腹腔镜胆总管探查 + T管引流与腹腔镜胆总管探查 + 胆道一期缝合在再发胆总管结石中应用的临床疗效比较

Clinical Efficacy Comparison of Laparoscopic Common Bile Duct Exploration + T-Tube Drainage versus Laparoscopic Common Bile Duct Exploration + Primary Suture in the Treatment of Recurrent Common Bile Duct Stones

摘要: 背景：胆总管结石(CBDS)是常见的外科疾病之一，发病率约10%~20%，其中部分患者在取石术后6个月以上出现结石复发，称为再发性胆总管结石，总体发生率可达6.3%~21.0%。再发结石的治疗面临腹腔粘连、解剖结构改变等挑战，目前尚无统一治疗指南。主要手术方式包括内镜治疗和LCBDE，而LCBDE术后对胆总管的处理主要有两种：留置T管引流或进行一期缝合。分析：近年来，随着腹腔镜技术发展，LCBDE因其创伤小、恢复快的优势逐渐成为主流术式。术后处理方式的选择直接影响患者预后：T管引流可通过T管引流胆汁、减压、造影及后续经窦道取石，但存在胆漏、T管脱落、护理不便及可能损害Oddi括约肌功能等风险。胆道一期缝合避免了T管相关并发症，保留了胆汁正常排泄途径，符合加速康复外科(ERAS)理念，但在胆漏、残余结石等方面曾存争议。研究表明，对于符合条件的患者，一期缝合不仅安全可行，且优势明显。有研究指出，该术式可缩短住院时间并降低医疗费用。国外对照试验也发现，一期缝合术后并发症少于T管引流，可视为LCBDE后的理想选择。结论：综合现有研究，对于再发性胆总管结石患者，若术中评估条件适宜，腹腔镜胆总管探查术后行胆道一期缝合是一种更安全有效的选择，其在缩短住院时间、降低费用、减少并发症方面表现更优，值得在临床中推广应用。

Abstract: Background: Common bile duct stones (CBDS) are one of the common surgical diseases, with an incidence rate of approximately 10%~20%. Some patients experience stone recurrence more than 6 months after stone extraction, termed recurrent common bile duct stones, with an overall incidence ranging from 6.3% to 21.0%. The treatment of recurrent stones faces challenges such as abdominal adhesion and anatomical changes in Broussonetia papyrifera, and there is currently no unified treatment guideline. The main surgical approaches include endoscopic therapy and LCBDE, while postoperative management of the common bile duct after LCBDE primarily involves two methods: T-tube drainage or primary closure. Analysis: In recent years, with the advancement of laparoscopic techniques, LCBDE has gradually become the mainstream surgical approach due to its advantages of minimal invasiveness and rapid recovery. The choice of postoperative management directly impacts patient outcomes: T-tube drainage allows bile drainage, decompression, cholangiography, and subsequent stone extraction via the sinus tract, but carries risks such as bile leakage, T-tube dislodgement, inconvenient care, and potential impairment of Oddi sphincter function. Primary closure of the bile duct avoids T-tube-related complications, preserves the normal bile excretion pathway, and aligns with the Enhanced Recovery After Surgery (ERAS) concept, though it has been controversial regarding bile leakage and residual stones. Studies indicate that for eligible patients, primary closure is not only safe and feasible but also offers significant advantages. Some research suggests that this approach can shorten hospital stays and reduce medical costs. Foreign comparative trials have also found that primary closure results in fewer postoperative complications than T-tube drainage, making it an ideal choice after LCBDE. Conclusion: Based on existing research, for patients with recurrent common bile duct stones, if intraoperative evaluation confirms suitability, primary closure after laparoscopic common bile duct exploration is a safer and more effective option. It demonstrates superior performance in shortening hospital stays, reducing costs, and minimizing complications, making it worthy of clinical promotion.