Monklands Hospital, NHS Lanarkshire, Airdrie, ML6 0JS, UK.
Surg Endosc. 2010 Jul;24(7):1552-6. doi: 10.1007/s00464-009-0809-4. Epub 2010 Jan 1.
This study was designed to explore the role of transcystic bile duct exploration (TCE) as a first line of treatment for patients with suspected or incidental common bile duct (CBD) stones.
A prospective, case-control study of clinically comparable groups of patients who underwent laparoscopic cholecystectomy (LC) alone (n = 1,854) and combined LC/TCE for CBD stones (n = 253) under the care of one surgeon was performed. Other than ultrasonography, no routine preoperative imaging was used; however, we performed routine intraoperative cholangiography on all patients.
There was no difference in age (49 +/- 15 vs. 57 +/- 19, p = 0.7), sex (79% vs. 82% females, p = 0.6), and ASA grade (1.9 +/- 1 vs. 1.8 +/- 1, p = 0.7). A larger proportion of the TCE group presented as an emergency (TCE 45% vs. LC alone 27%, p = 0.03) and more often presented with acute biliary pain compared with LC alone (27% vs. 13%, p = 0.02). Although a majority of the patients in the TCE group had clinical or biochemical risk factors for CBD stones (86%), only 27% had suspected stones on preoperative ultrasound. The incidence of jaundice (6% vs. 20%, p = 0.01) was lower in the LC alone group compared with TCE patients. Previous abdominal surgery was noted in 34% patients who underwent LC alone and 30% in LC/TCE (p = 0.06). Significantly there was no difference in open conversion between the two groups (LC alone 0.5% vs. LC/TCE 0.6%, p = 0.07). Comparison of selected outcome parameters for LC versus TCE showed a postoperative hospital stay of 2 (1-14) vs. 2 (1-17) days (p = 0.07), presentation to resolution 1 (1-11) vs. 1 (1-11) weeks (p = 0.07), and morbidity 1.07% vs. 1.2% (p = 0.07).
The study advocates single-session laparoscopic cholecystectomy with transcystic CBD exploration as a feasible first choice treatment and the logical next step in the management of patients with CBD stones.
本研究旨在探讨经胆囊管胆管探查术（TCE）作为疑似或偶发性胆总管（CBD）结石患者一线治疗方法的作用。
对在同一位外科医生的治疗下，分别接受腹腔镜胆囊切除术（LC）单独治疗（n = 1,854）和 LC/TCE 联合治疗（n = 253）的临床可比组患者进行前瞻性、病例对照研究。除超声检查外，不使用任何常规术前影像学检查；但我们对所有患者常规进行术中胆管造影。
两组患者的年龄（49 ± 15 岁 vs. 57 ± 19 岁，p = 0.7）、性别（79% vs. 82%女性，p = 0.6）和 ASA 分级（1.9 ± 1 分 vs. 1.8 ± 1 分，p = 0.7）均无差异。TCE 组中急诊手术比例更高（TCE 组 45% vs. LC 组单独治疗 27%，p = 0.03），且与 LC 组单独治疗相比，TCE 组中更常出现急性胆绞痛（27% vs. 13%，p = 0.02）。尽管 TCE 组中大多数患者有 CBD 结石的临床或生化危险因素（86%），但仅 27%的患者在术前超声检查中怀疑有结石。LC 组单独治疗患者的黄疸发生率（6% vs. 20%，p = 0.01）低于 TCE 患者。LC 组单独治疗中有 34%的患者既往有腹部手术史，LC/TCE 组中有 30%（p = 0.06）。两组中转开腹率无显著差异（LC 组单独治疗 0.5% vs. LC/TCE 0.6%，p = 0.07）。LC 与 TCE 两组的术后住院时间（2（1-14）天 vs. 2（1-17）天，p = 0.07）、表现至缓解时间（1（1-11）周 vs. 1（1-11）周，p = 0.07）和发病率（1.07% vs. 1.2%，p = 0.07）的比较结果无显著差异。
该研究提倡单次腹腔镜胆囊切除术联合经胆囊管胆管探查术作为可行的一线治疗方法，也是治疗 CBD 结石患者的合理下一步。
