【作者】 孟宇；

【导师】 张平；

【作者基本信息】 吉林大学 ， 外科学（专业学位）， 2015， 硕士

【摘要】 胆管结石是肝胆胰外科的常见病及多发病,最新研究表明,胆囊结石发病占79.9%；肝外胆管结石合并胆囊结石发病占9.2%；肝外胆管结石占6.2%。据统计,在西方国家,胆结石的发病率约为10%-40%,且主要为胆囊结石；而在东方国家,其发病率约为2%-6%,近年来胆石症的发病率呈逐渐上升趋势[1、2]。大多数胆管结石都会出现发热、腹痛、黄疸等临床症状,严重者出现急性梗阻性化脓性胆管炎,危及生命,故胆管结石患者大多需要手术治疗。自Phillip于1991年率先开展了腹腔镜胆总管切开取石、T管引流术[3],该术式已逐渐被外科医师和患者接受,但长期T管引流存在着胆汁大量流失、电解质紊乱、延长患者恢复时间、增加患者痛苦等诸多问题,随着微创技术的不断发展及患者对治疗的要求不断提高,腹腔镜下一期缝合术逐渐开始应用于临床,但一期缝合存在其严格的局限性,随着内镜技术的日臻完善,全国数个医疗中心采用术中腹腔镜、胆道镜、十二指肠镜联合(以下简称三镜联合)解决肝外胆管结石,收到了很好的效果[1,6]。目前我国肝胆胰外科针对肝外胆管结石的腹腔镜手术治疗主要存在上述三种术式。评估比较这三种术式对肝外胆管结石的疗效对比具有积极意义。目的：探讨腹腔镜胆总管探查一期缝合及术中腹腔镜、胆道镜、十二指肠镜三镜联合的可行性及安全性,比较肝外胆管结石三种解决模式的优劣材料及方法：采用回顾性分析方法收集自2013年1月至2015年4月于我院我科接受手术治疗的77例肝外胆管结石患者,按其采取T管引流、胆管一期缝合、术中胆管一期缝合联合留置鼻胆管分为3组(LCBDE-T组、LCBDE-PS组、LCBDE-ENBD组),分别比较术后住院天数、引流管留置时间、首次排气时间、术后并发症发生率,评价该两种术式的临床疗效。结果：所有患者均采用手术治疗,近期结果中,T管引流术组与一期缝合组(LCBDE-T组、LCBDE-PS组)在术后平均住院天数、首次排气时间、引流管留置时间、胆瘘发生率等方面均存在统计学差异(P<0.05)。一期缝合组与三镜联合组(LCBDE-PS组、LCBDE-ENBD组)在以上方面无统计学差异(P>0.05)。结论：1、一期缝合相较于T管引流可有效地缩短术后住院时间、术后排气时间及引流管留置时间。2、三镜联合技术拓宽了一期缝合的适应证,通过内镜技术的组合最大限度地实现了胆石症的微创治疗。3、肝外胆管结石的手术治疗需遵循个体化治疗的原则。更多还原

【Abstract】 Cholelithiasis is a common disease and frequently occurring disease of hepatobiliary and pancreatic surgery. Recent study shows gallbladder weighs 79.9%; Extrahepatic bile duct stones with gallbladder stones weighs 9.2%; Extrahepatic bile duct stones weighs 6.2%. According to statistics, in the western countries, the incidence of gallstones is about 10%-40%, and mainly for gallbladder stones;while in eastern countries, its incidence is about 2%-6%, and in recent years, the incidence of cholelith disease showed a trend of rising. Most bile duct stone would appear clinical symptoms such as fever, abdominal pain, jaundice, severe cases of acute obstructive suppurative cholangitis, life-threatening, so the bile duct calculi patients usually need surgery. Since Phillip took the lead in the laparoscopic common bile duct incision to take stone, T tube drainage in 1991, the operation has been gradually accepted by surgeons and patients, but there is a huge loss of bile long-term T tube drainage, electrolyte disorder, prolong patient recovery time, increase patients’pain, and many other problems,. With the continuous development of minimally invasive technology and the requirements of patients to treatment, laparoscopic primary closure gradually occurred in clinical applications, but primary closure has its strict limitation. With the fulfillment of endoscopic technology, a number of national medical centers use laparoscopic, choledochoscope, and duodenumscope to solve the extrahepatic bile duct stones,which has received pretty good effects. It is very important for the comparison of the three surgical methods of extrahepatic bile duct stones.Objective:To explore the three surgical moods of extrahepatic bile duct stones:T tube drainage,primary closure and LCEPN.Materials and methods:This reseach has chosen 52 cases of choledocholithiasis patients who had accept operation treatment from 2013 October to 2015 March in our hospital. According to the operation methods, the patients were divided into 3 groups (LCBDE-T, LCBDE-PS, LCBDE-ENBD group), respectively, to compare the following results:complication incidence, the average posthospitalization days, drainage tube indwelling time, first exhaust time and postoperative recurrence rate, to evaluate the clinical efficacy of the three different kinds of operations.Result:All patients were treated with operation.There exist significant differences (P<0.05) for the complication incidence, the average posthospitalization days, drainage tube indwelling time, first exhaust time and postoperative recurrence rateConclusion:1. Compared with T-drainage,primary suture can effectively shorten the postoperative hospital stay, postoperative exhaust time and drainage time indwelling time.2. LECPN can widen the indication of primary suture.3.The surgical treatment of extrahepatic bile duct stones need to follow the principle of individualized treatment.更多还原