腹腔镜胆总管探查术在既往腹部胆道手术患者中的应用。
Laparoscopic common bile duct exploration in patients with previous abdominal biliary tract operations.
机构信息
Department of General Surgery, Zhongshan Hospital, Fudan University, 180, Fenglin Road, Shanghai, 200032, China.
Department of General Surgery, Xuhui Central Hospital, Shanghai, 200031, China.
出版信息
Surg Endosc. 2020 Apr;34(4):1551-1560. doi: 10.1007/s00464-020-07429-3. Epub 2020 Feb 18.
BACKGROUND
A history of abdominal biliary tract surgery has been identified as a relative contraindication for laparoscopic common bile duct exploration (LCBDE), and there are very few reports about laparoscopic procedures in patients with a history of abdominal biliary tract surgery.
METHODS
We retrospectively reviewed the clinical outcomes of 227 consecutive patients with previous abdominal biliary tract operations at our institution between December 2013 and June 2019. A total of 110 consecutive patients underwent LCBDE, and 117 consecutive patients underwent open common bile duct exploration (OCBDE). Patient demographics and perioperative variables were compared between the two groups.
RESULTS
The LCBDE group performed significantly better than the OCBDE group with respect to estimated blood loss [30 (5-700) vs. 50 (10-1800) ml; p = 0.041], remnant common bile duct (CBD) stones (17 vs. 28%; p = 0.050), postoperative hospital stay [7 (3-78) vs. 8.5 (4.5-74) days; p = 0.041], and time to oral intake [2.5 (1-7) vs. 3 (2-24) days; p = 0.015]. There were no significant differences in the operation time [170 (60-480) vs. 180 (41-330) minutes; p = 0.067]. A total of 19 patients (17%) in the LCBDE group were converted to open surgery. According to Clavien's classification of complications, the LCBDE group had significantly fewer postoperative complications than the OCBDE group (40 vs. 57; p = 0.045). There was no mortality in either group. Multiple previous operations (≥ 2 times), a history of open surgery, and previous biliary tract surgery (including bile duct or gallbladder + bile duct other than cholecystectomy alone) were risk factors for postoperative adhesion (p = 0.000, p = 0.000, and p = 0.000, respectively).
CONCLUSION
LCBDE is ultimately the least invasive, safest, and the most effective treatment option for patients with previous abdominal biliary tract operations and is especially suitable for those with a history of cholecystectomy, few previous operations (< 2 times), or a history of laparoscopic surgery.
背景
既往腹部胆道手术史被认为是腹腔镜胆总管探查术（LCBDE）的相对禁忌证，仅有少数关于既往有胆道手术史患者行腹腔镜手术的报道。
方法
我们回顾性分析了 2013 年 12 月至 2019 年 6 月期间我院 227 例既往有腹部胆道手术史患者的临床资料。其中 110 例行 LCBDE，117 例行开腹胆总管探查术（OCBDE）。比较两组患者的一般资料和围手术期指标。
结果
LCBDE 组在术中出血量[30（5-700）ml 比 50（10-1800）ml；p=0.041]、残余胆总管结石（17%比 28%；p=0.050）、术后住院时间[7（3-78）d 比 8.5（4.5-74）d；p=0.041]和术后开始经口进食时间[2.5（1-7）d 比 3（2-24）d；p=0.015]方面明显优于 OCBDE 组，而手术时间[170（60-480）min 比 180（41-330）min；p=0.067]无显著差异。LCBDE 组中有 19 例（17%）患者中转开腹。LCBDE 组术后并发症发生率明显低于 OCBDE 组（40%比 57%；p=0.045），两组均无死亡病例。既往多次手术（≥2 次）、开腹手术史和既往胆道手术史（包括胆管或胆囊+胆管以外的手术而非单纯胆囊切除术）是术后粘连的危险因素（p=0.000、p=0.000 和 p=0.000）。
结论
LCBDE 是既往有腹部胆道手术史患者最微创、最安全、最有效的治疗方法，尤其适用于既往有胆囊切除术、手术次数少（<2 次）或有腹腔镜手术史的患者。
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