Stain S C, Marsri L S, Froes E T, Sharma V, Parekh D
Department of Surgery, University of Southern California, School of Medicine, Los Angeles 90033-4612.
Am Surg. 1994 Oct;60(10):767-71.
Liver function tests (LFTs) are most often employed to select patients for preoperative endoscopic retrograde cholangiography (ERC) and therapeutic sphincterotomy. Although ERC accurately detects CBD stones, the associated financial costs and potential morbidity argue against its indiscriminate use. We analyzed the value of LFTs to predict CBD stones in patients treated by laparoscopic cholecystectomy (LC). CBD stones were identified in 41 of 660 patients (6.2%) treated by LC during the study period (January 1991 to May 1993). CBD stones were identified by preoperative ERC in 19 of 33 patients (57.6%); by operative cholangiography in 18 of 289 patients (6.2%), and by postoperative ERC in 4 patients. In patients with CBD stones, there was a significant difference in alkaline phosphatase, total bilirubin, SGPT, and SGOT (P < 0.001). The positive predictive value (PPV) of a value > normal at admission was 5%-19%; and immediately before operation was 9%-36%. The PPV of a value > 2X normal was 30%-47%. Alkaline phosphatase and total bilirubin were independent predictors of CBD stones. If both were greater than twice normal, there was a 55 per cent incidence of CBD stones. Our analysis suggests that patients with greater than twice normal liver function tests have a sufficient incidence of CBD stones to warrant ERC. Patients without both these criteria should be managed by laparoscopic CBDE, with postoperative endoscopic stone retrieval for the failures of laparoscopic CBDE.
肝功能检查（LFTs）常用于选择术前进行内镜逆行胆管造影（ERC）和治疗性括约肌切开术的患者。尽管ERC能准确检测出胆总管结石，但相关的经济成本和潜在发病率使其不宜被随意使用。我们分析了肝功能检查对预测接受腹腔镜胆囊切除术（LC）患者胆总管结石的价值。在研究期间（1991年1月至1993年5月），660例接受LC治疗的患者中有41例（6.2%）被发现有胆总管结石。33例患者中有19例（57.6%）通过术前ERC发现胆总管结石；289例患者中有18例（6.2%）通过术中胆管造影发现，4例通过术后ERC发现。有胆总管结石的患者，碱性磷酸酶、总胆红素、谷丙转氨酶和谷草转氨酶有显著差异（P<0.001）。入院时数值>正常的阳性预测值（PPV）为5%-19%；手术前即刻为9%-36%。数值>正常两倍的PPV为30%-47%。碱性磷酸酶和总胆红素是胆总管结石的独立预测指标。如果两者均大于正常两倍，则胆总管结石的发生率为55%。我们的分析表明，肝功能检查大于正常两倍的患者胆总管结石发生率足以保证进行ERC。不符合这两个标准的患者应采用腹腔镜胆总管探查术（CBDE）治疗，对于腹腔镜CBDE失败的患者术后进行内镜取石。
