De Silva Harendra Maneesha, Howard Tess, Yong Tuck, Hodgson Russell
Division of Surgery, Northern Health, Epping, Australia.
Department of Surgery, University of Melbourne, Epping, Australia.
J Laparoendosc Adv Surg Tech A. 2023 Apr;33(4):389-396. doi: 10.1089/lap.2022.0526. Epub 2023 Feb 3.
Laparoscopic common bile duct exploration (LCBDE) and endoscopic retrograde cholangiopancreatography (ERCP) are two methods of retrieving common bile duct (CBD) stones. Aspects of CBD stone management, such as sphincterotomy, have been implicated as risks for CBD stone recurrence although evidence is weak. The aim of this study was to compare stone recurrence following LCBDE and/or ERCP. Data were collected retrospectively for patients undergoing LCBDE and/or ERCP for CBD stones at a single center from 2008 to 2018. Primary outcome was stone recurrence (>6 months after duct clearance). Risk factors for recurrence were assessed using univariate and multivariate analyses. A total of 445 patients underwent LCBDE-only, 79 patients underwent ERCP-only and 80 patients underwent LCBDE-ERCP. LCBDE-only patients were younger and preoperatively less morbid than ERCP-only patients. Although there was no significant difference for recurrence, there was a trend toward higher recurrence with ERCP-only compared with LCBDE-only and LCBDE-ERCP (5.1% versus 2.0% and 2.5%, = .280). On univariate comparison, patients with a recurrence were significantly older, had a higher admission white cell count, higher number of ERCPs, increased transampullary stent use, and higher maximum CBD diameter. Total number of ERCP was the only independent predictor of stone recurrence (odds ratio 6.85 [2.55-18.42], < .001) following multivariate regression. Management plan was not associated with stone recurrence. The total number of ERCP was the only independent predictor of recurrence. Within the limitations of case selection and bias toward LCBDE, this study suggests that limiting repeated ERCP may reduce CBD stone recurrence.
腹腔镜胆总管探查术（LCBDE）和内镜逆行胰胆管造影术（ERCP）是两种取出胆总管（CBD）结石的方法。尽管证据不足，但胆总管结石处理的某些方面，如括约肌切开术，被认为是胆总管结石复发的风险因素。本研究的目的是比较LCBDE和/或ERCP术后结石复发情况。回顾性收集了2008年至2018年在单一中心因胆总管结石接受LCBDE和/或ERCP治疗的患者的数据。主要结局是结石复发（胆管清除后>6个月）。使用单因素和多因素分析评估复发的危险因素。共有445例患者仅接受了LCBDE，79例患者仅接受了ERCP，80例患者接受了LCBDE-ERCP联合治疗。仅接受LCBDE的患者比仅接受ERCP的患者更年轻，术前病情更轻。尽管复发率没有显著差异，但与仅接受LCBDE和LCBDE-ERCP联合治疗相比，仅接受ERCP的患者复发率有升高趋势（5.1%对2.0%和2.5%，P = 0.280）。单因素比较显示，复发患者年龄显著更大，入院时白细胞计数更高，ERCP次数更多，经壶腹支架使用增加，胆总管最大直径更大。多因素回归分析后，ERCP总次数是结石复发的唯一独立预测因素（比值比6.85[2.55 - 18.42]，P < 0.001）。治疗方案与结石复发无关。ERCP总次数是复发的唯一独立预测因素。在病例选择的局限性和对LCBDE的偏倚范围内，本研究表明限制重复ERCP可能会降低胆总管结石的复发率。
