目的 比较腹腔镜胆总管探查术(LCBDE)和内镜下括约肌切开术(EST)治疗不同胆总管结石的疗效及并发症,探讨其适应证的差异,指导临床合理应用.方法 202例胆总管结石患者,按手术方式分为腹腔镜胆总管探查术组(LCBDE组,45例)和内镜下括约肌切开术组(EST组,157例);评价两组操作成功率、一期手术治愈率、残余结石和(或)病变率、并发症率、平均住院时间和费用.结果 LCBDE组和EST组操作成功率分别为97.8％(44/45)和98.7％(155/157)(P＞ 0.05).一期手术治愈率分别为84.4％(38/45)和45.2％(71/157) (P＜0.01).LCBDE组术后残余病变主要为残石,残石率为15.6％(7/45); EST组主要为术后遗留未处理的胆囊病变和肝内外胆管结石,残留率为54.8％(86/157)(P＜0.01).LCBDE组并发术后胆漏4例、残余感染1例,并发癌率为11.1％；EST组并发术后胆漏3例、出血4例、高淀粉酶血症32例(其中急性胰腺炎14例)、急性胆管炎15例,并发症率34.4％ (P＜ 0.05).平均住院时间为(10.0±2.8)和(9.4±4.1)d (P＞0.05);住院费用为(17504±4128)和(16453±3541)元(P＞0.05).结论 LCBDE和EST均有操作成功率高、住院时间短等优点；但LCBDE并发症率、残余病变率均低于EST; LCBDE主要适于胆囊合并胆总管结石的患者,尤其是Oddi括约肌功能完好者；EST主要适于单纯胆总管结石或胆管炎患者,特别是年老体弱、Oddi括约肌无功能或既往有胆道手术史且不愿再次手术者.%Objective To compare the clinical effectiveness and complication of laparoscopic common bile duct exploration (LCBDE) and endoscopic sphincterotomy (EST) in the treatment of common bile duct stones, to probe the indication between two techniques and guide the reasonable clinical application. Methods Two hundred and two patients with common bile duct stones were divided into the LCBDE group (n =45) and EST group (n=157) according to the operation manner. The success rate of operation, cure rate of one stage operation, residual stone/lesion rate, complication rate, average hospital stav and expenses were evaluated. Results The success rates of operation were 97.8% (44/45) in LCBDE group and 98.7% (155/157) in EST group (P> 0.05), respectively. The recovery rate of one stage operation were 84.4% (38/45) and 45.2% (71/157) (P< 0.01), respectively. The main residual disease in LCBDE group was stone with the residual stone rate 15.6% (7/45); The main residual disease in EST group were unresected gallbladder and rest stones with the residue rate 54.8% (86/157) (P < 0.01). Postoperative complication in LCBDE group included 4 cases of bile leaks and 1 residual infection with complication rate 11.1%; and complication in EST group included 3 bile leaks, 4 hemorrhages, 32 hyperamylasemias(14 acute pancreatitis) and 15 acute cholangitis with complication rate 34.4% (P< 0.05).The average hospital stays in two group were (10.0 ± 2.8) and (9.4 ± 4.1)d (P > 0.05), respectively; and the total hospital charges were (17504 ± 4128) and (16453 ±3541) RMB (P> 0.05),respectively. Conclusion Both LCBDE and EST possess some advantages such as higher success rate and shorter hospital stay, but complication rate and residue disease rate of LCBDE are lower than those of EST; LCBDE mainly applies to the patients with gallbladder and CBD stone, especially patients with excellent Oddi sphincter function. EST mainly applies to the patients with simple CBD stone or cholangitis, especially aged and physically weak patients with had Oddi -phincter function or patients who underwent biliary surgical procedures or refuse to do operation again.
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