Department of Hepatobiliary and Pancreatic Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Yanchang Road 301, Shanghai, 200072, China.
Surg Endosc. 2017 Sep;31(9):3581-3589. doi: 10.1007/s00464-016-5388-6. Epub 2016 Dec 30.
Laparoscopic common bile duct exploration (LCBDE) has gained wide popularity in the treatment of choledocholithiasis. Bile leakage remains a major cause of postoperative morbidity. The aim of this study was to report 5-year results of 500 LCBDEs and identify risk factors associated with bile leakage.
Five hundred consecutive LCBDEs performed in one institution from September 2011 to June 2016 were reviewed. Patients' clinical data were retrospectively collected and analyzed. Univariable and multivariable analysis of bile leakage was performed by logistic regression.
We found stones (n = 388) or bile sludge (n = 71) in 459 patients (92%) on exploration, leaving 41 patients (8%) without stones. Operative time was 128 min in the first 250 LCBDEs, and this decreased to 103 min in the second 250 LCBDEs (P = 0.0004). Four hundred and eight (82%) procedures were completed with primary closure after choledochotomy; the rate of primary closure increased significantly in the second 250 patients compared with the first (88 vs 76%; P = 0.0005), whereas T-tube placement (2 vs 6%; P = 0.0225) and transcystic approach (7 vs 12%; P = 0.0464) decreased, respectively. Stone clearance was successful in 495 patients (99%). Overall morbidity was 5%, and bile leakage occurred in 17 patients (3.4%). Two patients died from bile leakage. The median follow-up was 24 months with stone recurrence occurred in two patients and bile duct stricture in one patient. Univariable analysis identified diameter of the common bile duct (CBD), stone clearance, and T-tube insertion as risk factors related to bile leakage. Multivariable analysis taking these three factors into account identified non-dilated CBD (risk ratio (RR) = 9.87; P = 0.007) and failure in stone clearance (RR = 11.88; P = 0.024) as significant risk factors.
Bile leakage following LCBDE is associated with diameter of the CBD and stone clearance. LCBDE would be safer in proficient laparoscopic surgeons with a careful selection of patients.
腹腔镜胆总管探查术（LCBDE）在治疗胆总管结石方面已得到广泛应用。胆漏仍然是术后发病率的主要原因。本研究旨在报告 500 例 LCBDE 的 5 年结果，并确定与胆漏相关的危险因素。
回顾性分析 2011 年 9 月至 2016 年 6 月在一家医院进行的 500 例连续 LCBDE 患者的临床资料。对患者的临床资料进行回顾性收集和分析。采用逻辑回归对胆漏进行单变量和多变量分析。
在探查中发现 459 例（92%）患者有结石（n=388）或胆汁淤渣（n=71），41 例（8%）患者无结石。前 250 例 LCBDE 的手术时间为 128 分钟，后 250 例手术时间减少至 103 分钟（P=0.0004）。胆总管切开后，408 例（82%）采用一期缝合；与前 250 例相比，第二期患者中一期缝合的比例显著增加（88%比 76%；P=0.0005），而 T 管放置（2%比 6%；P=0.0225）和经胆囊管入路（7%比 12%；P=0.0464）分别减少。495 例（99%）患者结石清除成功。总发病率为 5%，17 例（3.4%）发生胆漏。2 例患者死于胆漏。中位随访时间为 24 个月，2 例患者复发结石，1 例患者胆管狭窄。单变量分析发现胆总管直径（CBD）、结石清除和 T 管插入是与胆漏相关的危险因素。多变量分析考虑这三个因素后发现非扩张 CBD（风险比（RR）=9.87；P=0.007）和结石清除失败（RR=11.88；P=0.024）是显著的危险因素。
LCBDE 后胆漏与 CBD 直径和结石清除有关。在经验丰富的腹腔镜外科医生中，对患者进行精心选择，LCBDE 会更安全。
