本文選題：膽總管復(fù)發(fā)結(jié)石　切入點(diǎn)：肝膽濕熱型　出處：《大連醫(yī)科大學(xué)》2017年碩士論文　論文類(lèi)型：學(xué)位論文

【摘要】：目的:分析比較我院開(kāi)腹膽總管探查術(shù)、腹腔鏡膽總管探查術(shù)及EST/EPBD取石術(shù)對(duì)膽總管結(jié)石術(shù)后復(fù)發(fā)結(jié)石的療效,以及對(duì)患者術(shù)后進(jìn)行隨訪(fǎng),了解術(shù)后結(jié)石再?gòu)?fù)發(fā)情況以及探討服用中藥清熱利膽顆粒對(duì)結(jié)石再?gòu)?fù)發(fā)的預(yù)防作用。方法:回顧性分析大連醫(yī)科大學(xué)附屬第一醫(yī)院自2013年01月至2016年09月收治的中醫(yī)辯證屬肝膽濕熱型的膽總管復(fù)發(fā)結(jié)石患者68例,根據(jù)手術(shù)方式分為A組:13 例 OCBDE(open common bile duct exploration,開(kāi)腹膽總管探查術(shù)),B 組:10 例 LCBDE(laparoscopic common bile duct exploration,腹腔鏡下膽總管探查術(shù)),C組:45例EST(endoscopic sphincterotomy,內(nèi)鏡下十二指腸乳頭括約肌切開(kāi)術(shù))/EPBD(endoscopic papillary balloon dilation,內(nèi)鏡下十二指腸乳頭球囊擴(kuò)張術(shù)),比較三組患者一般情況、膽道情況、術(shù)后胃腸功能恢復(fù)時(shí)間、術(shù)后住院天數(shù)、并發(fā)癥種類(lèi)及發(fā)生率。通過(guò)電話(huà)及復(fù)診隨訪(fǎng),獲得確切病例62例。比較三組病例術(shù)后再次復(fù)發(fā)結(jié)石的情況及時(shí)間間隔,同時(shí)隨訪(fǎng)術(shù)后中藥清熱利膽顆粒服用情況,將服用清熱利膽顆粒的患者歸為中藥組,未服用清熱利膽顆粒的患者歸為對(duì)照組,分析清熱利膽顆粒對(duì)術(shù)后再?gòu)?fù)發(fā)結(jié)石的預(yù)防作用。結(jié)果:本研究共68例肝膽濕熱型膽總管復(fù)發(fā)結(jié)石患者,男32例,女性36例,平均年齡68.88±12.78歲。A組患者平均年齡66.46±12.87歲,B組平均年齡60.60±13.31歲,C組平均年齡71.42±11.97歲,三組間、C組與B組年齡比較具有統(tǒng)計(jì)學(xué)差異(P0.05),C組平均年齡最大。而在合并基礎(chǔ)疾病、既往膽道手術(shù)史方面,三組間比較并無(wú)統(tǒng)計(jì)學(xué)差異(P0.05)。伴有壺腹周?chē)以谌M中比較具有顯著統(tǒng)計(jì)學(xué)意義(P0.01),其中C組伴發(fā)壺腹周?chē)冶壤罡?與A組相比有顯著統(tǒng)計(jì)學(xué)差異(P0.01),與B組相比存在統(tǒng)計(jì)學(xué)差異(P0.05)。而在膽總管最大直徑、結(jié)石最大直徑及數(shù)量方面,三組間差異并無(wú)統(tǒng)計(jì)學(xué)意義(P0.05)。術(shù)后胃腸功能恢復(fù)時(shí)間、術(shù)后住院天數(shù):A組胃腸功能恢復(fù)時(shí)間2.69±0.95天,術(shù)后住院14.69±6.71天;B組胃腸功能恢復(fù)時(shí)間2.30±1.06天,術(shù)后住院9.40±2.91天;C組基本不影響胃腸功能,術(shù)后住院6.24±2.81天。A組與B組相比,胃腸功能恢復(fù)時(shí)間無(wú)統(tǒng)計(jì)學(xué)差異(P0.05);術(shù)后住院天數(shù)人組B組C組,三組間差異有顯著統(tǒng)計(jì)學(xué)意義(P0.01)。A組圍手術(shù)期并發(fā)癥發(fā)生率30.77%,B組圍手術(shù)期并發(fā)癥發(fā)生率10%,C組圍手術(shù)期并發(fā)癥發(fā)生率8.89%,三組間并發(fā)癥發(fā)生率并無(wú)統(tǒng)計(jì)學(xué)差異(P0.05);A組相比于C組,圍手術(shù)期并發(fā)癥發(fā)生率較高,差異具有統(tǒng)計(jì)學(xué)意義(P0.05)。術(shù)后隨訪(fǎng)獲得了 62例完整病例資料,其中12例出現(xiàn)了再?gòu)?fù)發(fā),復(fù)發(fā)率19.35%。A組復(fù)發(fā)2例,再?gòu)?fù)發(fā)率16.67%,其再?gòu)?fù)發(fā)的時(shí)間分布為1～2年再?gòu)?fù)發(fā)率8.33%,2年再?gòu)?fù)發(fā)率8.33%;B組復(fù)發(fā)1例,再?gòu)?fù)發(fā)率11.11%,其再?gòu)?fù)發(fā)的時(shí)間分布為1～2年再?gòu)?fù)發(fā)率11.11%;C組復(fù)發(fā)9例,再?gòu)?fù)發(fā)率21.95%,其再?gòu)?fù)發(fā)的時(shí)間分布為0.5～1年再?gòu)?fù)發(fā)率14.63%,1～2年再?gòu)?fù)發(fā)率2.44%,2年再?gòu)?fù)發(fā)率4.88%;三組間總再?gòu)?fù)發(fā)率差異無(wú)統(tǒng)計(jì)學(xué)意義(P0.05),再?gòu)?fù)發(fā)時(shí)間間隔分布情況具有顯著統(tǒng)計(jì)學(xué)差異(P0.01)。中藥組中28例患者服用清熱利膽顆粒,2例再?gòu)?fù)發(fā),再?gòu)?fù)發(fā)率7.14%;對(duì)照組中34例患者未服用清熱利膽顆粒,10例復(fù)發(fā),再?gòu)?fù)發(fā)率29.41%;兩者相比較,中藥組再?gòu)?fù)發(fā)率較低,差異具有統(tǒng)計(jì)學(xué)意義(P0.05)。對(duì)比三種術(shù)式術(shù)后服用清熱利膽顆粒結(jié)石再?gòu)?fù)發(fā)情況:A組與B組服用中藥與未服用再?gòu)?fù)發(fā)率比較無(wú)統(tǒng)計(jì)學(xué)差異(P0.05);而C組中服用清熱利膽顆粒的再?gòu)?fù)發(fā)率9.52%,未服用再?gòu)?fù)發(fā)率35%,差異具有統(tǒng)計(jì)學(xué)意義(P0.05)。結(jié)論:綜合比較治療膽總管復(fù)發(fā)結(jié)石的三種不同術(shù)式,EST/EPBD因不需經(jīng)腹手術(shù)更加微創(chuàng),具有對(duì)胃腸道功能干擾少、住院時(shí)間短等優(yōu)勢(shì),總體并發(fā)癥發(fā)生率方面同LCBDE組相當(dāng)且明顯低于OCBDE組,結(jié)石復(fù)發(fā)率方面同OCBDE和LCBDE組比較無(wú)顯著差異。但其術(shù)后短時(shí)間內(nèi)易于再次復(fù)發(fā)結(jié)石,可能同乳頭括約肌功能損傷有關(guān)。對(duì)于乳頭括約肌功能正常的年輕患者,為保留乳頭括約肌功能,我們傾向于選擇LCBDE治療膽總管復(fù)發(fā)結(jié)石;對(duì)于多次手術(shù)腹腔粘連重、腔鏡手術(shù)困難且結(jié)石大,EST/EPBD無(wú)法取出的患者,仍應(yīng)采用OCBDE治療。中藥清熱利膽顆粒對(duì)于肝膽濕熱型的膽總管復(fù)發(fā)結(jié)石患者再發(fā)結(jié)石有較滿(mǎn)意的預(yù)防作用,術(shù)后規(guī)律服用清熱利膽顆粒預(yù)防結(jié)石復(fù)發(fā)在臨床上值得推薦。
[Abstract]:Objective: to analyze and compare our hospital open choledocholithotomy, the curative effect of recurrent stones of bile duct stones after laparoscopic choledochotomy and EST/EPBD lithotomy, and the patients were followed up after surgery, postoperative recurrence of stones to understand and explore the preventive effect of traditional Chinese medicine Qingre Lidan Granule on stone recurrence. A retrospective analysis of 68 patients with common bile duct calculi of traditional Chinese medicine from 2013 01 to 2016 09 months from the First Affiliated Hospital of Dalian Medical University is a dialectical hepatobiliary damp heat type patients, the patients were divided into group A: 13 cases of OCBDE (open common bile duct exploration, open choledocholithotomy), group B: 10 cases of LCBDE (laparoscopic common bile duct exploration, laparoscopic choledochotomy), group C: 45 cases of EST (endoscopic sphincterotomy, endoscopic sphincterotomy (endoscopic PA /EPBD) Pillary balloon dilation, endoscopic papillary balloon dilation), compared three groups of patients in general, biliary tract, postoperative gastrointestinal function recovery time, postoperative hospital stay, incidence of complications and types. And for follow-up by telephone, get the exact 62 cases. And the time interval of recurrence calculus cases three group, and postoperative follow-up of Qingre Lidan Granule taking, taking Qingrelidan particles were classified into traditional Chinese medicine group, not taking Qingrelidan particles were classified as control group, analysis of preventive effect of Qingre Granule on postoperative recurrence of biliary calculi. Results: a total of 68 cases of hepatobiliary damp heat type common bile duct calculi patients, male 32 cases, female 36 cases, mean age 68.88 + 12.78 years in.A group were 66.46 + 12.87 years old, the average age of 60.60 + 13.31 B group, C group the average age of 71.42 + 11.97 Age between the three groups, C group and B group had statistical differences in age (P0.05), C group. The average age of the largest in terms with basic diseases, history of biliary tract surgery, there was no statistical difference between the three groups (P0.05). Compared with periampullary diverticulum has significant statistical significance in three groups (P0.01), C group with the highest proportion of periampullary diverticulum, with significant difference compared with A group (P0.01), there was significant difference compared with B group (P0.05). And the largest in the common bile duct diameter, maximum diameter and number of stones, no significant difference was found between the three groups (P0.05). The recovery time postoperative gastrointestinal function, postoperative hospital stay: group A, gastrointestinal function recovery time 2.69 + 0.95 days, postoperative hospital stay was 14.69 + 6.71 days; group B, gastrointestinal function recovery time was 2.30 + 1.06 days, postoperative hospital stay was 9.40 + 2.91 days; C group does not affect gastrointestinal function, postoperative hospital stay was 6.24 + 2.81 days.A Compared with B group, the recovery time of gastrointestinal function was no significant difference (P0.05); postoperative hospitalization group B group C group, there was significant difference between the three groups (P0.01 group.A) perioperative complication rate was 30.77%, B group the incidence rate of perioperative complications in perioperative group 10%, C complications occurred in 8.89%, between the three groups had no statistical differences in complication rate (P0.05); A group compared to C group, the incidence of perioperative complications is higher, the difference was statistically significant (P0.05). The postoperative follow-up was 62 cases, including 12 cases of the recurrence, the recurrence rate 19.35%.A group of 2 cases of recurrence, the recurrence rate was 16.67%, the recurrence time distribution for 1~2 years, the recurrence rate was 8.33%, 2 years, the recurrence rate was 8.33%; 1 cases of group B recurrence, the recurrence rate was 11.11%, the recurrence time distribution for 1~2 years, the recurrence rate was 11.11%; 9 cases of recurrence in C group, then the recurrence rate was 21.95%. The time distribution of recurrence ranged from 0.5 to 1 years, the recurrence rate was 14.63%, 1~2 years, the recurrence rate was 2.44%, 2 years, the recurrence rate was 4.88%; the total recurrence rate between the three groups showed no significant difference (P0.05), the recurrence interval distribution has significant difference (P0.01). In 28 cases of patients taking traditional Chinese medicine group Qingre Lidan granules, 2 cases of recurrence, the recurrence rate was 7.14%; the control group in 34 cases of patients not taking Qingre Lidan granules, 10 cases of recurrence, the recurrence rate was 29.41%; compared with traditional Chinese medicine group, the recurrence rate is low, the difference was statistically significant (P0.05). Taking Qingrelidan stones recurrence comparison of particles three operative methods: A group and B group were treated with traditional Chinese medicine and not taking no significant difference in the recurrence rate (P0.05); and group C taking Qingrelidan particles the recurrence rate of 9.52%, not taking the recurrence rate was 35%, the difference has statistical significance (P0.05). Conclusion: the comprehensive comparison Three different surgical treatment of common bile duct calculi, EST/EPBD without abdominal surgery are minimally invasive, with less interference on gastrointestinal function, short hospitalization time and other advantages, the overall complication rate of group LCBDE and was significantly lower in group OCBDE, recurrence rate compared with OCBDE and LCBDE group had no significant difference but a short time. After the operation, it is easy to recurrence of stones, may be related to the function of sphincter with nipple injury. For young patients with papillary sphincter function, to preserve the papillary sphincter function, we tend to choose LCBDE for the treatment of common bile duct calculi; surgery for multiple peritoneal adhesion, laparoscopic surgery is difficult and the big stones, not EST/EPBD out of the patients, should be treated by OCBDE. Traditional Chinese medicine Qingre Lidan granules for hepatobiliary damp heat type common bile duct calculi in patients with recurrent stones have satisfactory prevention for postoperative The regular use of clearing heat and gallbladder to prevent the recurrence of calculi is worthy of recommendation.

【學(xué)位授予單位】：大連醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類(lèi)號(hào)】：R657.4

【參考文獻(xiàn)】

中國(guó)期刊全文數(shù)據(jù)庫(kù) 前10條

1 李振毅;陶立;;膽總管結(jié)石取石術(shù)后結(jié)石復(fù)發(fā)的危險(xiǎn)因素Logistic回歸分析[J];中國(guó)現(xiàn)代醫(yī)學(xué)雜志;2016年11期

2 李衛(wèi);田志強(qiáng);張重陽(yáng);周立芳;;清熱利膽中藥結(jié)合十二指腸鏡治療膽總管復(fù)發(fā)結(jié)石的臨床療效[J];現(xiàn)代消化及介入診療;2016年01期

3 李冰;郭亞民;趙順云;;消炎利膽片預(yù)防膽總管結(jié)石術(shù)后結(jié)石復(fù)發(fā)的體會(huì)[J];甘肅醫(yī)藥;2014年11期

4 Piero Boraschi;Francescamaria Donati;;Postoperative biliary adverse events following orthotopic liver transplantation: Assessment with magnetic resonance cholangiography[J];World Journal of Gastroenterology;2014年32期

5 于麗;高文艷;劉楊;鞏陽(yáng);雷春紅;盛天驕;林一帆;;林一帆“從肝論治”膽總管結(jié)石經(jīng)驗(yàn)總結(jié)[J];遼寧中醫(yī)雜志;2014年04期

6 Kazuhisa Uchiyama;;The role and mechanism of fatty acids in gallstones[J];Hepatobiliary & Pancreatic Diseases International;2007年04期

7 李國(guó)熊,張嘯;ERCP并發(fā)癥及防治對(duì)策[J];中國(guó)內(nèi)鏡雜志;2005年08期

8 楊六成,黃寶裕,薛桂芳,李曉林,莫頂立;華支睪吸蟲(chóng)感染與肝膽胰外科疾病的關(guān)系(附650例臨床分析)[J];中華肝膽外科雜志;2004年03期

9 崔乃強(qiáng),李忠廉,邱奇,趙二鵬;10年膽道再手術(shù)的臨床分析[J];中華肝膽外科雜志;2002年08期

10 項(xiàng)建斌,蔡端,張延齡;膽汁成核效應(yīng)蛋白的研究進(jìn)展[J];中華肝膽外科雜志;2000年03期

，

本文編號(hào)：1603441