| Background:Cholelithiasis is a common clinical disease that occurs in the biliary system including gallbladder or bile duct.In Europe,the incidence of cholelithiasis is from 10%to 15%.In China,the incidence of cholelithiasis is as high as 10%,and the number is still increasing year by year.In recent years,the development of minimally invasive surgical techniques represented by laparoscope,choledochoscope and digestive endoscope has brought more options for the treatment of cholelithiasis.At present,laparoscopic cholecystectomy+ choledochotomy and endoscopic retrograde cholangiopancreatography and duodenal papillary lithotomy are the main surgical methods for choledocholithiasis.How to choose the appropriate treatment according to the patient's condition is what every surgeon will face in his clinical work.Many surgeons began to try the combined application of laparoscope,duodenoscope and choledocholithiasis(Three-Scope),which brought good treatment experience to patients.Objective:(1)To investigate and analyze the treatment methods and influencing factors of different types of choledocholithiasis,and identify the clinicopathological factors that affect the therapeutic effect of choledocholithiasis;(2)To Analyze and compare the therapeutic effects of three surgical methods,Three-Scope?LCBDE and ERCP+LC,in the treatment of choledocholithiasis combined with cholecystolithiasis;(3)To recommend the preferred minimally invasive treatment for different types of choledocholithiasis and clarify its efficacy.Methods:(1)Retrospective study:collecting and analyzing all clinical data of 707 patients who treated with choledocholithiasis in Sir Run Run Shaw Hospital from January 2016 to December 2017.Including age,sex,the maximum diameter of common bile duct,common bile duct calculi maximum diameter,number of common bile duct calculi,preoperative testing results(White blood cells,alanine aminotransferase,alanine aminotransferase,alkaline phosphatase,glutamyl transpeptidase,total bilirubin,direct bilirubin,hypersensitive c-reactive protein),operation method,length of hospitalization,treatment cost,the stone extraction rate,complications,recurrence of stones.Analyzing the clinical factors influencing minimally invasive treatment of common bile duct stones.Patients were divided into two treatment groups(ERCP group and LCBDE group).Comparing the therapeutic effects between the two groups,including length of hospitalization,treatment cost,the stone extraction rate,incidence of complications and recurrence rate of calculi.Patients were divided into two groups according to different stone locations(choledocholithiasis and choledocholithiasis combined with gallstone)or the diameter of the choledocholithiasis(<1 cm,?1cm).Comparing the therapeutic effects of different minimally invasive treatment methods for choledocholithiasis.(2)Prospective study:Three-Scope was performed on patients with choledocholithiasis complicated with cholecystolithiasis with the choledocholithiasis diameter ?1cm.Comparing and analyzing the therapeutic effects of Three-Scope group,LC+LCBDE group and ERCP group.Results:(1)In the retrospective study,there were 707 patients underwent surgery,including 483 cases of ERCP and 224 cases of LCBDE.The average length of hospitalization in ERCP group was 11.21±0.35 days,which was shorter than that in LCBDE group(14.54±1.70 days,P=0.0085).The average treatment cost in ERCP group was 3.56?0.14 million yuan,which was lower than that in LCBDE group(4.09±0.25 million yuan,P=0.0429).The single stone extraction rate in ERCP group was 69.15%(334/483),which was lower than that in LCBDE group(95.54%(214/224)(P<0.0001).There was no statistical difference in clinical data between the two groups,including age,sex,the maximum diameter of common bile duct,common bile duct calculi maximum diameter,number of common bile duct calculi,preoperative testing results(White blood cells,alanine aminotransferase,alanine aminotransferase,alkaline phosphatase,glutamyl transpeptidase,total bilirubin,direct bilirubin,hypersensitive c-reactive protein),complication rate,recurrence rate.(2)For patients with choledocholithiasis and choledochal diameter<1cm,the average length of hospitalization in ERCP group was 8.62±0.49 days,which was shorter than that in LCBDE group(11.77±2.34 days,P=0.0421).The average treatment cost in ERCP group was 2.47±0.11 million yuan,which was lower than that in LCBDE group(3.38±0.74 million yuan,P=0.025).The stone extraction rates of the two groups were 85.90%(67/78)in ERCP group and 100%(13/13)in LCBDE group,with no statistical difference(P=0.1487).The complication rates in the two groups was 2.56%(2/78)in ERCP group and 7.69%(1/13)in LCBDE group,with no statistical difference(P=0.3377).The recurrence rates of the two groups were 5.13%(4/78)in ERCP group and 15.38%(2/13)in LCBDE group,with no statistical difference(P=0.1677);(3)For patients with choledocholithiasis and choledochal diameter?1cm,the average length of hospitalization in ERCP group was 10.27±0.53days,which was shorter than that in LCBDE group(13.55±0.86 days,P=0.0026).The treatment costs of the two groups were 3.30±0.24 million yuan in ERCP group and 3.57±0.28 million yuan in LCBDE group,with no statistical difference(P=0.5714).The stone extraction rate in ERCP group was 64.94%(150/231),which was lower than that in LCBDE group(97.01%(65/67)(P<0.0001).The complication rates of the two groups were 13.85%(32/231)in ERCP group and 11.94%(8/67)in LCBDE group,with no statistical difference(P=0.6860).The recurrence rates of the two groups were 23.38%(54/231)in ERCP group and 20.90%(14/67)in LCBDE group,with no statistical difference(P=0.6701).(4)For patients with choledocholithiasis combined with gallstone and choledochal diameter<lcm,the average length of hospitalization in the two groups was 12.43±0.69 days in ERCP+LC group and 18.83±6.99 days in LC+LCBDE group,with no statistical difference(P=0.3384).The treatment costs in the two groups were 4.25±0.23 million yuan in ERCP+LC group and 3.35±0.24 million yuan in LC+LCBDE group,with no statistical difference(P=0.0706).The stone extraction rate in ERCP+LC group was 77.59%(45/58),which was lower than that in LC+LCBDE group(94.23%(49/52),(P=0.0134).The complication rates in the two groups were 10.34%(6/58)in ERCP+LC group and 11.54%(6/52)in LC+LCBDE group,with no statistical difference(P=0.8411).The recurrence rates of the two groups were 12.07%(7/58)in ERCP+LC group and 11.54%(6/52)in LC+LCBDE group,with no statistical difference(P=0.9314).(5)For patients with choledocholithiasis combined with gallstone and choledochal diameter ?1cm,the average length of hospitalization in ERCP+LC group was 13.95±0.72 days,which was longer than that in LC+LCBDE group(11.78±0.63 days,P=0.0284).The treatment costs in the two groups were 4.47±0.23 million yuan in ERCP+LC group and 4.88±0.55 million yuan in LC+LCBDE group,with no statistical difference(P=0.4573).The stone extraction rate in ERCP+LC group was 62.07%(72/116),which was lower than that in LCBDE group(94.57%(87/92),(P=0.0196).The recurrence rate in ERCP+LC group was 26.72%(31/116),which was higher than that in LCBDE group(11.96%(11/92),(P=0.0084).The complication rates of the two groups were 18.97%(22/116)in ERCP+LC group and 17.39%(16/92)in LC+LCBDE group,with no statistical difference(P=0.7704).(6)In prospective study,there were 31 patients underwent Three-Scope treatment.the average length of hospitalization in the Three-Scope group was 9.36±0.26 days,which was lower than that in the ERCP+LC group(13.95±0.72 days,P=0.0278)or 11.78±0.63 days in the LC+LCBDE group(P=0.0203).The treatment cost in the Three-Scope group was 2.41 ? 0.11 million yuan,which was lower than that in the ERCP+LC group(4.47±0.23 million yuan,P<0.0001)or in the LC+LCBDE group(4.88±0.55 million yuan,P=0.0094).The stone extraction rate of the Three-Scope group was 100%(31/31),which was significantly higher than that in the ERCP+LC group(62.07%(72/116),(P<0.0001),and with no statistical difference with that in LC+LCBDE group(94.57%(87/92)(P=0.1851).There was no complication or recurrence occurred in all the 31 patients treated with Three-Scope treatment.Conclusion:(1)In the treatment of choledocholithiasis,ERCP has the advantages of short hospitalization time and low treatment cost,and LCBDE has the advantages of high stone extraction rate;(2)For patients with choledocholithiasis,the hospitalization time of ERCP is short,especially for patients with choledochal diameter<1cm,the treatment cost is lower;(3)For patients with choledocholithiasis complicated with gallstone and choledochal diameter?1cm,the Three-Scope treatment can be the first choice.The hospitalization time is short,the treatment cost?the complication rate?recurrence rate are low,the stone extraction rate is high.LCBDE has shorter hospital stay and lower recurrence rate than ERCP+LC. |
PDF Full Text Request