Department of General Surgery, Yancheng City No. 1 People's Hospital, 16 Yuehe Road, Yancheng 224005, Jiangsu Province, China.
Department of Gastroenterology, Yancheng City No. 1 People's Hospital, 16 Yuehe Road, Yancheng 224005, Jiangsu Province, China.
Int J Surg. 2017 Aug;44:269-273. doi: 10.1016/j.ijsu.2017.06.032. Epub 2017 Jun 28.
Choledocholithiasis can be managed by endoscopic retrograde cholangiopancreaticography/endoscopic sphincterotomy (ERCP/EST) or laparoscopic common bile duct (CBD) exploration by transcystic (TC) or transductal (TD) stone extraction.
The aim of this study was to evaluate the safety and effectiveness of common bile duct stones extraction by ERCP/EST, TC approach and TD approach for choledocholithiasis, with specific emphasis on ERCP/EST, TC approach versus TD approach.
Between January 2011 and June 2014, a total of 161 patients were scheduled for two-stage (preoperative ERCP/EST followed by cholecystectomy, ERCP group, n = 52)or single-stage (laparoscopic exploration of the CBD combined with cholecystectomy, n = 109) treatment for choledocholithiasis with concomitant cholecystitis. Laparoscopic common bile duct exploration was performed by TC approach (TC group, n = 63)or TD approach (TD group, n = 46). T-tube insertion was performed in selected patients. Patients were regularly followed up at bimonthly intervals or more frequently in presence of any symptom. Primary outcomes measures included length of hospital stay, successful bile duct clearance, postoperative/procedural morbidity and mortality.
Successful bile duct clearance was 100.0% in TD group, 93.7% in TC group and 92.3% in ERCP group. 4 cases in the TC group and 4 cases in the ERCP group required an extra choledocholithotomy due to impacted stones. 9 patients underwent T-tube drainage in TD group comparing to 1 case in ERCP group and no cases in TC group. Comparing to TC group, there was more postoperative morbidity in TD and ERCP group. Bile leaks were more frequent in TD group (8.7%) than TC (3.2%) and ERCP group (3.8%), which prolonged hospitalization in TD group than TC and ERCP group. 2 patients in ERCP group suffered duodenal perforation and one of them died because of the complication. However, total procedural morbidity was 0% in TC and TD group.
TD stone extraction has a higher stone clearance but with a higher risk of bile leaks. Procedural morbidity is more often happened in ERCP/EST, which may result in serious consequences. TC stone extraction, which seems an effective approach with lower complication rates, is accessible techniques simplifying the operation procedure by avoiding choledocholithotomy and subsequent T-tube insertion.
胆总管结石可通过内镜逆行胰胆管造影/内镜下括约肌切开术（ERCP/EST）或经胆囊管（TC）或经胆管（TD）取石的腹腔镜胆总管探查术治疗。
本研究旨在评估 ERCP/EST、TC 途径和 TD 途径治疗胆总管结石的安全性和有效性，特别强调 ERCP/EST、TC 途径与 TD 途径的比较。
2011 年 1 月至 2014 年 6 月，共有 161 例患者因合并胆囊炎需行两阶段（术前 ERCP/EST 后行胆囊切除术，ERCP 组，n=52）或单阶段（腹腔镜胆总管探查联合胆囊切除术，n=109）治疗胆总管结石。腹腔镜胆总管探查采用 TC 途径（TC 组，n=63）或 TD 途径（TD 组，n=46）。在选择的患者中进行 T 管插入。患者定期每两个月或出现任何症状时更频繁地随访。主要观察指标包括住院时间、胆管清除率、术后/操作并发症发生率和死亡率。
TD 组胆管清除率为 100.0%，TC 组为 93.7%，ERCP 组为 92.3%。TC 组有 4 例和 ERCP 组有 4 例因结石嵌顿需额外行胆总管切开取石。TD 组有 9 例行 T 管引流，ERCP 组 1 例，TC 组无。与 TC 组相比，TD 组和 ERCP 组术后并发症更多。TD 组胆漏发生率（8.7%）高于 TC 组（3.2%）和 ERCP 组（3.8%），TD 组住院时间延长。ERCP 组 2 例患者发生十二指肠穿孔，其中 1 例因并发症死亡。然而，TC 组和 TD 组总操作并发症发生率为 0%。
TD 取石有更高的结石清除率，但胆漏风险更高。ERCP/EST 操作并发症更常见，可能导致严重后果。TC 取石似乎是一种有效的方法，并发症发生率较低，通过避免胆总管切开和随后的 T 管插入简化了操作程序。
