【作者】 李健；

【导师】 陈海龙；

【作者基本信息】 大连医科大学 ， 中西医结合临床， 2015， 硕士

【摘要】 目的:通过对我院行胆总管取石并行胆囊切除术的患者随访,了解术后的复发情况及中药利胆汤的服用情况,探求胆总管结石术后复发的各种危险因素及利胆汤预防结石复发的作用。方法:回顾性分析大连医科大学附属第一医院自2004年1月至2014年1月间收治的283例行胆总管取石(包括开腹胆总管探查、腹腔镜胆总管探查、内镜下经十二指肠乳头括约肌切开)并行切除胆囊的患者的病例资料,通过电话及复诊进行随访,获得完整数据的病例201例。根据胆总管结石复发标准将其分为复发组和未复发组,对患者的一般情况(性别、年龄、体重指数)、个人史(吸烟史、饮酒史)、既往史(高血压病病史、糖尿病病史)、胆总管直径、胆总管结石大小及数量、手术方式、十二指肠乳头旁憩室(juxtapapillary duodenal diverticulum,JPD)等指标进行单因素分析,具有统计学意义的变量再进行非条件Logistic回归分析,确定胆总管结石术后复发的危险因素。随访术后患者的利胆汤服用情况,将规范服药超过半年的患者定义为中药组,未规范服用中药的患者定义为对照组,通过卡方检验对利胆汤预防术后结石复发的作用进行分析。结果:获得完整数据的随访资料201例,男性患者115例,女性86例,其中胆总管结石术后复发的患者30例,复发率达14.9%,复发病例中男性20人,女性10人,年龄从30岁至89岁,平均年龄67岁。首次复发时间距前期手术最短为8个月,最长达8年,1年累积复发率(10例)达4.9%,3年累积复发率(22例)达10.9%,5年累积复发率(28例)达13.9%,8年累积复发率(30例)达14.9%。规范服用中药利胆汤超过半年的患者43人,复发2人(4.7%)。单因素分析结果示:胆总管直径扩张组(直径≥1.5cm)术后结石的复发率较不扩张组有统计学差异(P﹤0.05),伴JPD组较无憩室组有统计学差异(P﹤0.05),胆总管结石多发组(数量≥2枚)较单发组(数量1枚)有统计学差异(P﹤0.05)。相比之下,患者的手术方式、胆总管结石直径、性别、年龄、BMI、吸烟史、饮酒史、高血压病史、糖尿病史等因素,对于胆总管结石术后复发无统计学差异(P值均﹥0.05)。将有统计学差异的变量引入非条件Logistic回归模型进行多因素分析,结果示:胆总管直径≥1.5cm(P=0.021,OR=2.946)、十二指肠乳头旁憩室(JPD)(P=0.041,OR=2.382)、这二个因素有统计学意义(P﹤0.05),说明其为胆总管结石术后复发的独立危险因素,而胆总管结石多发(数量≥2枚)(P=0.051,OR=2.612)(P﹥0.05)不是复发的独立危险因素。利胆汤对预防术后结石复发的影响较对照组(P﹤0.05)有统计学差异,说明利胆汤对预防结石复发有一定作用。结论:胆总管直径≥1.5cm、伴有十二指肠乳头旁憩室(JPD),这二个因素为胆总管取石并行胆囊切除术后患者结石复发的危险因素。利胆汤对预防结石复发有一定作用。在临床治疗过程中,为评估术后复发风险提供了参考,对具备上述复发因素的患者,积极给予利胆中药预防。更多还原

【Abstract】 Objectives: Through the way that follow up the patients who had common bile duct stones removal and cholecystectomy, to explore the risk factors for recurrence of choledocholithiasis after biliary tract surgery and the preventive effect of Lidan decoction.Methods: A retrospective analysis about the clinical data of 283 cases were performed, these cases were performed with common bile duct stones removal operation(including OCBDE、LCBDE and EST) and meanwhile cholecystectomy in the first Affiliated Hospital of Dalian Medical University since January 2004 to January 2014, 201 cases of complete data were obtained through the telephone and follow-up visit. According to the common bile duct stones recurrence standard, these patients were divided into recurrence group and non-recurrence group. We make a univariate analysis of the patient’s gender, age, BMI, smoking history, drinking history, hypertension history, diabetes history, surgery methods, the diameter of common bile duct, the size and number of stones, the juxtapapillary duodenal diverticulum(JPD). And the variable that has statistically significant was involved in the non-conditional logistic regression analysis to determine the risk factors for recurrence of common bile duct stones after biliary tract surgery. The patients were divided into the Lidan decoction group and the non-Lidan decoction group according to the standard that taking Lidan decoction more than half a year specificatly. The preventive effect of Lidan decoction to stone recurrence use chi-square test to analysis.Results: Among the 201 cases with complete follow-up datas, 115 male patients, 86 female patients, 30 patients had recur common bile duct stone after biliary tract surgery, and the recurrence rate was 14.9%(30/201), 20 males and 10 females, aged from 30 to 89 years old, the average age of those recurrent patients was 67 years old. The interval of first time to recur from previous surgery was 0.8 to 8.0 year. 1-year, 3-year, 5-year and 8-year cumulative recurrence rate was respectively about 4.9%(10cases), 10.9%(22cases), 13.9%(28cases) and 14.9%(30cases). 43 patients had taken Lidan decoction more than half a year specificatly, among those cases 2 patients recur common bile duct stone. The univariate analysis between the common bile duct stone recurrence group and the non-recurrence group were performed: the recurrence rate of common bile duct stones between the group with a diameter of common bile duct more than 1.5 cm and the group with a diameter of less than 1.5 cm, have a statistically significant difference(P﹤0.05). The group with juxtapapillary duodenal diverticulum compared with the non-juxtapapillary duodenal diverticulum group, the recurrence rate of common bile duct stones was statistically significant difference(P﹤0.05). The postoperative common bile duct stone recurrence rate of multiple stones group(the number of stones more than 2) compared with the single stone group was significantly different(P﹤0.05). However, those factors such as the age, gender, BMI, alcohol using history, smoking history, diabetes history hypertension history, surgery methods and the size of common bile duct stone have no significant difference(P>0.05). After the Logistic regression multivariate analysis, juxtapapillary duodenal diverticulum(P=0.041,OR=2.382), the diameter of common bile duct more than 1.5cm(P=0.021,OR=2.946), are the more important recurrence risk factors, but multiple stones(the number of stones more than 2)(P=0.051,OR=2.612)is not the independent risk factor. Lidan decoction for the prevention of stone recurrence than the non-Lidan decoction group(P﹤0.05), indicating that Lidan decoction in the prevention of recurrence of stones have a role.Conclusion: Juxtapapillary duodenal diverticulum, a diameter of common bile duct more than 1.5cm, are the independent risk factors of common bile duct stone recurrence in the patients after biliary tract surgery. Lidan decotion may have a certain effect to prevent common bile duct recurrence.更多还原