吲哚菁绿荧光导航在治疗I型Mirizzi综合征腹腔镜胆囊切除术中的运用
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作者单位:

1.重庆两江新区人民医院 普通外科,重庆 401121;2.昆明医科大学第二附属医院 肝胆外科,云南 昆明 650032

作者简介:

王云丰,重庆两江新区人民医院住院医师,主要从事普通外科基础疾病与临床方面的研究。

通信作者:

田大广,Email: tiandaguang11@126.com

基金项目:


Application of indocyanine green fluorescent navigation in laparoscopic cholecystectomy for type I Mirizzi syndrome
Author:
Affiliation:

1.Department of General Surgery, People's Hospital of Liangjiang New Area, Chongqing 401121, China;2.Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Kunming Medical University, Kunming 650032, China

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    摘要:

    背景与目的 Mirizzi综合征(MS)是胆囊炎和慢性胆石症的罕见并发症。随着微创技术的发展,越来越多的I型MS采用腹腔镜胆囊切除术(LC)进行治疗,而术中胆道损伤仍是最严重的并发症,能否在术中准确辨别胆管是减少胆道损伤的关键。吲哚菁绿(ICG)荧光导航目前越来越广泛应用于肝胆外科腹腔镜手术的临床运用,该技术可以很好地显示肝脏门静脉流域,在肝脏解剖性切除中发挥重要作用。ICG在代谢过程中通过肝细胞摄取进入胆汁通过胆道排入十二指肠,能对整个胆道系统解剖结构进行导航示踪。因此,本研究旨在探讨ICG在LC治疗I型MS中胆道识别导航作用效果。方法 回顾性分析昆明医科大学第二附属医院2019年10月—2022年1月收治的67例行LC的I型MS患者临床资料。其中35例行ICG荧光导航下LC(荧光导航组),32例行常规LC(常规手术组)。比较两组患者的相关临床指标。结果 两组术前一般资料及实验室指标差异均无统计学意义(均P>0.05)。与常规手术组比较,荧光导航组平均手术时间(74.66 min vs. 93.03 min)、平均术中出血量(20.43 mL vs. 57.34 mL)、中转开腹率(0 vs. 12.5%)均明显降低(均P<0.05);平均术后第1天引流量(25.43 mL vs. 36.63 mL)、平均拔管时间(1.29 d vs. 1.91 d)、平均术后住院时间(2.8 d vs. 3.66 d)、平均总住院费用(11 349.43元 vs. 12 907.41元)均明显减少(均P<0.05)。术后荧光导航组发生腹部切口感染2例,常规手术组发生胆管损伤2例,胆汁漏2例,腹部切口感染4例,荧光导航组术后总并发症发生率明显低于常规手术组(5.7% vs. 25.0%,P=0.039)。结论 ICG荧光导航可实时显示胆道系统、减少术中出血、缩短手术时间、降低中转开腹、减少并发症发生率、预防胆道损伤。

    Abstract:

    Background and Aims Mirizzi syndrome (MS) is a rare complication of cholecystitis and chronic cholelithiasis. With the development of minimally invasive techniques, laparoscopic cholecystectomy (LC) is increasingly being used for the treatment of type I MS, in which, the intraoperative biliary tract injury is still the most serious complication. At present, indocyanine green (ICG) fluorescent navigation technique is more and more widely being used in the clinical practice of laparoscopic hepatobiliary surgery. This technique can well display the drainage area of the hepatic portal vein and play an important role in anatomical liver resection. During metabolism, ICG is taken up by hepatocytes and excreted into bile and thereby delivered into the duodenum through the biliary tract, which can guide and trace the anatomical structure of the entire biliary tract system. Therefore, this study was performed to investigate the efficacy of ICG in identification and navigation of biliary tract during LC for type I MS.Methods The clinical data of 67 patients with type I MS undergoing LC in the Second Affiliated Hospital of Kunming Medical University from October 2019 to January 2022 were retrospectively analyzed. Of the patients, 35 cases underwent LC under the guidance of intraoperative fluorescence navigation using ICG (fluorescence navigation group), and 32 cases underwent conventional LC (conventional surgery group). The main clinical variables were compared between the two groups of patients.Results There were no significant differences in preoperative data and laboratory measurements between the two groups of patients (all P>0.05). In fluorescence navigation group compared with conventional surgery group, the mean operative time (74.66 min vs. 93.03 min), mean intraoperative blood loss (20.43 mL vs. 57.34 mL) and open conversion rate (0 vs. 12.5%) were significantly reduced; the average drainage volume on postoperative day 1 (25.43 mL vs. 36.63 mL), average time to tube removal (1.29 d vs. 1.91 d), average length of postoperative hospital stay (2.8 d vs. 3.66 d) and average total hospitalization cost (11 349.43 yuan vs. 12 907.41 yuan) were significantly decreased (all P<0.05). After operation, abdominal wound infection occurred in 2 cases in fluorescence navigation group, while biliary tract injury occurred in 2 cases, bile leakage occurred in 2 cases, and abdominal wound infection occurred in 4 cases in conventional surgery group. The overall incidence rate of postoperative complications in fluorescence navigation group was significantly lower than that in conventional surgery group (5.7% vs. 25.0%, P=0.039).Conclusion ICG fluorescent navigation can display biliary tract system in real time, reduce intraoperative bleeding, operative time, conversion to open surgery and incidence of complications, and prevent biliary tract injury.

    表 5 两组患者术后并发症发生率对比[n(%)]Table 5 Comparison of the incidence rates of postoperative complications between the two groups of patients[n(%)]
    图1 MRI+MRCP诊断为I型MS患者影像学资料Fig.1 Imaging data of patients diagnosed with type I MS by MRI+MRCP
    图2 在荧光导航下确认胆总管,依次游离出胆囊动脉与胆囊管,胆囊管未染色,胆总管染为绿色(1号箭头所示为嵌顿的结石,2号箭头所示为胆囊管,3号箭头为染为绿色的胆总管)Fig.2 Identification of the common bile duct under fluorescence navigation and successive separation of the cystic artery and the cystic duct, and seeing the cystic duct without stained and the common bile duct with green staining (arrow 1 indicating the incarcerated stone, arrow 2 indicating the cystic duct and arrow 3 indicating the common bile duct)
    图3 荧光模式下(左)与普通模式下(右)术中离断胆囊管图像(1号箭头所示为胆囊管,2号箭头所示为胆总管)Fig.3 Intraoperative view of division of the cystic duct under fluorescence mode (left) and the ordinary mode (right) (arrow 1 indicating the cystic duct and arrow 2 indicating the common bile duct)
    图4 胆管损伤患者术后T管造影Fig.4 Postoperative T-tube angiography in patients with bile duct injury
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王云丰,寸冬云,黄洁,田大广.吲哚菁绿荧光导航在治疗I型Mirizzi综合征腹腔镜胆囊切除术中的运用[J].中国普通外科杂志,2022,31(8):1031-1038.
DOI:10.7659/j. issn.1005-6947.2022.08.006

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  • 收稿日期:2022-04-08
  • 最后修改日期:2022-08-04
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  • 在线发布日期: 2022-09-02