胆总管结石的治疗：网状荟萃分析。

Common bile duct stones management: A network meta-analysis.

机构信息

From the Division of Trauma and Emergency Surgery, Department of Surgery (S.M., M.P.F.), Orebro University Hospital; School of Medical Sciences, Orebro University (S.M., G.A.B., M.P.F.), Orebro, Sweden; Division of Traumatology, Surgical Critical Care and Emergency Surgery (G.A.B.), Penn Presbyterian Medical Center, University of Pennsylvania, Philadelphia, Pennsylvania; Servicio de Cirugía General y Digestiva, Unidad de Cirugía de Urgencias y Trauma (I.M.C.), Hospital Universitario Virgen del Rocio, Sevilla, Andalucia, Spain; Division of Acute Care Surgery (M.M.), Los Angeles County + USC Medical Center, Uniformed Services University Health Sciences, Los Angeles, California; Division of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery (K.A.D.), Yale School of Medicine, New Haven, Connecticut; Division of Acute Care Surgery, Department of Surgery (E.R.H.), Department of Anesthesiology and Critical Care Medicine (E.R.H.), and Department of Emergency Medicine (E.R.H.), The Johns Hopkins University School of Medicine; Department of Health Policy and Management (E.R.H.), The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Letterkenny Hospital (M.S.), Galway University, Galway, Ireland; UOSD Chirurgia d'Urgenza (H.K.), Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Center of Trauma and Critical Care (B.S.), George Washington University, Washington, DC; Clinical Epidemiology and Biostatistics (Y.C.), School of Medical Sciences, Orebro University, Orebro, Sweden; Department of Surgery, Riverside University Health System Medical Center (R.C.); Department of Surgery, Loma Linda University School of Medicine (R.C.), Loma Linda; and Department of Surgery, Comparative Effectiveness and Clinical Outcomes Research Center (R.C.), California.

出版信息

J Trauma Acute Care Surg. 2022 Nov 1;93(5):e155-e165. doi: 10.1097/TA.0000000000003755. Epub 2022 Aug 5.

DOI:10.1097/TA.0000000000003755

PMID:35939370

Abstract

BACKGROUND

Timely management is critical for treating symptomatic common bile duct (CBD) stones; however, a single optimal management strategy has yet to be defined in the acute care setting. Consequently, this systematic review and network meta-analysis, comparing one-stage (CBD exploration or intraoperative endoscopic retrograde cholangiopancreatography [ERCP] with simultaneous cholecystectomy) and two-stage (precholecystectomy or postcholecystectomy ERCP) procedures, was undertaken with the main outcomes of interest being postprocedural complications and hospital length of stay (LOS).

METHODS

PubMed, SCOPUS, MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were methodically queried for articles from 2010 to 2021. The search terms were a combination of medical subject headings terms and the subsequent terms: gallstone; common bile duct (stone); choledocholithiasis; cholecystitis; endoscopic retrograde cholangiography/ERCP; common bile duct exploration; intraoperative, preoperative, perioperative, and postoperative endoscopic retrograde cholangiography; stone extraction; and one-stage and two-stage procedure. Studies that compared two procedures or more were included, whereas studies not recording complications (bile leak, hemorrhage, pancreatitis, perforation, intra-abdominal infections, and other infections) or LOS were excluded. A network meta-analysis was conducted to compare the four different approaches for managing CBD stones.

RESULTS

A total of 16 studies (8,644 participants) addressing the LOS and 41 studies (19,756 participants) addressing postprocedural complications were included in the analysis. The one-stage approaches were associated with a decrease in LOS compared with the two-stage approaches. Common bile duct exploration demonstrated a lower overall risk of complications compared with preoperative ERCP, but there were no differences in the overall risk of complications in the remaining comparisons. However, differences in specific postprocedural complications were detected between the four different approaches managing CBD stones.

CONCLUSION

This network meta-analysis suggests that both laparoscopic CBD exploration and intraoperative ERCP have equally good outcomes and provide a preferable single-anesthesia patient pathway with a shorter overall length of hospital stay compared with the two-stage approaches.

LEVEL OF EVIDENCE

Systematic Review/Meta Analysis; Level III.

摘要

背景

及时治疗有症状的胆总管（CBD）结石至关重要；然而，在急性护理环境中，尚未确定单一的最佳治疗策略。因此，进行了这项系统评价和网络荟萃分析，比较了一期（CBD 探查或术中内镜逆行胰胆管造影 [ERCP] 联合胆囊切除术）和两期（胆囊切除术前或术后 ERCP）治疗方法，主要关注的结局是术后并发症和住院时间（LOS）。

方法

从 2010 年到 2021 年，系统地检索了 PubMed、SCOPUS、MEDLINE、Embase 和 Cochrane 对照试验中心注册库中的文章。检索词是医学主题词和随后的术语的组合：胆结石；胆总管（结石）；胆石症；胆囊炎；内镜逆行胰胆管造影/ERCP；胆总管探查；术中、术前、围手术期和术后 ERCP；结石取出术；以及一期和两期手术。纳入比较两种或多种手术方法的研究，而排除未记录并发症（胆漏、出血、胰腺炎、穿孔、腹腔内感染和其他感染）或 LOS 的研究。进行网络荟萃分析以比较四种不同的 CBD 结石治疗方法。

结果

共纳入 16 项研究（8644 名参与者）评估 LOS，41 项研究（19756 名参与者）评估术后并发症。与两期手术相比，一期手术方法与 LOS 降低相关。与术前 ERCP 相比，胆总管探查术总体并发症风险较低，但在其余比较中，并发症总体风险无差异。然而，在管理 CBD 结石的四种不同方法之间，检测到特定术后并发症之间存在差异。