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胰管结石治疗方案的选择分析与比较
DOI: 10.3969/j.issn.1001-5256.2022.11.023
伦理学声明：本研究方案于2020年10月21日通过海军军医大学附属公利医院医学伦理委员会批准，批号：研预审第2020-68号。
利益冲突声明：本研究不存在研究者、伦理委员会成员、受试者监护人以及与公开研究成果有关的利益冲突。
作者贡献声明：董金斌、石益海负责课题设计与指导，资料收集、分析与论文撰写及审校、修改等；方卫兵参与部分胰腺疾病的超声诊断与分析以及部分资料与数据收集等。
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摘要:
目的 收集并对比分析内镜逆行胰胆管造影(ERCP)、腹腔镜术和开腹手术三种方案治疗胰管结石(PDS)患者的临床资料及治疗效果，总结PDS治疗方案选择的经验，进一步研究探讨可行的使患者获益最大化、最优化的治疗方案。 方法 回顾性分析2014年6月—2018年12月海军军医大学附属公利医院治疗的131例PDS患者的临床资料。根据手术情况分为3组：ERCP组69例，腔镜组32例，开腹组30例。监测3组患者手术前后相关指标的变化；进一步对比分析腔镜组和开腹组的手术疗效。正态分布的计量资料两组间比较采用独立样本t检验；多组间比较采用单因素方差分析，进一步两两比较采用LSD-t检验或SNK-q检验。偏态分布的计量资料两组间比较采用Mann-Whitney U检验，多组间比较采用Kruskal-Wallis H检验。手术前后相关指标差异比较采用重复测量资料的方差分析和Friedman检验。计数资料组间比较采用χ2检验。 结果 131例PDS患者中Ⅰ型40例、Ⅱ型76例、Ⅲ型15例。腔镜组与开腹组主要手术方式的病例数比较差异无统计学意义(χ2=1.93，P＞0.05)。腔镜组和开腹组血WBC、CRP、PCT、HOMA-IR在手术前后的动态变化存在明显差异(F=24.68、χ2=227.66、F=45.37、F=106.71，P值均＜0.05)。腔镜组手术时长、术中出血量、术后首次排气时间、术后止痛药物应用频次、腹腔引流管拔除时间、术后近期并发症、术后平均住院时长等观察指标均较开腹组明显减少/缩短(t=-4.80、t=-9.43、Z=-6.78、t=-11.59、Z=-6.77、χ2=9.24、t=-3.60，P值均＜0.05)。ERCP组、腔镜组、开腹组术后近期并发症发生率分别为24.64%、28.13%、66.67%，差异有统计学意义(χ2=17.12，P＜0.05)；ERCP组及腔镜组术后近期并发症发生率均显著低于开腹组(χ2值分别为15.78、9.24，P值分别为＜0.05、0.02)。ERCP组、腔镜组、开腹组治疗有效率分别为91.30%、93.75%、73.33%，3组间有效率差异有统计学意义(χ2=7.70，P=0.02)，ERCP组及腔镜组有效率均好于开腹组(χ2值分别为5.56、4.77，P值分别为0.02、0.03)。 结论 ERCP为临床微创治疗部分Ⅰ、Ⅱ型PDS的首选治疗方法，安全有效、严重并发症少。外科手术是治疗复杂型PDS的重要手段，但技术复杂、操作难度大。腹腔镜术较开腹术创伤小、严重并发症少，腹痛缓解率高，可以显著减少手术时长、降低术中出血量及缩短术后平均住院时长。针对复杂型PDS宜优先选择腹腔镜术治疗。 -
关键词:
- 胰管结石 /
- 胰胆管造影术, 内窥镜逆行 /
- 腹腔镜检查 /
- 消化系统外科手术
Abstract:Objective To investigate the clinical efficacy of endoscopic retrograde cholangiopancreatography (ERCP), laparoscopy, and laparotomy in the treatment of pancreatic duct stones (PDS) by collecting related clinical data, to summarize the experience in selecting treatment regimens for PDS, and to further explore feasible treatment regimens that could maximize and optimize the benefits of PDS patients. Methods A retrospective analysis was performed for the clinical data of 131 PDS patients who were treated in Gongli Hospital Affiliated to Naval Medical University from June 2014 to December 2018, and according to the surgical procedure, they were divided into ERCP group with 69 patients, laparoscopy group with 32 patients, and laparotomy group with 30 patients. Related indices were monitored before and after treatment, and surgical outcome was compared between the laparoscopy group and the laparotomy group. The independent samples t-test was used for comparison of normally distributed continuous data between two groups; a one-way analysis of variance was used for comparison between multiple groups, and the least significant difference t-test or the SNK-q test was used for further comparison between two groups. The Mann-Whitney U test was used for comparison of continuous data with skewed distribution between two groups, and the Kruskal-Wallis H test was used for comparison between multiple groups. An repeated measures analysis of variance and the Friedman test were used for comparison of related indices before and after surgery, and the chi-square test was used for comparison of categorical data between groups. Results Among the 131 PDS patients, there were 40 patients with type Ⅰ PDS, 76 with type Ⅱ PDS, and 15 with type Ⅲ PDS. There was no significant difference in the distribution of main surgical methods between the laparoscopy group and the laparotomy group (χ2=1.93, P > 0.05). There were significant differences between the laparoscopy group and the laparotomy group in the dynamic changes of white blood cell count, C-reactive protein, procalcitonin, and Homeostasis Model Assessment of Insulin Resistance after surgery (F=24.68, χ2=227.66, F=45.37, F=106.71, all P < 0.05). Compared with the laparotomy group, the laparoscopy group had significantly shorter time of operation, significantly lower intraoperative blood loss, significantly shorter time to first flatus after surgery, a significantly lower frequency of use of pain-relieving drugs, shorter time to extraction of abdominal drainage tube, lower incidence rates of short-term postoperative complications, and a significantly shorter length of postoperative hospital stay (t=-4.80, t=-9.43, Z=-6.78, t=-11.59, Z=-6.77, χ2=9.24, t=-3.60, all P < 0.05). The incidence rate of short-term postoperative complications was 24.64% in the ERCP group, 28.13% in the laparoscopy group, and 66.67% in the laparotomy group, with a significant difference between groups (χ2=17.12, P < 0.05), and the ERCP group and the laparoscopy group had a significantly lower incidence rate of short-term postoperative complications than the laparotomy group (χ2=15.78 and 9.24, P < 0.05 and P=0.02). The treatment response rate was 91.30% in the ERCP group, 93.75% in the laparoscopy group, and 73.33% in the laparotomy group, with a significant difference between the three groups (χ2=7.70, P=0.02), and the ERCP group and the laparoscopy group had a significantly better response rate than the laparotomy group (χ2=5.56 and 4.77, P=0.02 and 0.03). Conclusion ERCP is the preferred method for minimally invasive treatment of some patients with type Ⅰ/Ⅱ PDS and is safe and effective with few serious complications. Surgical operation is an important method for the treatment of complex PDS, but with complicated techniques and difficult operation. Compared with laparotomy, laparoscopy has the advantages of small trauma, few serious complications, and high abdominal pain remission rate and can significantly shorten the time of operation, reduce intraoperative blood loss, and shorten the length of postoperative hospital stay. Therefore, laparoscopy should be the preferred regimen for the treatment of complex PDS. -
表 1 三组PDS患者术前一般资料比较
Table 1. Comparison of preoperative general data of PDS patients among three groups
指标 ERCP组(n=69) 腔镜组(n=32) 开腹组(n=30) 统计值 P值 性别(例) χ2=1.29 0.53 男 40 20 21 女 29 12 9 年龄(岁) 53.84±18.52 53.91±18.20 54.07±15.41 F=0.02 0.99 病因(例) χ2=0.35 0.99 胆源性 37 16 17 酒精性 28 14 11 免疫性 4 2 2 结石分型(例) χ2=7.30 0.12 Ⅰ型 23 9 8 Ⅱ型 43 17 16 Ⅲ型 3 6 6 NRS疼痛评分与分级(例) χ2=1.75 0.94 0级 0 0 0 1级 41 19 16 2级 13 4 7 3级 10 6 4 4级 5 3 3 WBC(×109/L) 7.57±2.78 7.82±4.16 7.91±4.28 F=0.12 0.89 CRP(mg/L) 14.00(11.00~21.00) 13.50(9.00~21.75) 12.00(8.00~21.50) H=0.82 0.66 PCT(μg/L) 0.25±0.10 0.25±0.13 0.25±0.14 F=0.00 ＞0.05 HOMA-IR 3.82±0.44 3.84±0.42 3.82±0.52 F=0.03 0.97 AMY(U/L) 120.00(109.50~177.50) 114.50(99.75~182.00) 115.00(94.00~258.50) H=1.83 0.40 CA19-9(U/mL) 15.00(10.00~23.50) 11.50(9.00~16.75) 11.00(9.00~20.00) H=4.07 0.13 
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表 2 腔镜组与开腹组主要手术方式
Table 2. Comparison of main operation methods between laparoscopy group and laparotomy group
组别 例数 Whipple术 PPPD术 DPPHR术 Frey术 Imaizumi术 Partington- Rochelle术 Puestow- Gillesby术 胰大部切除、胰管-空肠Roux-en- Y吻合术 TP术 腔镜组 32 1 1 2 3 2 16 4 2 1 开腹组 30 1 1 1 3 1 17 3 2 1
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表 3 腔镜组与开腹组患者术前及术后7天WBC、CRP、PCT及HOMA-IR比较
Table 3. Comparison of WBC, CRP, PCT and HOMA-IR between laparoscopy group and laparotomy group before operation and up to the 7th day after operation
项目 腔镜组(n=32) 开腹组(n=30) 统计值 P值 WBC(×109/L) F=24.68 ＜0.001 术前 7.82±4.16 7.91±4.28 术后第1天 13.40±2.08 14.99±1.64 术后第3天 11.48±1.14 13.05±1.16 术后第5天 9.95±1.32 11.35±1.16 术后第7天 7.91±1.26 9.17±1.47 CRP(mg/L) χ2=227.66 ＜0.001 术前 13.50(9.00~21.75) 12.00(8.00~21.50) 术后第1天 99.35(85.00~116.75) 117.50(100.50~135.25) 术后第3天 72.00(65.00~82.00) 90.50(83.75~97.25) 术后第5天 39.50(35.00~45.75) 58.50(53.25~62.25) 术后第7天 28.00(21.00~33.00) 37.50(31.75~41.00) PCT(μg/L) F=45.37 0.040 术前 0.25±0.13 0.25±0.14 术后第1天 0.34±0.11 0.34±0.10 术后第3天 0.46±0.11 0.49±0.14 术后第5天 0.48±0.09 0.53±0.08 术后第7天 0.38±0.06 0.44±0.11 HOMA-IR F=106.71 ＜0.001 术前 3.84±0.42 3.82±0.52 术后第1天 8.68±0.54 6.33±1.41 术后第3天 7.02±0.87 6.01±0.72 术后第5天 4.08±0.61 4.07±0.55 术后第7天 3.56±0.42 3.65±0.40
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表 4 腔镜组与开腹组手术观察指标的比较
Table 4. Comparison of observation indexes between laparoscopy group and laparotomy group
组别 例数 手术时长(min) 术中出血量(mL) 术后首次排气时间(h) 术后哌替啶使用频次(50 mg/次) 腹腔引流管拔除时间(h) 术后近期并发症(例) 术后住院时长(d) 腔镜组 32 159.84±25.35 146.59±73.19 31.00(30.00~32.00) 2.34±0.75 27.00(25.00~29.75) 9 9.42±1.63 开腹组 30 193.77±30.19 344.33±90.37 45.50(42.00~48.00) 5.27±1.20 122.50(118.00~132.00) 20 11.07±1.96 统计值 t=-4.80 t=-9.43 Z=-6.78 t=-11.59 Z=-6.77 χ2=9.24 t=-3.60 P值 ＜0.001 ＜0.001 ＜0.001 ＜0.001 ＜0.001 0.02 0.01
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表 5 三组患者术后腹痛情况比较
Table 5. Comparison of postoperative abdominal pain among three groups
组别 例数 有效 无效 完全缓解 部分缓解 ERCP组 69 52 11 6 腔镜组 32 25 5 2 开腹组 30 15 7 8
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