本文選題：高齡患者 + 膽囊結(jié)石　； 參考：《天津醫(yī)科大學(xué)》2015年碩士論文

【摘要】：目的:在當(dāng)今社會(huì),膽道結(jié)石發(fā)病率呈現(xiàn)明顯增高趨勢(shì)。膽道結(jié)石治療方法雖然很多但對(duì)于高齡患者膽囊并膽管結(jié)石的治療瓶頸尚未完全突破,依據(jù)現(xiàn)代損傷控制理論如何以最小的創(chuàng)傷和最快的恢復(fù)并充分運(yùn)用微創(chuàng)技術(shù)治療膽石病仍存爭(zhēng)議。本研究比較應(yīng)用傳統(tǒng)開(kāi)腹術(shù)治療與應(yīng)用現(xiàn)代腔鏡微創(chuàng)手術(shù)治療患者的臨床療效等臨床資料,觀(guān)察成功實(shí)施單純開(kāi)腹手術(shù)與雙鏡聯(lián)合手術(shù)包括腹腔鏡聯(lián)合膽道鏡行膽囊切除膽管取石術(shù)、內(nèi)鏡聯(lián)合腹腔鏡先行膽管取石而后行膽囊切除術(shù)的全部患者的性別、年齡、并存病等一般情況、術(shù)前術(shù)后血液化驗(yàn)、術(shù)后肛門(mén)恢復(fù)自主排氣時(shí)限、術(shù)后體溫波動(dòng)等生命體征變化、術(shù)后腹腔出血、消化道出血等并發(fā)癥發(fā)生率以及術(shù)中情況等與手術(shù)相關(guān)的臨床指標(biāo),以期能夠在制定針對(duì)高齡患者膽囊并膽管結(jié)石治療方案時(shí)提供參考。方法:收集整理南開(kāi)醫(yī)院微創(chuàng)外科自2012年6月至2013年6月住院接受各種膽道手術(shù)治療的900例患者資料,并從所選患者中選取年齡≥70歲且≤85歲的膽囊并膽總管結(jié)石的高齡病例108例。按照分別接受不同手術(shù)治療方式將入選的108例病例分成三組,開(kāi)腹手術(shù)A組和微創(chuàng)手術(shù)B組、C組,其中開(kāi)腹A組20例患者成功實(shí)施了開(kāi)腹膽囊切除、膽總管探查取石、T管引流術(shù)(OCHTD),微創(chuàng)B組60例患者為腹腔鏡聯(lián)合十二指腸鏡即首先施行內(nèi)鏡下Oddi括約肌切開(kāi)網(wǎng)籃膽總管內(nèi)取石而后施行腹腔鏡膽囊切除術(shù)(EST+LC),微創(chuàng)C組28例患者采用腹腔鏡聯(lián)合膽道鏡雙鏡聯(lián)合術(shù)式即在腹腔鏡下行膽囊切除、膽總管切開(kāi)后應(yīng)用膽道鏡網(wǎng)籃取石及T管引流術(shù)(LC+LCBDE+IOC)。通過(guò)對(duì)手術(shù)完成所用時(shí)間統(tǒng)計(jì),手術(shù)過(guò)程中失血計(jì)量,患者出現(xiàn)術(shù)后并發(fā)癥發(fā)生率,以及患者術(shù)后生命體征變化、肛門(mén)自主排氣恢復(fù)時(shí)間統(tǒng)計(jì),患者術(shù)前術(shù)后血液化驗(yàn)?zāi)懠t素、轉(zhuǎn)氨酶、白細(xì)胞恢復(fù)正常時(shí)間計(jì)算、住院時(shí)長(zhǎng)統(tǒng)計(jì)等指標(biāo)進(jìn)行觀(guān)察比較,對(duì)接受不同治療膽石癥手術(shù)方案的三組高齡患者臨床資料結(jié)果進(jìn)行統(tǒng)計(jì)學(xué)分析。結(jié)果:1.術(shù)前臨床資料:三組患者性別、年齡、術(shù)前白細(xì)胞、血TBIL、DBIL、ALP、ALT、AST、GGT、WBC水平、全身機(jī)體狀況、心肺功能及內(nèi)科基礎(chǔ)疾病等臨床資料相比,均無(wú)明顯差異(p0.05),可以進(jìn)行比對(duì)。2.術(shù)中指標(biāo):微創(chuàng)B組完成手術(shù)操作所用時(shí)限比開(kāi)腹A組和微創(chuàng)C組完成所用時(shí)限顯著縮短,手術(shù)操作過(guò)程中總出血量微創(chuàng)B組比開(kāi)腹A組和微創(chuàng)C組都顯著減少(p0.05);而微創(chuàng)C組完成手術(shù)操作所用時(shí)限要短于開(kāi)腹A組完成手術(shù)時(shí)限(p0.05),而開(kāi)腹A組在手術(shù)操作過(guò)程里的出血總量與微創(chuàng)C組手術(shù)相比較可以觀(guān)察到顯著增多,有統(tǒng)計(jì)學(xué)意義(p0.05)。3.術(shù)后恢復(fù)指標(biāo):開(kāi)腹A組和微創(chuàng)C組手術(shù)后早期體溫波動(dòng)和疼痛反應(yīng)要顯著高于微創(chuàng)B組,腹脹不適緩解及肛門(mén)自主排氣等胃腸道功能恢復(fù)時(shí)間亦長(zhǎng)于微創(chuàng)B組(p0.05);而微創(chuàng)C組胃腸道功能恢復(fù)時(shí)間則低于開(kāi)腹A組(p0.05),但三組患者術(shù)前血液生化化驗(yàn)比較無(wú)顯著差異,術(shù)后血液生化指標(biāo)膽紅素、轉(zhuǎn)氨酶、堿性磷酸酶、白細(xì)胞等降至正常時(shí)限所用時(shí)間接近,三者比較無(wú)明顯差異(p0.05)。4.手術(shù)療效和并發(fā)癥:所有病例手術(shù)均成功實(shí)施且順利康復(fù),三組病例手術(shù)成功率無(wú)差異。開(kāi)腹A組手術(shù)患者中有1例患者出現(xiàn)輕度膽汁滲漏經(jīng)充分引流等保守治療5天后停止?jié)B漏,并有1例患者出現(xiàn)切口感染經(jīng)積極換藥治療后2周內(nèi)愈合,3例出現(xiàn)肺部感染經(jīng)積極治療治愈;微創(chuàng)B組中3例患者在實(shí)施EST手術(shù)后出現(xiàn)了短暫性血淀粉酶升高并發(fā)輕度胰腺炎一周內(nèi)治愈,1例患者出現(xiàn)少量黑便(膽道出血)經(jīng)保守治療恢復(fù);微創(chuàng)C組(LC+LCBDE+IOC組)2例患者出現(xiàn)輕度膽漏均在一周內(nèi)治愈,三組病例A組術(shù)后并發(fā)癥發(fā)生率較BC兩組增高(p0.05),而B(niǎo)C兩組比較無(wú)顯著差異(p0.05)。5.住院時(shí)間:統(tǒng)計(jì)比較患者總住院天數(shù)和各組平均住院天數(shù)以及術(shù)后住院天數(shù)后發(fā)現(xiàn),開(kāi)腹A組與微創(chuàng)C組患者平均住院日均比微創(chuàng)B組顯著增多、尤其術(shù)后住院時(shí)間明顯延長(zhǎng),開(kāi)腹A組與微創(chuàng)C組術(shù)后平均住院日比B組均顯著增加(p0.05);而開(kāi)腹A組與微創(chuàng)C組兩組之間相比總住院天數(shù)相近,術(shù)后拔除T管至完全康復(fù)所用時(shí)間接近,無(wú)顯著差異(p0.05)。結(jié)論:1.年齡大于70歲的高齡膽石癥患者,膽囊并膽總管結(jié)石,尤其當(dāng)出現(xiàn)膽囊炎合并膽管炎時(shí)病情急進(jìn)展迅速,為能夠迅速阻斷膽系感染發(fā)展至重度感染治療原則應(yīng)力求安全、快速、簡(jiǎn)單、高效。由于EST+LC雙鏡聯(lián)合方案已廣泛應(yīng)用經(jīng)過(guò)實(shí)踐證明較為安全,并且具有諸多優(yōu)點(diǎn),可以最大限度的降低對(duì)患者的腹部損傷并可為患者帶來(lái)心理上的寬慰,能夠有效的降低因開(kāi)腹手術(shù)造成的腸粘連等手術(shù)并發(fā)癥,術(shù)后胃腸功能早期恢復(fù)可盡快恢復(fù)飲食、縮短住院時(shí)間相應(yīng)減輕了患者負(fù)擔(dān),故治療高齡膽石病患者時(shí)可作為首選方案。2.而LC+LCBDE+IOC比傳統(tǒng)開(kāi)腹手術(shù)術(shù)后恢復(fù)上具有優(yōu)勢(shì),腹部創(chuàng)傷小、術(shù)后胃腸功能恢復(fù)較快、腸粘連發(fā)生率低等優(yōu)勢(shì),該方案具有相應(yīng)應(yīng)用空間,但由于該術(shù)式要求患者能夠耐受氣腹、膽管結(jié)石直徑較小等嚴(yán)格條件,故需注意掌握相應(yīng)臨床適應(yīng)癥。雖然微創(chuàng)雙鏡聯(lián)合技術(shù)越來(lái)越廣泛應(yīng)用于臨床,但因其存在相應(yīng)局限性,故傳統(tǒng)開(kāi)腹手術(shù)仍然是微創(chuàng)技術(shù)的基礎(chǔ)及堅(jiān)強(qiáng)后盾。
[Abstract]:Objective: in today's society, the incidence of cholelithiasis is obviously increased. Although there are many methods for the treatment of cholelithiasis, the treatment bottlenecks of gallbladder and bile duct stones in elderly patients have not been completely broken. According to modern damage control theory, how to treat cholelithiasis with minimal trauma and quickest recovery and minimally invasive technique is still used to treat cholelithiasis. This study compared the clinical data of traditional open abdominal surgery and the application of modern endoscopic minimally invasive surgery to treat patients. The successful implementation of simple open laparotomy and double mirror combined operation including laparoscopic cholecystectomy choledochectomy with choledochoscopy, endoscopic combined laparoscopy and bile duct stone removal and biliary drainage All patients' sex, age, coexistence of disease and other general conditions, preoperative and postoperative blood tests, postoperative anus recovery time limit, postoperative body temperature fluctuations and other life signs, postoperative abdominal bleeding, digestive tract bleeding and other complications, as well as the operation related clinical indicators, in order to be able to be formulated. In order to provide reference for the treatment of gallbladder and bile duct stones in elderly patients. Methods: the data of 900 patients who were hospitalized from June 2012 to June 2013 were collected and treated in Nankai hospital from June 2012 to June 2013, and 108 elderly cases aged 70 years old and less than 85 years old were selected from the selected patients. 108 cases were divided into three groups according to the different surgical treatment methods, A group and B group of minimally invasive surgery, group C, of which 20 patients in group A were successfully operated on open cholecystectomy, choledocholithotomy, T tube drainage (OCHTD), and minimally invasive B group, and the laparoscopy combined with duodenoscopy was the first endoscopy. Laparoscopic cholecystectomy (EST+LC) was performed in the lower Oddi sphincterotomy net basket choledochus, and 28 patients in the minimally invasive C group were performed laparoscopic cholecystectomy with laparoscopic combined choledochoscopy combined operation. The choledochoscope was used to remove stones and T tube drainage (LC+LCBDE+IOC) after common bile duct incision. The operation was completed by the operation. Time statistics, blood loss in the operation, the incidence of postoperative complications, and the changes in the life signs, the recovery time of the anus, the blood test of the patients before and after the operation, the blood test of bilirubin, the aminotransferase, the normal time of leukocyte recovery, and the length of the hospital. The clinical data of three groups of elderly patients treated with cholelithiasis were analyzed statistically. Results: 1. clinical data before operation: three groups of patients' sex, age, preoperative leukocyte, blood TBIL, DBIL, ALP, ALT, AST, GGT, WBC level, body condition, cardiopulmonary function and basic diseases of internal medicine, no significant difference (P0.05) Compared with the.2. group, the time limit used in the minimally invasive B group was significantly shorter than that of the open A group and the minimally invasive C group. The total bleeding volume of the B group in the operation process was significantly lower than that of the open A group and the minimally invasive C group (P0.05), while the minimally invasive C group completed the operation of the hand operation shorter than the laparotomy A group. Time limit (P0.05), and the total amount of bleeding in the operation A group was significantly higher than that of the minimally invasive C group, and there was a statistically significant (P0.05) recovery index after.3.: the early temperature fluctuation and pain response of the open A group and the minimally invasive C group were significantly higher than the minimally invasive B group, abdominal distention remission and anus autonomic exhaust. The recovery time of gastrointestinal function was also longer than that of the minimally invasive B group (P0.05), while the recovery time of gastrointestinal function in the minimally invasive C group was lower than that of the open A group (P0.05), but there was no significant difference between the three groups before the operation, and the time of blood biochemical indexes of bilirubin, aminotransferase, alkaline phosphatase and white blood cells was close to the normal time limit, three There was no significant difference (P0.05) in the curative effect and complication of.4. operation: all cases were successfully implemented and recovered successfully. There was no difference in the success rate of the three cases. In the open A group, 1 cases had mild bile leakage through adequate drainage and other conservative treatment for 5 days. 2 weeks after the treatment, 3 cases of pulmonary infection were cured by active treatment, and 3 patients in the minimally invasive B group had transient blood amylase elevation and mild pancreatitis within one week after EST operation, and 1 cases had a small amount of black stool (biliary tract bleeding) recovered by conservative treatment; and 2 patients in the minimally invasive C group (group LC+LCBDE+IOC) were produced. The current mild bile leakage was cured within one week. The incidence of postoperative complications in the three group A group was higher than that in the BC two group (P0.05), while the BC two groups had no significant difference (P0.05).5. hospitalization time: the statistical comparison of the total hospital days, the average days of hospitalization and the number of postoperative hospitalization days, and the average daily average hospitalization of the open A group and the minimally invasive C group were found. Compared with the minimally invasive B group, especially after the operation, the hospitalization time was obviously prolonged. The average hospitalization days in the open A group and the minimally invasive C group were significantly higher than those in the B group (P0.05), while the total hospitalization days were similar in the open A group and the minimally invasive C group between the two groups. There was no significant difference (P0.05) when the T tube was removed to the complete recovery after the operation (P0.05). Conclusion: the 1. age is more than 70. The elderly gallstone patients, gallbladder and choledocholithiasis, especially when cholecystitis and cholangitis occur rapidly, should be safe, fast, simple and efficient for the rapid blocking of the development of biliary infection to severe infection. Since the EST+LC double mirror combination scheme has been widely used in practice, it has been proved safer and more safe. With many advantages, it can reduce the abdominal injury to the patient to the maximum and bring psychological comfort to the patient. It can effectively reduce the complications such as intestinal adhesion caused by laparotomy. The early recovery of gastrointestinal function after the operation can restore the diet as soon as possible, shorten the hospital time and reduce the burden of the patients accordingly. Therefore, the treatment of the elderly is in the age of age. Patients with cholelithiasis can be selected as the first choice.2. and LC+LCBDE+IOC has advantages over the traditional open operation, the abdominal trauma is small, the recovery of gastrointestinal function is faster and the incidence of intestinal adhesion is low. The scheme has the corresponding application space, but the patient can tolerate the pneumoperitoneum, the diameter of the bile duct stone is smaller and so on. It is necessary to pay attention to the corresponding clinical indications. Although the combination of minimally invasive and double mirrors is becoming more and more widely used in the clinic, the traditional open abdominal surgery is still the foundation and strong backing of the minimally invasive technique because of its limitation.
【學(xué)位授予單位】：天津醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2015
【分類(lèi)號(hào)】：R657.4

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本文編號(hào)：1919205