新型经腹腔入路引导十二指肠乳头切开治疗结石性胆管炎合并Vater壶腹部狭窄的临床研究

Clinical study of a novel transabdominal approach guiding sphincterotomy for choledocholithiasis complicated by stenosis of the ampulla of Vater

摘要:

背景与目的 临床中复杂的结石性胆管炎常合并Vater壶腹部狭窄，从而增加治疗的难度和复杂性。若只取除胆管内结石而不处理壶腹部狭窄问题，后期疾病容易反复发作。既往大多采取的方法主要是经内镜逆行胆胰管造影（ERCP）入路导丝顺向引导十二指肠乳头括约肌切开、取石术联合后期腹腔镜胆囊切除的方式处理。然而，ERCP在处理复杂情况时仍有一定局限性。为此，笔者团队首创了一种新型经腹腔入路治疗结石性胆管炎合并Vater壶腹部狭窄的方法。本研究探讨该方法的可行性与疗效，以期为临床提供新的治疗选择。方法 采用随机对照研究的方法，将2021—2023年因胆囊结石、胆管结石伴Vater壶腹部狭窄于成都市第二人民医院治疗的120例患者分为观察组和对照组，每组各60例，观察组行腹腔镜胆囊切除+胆管切开取石，并顺势从切开的胆管中插入导管逆向引导十二指肠乳头切开，同时处理胆囊、胆管结石及Vater壶腹部狭窄；对照组行传统ERCP入路乳头切开、胆管取石+腹腔镜胆囊切除术。收集两组患者围手术期相关指标，比较两组手术效果。结果 120例患者中，男性54例，女性66例。两组在胆道取石成功率、术中出血量、术后24 h总胆红素、直接胆红素、转氨酶、白细胞计数、黄疸缓解时间及胆汁漏、腹膜后出血/感染、重症胰腺炎发生率等方面，差异无统计学意义（均P>0.05）。观察组平均手术时间、术后住院时间均明显短于对照组（98.67 min vs. 110.8 min，P<0.05；3.81 d vs. 5.61 d，P<0.05），并且观察组术后高淀粉酶血症和（或）高脂肪酶血症、轻型胰腺炎发生率均明显更低（1.67% vs. 25.00%，P<0.001；0 vs. 10%，P=0.027）。结论 新型经腹腔入路在缩短手术时间、住院时间方面明显优于ERCP入路，术后发生轻症胰腺炎及高淀粉酶血症和（或）高脂肪酶血症的风险更低，并且胆管取石成功率不劣于ERCP入路，是一种可选择的治疗方式。

Abstract:

Background and Aims Complex choledocholithiasis often coexists with stenosis of the ampulla of Vater, which increases the difficulty and complexity of treatment. If only the stones in the bile duct are removed without addressing the ampullary stenosis, the disease is prone to recurrence. Previously, most treatments involved the use of endoscopic retrograde cholangiopancreatography (ERCP) to guide the wire for sphincterotomy and stone extraction, followed by laparoscopic cholecystectomy. However, ERCP has limitations in handling complex cases. In response, our team pioneered a new method of treating choledocholithiasis combined with stenosis of the ampulla of Vater via a transabdominal approach. This study was performed to investigate the feasibility and efficacy of this method, aiming to provide a new therapeutic option for clinical practice.Methods A randomized controlled study was conducted with 120 patients treated at Chengdu Second People's Hospital from 2021 to 2023 for gallbladder stones and choledocholithiasis with stenosis of the ampulla of Vater. Patients were divided into an observation group and a control group, with 60 cases in each group. The observation group underwent laparoscopic cholecystectomy with choledochotomy for stone extraction, followed by retrograde guidance of duodenal papillary sphincterotomy through the opened bile duct, simultaneously treating gallbladder, bile duct stones, and stenosis of the ampulla of Vater. The control group underwent traditional ERCP approach for sphincterotomy, stone extraction, and laparoscopic cholecystectomy. Perioperative variables were collected for both groups and the surgical outcomes were compared.Results Among the 120 patients, 54 were male and 66 were female. There were no statistically significant differences between the two groups in terms of stone extraction success rate, intraoperative blood loss, postoperative 24-h total bilirubin, direct bilirubin, transaminases, white blood cell count, jaundice relief time, or incidence rates of bile leakage, retroperitoneal bleeding/infection, and severe pancreatitis (all P>0.05). The observation group had significantly shorter average operative time and postoperative hospital stay compared to the control group (98.67 min vs. 110.8 min, P<0.05; 3.81 d vs. 5.61 d, P<0.05). Additionally, the observation group had a significantly lower incidence of postoperative hyperamylasemia and/or hyperlipasemia and mild pancreatitis (1.67% vs. 25.00%, P<0.001; 0 vs. 10%, P=0.027).Conclusion The novel transabdominal approach is superior to the ERCP approach in terms of reducing surgery time and hospitalization time, and it carries a lower risk of postoperative mild pancreatitis and hyperamylasemia and/or hyperlipasemia. The stone extraction success rate is comparable to that of ERCP, making it a viable alternative treatment option.