腹腔镜胆总管切开取石后行T管置入与一期缝合胆总管的差异

Differences between T-Tube Insertion and Primary Suture of the Common Bile Duct after Laparoscopic Common Bile Duct Exploration for Stone Removal

摘要: 背景：近年来腹腔镜胆总管切开取石(LCBDE)后一期缝合已经成为胆总管结石患者的手术方法之一，其治疗效果已逐渐得到越来越多的研究者认可。但LCBD后留置T管引流仍是重要的手术方法。本研究旨在证实LCBD后胆总管一次缝合术的有效性和安全性，并比较两种手术方法的优缺点。方法：回顾性分析深圳市人民医院(暨南大学第二临床医学院) 2019年1月至2023年6月收治的260例胆总管结石患者，根据LCBD术后胆总管闭合方式分为T管组(64例，24.6%)和一期缝合组(196例，75.4%)。T管组与一期缝合组之间按1:2的比例进行倾向得分匹配(PSM)，匹配变量包括年龄、性别、体重指数(BMI)、高血压病史、糖尿病病史、冠心病病史、术前白细胞计数(WBC)、C反应蛋白(CRP)水平、总胆红素水平和胆总管直径，确保两组患者的可比性。然后比较两组患者的术中参数、术后恢复结果差异。结果：通过1:2近邻倾向评分匹配分析(卡钳值 = 0.2)，T管组64例患者中有60例(93.75%)成功匹配，而一期缝合组有108例患者匹配成功。匹配后，所有协变量的标准化均值差异(SMD)均小于0.1。T管组的术中失血量、拔除引流管时间、术后住院时间均大于一期缝合组(P < 0.01)，两组间术中输血率、术后胆瘘、术后感染、胆管炎复发率、结石残余率等均无明显差异。结论：本研究表明，就术后并发症发生率和安全性而言，腹腔镜胆总管探查术(LCBDE)后行一期缝合不劣于T管置入，同时还能显著缩短手术时间，减少术中出血、提早拔管和住院时间。对于残留结石或术后感染风险较低的患者，一期缝合可能会带来更大的临床效益。

Abstract: Background: In recent years, primary suture following laparoscopic common bile duct exploration (LCBDE) has become one of the surgical options for choledocholithiasis patients, with its therapeutic efficacy gaining increasing recognition. However, T-tube drainage after LCBDE remains an important surgical approach. This study aimed to validate the efficacy and safety of primary duct closure after LCBDE and compare the advantages and disadvantages of the two methods. Methods: A retrospective analysis was conducted on 260 choledocholithiasis patients treated at Shenzhen People’s Hospital (The Second Clinical Medical College of Jinan University) from January 2019 to June 2023. Based on the bile duct closure method post-LCBDE, patients were divided into a T-tube group (64 cases, 24.6%) and a primary suture group (196 cases, 75.4%). Propensity score matching (PSM) was performed at a 1:2 ratio between the groups, with matching variables including age, sex, body mass index (BMI), history of hypertension, diabetes, coronary heart disease, preoperative white blood cell count (WBC), C-reactive protein (CRP) level, total bilirubin level, and common bile duct diameter to ensure comparability. Intraoperative parameters and postoperative recovery outcomes were compared between the two groups. Results: Using 1:2 nearest-neighbor propensity score matching (caliper value = 0.2), 60 of 64 patients (93.75%) in the T-tube group were successfully matched with 108 patients in the primary suture group. After matching, all covariates had standardized mean differences (SMD) < 0.1. The T-tube group exhibited significantly higher intraoperative blood loss, drainage tube removal time, and postoperative hospital stay compared to the primary suture group (P < 0.01). No significant differences were observed between the two groups in intraoperative transfusion rate, postoperative bile leakage, postoperative infection, cholangitis recurrence rate, or residual stone rate. Conclusion: This study demonstrates that primary suture after LCBDE is non-inferior to T-tube placement in terms of postoperative complication rates and safety, while also significantly reducing operative time, intraoperative bleeding, time to tube removal, and hospital stay. For patients with a low risk of residual stones or postoperative infection, primary suture may offer greater clinical benefits.