摘要目的 探讨胆囊结石继发胆总管结石(GCBDS)腹腔镜微创手术方法和操作技术的选择策略.方法 2013年1月至2017年12月首都医科大学宣武医院普通外科收治298例接受微创手术的GCBDS患者.男性138例,女性160例,年龄(60.4±18.6)岁(范围:25 ～ 89岁).分析GCBDS患者的微创手术方法、治疗效果及其安全性,比较腹腔镜胆总管探查术(LCBDE)一期缝合和T管引流的基本情况和治疗结果.计数资料的比较采用x2检验,计量资料的比较采用t检验.结果 纳入的298例患者中,腹腔镜胆囊切除术(LC)联合经胆囊管胆总管探查取石7例(2.3％,7/298),LC联合LCBDE 291例(97.7％,291/298).LCBDE胆管切开取石后T管引流133例(45.7％,133/291),一期缝合158例(54.3％,158/291).LCBDE一期缝合的患者中,行术中胆道测压18例(11.4％,18/158).所有患者术后6个月内无死亡.术后并发症发生率为10.0％(29/291).LCBDE一期缝合组和T管引流组在患者性别、年龄、美国麻醉师协会评分、合并症和既往腹部手术比例方面的差异均无统计学意义(P值均＞0.05).LCBDE一期缝合组合并急性胆管炎比例(43.3％)较T管引流组(76.7％)低(x2=9.061,P=0.002).LCBDE一期缝合组的手术时间[(134.2±28.3)min]和术后住院时间[(5.6±2.6)d]较T管引流组[(148.3± 19.6) min和(7.2±2.4)d]短(t=-1.830,P=0.011;t=-1.847,P=0.014),胆瘘发生率(6.3％)较T管引流组(0.8％)高(x2=3.934,P=0.047),残余结石发生率(1.3％)较T管引流组(6.8％)低(x2=6.008,P=0.014).结论 GCBDS患者接受腹腔镜手术时应依据术前评估和术中探查结果分步操作,逐步筛选合适的微创手术方法和操作技术,制定个体化的手术方案,达到治疗效果和安全性的统一.

abstractsObjective To explore the selection method and technology of laparoscopic surgery for gallbladder stones and common bile duct stones(GCBDS).Methods Data was collected from 318 in-patients of GCBDS at Department of General Surgery,Xuanwu Hospital of Capital Medical University from January 2013 to December 2017,and 298 in-patients acceptedlaparoscopic cholecystectomy(LC) and choledocholithotomy were recruited into final analysis.There were 138 males and 160 females,aged (60.4±18.6) years (range:25-89 years).Retrospective analysis was done on method distribution,effect and safety of laproscopic surgery.Comparisons of basic characters and therapeutic effects were performed betweenlaparoscopic common bile duct exploration (LCBDE) combined with primary closure and T tube drainage(TTD).Results Among therecruited in-patients,LC combined with common bile duct exploration was performed in 7 cases(2.3％,7/298),LC combined with LCBDE was performed in 291 cases(97.7％,291/298).There were 133 cases (45.7％,133/291) who treated by LCBDE combined with TFD and 158 cases (54.3％,158/291) who treated by LCBDE combined with primary closure.In LCBDE combined with primary closure group,18 cases (11.4％,18/158) had intraoperative biliary manometry.All patients were followed up for 6 months at least and there no death.Postoperative complications rate was 10.0％ (29/291).There were no significant differences in sex ratio,age,American Society of Anesthesiologists score,concomitant diseases and previous abdominal surgery history between LCBDE combined with primary closure and LCBDE combined with TTD group.Patients in LCBDE combined with primary closure group were accompanied with less acute cholangitis than TFD group (43.3％ vs.76.7％;x2=9.061,P=0.002).There were no significant differences in the diameter of common bile duct,the number of stones,hospitalization expenses and the incidence of complications between the two groups(all P＞0.05).LCBDE combined with primary closure had shorter operation time ((134.2 ± 28.3)minutes vs.(148.3 ± 19.6) minutes;t=-1.830,P=0.011) and post-operative hospitalization time ((5.6±2.6)days vs.(7.2±2.4)days;t=-1.847,P=0.014).Bile duct leakage rate was higher in primary closure group(6.3％ vs.0.8％,x2=3.934,P=0.047) and TTD group had higher residual stones rate (6.8％ vs.1.3％;x2=6.008,P=0.014).Conclusion Strategy for treating GCBDS by laparoscopic surgery should be considered preoperative evaluation and intraoperative exploration to select appropriate minimally invasive surgical methods and techniques.