胆总管复发结石不同术式疗效分析及中药清热利胆颗粒的预防作用

发布时间：2018-03-12 21:51

  本文选题：胆总管复发结石　切入点：肝胆湿热型　出处：《大连医科大学》2017年硕士论文　论文类型：学位论文

【摘要】：目的:分析比较我院开腹胆总管探查术、腹腔镜胆总管探查术及EST/EPBD取石术对胆总管结石术后复发结石的疗效,以及对患者术后进行随访,了解术后结石再复发情况以及探讨服用中药清热利胆颗粒对结石再复发的预防作用。方法:回顾性分析大连医科大学附属第一医院自2013年01月至2016年09月收治的中医辩证属肝胆湿热型的胆总管复发结石患者68例,根据手术方式分为A组:13 例 OCBDE(open common bile duct exploration,开腹胆总管探查术),B 组:10 例 LCBDE(laparoscopic common bile duct exploration,腹腔镜下胆总管探查术),C组:45例EST(endoscopic sphincterotomy,内镜下十二指肠乳头括约肌切开术)/EPBD(endoscopic papillary balloon dilation,内镜下十二指肠乳头球囊扩张术),比较三组患者一般情况、胆道情况、术后胃肠功能恢复时间、术后住院天数、并发症种类及发生率。通过电话及复诊随访,获得确切病例62例。比较三组病例术后再次复发结石的情况及时间间隔,同时随访术后中药清热利胆颗粒服用情况,将服用清热利胆颗粒的患者归为中药组,未服用清热利胆颗粒的患者归为对照组,分析清热利胆颗粒对术后再复发结石的预防作用。结果:本研究共68例肝胆湿热型胆总管复发结石患者,男32例,女性36例,平均年龄68.88±12.78岁。A组患者平均年龄66.46±12.87岁,B组平均年龄60.60±13.31岁,C组平均年龄71.42±11.97岁,三组间、C组与B组年龄比较具有统计学差异(P0.05),C组平均年龄最大。而在合并基础疾病、既往胆道手术史方面,三组间比较并无统计学差异(P0.05)。伴有壶腹周围憩室在三组中比较具有显著统计学意义(P0.01),其中C组伴发壶腹周围憩室比例最高,与A组相比有显著统计学差异(P0.01),与B组相比存在统计学差异(P0.05)。而在胆总管最大直径、结石最大直径及数量方面,三组间差异并无统计学意义(P0.05)。术后胃肠功能恢复时间、术后住院天数:A组胃肠功能恢复时间2.69±0.95天,术后住院14.69±6.71天;B组胃肠功能恢复时间2.30±1.06天,术后住院9.40±2.91天;C组基本不影响胃肠功能,术后住院6.24±2.81天。A组与B组相比,胃肠功能恢复时间无统计学差异(P0.05);术后住院天数人组B组C组,三组间差异有显著统计学意义(P0.01)。A组围手术期并发症发生率30.77%,B组围手术期并发症发生率10%,C组围手术期并发症发生率8.89%,三组间并发症发生率并无统计学差异(P0.05);A组相比于C组,围手术期并发症发生率较高,差异具有统计学意义(P0.05)。术后随访获得了 62例完整病例资料,其中12例出现了再复发,复发率19.35%。A组复发2例,再复发率16.67%,其再复发的时间分布为1～2年再复发率8.33%,2年再复发率8.33%;B组复发1例,再复发率11.11%,其再复发的时间分布为1～2年再复发率11.11%;C组复发9例,再复发率21.95%,其再复发的时间分布为0.5～1年再复发率14.63%,1～2年再复发率2.44%,2年再复发率4.88%;三组间总再复发率差异无统计学意义(P0.05),再复发时间间隔分布情况具有显著统计学差异(P0.01)。中药组中28例患者服用清热利胆颗粒,2例再复发,再复发率7.14%;对照组中34例患者未服用清热利胆颗粒,10例复发,再复发率29.41%;两者相比较,中药组再复发率较低,差异具有统计学意义(P0.05)。对比三种术式术后服用清热利胆颗粒结石再复发情况:A组与B组服用中药与未服用再复发率比较无统计学差异(P0.05);而C组中服用清热利胆颗粒的再复发率9.52%,未服用再复发率35%,差异具有统计学意义(P0.05)。结论:综合比较治疗胆总管复发结石的三种不同术式,EST/EPBD因不需经腹手术更加微创,具有对胃肠道功能干扰少、住院时间短等优势,总体并发症发生率方面同LCBDE组相当且明显低于OCBDE组,结石复发率方面同OCBDE和LCBDE组比较无显著差异。但其术后短时间内易于再次复发结石,可能同乳头括约肌功能损伤有关。对于乳头括约肌功能正常的年轻患者,为保留乳头括约肌功能,我们倾向于选择LCBDE治疗胆总管复发结石;对于多次手术腹腔粘连重、腔镜手术困难且结石大,EST/EPBD无法取出的患者,仍应采用OCBDE治疗。中药清热利胆颗粒对于肝胆湿热型的胆总管复发结石患者再发结石有较满意的预防作用,术后规律服用清热利胆颗粒预防结石复发在临床上值得推荐。
[Abstract]:Objective: to analyze and compare our hospital open choledocholithotomy, the curative effect of recurrent stones of bile duct stones after laparoscopic choledochotomy and EST/EPBD lithotomy, and the patients were followed up after surgery, postoperative recurrence of stones to understand and explore the preventive effect of traditional Chinese medicine Qingre Lidan Granule on stone recurrence. A retrospective analysis of 68 patients with common bile duct calculi of traditional Chinese medicine from 2013 01 to 2016 09 months from the First Affiliated Hospital of Dalian Medical University is a dialectical hepatobiliary damp heat type patients, the patients were divided into group A: 13 cases of OCBDE (open common bile duct exploration, open choledocholithotomy), group B: 10 cases of LCBDE (laparoscopic common bile duct exploration, laparoscopic choledochotomy), group C: 45 cases of EST (endoscopic sphincterotomy, endoscopic sphincterotomy (endoscopic PA /EPBD) Pillary balloon dilation, endoscopic papillary balloon dilation), compared three groups of patients in general, biliary tract, postoperative gastrointestinal function recovery time, postoperative hospital stay, incidence of complications and types. And for follow-up by telephone, get the exact 62 cases. And the time interval of recurrence calculus cases three group, and postoperative follow-up of Qingre Lidan Granule taking, taking Qingrelidan particles were classified into traditional Chinese medicine group, not taking Qingrelidan particles were classified as control group, analysis of preventive effect of Qingre Granule on postoperative recurrence of biliary calculi. Results: a total of 68 cases of hepatobiliary damp heat type common bile duct calculi patients, male 32 cases, female 36 cases, mean age 68.88 + 12.78 years in.A group were 66.46 + 12.87 years old, the average age of 60.60 + 13.31 B group, C group the average age of 71.42 + 11.97 Age between the three groups, C group and B group had statistical differences in age (P0.05), C group. The average age of the largest in terms with basic diseases, history of biliary tract surgery, there was no statistical difference between the three groups (P0.05). Compared with periampullary diverticulum has significant statistical significance in three groups (P0.01), C group with the highest proportion of periampullary diverticulum, with significant difference compared with A group (P0.01), there was significant difference compared with B group (P0.05). And the largest in the common bile duct diameter, maximum diameter and number of stones, no significant difference was found between the three groups (P0.05). The recovery time postoperative gastrointestinal function, postoperative hospital stay: group A, gastrointestinal function recovery time 2.69 + 0.95 days, postoperative hospital stay was 14.69 + 6.71 days; group B, gastrointestinal function recovery time was 2.30 + 1.06 days, postoperative hospital stay was 9.40 + 2.91 days; C group does not affect gastrointestinal function, postoperative hospital stay was 6.24 + 2.81 days.A Compared with B group, the recovery time of gastrointestinal function was no significant difference (P0.05); postoperative hospitalization group B group C group, there was significant difference between the three groups (P0.01 group.A) perioperative complication rate was 30.77%, B group the incidence rate of perioperative complications in perioperative group 10%, C complications occurred in 8.89%, between the three groups had no statistical differences in complication rate (P0.05); A group compared to C group, the incidence of perioperative complications is higher, the difference was statistically significant (P0.05). The postoperative follow-up was 62 cases, including 12 cases of the recurrence, the recurrence rate 19.35%.A group of 2 cases of recurrence, the recurrence rate was 16.67%, the recurrence time distribution for 1~2 years, the recurrence rate was 8.33%, 2 years, the recurrence rate was 8.33%; 1 cases of group B recurrence, the recurrence rate was 11.11%, the recurrence time distribution for 1~2 years, the recurrence rate was 11.11%; 9 cases of recurrence in C group, then the recurrence rate was 21.95%. The time distribution of recurrence ranged from 0.5 to 1 years, the recurrence rate was 14.63%, 1~2 years, the recurrence rate was 2.44%, 2 years, the recurrence rate was 4.88%; the total recurrence rate between the three groups showed no significant difference (P0.05), the recurrence interval distribution has significant difference (P0.01). In 28 cases of patients taking traditional Chinese medicine group Qingre Lidan granules, 2 cases of recurrence, the recurrence rate was 7.14%; the control group in 34 cases of patients not taking Qingre Lidan granules, 10 cases of recurrence, the recurrence rate was 29.41%; compared with traditional Chinese medicine group, the recurrence rate is low, the difference was statistically significant (P0.05). Taking Qingrelidan stones recurrence comparison of particles three operative methods: A group and B group were treated with traditional Chinese medicine and not taking no significant difference in the recurrence rate (P0.05); and group C taking Qingrelidan particles the recurrence rate of 9.52%, not taking the recurrence rate was 35%, the difference has statistical significance (P0.05). Conclusion: the comprehensive comparison Three different surgical treatment of common bile duct calculi, EST/EPBD without abdominal surgery are minimally invasive, with less interference on gastrointestinal function, short hospitalization time and other advantages, the overall complication rate of group LCBDE and was significantly lower in group OCBDE, recurrence rate compared with OCBDE and LCBDE group had no significant difference but a short time. After the operation, it is easy to recurrence of stones, may be related to the function of sphincter with nipple injury. For young patients with papillary sphincter function, to preserve the papillary sphincter function, we tend to choose LCBDE for the treatment of common bile duct calculi; surgery for multiple peritoneal adhesion, laparoscopic surgery is difficult and the big stones, not EST/EPBD out of the patients, should be treated by OCBDE. Traditional Chinese medicine Qingre Lidan granules for hepatobiliary damp heat type common bile duct calculi in patients with recurrent stones have satisfactory prevention for postoperative The regular use of clearing heat and gallbladder to prevent the recurrence of calculi is worthy of recommendation.

【学位授予单位】：大连医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R657.4

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