Efficacy Of Two Types Of Laparoscopic Primary Suture In Treatment Of Choledocholithiasis With Cholecystolithiasis In Elderly: A Comparative Analysis

Objective: To investigate the clinical efficacy,pros and cons of simultaneous three endoscopes(laparoscopy + choledochoscope + duodenoscope)combined with nasobiliary drainage and primary suture and two endoscopes(laparoscopy + choledochoscope)combined with primary closure in elderly patients with choledocholithiasis and cholecystolithiasis.Methods: The data of elderly patients with choledocholithiasis and cholecystolithiasis who treated by simultaneous three endoscopes combined with nasobiliary drainage and primary closure or two endoscopes combined with primary closure in the Chengdu Second People’s Hospital were gathered.Divided into two groups according to different surgical procedures adopted by patients.Group1 with 100 cases underwent combination appliances of three-endoscopes combined with choledocholithotomy and nasobiliary drainage through abdomen and primary suture of common bile duct,and hereinafter referred to as the three-endoscopes group;another group with 100 cases underwent combination appliances of two-endoscopes combined with choledocholithotomy and primary suture of common bile duct,and hereinafter referred to as the two-endoscopes group.The general conditions before operation(Gender,age,preoperative acute pancreatitis,preoperative serum amylase,preoperative hypoalbuminemia,diameter of common bile duct,degree of cholangitis,ASA grade III,preoperative WBC,preoperative liver function(ALT and TBi L),previous history of upper abdominal surgery,underlying disease rate(arterial hypertension,diabetes mellitus,heart diseases,COPD)),situations at surgery(including the number of abdominal drainage tubes,operation time,intraoperative bleeding volume,calculus removal rate,calculus number and diameter),postoperative recovery(including postoperative WBC,postoperative ALT and TBi L,serum amylase value after surgery,the abdominal drainage volume on the 1st day after surgery,whether there is fever,postoperative hospitalization time and expenses,time to remove the abdominal drainage tube,eating time,time to recovery of gastrointestinal function),short-term complications(Bile leakage,peritonitis,bleeding,infection,reoperation,pancreatitis)and follow-up of the two groups were used for statistical analysis.At the same time,in order to increase the reliability of conclusions,multiple Logistic regression model was used to analyze the relationship between operation methods and bile leakage.Results: A total of 200 cases were gathered.All 200 cases underwent operations were successfully and recovered well.There were no cases of incision bleeding,biliary bleeding,intestinal perforation,deaths and reoperation after surgery.Through statistical analysis,it is meaningless in comparison of general information such as age and gender(P>0.05).Intraoperative surgical data comparison showed that there was no difference in the number and diameter of stones(P>0.05);while the difference in terms of operation time,number of abdominal drainage tubes,and intraoperative bleeding volume were significant(P<0.05).Comparison of postoperative recovery data showed no difference in postoperative WBC,postoperative TBi L,time to remove the abdominal drainage tube,and postoperative fever(P>0.05);while postoperative ALT,△ALT(Preoperative ALT value minus postoperative ALT value),postoperative serum amylase,△serum amylase(postoperative serum amylase value minus preoperative serum amylase value),the abdominal drainage volume on the 1st day after surgery,postoperative hospitalization time and expenses,eating and gastrointestinal recovery time were statistically significant(P<0.05).there was no difference in follow-up status and postoperative short-term complications of incision infection and mild pancreatitis(P>0.05),while the difference in postoperative bile leakage was significant(P < 0.05).The univariate analysis of bile leakage showed that no significant difference in age,diameter of common bile duct,preoperative acute pancreatitis,preoperative serum amylase,gender,preoperative WBC,preoperative liver function(ALT and TBi L),preoperative hypoalbuminemia,cholangitis grade,Anesthesia risk score sheet(ASA score sheet)score,previous history of upper abdominal surgery,underlying disease rate(arterial hypertension,diabetes mellitus,heart diseases,COPD),operation time,intraoperative bleeding volume,calculus diameter,and the number of abdominal drainage tubes between the biliary leakage group and the non-biliary leakage group;while the difference in the abdominal drainage volume on the 1st day after surgery,the number of stones,time to remove the abdominal drainage tube and the operation method were statistically significant(P<0.05).Multivariate Logistic regression analysis showed that there was a significant correlation between the operative procedure and bile leakage(OR(95% CI)= 0.132(0.029-0.603)),and the three endoscopes procedure could significantly reduce the postoperative bile leakage rate,at the same time,different stone diameters had no modification effect on the operation methods and bile leakage(P interactive value > 0.05).Conclusion: According to the results of the two groups and the correlation analysis between the operation and bile leakage,it can be seen that the overall curative effect of three endoscopes operation was slightly better than that of the two endoscopes operation.Although the operation time is longer,the cost is higher,and the postoperative serum amylase value is higher than that before operation,but it reduces the corresponding complications and the postoperative recovery is quicker.,Three endoscopes operation may be the preferred procedure for elderly patients when economic conditions permit and there is no history of pancreatitis.However,clinicians should fully consider the advantages and disadvantages of the two surgical methods and make a choice based on the patient’s own comprehensive situation when choosing surgical procedures,and formulate an individualized surgical plan.