熟的手術(shù)技術(shù)[9-10]。研究結(jié)果顯示再次手術(shù)組術(shù)中僅2例患者出現(xiàn)副損傷(橫結(jié)腸漿膜受損1例，十二指腸球部漿膜受損1例)，均在腹腔鏡下行漿肌層包埋，術(shù)后并未出現(xiàn)消化道瘺，證明了既往腹部手術(shù)史行腹腔鏡手術(shù)的安全性。2組患者術(shù)后均出現(xiàn)膽漏1例，量少，余并發(fā)癥有肺部感染、泌尿系感染、腸梗阻等，均經(jīng)保守治療后好轉(zhuǎn)，無(wú)再手術(shù)病例。對(duì)于術(shù)中有殘石或膽道狹窄的患者，均留置T管，待術(shù)后行經(jīng)T管膽道鏡治療。術(shù)后隨訪1年，2組患者均未發(fā)現(xiàn)膽管狹窄、膽道殘留結(jié)石或結(jié)石復(fù)發(fā)，表明腹腔鏡膽道再手術(shù)治療老年肝外膽管結(jié)石的有效性。此外，對(duì)于2組中符合一期縫合標(biāo)準(zhǔn)的患者，均選擇性行一期縫合，進(jìn)一步降低了患者創(chuàng)傷，避免術(shù)后T管相關(guān)并發(fā)癥的發(fā)生，促進(jìn)術(shù)后恢復(fù)[11-12]。因此，筆者認(rèn)為老年患者腹腔鏡再次膽道手術(shù)行一期縫合術(shù)也是可行的，但需要注意把握術(shù)中取凈結(jié)石和保持膽道通暢這兩個(gè)基本原則[13]。

盡管腹腔鏡膽道再手術(shù)治療老年肝外膽管結(jié)石的臨床療效較好，但仍存在一定的中轉(zhuǎn)開腹率和并發(fā)癥發(fā)生率，因此要求術(shù)者在提高手術(shù)操作水平的基礎(chǔ)上，還應(yīng)注意把握手術(shù)適應(yīng)證及優(yōu)化圍手術(shù)期處理。只要患者未合并嚴(yán)重的心肺疾病及無(wú)嚴(yán)重腹腔黏連，即可行腹腔鏡手術(shù)。腹腔黏連的嚴(yán)重程度不好把握，目前臨床上并無(wú)術(shù)前可以準(zhǔn)確評(píng)估的檢查手段，只能依靠術(shù)中探查。一般而言，既往上腹部手術(shù)次數(shù)越多，腹腔黏連越嚴(yán)重，膽總管的定位越困難。本研究選取僅有1次膽道手術(shù)史的老年患者行腹腔鏡膽道再手術(shù)，對(duì)于既往多次上腹部手術(shù)或膽道手術(shù)的老年患者，其手術(shù)時(shí)間長(zhǎng)，成功率低，且麻醉相關(guān)風(fēng)險(xiǎn)大，因此不建議行腹腔鏡膽道再手術(shù)。本研究中2組患者術(shù)后并發(fā)癥主要以非膽道相關(guān)并發(fā)癥為主，均與患者高齡相關(guān)，故對(duì)于老年肝外膽管結(jié)石患者，優(yōu)化圍手術(shù)期處理對(duì)降低術(shù)后并發(fā)癥的發(fā)生十分重要。圍手術(shù)期需貫穿快速康復(fù)理念，術(shù)前準(zhǔn)確評(píng)估患者各臟器功能，尤其是心肺功能，必要時(shí)予以一定干預(yù)。避免留置胃管及尿管，早期拔除腹腔引流管、下床活動(dòng)及進(jìn)食，術(shù)后加強(qiáng)鎮(zhèn)痛[14-16]。

綜上所述，腹腔鏡膽道再手術(shù)治療老年肝外膽管結(jié)石安全、有效，但存在一定的中轉(zhuǎn)開腹率和并發(fā)癥發(fā)生率，應(yīng)注意提升操作水平，避免術(shù)中副損傷，并合理把握手術(shù)適應(yīng)證和優(yōu)化圍手術(shù)期處理。

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引證本文：DUAN RQ,WANG W,ZHANG HH,et al.Clinical effect of laparoscopic biliary reoperation in treatment of elderly patients with extrahepatic bile duct stones[J].J Clin Hepatol,2017,33(2):289-292.(in Chinese)

段仁全，王偉，張慧慧，等.腹腔鏡膽道再手術(shù)治療60歲以上肝外膽管結(jié)石患者的效果觀察[J].臨床肝膽病雜志,2017,33(2):289-292.

(本文編輯：王 瑩)

Clinical effect of laparoscopic biliary reoperation in treatment of elderly patients with extrahepatic bile duct stones

DUANRenquan,WANGWei,ZHANGHuihui,etal.

(DepartmentofGeneralSurgery,TheFirstPeople′sHospitalofZaoyang,Zaoyang,Hubei441200,China)

Objective To investigate the clinical effect of laparoscopic biliary reoperation in the treatment of elderly patients with extrahepatic bile duct stones.Methods A retrospective analysis was performed for the clinical data of 86 elderly patients with extrahepatic bile duct stones who were admitted to The First People′s Hospital of Zaoyang from January 2013 to June 2015 and underwent laparoscopic biliary reoperation.The surgical conditions and follow-up results were compared between groups.Thet-test was used for comparison of continuous data between groups,the chi-square test was used for comparison of categorical data between groups.Results All the patients underwent the surgery successfully and no patient died during the perioperative period.The postoperative stone clearance rate was 100%.There was no significant difference in the surgical procedure (primary suture/T-tube drainage) between the two groups (P>0.05).Compared with the first operation group,the reoperation group had a higher rate of conversion to laparotomy,a longer length of hospital stay,higher intraoperative stone clearance rate and incidence rates of intraoperative and postoperative complications,and a significantly longer time of operation (t=2.126,P=0.036).In the first operation group,one patient experienced intraoperative cystic artery injury and was given ligation for hemostasis; in the reoperation group,2 patients experienced gastrointestinal serosal injury and were treated with embedding of the seromuscular layer.In the first operation group,1 patient each experienced bile leakage,pulmonary infection,and urinary system infection after surgery and were all cured after conservative treatment; in the reoperation group,1 patient experienced bile leakage and 2 experienced pulmonary infection,and all the patients were cured after conservative treatment.The overall follow-up rate was 94.19% (50/54) in the first operation group and 96.88% (31/32) in the reoperation group.The imaging examination showed no complications such as biliary stricture,residual bile duct stones,and recurrence of stones.Conclusion Laparoscopic biliary reoperation is safe and effective in the treatment of elderly patients with extrahepatic bile duct stones,but there are a certain rate of conversion to laparotomy and incidence rates of complications.The operation techniques should be improved to avoid intraoperative injury,surgical indications should be strictly followed,and perioperative management should be optimized.

laparoscopy; bile ducts,extrahepatic； cholecystolithiasis； treatment outcome; aged

10.3969/j.issn.1001-5256.2017.02.017

2016-09-08；

2016-10-14。

段仁全(1972-)，男，主治醫(yī)師，主要從事腹腔鏡診療方面的研究。

R657.42

A

1001-5256(2017)02-0289-04