新型自脱落式胆道支架在腹腔镜胆总管探查术中的应用(附视频)
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1.陕西省西乡县人民医院 普通外科,陕西 西乡 723599;2.陕西省榆林市第二人民医院 普通外科,陕西 榆林 719000;3.西安交通大学第一附属医院 肝胆外科,陕西 西安 710061

作者简介:

杨先伟,陕西省西乡县人民医院主治医师,主要从事胆道结石、肝胆胰肿瘤方面的研究。

基金项目:

陕西省自然科学基础研究计划基金资助项目(2022JM-564);陕西省西安市科技计划基金资助项目(21YXYJ0109)。


Application of a new self-shedding biliary stent in laparoscopic common bile duct exploration (with video)
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1.Department of General Surgery, Xixiang County People's Hospital, Xixiang, Shaanxi 723599, China;2.Department of General Surgery, Yulin Second Hospital, Yulin, Shaanxi 719000, China;3.Department of Hepatobiliary Surgery, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China

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    摘要:

    背景与目的 腹腔镜胆总管探查术(LCBDE)是治疗胆总管结石的常规方法,术中胆道支架置入(BSI)可能降低术后胆汁漏风险,但支架可能存在滞留、过早脱落等风险。本研究探讨新型自脱落式BSI在LCBDE治疗胆囊结石合并胆总管结石中的安全性和有效性。方法 回顾性分析2019年6月—2020年12月西安交通大学第一附属医院收治的胆囊结石合并胆总管结石的患者临床资料,将行LCBDE联合新型自脱落式BSI的患者作为观察组,行LCBDE联合一期缝合的患者作为对照组。所用支架直径5 Fr,长度5 cm,主体上有长度标识,其防滑侧翼采用同向开口,可预防支架过早脱落及长期滞留,螺旋尾部留置于十二指肠乳头外,可在消化道流体带动下牵引支架通过消化道排出体外。BSI方法:胆道镜下直视胆总管末端乳头内口,将0.035"导丝插过十二指肠乳头,使用取石网篮外鞘作为推送器将支架沿着导丝推入胆道内,当支架主体1 cm标记处通过乳头内口后,边退镜边推送支架,当支架末端完全脱离镜头后,撤除导丝完成直视下BSI。比较两组患者一般资料、术前血液化验指标、胆总管结石数量及最大直径、BSI所需时间、手术时间、术后并发症、术后住院时间,记录观察组胆道支架脱落率。结果 观察组纳入43例,对照组纳入52例。两组患者在术前一般资料、血常规、肝功能、胆总管直径及胆管结石大小上均具有可比性(均P>0.05)。观察组BSI操作耗时中位时间14(10~20)min,但两组总体手术时间无明显差异[125(55~210)min vs. 116(50~200)min,P>0.05]。对照组术后有2例轻度胆汁漏(<50 mL/d),延长带管时间好转,观察组未观察到胆汁漏发生,两组之间胆汁漏发生率无明显差异(P>0.05)。高淀粉酶血症在两组患者中均能观察到,无明显临床表现,保守好转,其发生率在两组间无明显差异(11.6% vs. 3.8%,P>0.05)。两组术后总并发症发生率无明显差异(16.3% vs. 9.6%,P>0.05)。观察组中位带管时间及中位术后住院时间均明显短于对照组[1(1~3)d vs. 2(1~5)d;2(2~6)d vs. 3(2~8)d,均P<0.05]。观察组术后2 d复查腹部X片提示支架均在位,2周后支架脱落率88.4%,术后1个月所有患者支架均脱落。结论 LCBDE术中联合自脱落式BSI安全有效,可缩短术后拔管时间和术后住院时间。

    Abstract:

    Background and Aims Laparoscopic common bile duct exploration (LCBDE) is a traditional method for treating common bile duct stones. Intraoperative biliary stent implantation may reduce the risk of postoperative bile leakage but may give rise to prolonged retention or premature shedding of the stent. This study investigated the safety and effectiveness of implantation of a new type of self-shedding biliary stent in LCBDE for cholecystolithiasis with choledocholithiasis.Methods The clinical data of patients with concomitant cholecystolithiasis and choledocholithiasis treated in the First Affiliated Hospital of Xi'an Jiaotong University from June 2019 to December 2020 were retrospectively analyzed. Patients receiving LCBDE plus biliary stent implantation were selected as the observation group, and those undergoing LCBDE with primary closure were set as the control group. The stent used was 5 Fr in diameter and 5 cm in length, with a length scale marked in the main body, its anti-skid side wings opened toward the direction of the head to prevent the premature detachment or prolonged retention of the stent, and a spiral tail left outside the duodenal papilla for being pulled out under the drive of digestive tract fluid. The stent placement method was advancing the choledochoscope to the end of the common bile duct, endoscopically inserting a 0.035" guidewire through the duodenal papilla, using the outer sheath of the stone basket as a pusher to push the stent into the bile duct over the guide wire, pushing the stent while retrieving the choledochoscope when the 1-cm mark of the stent body passed through the inner orifice of the papilla, and removing the guidewire to complete the placement of the stent under the direct vision when the end of the stent completely disengages from the lens. The general data of patients, preoperative blood test results, the number and maximum diameter of common bile duct stones, the time for intraoperative biliary stent implantation, operative time, postoperative complications, and length of postoperative hospital stay were compared between the two groups, and the rate of stent shedding in observation group was recorded.Results Forty-three patients in the observation group and 52 patients in the control group were included. The general preoperative data, blood routine test, liver function parameters, common bile duct diameter and size of bile duct stones were comparable between the two groups (all P>0.05). The median time for stent implantation in observation group was 14 (10-20) min, but there was no significant difference in overall operative time between the two groups [125 (55-210) min vs. 116 (50-200) min, P>0.05]. In control group, there were 2 cases of mild bile leakage (<50 mL/d) after operation, which was improved after prolonging the abdominal drainage time. No bile leakage was observed in observation group, but there was no significant difference in the incidence of bile leakage between the two groups (P>0.05). Hyperamylasemia was observed in both groups, which caused no obvious clinical symptoms and was cured with conservative treatment. Its incidence rates showed no significant difference between the two groups (11.6% vs. 3.8%, P>0.05). There was no significant difference in the overall incidence of postoperative complications between the two groups (16.3% vs. 9.6%, P>0.05). The median time of abdominal drainage and length of postoperative hospital stay was significantly shorter in observation group than those in control group [1 (1-3) d vs. 2 (1-5) d; 2 (2-6) d vs. 3 (2-8) d, both P<0.05]. In observation group, the abdominal X-ray showed that the stents were all in place on postoperative day 2, the rate of stent detachment was 88.4% after two weeks, and all stents fell off one month after the operation.Conclusion Using the new type of self-shedding biliary stent in LCBDE is safe and effective, and it can reduce the time of abdominal drainage and length of postoperative hospitalization.

    表 2 观察组与对照组组术中、术后资料比较Table 2 Comparison of the intra- and postoperative variables between observation group and control group
    图1 研究入组流程Fig.1 Inclusion process of the study
    图2 自脱落式胆道支架Fig.2 The self-shedding biliary stent
    Fig.
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杨先伟,杨刚,董鼎辉,刘学民,李宇.新型自脱落式胆道支架在腹腔镜胆总管探查术中的应用(附视频)[J].中国普通外科杂志,2023,32(2):181-189.
DOI:10.7659/j. issn.1005-6947.2023.02.003

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  • 收稿日期:2022-04-05
  • 最后修改日期:2023-01-28
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  • 在线发布日期: 2023-03-02