【作者】 郑民华；

【导师】 毛正中； 张圣道； 魏强；

【作者基本信息】 四川大学 ， 社会医学与卫生事业管理， 2002， 硕士

【摘要】 【目的】 1．探讨腹腔镜胆囊切除(LC)术中胆道造影(LOC)和腹腔镜超声(LUS)诊断胆总管结石的临床价值，寻找诊断胆总管结石最安全、有效、可靠的检查手段，为外科医师选择方案提供依据。 ⅰ．中胆道造影(LOC)和腹腔镜超声(LUS)进行卫生经济学评价，探讨诊断胆总管结石最经济有效的方法。 【研究地点】 上海第二医科大学附属瑞金医院普外科和瑞金分院(原上海市政医院)普外科。 【对象和方法】 本研究采用平行性诊断性试验。对2000年6月-2001年9月行LC手术、有胆总管探查指证、且符合纳入标准的100例住院患者进行临床研究。所有患者在切除胆囊前均先行LUS检查再行LOC检查，统计两种检查方法的操作 成功率和操作时间：根据四格表计算uS、LOC以及MS联合LOC三种方法的 敏感性、特异性、阳性预测值、阴性预测值、阳性似然比和阴性似然比。应 用成本－效果分析评价三种方法的诊断效果；应用增量分析和成本－效益分析计算LUS联合LOC与单纯LOC相比，每多诊断出1例胆总管结石患者所需增加的成本和可获得的效益，并计算成本－效果比和净效益。 【研究结果】l．LOC的操作成功率为 94．9％，LUS为 100％。LL的操作时间为门 ．37土 3．53分，LUS为 7．68士 2．14分。两种方法在操作时间上差异有显著性（P＜0．01）。2．LOC的敏感性为85．0％，特异性为96．2％，准确性为gi．4％，阳性预测值为94．4％，阴性预测值为 89．5％，阳性似然比为 22．4，阴性似然比为 0．156；LUS的敏感性为82．5兄 特异性为98．1兄 准确性为91．4兄阳性预测值为97．1兄阴性预测值为88．l％，阳性似然比为43．4，阴性似然比为0．178；LUS联合LOC的敏感性为97．5％，特异性为94．3％，准确性为95．7％，阳性预测值为92．9％，阴性预测值为 98．0％，阳性似然比为 17．1，阴性似然比为 0．027。 LOC、LUS和WS联合LOC的成本／效果比分别为601．76元／人、845，45元／人和963刀8元／人。LUS联合LOC与LOC相比，每多诊断出1例胆总管结石需增加成本 3420元，可获得效益为 5545．5元，效益／成本比是 1．62，净效益为 10627．5元。【结论】 在LC术中，对LOC检查阴性的患者再进行LUS检查可提高诊断效果。成本－效果分析和成本－效益分析表明LOC联合LUS是一种既具有临床意义、又具有卫生经济学意义的诊断方法。更多还原

【Abstract】 [Purpose]1 .To evaluate the value of laparoscopic ultrasound ( LUS ) and intraoperative cholangiography (IOC) in common bile duct exploration by comparing the results and feasibility of IOC and LUS.2. To analysis the cost/benefit of laparoscopic ultrasound ( LUS ) and intraoperative cholangiography (IOC).[Setting]Department of General Surgery, RuiJin Hospital and ShiZheng Hospital, Shanghai Second Medical University. [Method]100 patients with LC and CBD exploration indication had been included this clinical diagnostic test during June of 2000 to September of 2001.All patients were examined LUS and LOG before cholecystectomy, The successful rate and examining time was recorded in order to result the sensitivity, specificity, positive predictive value, negative predictive value LUS, LOG, and LUS combining with LOG respectively. We evaluated 3 diagnostic methods with cost-effect analysis and calculated the cost/benefit with incremental analysis bycomparing LUS and LOG combining LUS. Also we calculated the cost and benefit of each additional diagnosis of CBD stone by LUS+IOC[Measurement and Result]Success rate LOG 94.9%, LUS % 100%0 Operative time LOC= 11.37+ 3.53min, LUS=7.68+2.14mino There are no significant difference between 2 groups (P<0.01).LOG sensitivity 85.0%, specificity 96.2%, accuracy 91.4%,Positive predictive value:94.4%, Negative predictive value: 89.5%, Positive likelihood ratio:22.4; Negative likelihood ratio: 0.156; LUS sensitivity 82.5%, specificity 98.1%, accuracy 91.4%, Positive predictive value:97.1% , Negative predictive value:88.1%, Positive likelihood ratio: 43.4, Negative likelihood ratio: 0.178; LUS+LOC sensitivity: 97.5%, specificity: 94.3%, accuracy: 95.7%, Positive predictive value:92.9%, Negative predictive value:98.0%, Positive likelihood ratio: 17.1, Negative predictive value:0.027,IOC, LUS and LUS+LOC cost/effectiness is 601.76RMB, 845.45RMB and 963.08RMB respectively. Comparing with IOC alone, each additional diagnosis of CBD stone by LUS+IOC will increase the cost of 3420RMB but gain the benefit of 5545.5RMB, and pure benefit was 10627.5RMB.[Conclusion]LUS can increase the accuracy of diagnosing CBD stone for whom can not be diagnosed by IOC. The cost/effect and cost/benefit show that IOC combining with LUS is not only a clinical valuable method but also an economic way in diagnosing CBD stone.更多还原