目的 探讨腹腔镜胆道再手术治疗老年肝外胆管结石的临床疗效.方法 回顾性分析2013年1月-2015年6月枣阳市第一人民医院收治的86例行腹腔镜胆道手术的60岁以上肝外胆管结石患者的临床资料,根据入选患者手术情况分为初次手术组(n=54)和再次手术组(n=32),比较2组患者手术相关情况及随访情况.计量资料组间比较采用t检验,计数资料组间比较采用x2检验.结果 2组患者均顺利完成手术,无围手术期死亡病例,且术后结石清除率均为100％.2组患者的手术方式(一期缝合/T管引流)差异无统计学意义(P＞0.05).再次手术组的中转开腹率、手术时间、手术出血量、住院时间、术中结石清除率、术中及术后并发症发生率均高(长)于初次手术组,但仅在手术时间方面差异有统计学意义(t=2.126,P=0.036).初次手术组术中胆囊动脉损伤1例,予结扎止血;再次手术组术中胃肠道浆膜损伤2例,予浆肌层包埋处理.初次手术组术后出现胆漏1例,肺部感染1例,泌尿系感染1例,均经保守治疗后治愈;再次手术组术后出现胆漏1例,肺部感染2例,均经保守治疗后治愈.总随访率为94.19％,其中初次手术组50例,随访率为92.59％;再次组31例,随访率为96.88％.经影像学检查证实均无胆道狭窄、胆道残留结石或结石复发等并发症.结论 腹腔镜胆道再手术治疗老年肝外胆管结石安全、有效,但存在一定的中转开腹率和并发症发生率,应注意提升操作水平,避免术中副损伤,并合理把握手术适应证和优化围手术期处理.%Objective To investigate the clinical effect of laparoscopic biliary reoperation in the treatment of elderly patients with extrahepatic bile duct stones.Methods A retrospective analysis was performed for the clinical data of 86 elderly patients with extrahepatic bile duct stones who were admitted to The First People's Hospital of Zaoyang from January 2013 to June 2015 and underwent laparoscopic biliary reoperation.The surgical conditions and follow-up results were compared between groups.The t-test was used for comparison of continuous data between groups,the chi-square test was used for comparison of categorical data between groups.Results All the patients underwent the surgery successfully and no patient died during the perioperative period.The postoperative stone clearance rate was 100％.There was no significant difference in the surgical procedure (primary suture/T-tube drainage) between the two groups (P ＞ 0.05).Compared with the first operation group,the reoperation group had a higher rate of conversion to laparotomy,a longer length of hospital stay,higher intraoperative stone clearance rate and incidence rates of intraoperative and postoperative complications,and a significantly longer time of operation (t =2.126,P =0.036).In the first operation group,one patient experienced intraoperative cystic artery injury and was given ligation for hemostasis;in the reoperation group,2 patients experienced gastrointestinal serosal injury and were treated with embedding of the seromuscular layer.In the first operation group,1 patient each experienced bile leakage,pulmonary infection,and urinary system infection after surgery and were all cured after conservative treatment;in the reoperation group,1 patient experienced bile leakage and 2 experienced pulmonary infection,and all the patients were cured after conservative treatment.The overall follow-up rate was 94.19％ (50/54) in the first operation group and 96.88％ (31/32) in the reoperation group.The imaging examination showed no complications such as biliary stricture,residual bile duct stones,and recurrence of stones.Conclusion Laparoscopic biliary reoperation is safe and effective in the treatment of elderly patients with extrahepatic bile duct stones,but there are a certain rate of conversion to laparotomy and incidence rates of complications.The operation techniques should be improved to avoid intraoperative injury,surgical indications should be strictly followed,and perioperative management should be optimized.
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