66例经ERCP联合熊去氧胆酸治疗老年胆总管并胆囊结石患者与其他疗法比较

doi:10.6040/j.issn.1671-7554.0.2021.1065

摘要/Abstract

摘要： 目的探讨经内镜逆行胰胆管造影(ERCP)联合熊去氧胆酸(UDCA)与其他两种主流疗法治疗75岁以上老年胆总管结石合并胆囊结石的疗效及术后生存质量的影响因素。方法选取2017年6月至2019年6月山东第一医科大学附属省立医院收治的184例年龄≥75岁胆总管结石合并胆囊结石患者,根据治疗方案不同分为ERCP+UDCA组(66例)、腹腔镜胆囊切除术(LC)+腹腔镜胆总管探查术(LCBDE)组(64例)和ERCP+LC组(54例)。统计三组患者一般资料,比较手术疗效、术后近期及远期并发症情况,选择胃肠疾病生存质量指数(GIQLI)量表评定患者术后2年生存质量。计量资料组间比较采用单因素方差分析或Kruskal-Wallis H检验,计数资料组间比较采用χ2检验或 Fisher确切概率法。数据两两多重比较均采用Bonferroni校正法。采用多项式Logistic回归模型分析术后2年GIQLI评分的独立影响因素。结果 3组患者的年龄、性别、结石数量、合并基础疾病等基线水平具有可比性(P>0.05)。ERCP+UDCA组、LC+LCBDE组和ERCP+LC组在手术时间［43.0(37.0, 61.8)min vs 200.0(170.0,243.8)min vs 189.0(172.0,215.5)min ］、住院费用［3.19(2.71,3.80)万元 vs 4.58(3.81,5.25)万元vs 5.44(4.86,6.52)万元］、住院时间［6.0(5.0,8.8)d vs 10.5(8.0,12.0)d vs 13.0(9.0,15.5)d］、引流管拔除时间［3(2,4)d vs 30(28,30)d vs 4(4,7)d］方面差异均有统计学意义(P均<0.001),其中ERCP+UDCA组的手术时间、住院费用、住院时间和引流管拔除时间较其余两组减少,差异有统计学意义(P均<0.05);3组的手术成功率和术后引流管放置率无统计学差异(P均>0.05)。3组患者的术后近、远期并发症发生率及GIQLI评分组间差异无统计学意义(P均>0.05)。患者年龄增高与术后发生并发症是影响术后2年GIQLI评分的独立危险因素。结论 ERCP+UDCA疗法能在不降低老年患者生存质量的前提下使疾病得到有效控制。临床治疗中应避免盲目实行LC, 要根据疾病特点进行综合考虑,实现个体化治疗。早发现、早治疗和减少术后并发症是提高老年患者术后生存质量的有效途径。

关键词: 胆总管结石, 胆囊结石, 熊去氧胆酸, 老年患者, 生存质量

Abstract: Objective To investigated the curative effects of endoscopic retrograde cholangiopancreatography(ERCP)combined with ursodeoxycholic acid(UDCA)and other two mainstream therapies in the treatment of patients over 75 with choledocholithiasis complicated with cholecystolithiasis, and to analyze factors affecting quality of life after surgery. Methods Clinical data of 184 elderly patients(≥75 years old)with choledocholithiasis and cholecystolithiasis treated in Shandong Provincial Hospital Affiliated to Shandong First Medical University during June 2017 and June 2019 were retrospectively analyzed. According to the treatment options, the patients were divided into ERCP+UDCA group with 66 patients, laparoscopic cholecystectomy(LC)+laparoscopic common bile duct exploration(LCBDE)group with 64 patients, and ERCP+LC group with 54 patients. The general data, short-term and long-term complications, and surgical condition were compared, and the quality of life was assessed with Gastrointestinal Quality of Life Index(GIQLI)scale two years after surgery. One-way analysis of variance or the Kruskal-Wallis H test was used for comparison of continuous data, and chi-square test or Fishers exact test was used for comparison of categorical data between groups. Bonferroni correction was used for multiple comparisons. Multinomial Logistic regression model was used to explore the independent factors of GIQLI scale two years after surgery. Results The three groups were comparable in age, sex, stone number and previous history(P>0.05). There were statistically significant differences among the ERCP+UDCA group, LC+LCBDE group and ERCP+LC group in operation time ［43.0(37.0, 61.8)min vs 200.0(170.0, 243.8)min vs 189.0(172.0, 215.5)min］, hospitalization costs ［31.9(27.1, 38.0)thousand yuan vs 45.8(38.1, 52.5)thousand yuan vs 54.4(48.6, 65.2)thousand yuan］, hospital stay ［6.0(5.0, 8.8)d vs 10.5(8.0, 12.0)d vs 13.0(9.0, 15.5)d］ and time to extraction of drainage tube ［3(2,4)d vs 30(28,30)d vs 4(4,7)d, all P<0.001］. Compared with the other two groups, the ERCP+UDCA group had shorter operation time, hospital stay and extraction of drainage tube, and lower hospital costs(all P<0.05). There were no significant differences in the rate of surgical success, postoperative catheterization, incidence of short-term and long-term complications, and GIQLI score among the three groups(all P>0.05). Age increase and postoperative complications were independent risk factors affecting GIQLI scale 2 years after surgery. Conclusion ERCP+UDCA could effectively control the disease without reducing elderly patients quality of life. Comprehensive therapy and individualized treatment based on the characteristics of the disease should be carried out in clinical treatment instead of performing the LC blindly. Early detection, early treatment and reduction of postoperative complications are effective ways to improve postoperative quality of life.

Key words: Choledocholithiasis, Cholecystolithiasis, Ursodeoxycholic acid, Elderly patients, Quality of Life

中图分类号:

R657.42

董晓倩,李冠江,许倩倩,许洪伟. 66例经ERCP联合熊去氧胆酸治疗老年胆总管并胆囊结石患者与其他疗法比较[J]. 山东大学学报 (医学版), 2022, 60(5): 59-66.

DONG Xiaoqian, LI Guanjiang, XU Qianqian, XU Hongwei. Comparison among ERCP combined with ursodeoxycholic acid and other therapies in the treatment of choledocholithiasis complicated with cholecystolithiasis[J]. Journal of Shandong University (Health Sciences), 2022, 60(5): 59-66.

参考文献

[1] Moffatt DC, Yu BN, Yie W, et al. Trends in utilization of diagnostic and therapeutic ERCP and cholecystectomy over the past 25 years: a population-based study [J]. Gastrointestinal Endosc, 2014, 79(4): 615-622.
[2] European Association for the Study of the Liver(EASL). EASL Clinical Practice Guidelines on the prevention, diagnosis and treatment of gallstones [J]. J Hepatol, 2016, 65(1): 146-181.
[3] 林秋满, 王桂良, 吴灶璇, 等. 一步法LCBDE+LC和序贯二步法ERCP/EST+LC治疗胆囊结石合并胆总管结石有效性及安全性的Meta分析 [J]. 中国全科医学, 2021, 24(14): 1805-1812. LIN Qiuman, WANG Guiliang, WU Zaoxuan, et al. Comparisin of efficacy and safety of one-stage LCBDE+LC and sequential two-stage ERCP/EST+LC in the treatment of cholecystolithiasis complicated with choledocholithiasis: a Meta-analysis [J]. Chinese General Practice, 2021, 24(14): 1805-1812.
[4] Mohamed MA, Bahram M, Ammar MS, et al. One-session laparoscopic management of combined common bile duct and gallbladder stones versus sequential ERCP followed by laparoscopic cholecystectomy [J]. J Laparoendosc Adv Surg Tech A, 2015, 25(6): 482-485.
[5] Kim Y, Lee E. The association between elderly peoples sedentary behaviors and their health-related quality of life: focusing on comparing the young-old and the old-old [J]. Health Qual Life Outcomes, 2019, 17(1): 131.
[6] 胡雪晴, 赵赟博, 张子瑾, 等. 75岁以上老年Ⅱ期结直肠癌根治术后患者复发因素分析[J]. 中华老年医学杂志, 2020, 39(5): 564-568. HU Xueqing, ZHAO Yunbo, ZHANG Zijin, et al. Analysis of factors for recurrence of stage Ⅱ colorectal cancer in patients aged 75 years and over after radical resection [J]. Chin J Geriatr, 2020, 39(5): 564-568.
[7] Wang HH, Portincasa P, Bari OD, et al. Prevention of cholesterol gallstones by inhibiting hepatic biosynthesis and intestinal absorption of cholesterol [J]. Eur J Clin Invest, 2013, 43(4): 413-426.
[8] May GR, Sutherland LR, Shaffer EA. Efficacy of bile acid therapy for gallstone dissolution: a meta-analysis of randomized trials [J]. Aliment Pharmacol Ther, 2010, 7(2): 139-148.
[9] Eypasch E, Williams JI, Wood-Dauphinee S, et al. Gastrointestinal Quality of Life Index: development, validation and application of a new instrument [J]. Br J Surg, 2010, 82(2): 216-222.
[10] Yeung SM, Shiu A, Martin CR, et al. Translation and validation of the Chinese version of the Gastrointestinal Quality of Life Index in patients with gastric tumor [J]. J Psychosom Res, 2006, 61(4): 469-477.
[11] Bansal VK, Misra MC, Rajan K, et al. Single-stage laparoscopic common bile duct exploration and cholecystectomy versus two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy for patients with concomitant gallbladder stones and common bile duct stones: a randomized controlled trial [J]. Surg Endosc, 2014, 28(3): 875-885.
[12] Zhou Y, Zha WZ, Wu XD, et al. Three modalities on management of choledocholithiasis: a prospective cohort study [J]. Int J Surg, 2017, 44: 269-273. doi: 10.1016/j.ijsu.2017.06.032.
[13] Ricci C, Pagano N, Taffurelli G, et al. Comparison of efficacy and safety of 4 combinations of laparoscopic and intraoperative techniques for management of gallstone disease with biliary duct calculi: a systematic review and network meta-analysis [J]. JAMA Surg, 2018, 97(19): e181167. doi: 10.1001/jamasurg.2018.1167.
[14] Pan L, Chen M, Ji L, et al. The safety and efficacy of laparoscopic common bile duct exploration combined with cholecystectomy for the management of cholecysto-choledocholithiasis: an up-to-date meta-analysis [J]. Ann Surg, 2018, 268(2): 247-253.
[15] Lyu Y, Cheng Y, Li T, et al. Laparoscopic common bile duct exploration plus cholecystectomy versus endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy for cholecystocholedocholithiasis: a meta-analysis [J]. Surg Endosc, 2019, 33(10): 3275-3286.
[16] 林鸿坡. 胆总管结石大小对内镜腔镜联合与开腹手术治疗策略选择的影响[D]. 福州: 福建医科大学, 2017.
[17] 梁成刚, 冯春林, 梅永,等. ERCP和LCBDE治疗胆总管直径10~15 mm的肝外胆道结石疗效比较[J]. 齐齐哈尔医学院学报, 2020, 41(22): 2792-2796. LIANG Chenggang, FENG Chunlin, MEI Yong, et al. Comparison of efficacy of ERCP and LCBDE in the treatment of extrahepatic cholelithiasis with a common bile duct diameter of 10-15 mm [J]. Journal of Qiqihar Medical University, 2020, 41(22): 2792-2796.
[18] 李文晓, 李燕萍, 李秀军, 等. 胆总管结石内镜治疗的现代进展[J]. 中国医刊, 2020, 55(11): 1164-1168.
[19] Mohseni S, Ivarsson J, Ahl R, et al. Simultaneous common bile duct clearance and laparoscopic cholecystectomy: experience of a one-stage approach [J]. Eur J Trauma Emerg Surg, 2019, 45(2): 337-342.
[20] 依鸿魁, 荣大庆. LC联合术中ERCP同期治疗老年病人胆囊结石合并胆总管结石的临床研究[J]. 中国医疗器械信息, 2020, 26(8): 93-94. YI Hongkui, RONG Daqing. Clinical study of simultaneous ercp in lc combined with gallbladder stones and common bile duct stones in elderly patients [J]. China Medical Device Information, 2020, 26(8): 93-94.
[21] 胡益挺, 方哲平, 王爱东. ERCP联合LC治疗高龄胆囊结石合并胆总管结石临床经验[J]. 肝胆胰外科杂志, 2018, 30(6): 510-512.
[22] 杜前程, 周瀛, 张灵强,等. 结石性胆囊炎的个体化治疗[J]. 临床肝胆病杂志, 2018, 34(10): 2251-2256. DU Qiancheng, ZHOU Ying, ZHANG Lingqiang, et al. Individualized treatment of calculous cholecystitis [J]. Joural Clinical Hepatology, 2018, 34(10): 2251-2256.
[23] Sreyram K, Julie AS, Sanziana AR, et al. Age matters: a study of clinical and economic outcomes following cholecystectomy in elderly Americans [J]. Am J Surg, 2011, 201(6): 789-796.
[24] Mcalister VC, Davenport E, Renouf E. Cholecystectomy deferral in patients with endoscopic sphincterotomy [J]. Cochrane Database Syst Rev, 2007, 17(4): CD006233.doi:10.1002/14651858.CD006233.
[25] Chang HY, Wang CJ, Liu B, et al. Ursodeoxycholic acid combined with percutaneous transhepatic balloon dilation for management of gallstones after elimination of common bile duct stones [J]. World J Gastroenterol, 2018, 24(39): 4489-4498.
[26] Chen X, Yan XR, Zhang LP, et al. Ursodeoxycholic acid after common bile duct stones removal for prevention of recurrence: a systematic review and meta-analysis of randomized controlled trials [J]. Medicine, 2018, 97(45): e13086. doi: 10.1097/MD.0000000000013086.
[27] Kuy S, Sosa JA, Roman SA, et al. Age matters: a study of clinical and economic outcomes following cholecystectomy in elderly Americans [J]. Am J Surg, 2011, 201(6): 789-796.
[28] Holdsworth RJ, Sadek SA, Ambikar S, et al. Dynamics of bile flow through the human choledochal sphincter following exploration of the common bile duct [J]. World J Surg, 1989, 13(3): 300-304.
[29] Williams J, Treacy PJ, Sidey P, et al. Primary duct closure versus T-tube drainage following exploration of the common bile duct [J]. Aust N Z J Surg, 2010, 64(12): 823-826.
[30] Mattila A, Mrena J, Kellokumpu I. Cost-analysis and effectiveness of one-stage laparoscopic versus two-stage endolaparoscopic management of cholecystocholedocholithiasis: a retrospective cohort study [J]. BMC Surg, 2017, 17(1): 79.
[31] 印弘, 车素华, 魏经国, 等. 胆囊切除术后Oddi氏括约肌的功能评价 [J]. 实用放射学杂志, 1997, 13(8): 470-473. YIN Hong, CHE Suhua, WEI Jingguo, et al. The appreciation of sphincter of oddi motility post-cholecystectomy [J] Journal of Practical Radiology,1997, 13(8):470-473.
[32] Ng WW, Lai KH, Liu RS, et al. Biliary motility following endoscopic sphincterotomy for recurrent common bile duct stones [J]. Chin Med J, 1995, 56(3): 159-165.

多维度评价

Viewed

Full text

Abstract

Cited

Shared

Discussed