Uchiyama Kazuhisa, Onishi Hironobu, Tani Masaji, Kinoshita Hiroyuki, Kawai Manabu, Ueno Masaki, Yamaue Hiroki
Second Department of Surgery, Wakayama Medical University, School of Medicine, 811-1 Kimidera, Wakayama 641-8510, Japan.
Ann Surg. 2003 Jul;238(1):97-102. doi: 10.1097/01.sla.0000077923.38307.84.
This study was conducted to examine the long-term prognosis of after treatment of patients with choledocholithiasis, including the recurrence of lithiasis, and to thereby determine the best treatment modality for choledocholithiasis based on its pathological entity.
Choledocholithiasis can be caused by either primary bile duct stones that originate in the bile duct or by secondary bile duct stones that have fallen out of the gallbladder. The recurrence rates vary depending on the type of choledocholithiasis.
Two-hundred thirteen outpatients who were treated for choledocholithiasis from 1982 to 1996 were selected as subjects and monitored for a period ranging from 5 to 19 years (mean, 9.6 years). The 213 patients were divided into 3 groups: 87 patients who had undergone choledocholithotomy and T-tube drainage (including the use of the laparoscopic method), 44 patients who had undergone choledochoduodenostomy, and 82 patients whose stones were removed by endoscopic sphincterotomy (EST). Recurrence of lithiasis was examined for each type of treatment modality.
Choledochoduodenostomy was performed in 44 cases for the purpose of preventing any recurrence. The recurrent rate was analyzed in 169 cases. Choledocholithiasis recurred in 17 of the 169 cases (10.1%). The remaining 152 patients that showed no recurrence of lithiasis were examined and compared. The diameter of the common bile duct measured during the initial treatment was more dilated in patients with recurrent lithiasis (16.6 +/- 5.9 mm) than in patients without any recurrence (9.8 +/- 4.9 mm; P < 0.05). Peripapillary diverticula were observed in 10 of the 17 patients with recurrent lithiasis (58.8%), and in 34 of the 152 nonrecurrent patients (22.3%), showing that diverticula were more common in recurrent cases (P < 0.05). Furthermore, while primary bile duct stones were found in 11 of the 17 cases with recurrent lithiasis (64.7%), primary stones were found in only 37 of the 152 nonrecurrent patients (24.3%), showing primary bile duct stones were also more common in recurrent patients (P < 0.05). The recurrent patients were examined by surgical procedure. Nine patients with choledocholithotomy and T-tube drainage had a recurrence (10.3%), and 8 patients in the EST group had a recurrence (9.8%). The recurrence rates for these procedures were higher than for cases with choledochoduodenostomy (recurrence rate: 0%, P < 0.05). In particular, lithiasis recurred in 5 of the 12 patients with T-tube drainage for primary bile duct stones (41.7%).
Although choledocholithotomy and T-tube drainage, including open and laparoscopic surgery, is presently a common procedure for choledocholithiasis, this procedure will not necessarily prevent a recurrence of the disease. For older patients with primary bile duct stones, choledochoduodenostomy or EST is recommended.
本研究旨在探讨胆总管结石患者治疗后的长期预后，包括结石复发情况，从而根据其病理类型确定胆总管结石的最佳治疗方式。
胆总管结石可由起源于胆管的原发性胆管结石或从胆囊脱落的继发性胆管结石引起。复发率因胆总管结石的类型而异。
选取1982年至1996年接受胆总管结石治疗的213例门诊患者作为研究对象，进行5至19年（平均9.6年）的随访。213例患者分为3组：87例行胆总管切开取石及T管引流术（包括腹腔镜手术），44例行胆总管十二指肠吻合术，82例行内镜括约肌切开取石术（EST）。对每种治疗方式的结石复发情况进行检查。
为预防复发，44例患者行胆总管十二指肠吻合术。对169例患者分析复发率。169例中有17例胆总管结石复发（10.1%）。对其余152例未复发结石的患者进行检查并比较。复发结石患者初次治疗时胆总管直径（16.6±5.9mm）比未复发患者（9.8±4.9mm）更宽（P<0.05）。17例复发结石患者中有10例（58.8%）观察到乳头周围憩室，152例未复发患者中有34例（22.3%）观察到乳头周围憩室，表明憩室在复发患者中更常见（P<0.05）。此外，17例复发结石患者中有11例（64.7%）为原发性胆管结石，152例未复发患者中仅37例（24.3%）为原发性结石，表明原发性胆管结石在复发患者中也更常见（P<0.05）。对复发患者进行手术方式分析。9例行胆总管切开取石及T管引流术的患者复发（10.3%），EST组8例患者复发（9.8%）。这些手术的复发率高于胆总管十二指肠吻合术（复发率：0%，P<0.05）。特别是，12例原发性胆管结石行T管引流的患者中有5例复发（41.7%）。
尽管胆总管切开取石及T管引流术，包括开放手术和腹腔镜手术，目前是胆总管结石的常见手术方式，但该手术不一定能预防疾病复发。对于老年原发性胆管结石患者，推荐行胆总管十二指肠吻合术或EST。
