腹腔镜胆道探查一期缝合在老年患者的应用

发布时间：2018-04-20 22:01

本文选题：胆石病 + 胆道探查　；参考：《吉林大学》2017年硕士论文

【摘要】：胆石病在外科系统中较为常见,高龄是其高危因素,65岁以上的老年人发病率高达38%,其中胆管结石约占10%[1]。由于老年人免疫功能和机体抵抗力下降,常合并有心、肺、脑等慢性全身性病变,常常病情较重。青年病患可以承受的手术打击,可能使老年患者致命。胆管结石严重威胁患者身心健康,因此,一旦确诊,需要立即治疗。开腹胆管探查取石是常用的外科治疗手段,但值得探讨的是取石后是常规留置T管引流还是直接一期缝合胆管。传统的观点是,T管引流可有效降低胆道压力,避免胆道狭窄,促进康复,而且便于术后T管造影和治疗胆道残余结石。但术后T管相关并发症给患者带来的痛苦是不可避免的,尤其在老年患者中体现更为明显。近年来,随着诸多腹腔镜胆总管探查(Laparoscopic common bile duct exploration LCBDE)后一期缝合的成功报道,其优越性更符合快速康复外科理念,让人们质疑留置T管的必要性。因此,通过对比两种术式有利于临床中更好的选择手术方案。目的:探讨腹腔镜胆道探查后一期缝合在老年患者中的可行性及应用价值。材料及方法:选择吉林大学第一医院于2015年11月-2016年11月期间符合标准行腹腔镜胆道探查取石的老年患者60例,其中30例行腹腔镜胆道探查一期缝合术(primary suture,PS组-实验组,),其余30例行腹腔镜胆道探查、T形管引流术(T—tube drainage,TD组-对照组)。比较两组手术时间、术中出血量、术后输液量、术后住院时间、术后肛门恢复排气时间、住院费用、术后并发症(胆瘘、胆道出血、胆道狭窄、结石复发、T管脱落、消化不良等)、肝功恢复情况(ALT、AST、Tbil、Dbil)等情况。结果:与TD组相比,PS组患者术后输液量大大减少,术后住院时间,术后肛门恢复排气时间均缩短,住院费用降低;胆瘘、胆道出血、胆道狭窄、残余结石、T管脱落并发症与TD组相比无统计学差异,但消化功能及肝功能比TD组恢复更快。结论:在合适的老年胆总管结石患者中,腹腔镜胆道探查后一期缝合是安全可行的,而且能降低治疗费用,缩短住院时间,改善患者的生活质量,对患者消化功能、肝功能等恢复存在优势,更能体现出微创外科的优越性。
[Abstract]:Cholelithiasis is common in the surgical system. The incidence of cholelithiasis in the elderly aged over 65 years is as high as 38%, in which bile duct stones account for about 10% [1]. As the immune function and body resistance of the elderly decreased, often accompanied by heart, lung, brain and other chronic systemic diseases, often more serious. The surgical blow that young patients can afford can kill elderly patients. Choledocholithiasis is a serious threat to the patient's physical and mental health, therefore, once diagnosed, it needs immediate treatment. Open bile duct exploration and lithotripsy is a common surgical treatment, but it is worth discussing whether it is a conventional T-tube drainage or a direct primary suture of bile duct after lithotomy. The traditional view is that T-tube drainage can effectively reduce biliary pressure, avoid biliary stricture, promote rehabilitation, and facilitate postoperative T-tube angiography and treatment of residual stones of the biliary tract. However, the pain caused by postoperative T tube-related complications is inevitable, especially in elderly patients. In recent years, with the successful report of one stage suture after laparoscopic common bile duct exploration LCBDEs, its superiority is more in line with the idea of rapid rehabilitation surgery, which makes people question the necessity of indwelling T tube. Therefore, the comparison of the two surgical procedures is beneficial to the better choice of surgical options in clinical practice. Objective: to evaluate the feasibility and value of primary suture after laparoscopic choledochotomy in elderly patients. Materials and methods: sixty elderly patients who met the standard of laparoscopic choledocholithotomy between November 2015 and November 2016 in the first Hospital of Jilin University were selected. Among them, 30 cases were treated with primary suture of primary suture PS and 30 cases with T-tube tube drainage, and 30 cases were treated with T-tube tube drainage, the control group was treated with laparoscope exploration of bile duct in the primary suture group (n = 30), experimental group (n = 30), and the control group (n = 30). The operation time, intraoperative bleeding volume, postoperative transfusion volume, postoperative hospitalization time, postoperative anus recovery time, hospitalization cost, postoperative complications (biliary fistula, biliary bleeding, biliary stricture, stone recurrence and T tube fall off) were compared between the two groups. Dyspepsia and other conditions, recovery of liver function and alt Tbiln Tbiln, and other conditions. Results: compared with TD group, the postoperative infusion volume, postoperative hospitalization time, postoperative anal recovery and exhaust time and hospitalization cost were significantly reduced in PS group. There was no significant difference in the complications of T tube exfoliation of residual stones compared with TD group, but the digestive function and liver function recovered more quickly than that in TD group. Conclusion: in the elderly patients with choledocholithiasis, the primary suture after laparoscopic choledocholithiasis is safe and feasible, and it can reduce the cost of treatment, shorten the hospitalization time, improve the quality of life of the patients, and improve the digestive function of the patients. Recovery of liver function has advantages, which can reflect the superiority of minimally invasive surgery.
【学位授予单位】：吉林大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R657.4

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