1.四川省资中县人民医院 肝胆胰外科，四川 资中 641200;2.遵义医科大学附属成都医院/四川省成都市第二人民医院 肝胆外科，四川 成都 611246
陈安平， Email: email@example.com
1.Department of Hepatopancreatobiliary Surgery, Zizhong People's Hospital, Zizhong, Sichuan 641200, China;2.Department of Hepatobiliary Surgery, Chengdu Hospital Affiliated to Zunyi Medical University/Chengdu Second People's Hospital, Chengdu 611246, China
背景与目的 胆囊结石、胆总管结石合并十二指肠乳头狭窄的处理方式常用方式有分期内镜下十二指肠乳头括约肌切开（EST）+腹腔镜下胆囊切除术（LC），但在结石较大或较多时分期内镜下胆总管结石清除率相较腹腔镜手术更低。为了能在较高的胆总管结石清除率下一并处理十二指肠乳头狭窄，且能减少传统胆总管前壁手术创伤以及能够一期缝合胆总管，本研究探讨输尿管导管引导下同期行LC+腹腔镜下经胆囊管胆总管探查（LTCBDE）+EST+胆总管一期缝合术治疗胆囊结石、胆总管结石合并乳头狭窄的可行性及其临床应用价值。方法 收集成都市第二人民医院2018年1月—2020年1月微创治疗胆囊结石、胆总管结石合并乳头狭窄的患者临床资料，纳入符合标准的患者共78例，其中40例在输尿管导管引导下同期行LC+LTCBDE+EST+一期缝合（观察组），38例分期行EST+LC（对照组），比较两组患者围手术期临床资料。结果 两组术前基本资料具有可比性。两组患者术后均无胆汁漏发生，观察组术后无急性胰腺炎发生，对照组术后出现3例急性胰腺炎（7.9%）。观察组手术时间、术后住院时间短于对照组，术后血淀粉酶水平低于对照组（均P<0.05），两组术中出血量、术后肝功能指标、术后鼻胆管拔出时间差异无统计学意义（均P>0.05）。两组共62例获随访1~8个月，中位随访时间为6个月，随访病例均无反复腹痛，无反复发作的黄疸，无胆道狭窄、残留结石或结石复发。结论 输尿管导管引导下同期行LC+LTCBDE+EST+一期缝合治疗胆囊结石、胆总管结石合并十二指肠乳头狭窄安全可行，且使术中操作均更加精确，可在一定程度上控制手术创伤，减少并发症，从而加快患者术后康复。
Background and Aims The staged endoscopic sphincterotomy (EST) plus laparoscopic cholecys-tectomy (LC) is the common treatment method for concomitant gallbladder and common bile duct stones combined with papillary stenosis. However, for large stone or multiple stones, the clearance rate of staged endoscopic stone extraction is lower than that of laparoscopic operation. For the purpose of achieving a high clearance rate of choledocholithiasis with simultaneous treatment of papillary stenosis, and reducing the injury of the anterior wall of the common bile duct by traditional surgery with primary closure of the common bile duct, this study was conducted to investigate the feasibility and clinical value of the one-stage procedure of LC plus laparoscopic transcystic common bile duct exploration (LTCBDE) and EST with primary closure of the common bile duct under the guidance of the ureteral catheter in the treatment of concomitant gallbladder and common bile duct stones combined with papillary stenosis.Methods The clinical data of patients with gallbladder and common bile duct stones combined with papillary stenosis treated by minimally invasive surgery in Chengdu Second People's Hospital from January 2018 to January 2020 were collected. A total of 78 patients meeting the criteria were enrolled, including 40 patients undergoing one-stage procedure of LC+LTCBDE+EST with primary closure of the common bile duct under the guidance of ureteral catheter (observation group) and 38 patients undergoing staged procedures of EST followed by LC (control group), The perioperative clinical data of the two groups of patients were compared.Results The preoperative general data were comparable between the two groups of patients. After operation, no bile leakage occurred in both groups, acute pancreatitis occurred in none of the cases in observation group but occurred in 3 cases (7.9%) in control group. The operative time and length of postoperative hospital stay were shorter and the level of postoperative blood amylase was lower in observation group than those in control group (all P<0.05), while there were no significant differences in terms of intraoperative blood loss, postoperative liver function parameters and nasobiliary drainage time between the two groups (all P>0.05). A total of 62 patients in both groups were followed up for one month to 8 months, with a median follow-up time of 6 months, and in all of them, no repeated abdominal pain and repeated bouts of jaundice occurred, and no biliary stricture and retained or recurrent stones were found.Conclusion Synchronous LC+LCBDE+EST with primary closure under the guidance of the ureteral catheter in the treatment of gallbladder and common bile duct stones combined with papillary stenosis is safe and feasible, and it makes operation more accurate, which can reduce the surgical trauma and complications to a certain extent, and thereby accelerate the postoperative recovery of the patients.