腹腔镜胆总管探查术中T管、双J管引流与单纯一期缝合的应用比较

Comparison of the application of T-tube or double J-tube drainage and primary duct closure in laparoscopic common bile duct exploration

摘要:

背景与目的 腹腔镜胆总管探查术（LCBDE）以“创伤小、恢复快”的临床优势成为临床治疗胆总管结石的主要手段，甚至是一线推荐方案。但LCBDE后是否需引流胆汁及不同胆汁引流方式的选择仍存在诸多争议，如传统的LCBDE+胆道外引流管（T管）引流适应证的探讨、单纯一期缝合（PDC）是否导致高术后并发症发生率、胆道内引流是否优于外引流等。针对以上问题，本文采取回顾性研究，比较T管、胆道内引流管（双J管）与PDC在LCBDE中的临床应用，并就其相应适应证进行探讨。方法 回顾性收集2015年3月—2018年5月昆明医科大学第二附属医院363例行LCBDE患者的临床资料，根据治疗方式不同分为T管组（128例）、双J管组（115例）和PDC组（120例）。比较三组术前一般资料（性别、肝功能、胆总管直径、结石直径）；围手术期相关资料（手术时间、住院时间、住院费用）及术后并发症（胆源性胰腺炎、胆汁漏、胆管狭窄、引流管脱落、残余结石）发生率等。结果 三组患者术前一般资料差异无统计学意义（均P>0.05）。PDC组平均手术时间（75.5 min）明显短于T管组（98.5 min）与双J管组（90.5 min），PDC组与双J管组的平均住院时间（4.8 d与5.4 d）均少于T管组（7.8 d），PDC组与双J管组平均住院费用（18 489 元与20 157元）均低于T管组（24 034 元），差异均有统计学意义（均P<0.05）。三组术后总并发症发生率差异无统计学意义（P=0.521）；PDC组胆汁漏发生率（3.3%）高于另两组（均P<0.05），且患者均为多发胆管结石（>1枚），其中3例结石嵌顿于Oddi括约肌，2例胆管直径<10 mm；双J管组术后胆源性胰腺炎发生率（4.3%）明显高于另两组（均P<0.05），其中2例患者由于结石嵌顿致十二指肠乳头水肿，2例十二指肠乳头旁憩室，1例乳头炎性狭窄。结论 虽然PDC在住院时间及住院花费方面有优势，但术后并发症发生率较高，T管引流与双J管引流也有各自优势与适应证。是否需要引流及引流方式的选择，应根据患者经济情况，结合术前检查，术中腹腔镜及胆道镜对胆道情况的评估进行综合判断，“个体化”选择，以期尽量减少术后并发症，提高患者满意度。

Abstract:

Background and Aims Laparoscopic common bile duct exploration (LCBDE) has become the main method and even the first-line recommended procedure for the treatment of common bile duct stones because of its clinical advantages of small trauma and rapid recovery. However, whether bile drainage is required after LCBDE and the choice of different bile drainage methods are still controversial, such as the discussion of the indications of traditional LCBDE plus external biliary drainage tube (T-tube), whether the primary suture alone leads to high incidence rate of postoperative complications, and whether the internal biliary drainage (double J-tube) is superior to T-tube. To solve the problem mentioned above, this study was conducted to compare the clinical application of T-tube drainage, double J-tube drainage and primary duct closure (PDC) in LCBDE through a retrospective method, and discuss their indications.Methods The clinical data of 363 patients undergoing LCBDE in the Second Affiliated Hospital of Kunming Medical University from March 2015 to May 2018 were retrospectively collected. The patients were divided into T-tube group (128 cases), double J-tube group (115 cases) and PDC group (120 cases) according to the treatment method used. The preoperative general data (sex, liver function, diameter of the common bile duct, and stone size), perioperative variables (operation time, postoperative hospital stays, and hospitalization cost), and incidence of postoperative complications (biliary pancreatitis, bile leakage, biliary stricture, tube detachment, and residual stones) were compared among the three groups.Results There were no significant differences in the preoperative general data among the three groups of patients (all P>0.05). The average operative time in PDC group (75.5 min) was shorter than that in T-tube group (98.5 min) or double J-tube group (90.5 min), the average length of hospital stay in PDC group (4.8 d) or double J-tube group (5.4 d) was shorter than that in T-tube group (7.8 d), and the average medical cost in PDC group (18 489 yuan) or double J-tube group (20 157 yuan) was less than that in T-tube group (24 034 yuan). All the differences had statistical significance (all P<0.05). There was no significant difference in the overall incidence of complications among the three groups (P=0.521), but the incidence rate of biliary leakage in PDC group (3.3%) was higher than those in the other two groups (both P<0.05), and all the patients had multiple bile duct stones (>1 stone), of whom, 3 cases had incarcerated calculus of the sphincter of Oddi, and the diameter of the common bile duct in 2 cases was less than 10 mm; the incidence rate of postoperative pancreatitis in double J-tube group (4.3%) was higher than those in the other two groups (both P<0.05), and the causes included duodenal papillary edema were caused by incarcerated stones in 2 cases, juxta-papillary duodenal diverticula in 2 cases, and inflammatory papillary stenosis in 1 case.Conclusion Although the PDC has some advantages in terms of length of hospital stay and cost of hospitalization, the incidence of postoperative complications is higher, and T-tube drainage and double J-tube drainage also have their own advantages and indications. The necessity of drainage and drainage method selection should be considered based on the patient's economic situation, combined with a comprehensive judgment on the biliary tract conditions by preoperative examination, intraoperative laparoscopy and choledochoscopy, so as to make an "individualized" determination, minimize the postoperative complications and improve patients' satisfaction.