·論著·

急性膽源性胰腺炎膽道結(jié)石手術(shù)時(shí)機(jī)的探討

顧玉青徐紅星汪意青

【摘要】目的探討急性膽源性胰腺炎患者膽道結(jié)石手術(shù)時(shí)機(jī)。方法回顧性分析2011年1月至2013年12月江蘇省太倉(cāng)市第一人民醫(yī)院普通外科手術(shù)治療的44例急性膽源性胰腺炎患者的病例資料。根據(jù)手術(shù)治療的時(shí)間將患者分為早期手術(shù)組和延期手術(shù)組。早期手術(shù)指非手術(shù)治療2周內(nèi)，胰腺炎癥狀、體征基本消失后行手術(shù)治療；延期手術(shù)是在非手術(shù)治療2周后行手術(shù)治療。結(jié)果44例膽源性胰腺炎患者中男性18例，女性26例，年齡26～83歲，平均54歲，42例為輕癥急性胰腺炎，2例為重癥急性胰腺炎。術(shù)前影像學(xué)檢查提示膽囊結(jié)石合并膽總管結(jié)石5例，單純膽囊結(jié)石39例。5例膽囊結(jié)石合并膽總管結(jié)石患者均剖腹行膽囊切除+膽總管切開(kāi)取石T管引流術(shù)，其中1例因合并急性化膿性膽管炎而急診手術(shù)，2例Ranson評(píng)分≤3分者行早期手術(shù)，2例Ranson評(píng)分≥4分者行延期手術(shù)，均治愈出院。39例單純膽囊結(jié)石患者均行腹腔鏡下膽囊切除術(shù)，其中25例早期手術(shù)，14例延期手術(shù)，均治愈出院。與延期手術(shù)組比較，早期手術(shù)組患者平均年齡低[(46±12)歲比(64±11)歲]、Ranson評(píng)分低[(1.0±0.5)分比(1.5±0.8)分]、總住院時(shí)間短[(14.0±2.8)d比(18.1±3.3)d]、住院費(fèi)用少[(17 899±3 461)元比(23 710±3 230)元]，兩組差異均有統(tǒng)計(jì)學(xué)意義(P值均<0.05)。兩組患者平均手術(shù)時(shí)間、術(shù)后恢復(fù)時(shí)間差異均無(wú)統(tǒng)計(jì)學(xué)意義。兩組均無(wú)中轉(zhuǎn)開(kāi)腹病例，術(shù)后也均無(wú)并發(fā)癥發(fā)生。結(jié)論重癥急性膽源性胰腺炎患者應(yīng)盡可能在非手術(shù)治療后癥狀完全緩解時(shí)行延期手術(shù)；輕癥急性膽源性胰腺炎患者早期手術(shù)并不增加手術(shù)難度及并發(fā)癥發(fā)生率，且能減少住院天數(shù)及住院費(fèi)用。

【關(guān)鍵詞】胰腺炎；膽石；外科手術(shù)

DOI:10.3760/cma.j.issn.1674-1935.2015.01.003

收稿日期：(2014-07-01)

Operation time on biliary duct stone with acute gallstone pancreatitisGuYuqing,XuHongxing,WangYiqing.DepartmentofGeneralSurgery,TaicangFirstPeople′sHospital,Taicang215400,China

Correspondingauthor:WangYiqing,Email: 551177wyq@163.com

Abstract【】ObjectiveTo investigate operation time on biliary duct stone with acute gallstone pancreatitis. MethodsThe clinical data of 44 patients with acute gallstone pancreatitis who were admitted to Department of General Surgery, Taicang First People′s Hospital for surgical management from January 2011 to December 2013 were retrospectively analyzed. Patients were divided into early surgery group and delayed surgery group according to the timing. Early surgery group was defined as the patients whose symptoms of pancreatitis were basically disappeared after conservative treatment and surgery was performed within two weeks, while delayed surgery group was defined as the patients who underwent surgery after two weeks. Results Of the 44 acute gallstone pancreatitis cases, 18 patients were males, and 26 were females, with median age of 54 years old (range 26-83 years old). Forty-two cases were mild acute pancreatitis and the other two cases were severe acute pancreatitis. Preoperative imaging indicated both cholecystolithiasis and choledocholithiasis in 5 patients, cholecystolithiasis alone in 39 patients. The 5 patients underwent cholecystectomy and choledocholithotomy with T-tube drainage. Among these 5 cases, one patient with concomitant acute suppurative cholangitis had an emergency surgery, two patients with Ranson score ≤3 had early surgery, and

作者單位：215400江蘇太倉(cāng)，太倉(cāng)市第一人民醫(yī)院普通外科

通信作者：汪意青，Email: 551177wyq@163.com

two patients with Ranson score ≥4 had delayed surgery, and all the patients were cured and discharged. Thirty-nine cases with cholecystolithiasis alone were treated with laparoscopic cholecystectomy. Among the 39 patients, 25 patients underwent early laparoscopic cholecystectomy, and the other 14 patients underwent delayed surgery, and all the patients were cured and discharged. When compared with delayed group, the average age and Ranson score of early group were lower [(46±12)yrsvs(64±11) yrs and (1.0±0.5)vs(1.5±0.8)], and the median hospital length of stay and the cost were significantly less in the early group than those in the delayed group [(14.0±2.8)dvs(18.1±3.3)d and (17 899±3461)Yuanvs(23 710±3 230) Yuan], and the difference between the two groups was statistically significant (P<0.05). Nevertheless, there was no difference between the operation time and recovery time. There was no conversion to open surgery or post-operative complication in the two groups. ConclusionsFor severe acute pancreatitis, the delayed operation is recommended when the symptom of pancreatitis is completely improved after conservative management, while for mild acute pancreatitis, early surgery does not increase operation difficulty and complication, and it can decrease the length of hospital stays and costs.

【Key words】Pancreatitis;Gallstones;Surgical procedures, operative

急性膽源性胰腺炎是急性胰腺炎(AP)的一種常見(jiàn)類(lèi)型，在我國(guó)所占比例大于50%[1-2]。一般認(rèn)為其發(fā)病機(jī)制是由于膽總管內(nèi)結(jié)石、腫瘤等因素造成膽、胰管共同通道炎癥、狹窄，導(dǎo)致膽、胰液逆流，引起胰腺自身消化所致[3]。關(guān)于膽源性胰腺炎診斷、治療和手術(shù)時(shí)機(jī)等方面目前仍存在爭(zhēng)議[4]。本研究回顧性分析急性膽源性胰腺炎行手術(shù)治療膽道結(jié)石的患者資料，探討對(duì)急性膽源性胰腺炎患者膽道結(jié)石的處理原則和手術(shù)時(shí)機(jī)。

資料和方法

一、臨床資料

2011年1月至2013年12月太倉(cāng)市第一人民醫(yī)院普外科共收治急性膽源性胰腺炎(acute biliary pancreatitis，ABP)并行手術(shù)治療膽道結(jié)石的患者44例。ABP診斷均符合中華醫(yī)學(xué)會(huì)外科學(xué)分會(huì)胰腺外科學(xué)組制定的急性胰腺炎的診斷標(biāo)準(zhǔn)[5]及以下條件[6]：(1)有膽石癥史和(或)發(fā)病前有膽絞痛發(fā)作史；(2)上腹部壓痛、肌緊張、反跳痛；(3)血、尿淀粉酶明顯升高；(4)血清總膽紅素>40 U/L或堿性磷酸酶(AKP)>225 U/L或ALT>75 U/L；(5)B超、CT檢查提示膽囊結(jié)石、膽管結(jié)石并發(fā)梗阻、膽總管擴(kuò)張和急性胰腺炎；(6)排除其他原因所引起的胰腺炎(酒精性、高鈣血癥、高脂血癥和外傷等)。

根據(jù)Ranson多因素分析法判斷病情輕重：(1)年齡>55歲； (2)血糖>11 mmol/L；(3)乳酸脫氫酶>350 U/L；(4)白細(xì)胞計(jì)數(shù)>16×109/L；(5)ASL>250 U/L。入院后48 h內(nèi)指標(biāo)：(1)紅細(xì)胞比積下降>10%；(2)血鈣<2 mmol/L；(3)PaO2<8 kPa；(4)剩余堿(BE)>4 mmol/L；(5)血尿素氮>1.785 mmol/L；(6)體液?jiǎn)适С^(guò)6 L。上述11項(xiàng)指標(biāo)中每項(xiàng)1分，≤3分為輕癥急性胰腺炎(mild acute pancratitis, MAP )，≥4分以上者為重癥急性胰腺炎(severe acute pancreatitis, SAP)。

二、治療方法

所有患者術(shù)前常規(guī)行MRCP檢查。除1例因膽總管結(jié)石并發(fā)AP，出現(xiàn)化膿性膽管炎癥狀而急診行手術(shù)治療外，其余43例均先行非手術(shù)治療，包括禁食、胃腸減壓、靜脈補(bǔ)液、預(yù)防性應(yīng)用抗生素、給予抑制胰液分泌和胰酶活性的藥物、維持水電解質(zhì)及酸堿平衡、對(duì)癥支持治療等。根據(jù)手術(shù)治療的時(shí)間將患者分為早期手術(shù)組和延期手術(shù)組。早期手術(shù)是指非手術(shù)治療2周內(nèi)，胰腺炎臨床癥狀和體征基本消失，血常規(guī)、肝功能基本正常，血、尿淀粉酶基本降至正常，復(fù)查B超、CT提示胰腺水腫明顯好轉(zhuǎn)或消退后行手術(shù)治療；延期手術(shù)是在非手術(shù)治療2周后行手術(shù)治療。手術(shù)治療方式為膽囊切除術(shù)，合并膽總管結(jié)石者行膽總管切開(kāi)取石T管引流術(shù)。

三、統(tǒng)計(jì)學(xué)處理

結(jié)果

一、一般情況

ABP患者中男性18例，女性26例，年齡26～83歲，平均54歲，MAP 42例，SAP 2例。術(shù)前B超、MRCP提示膽囊結(jié)石合并膽總管結(jié)石5例，單純膽囊結(jié)石39例。Ranson評(píng)分≤3分42例，≥4分2例。

二、手術(shù)治療方式

膽囊結(jié)石合并膽總管結(jié)石5例均行膽囊切除+膽總管切開(kāi)取石T管引流術(shù)，其中1例因合并急性化膿性膽管炎而急診手術(shù)，2例Ranson評(píng)分≤3分者行早期手術(shù)，2例Ranson評(píng)分≥4分者行延期手術(shù)。5例患者均治愈出院。

39例單純膽囊結(jié)石者Ranson評(píng)分均≤3分，均行腹腔鏡下膽囊切除術(shù)，其中25例行早期手術(shù)，14例行延期手術(shù)。39例患者均治愈出院。

三、早期單純膽囊切除術(shù)與延期手術(shù)患者的對(duì)比

早期手術(shù)組患者年齡26～74歲，平均(46±12)歲；延期手術(shù)組患者年齡48～83歲，平均(64±11)歲。早期手術(shù)組Ranson評(píng)分3例為0分，20例1分，2例2分；延期手術(shù)組分別為9例1分，3例2分，2例3分。早期手術(shù)組患者平均年齡、Ranson評(píng)分顯著低于延期手術(shù)組；總住院時(shí)間顯著短于延期手術(shù)組；住院費(fèi)用顯著低于延期手術(shù)組，兩組差異均有統(tǒng)計(jì)學(xué)意義(P值均<0.05，表1)。兩組患者平均手術(shù)時(shí)間、術(shù)后恢復(fù)時(shí)間差異均無(wú)統(tǒng)計(jì)學(xué)意義。兩組均無(wú)中轉(zhuǎn)開(kāi)腹病例，術(shù)后也均無(wú)并發(fā)癥發(fā)生(表1)。延期手術(shù)組中有1例患者在膽源性胰腺炎治愈后出院等待手術(shù)的第5天再次出現(xiàn)AP癥狀，經(jīng)非手術(shù)治療胰腺炎癥狀好轉(zhuǎn)后行早期手術(shù)。

表1單純膽囊切除術(shù)早期手術(shù)組與延期手術(shù)組患者臨床指標(biāo)的比較

項(xiàng) 目早期手術(shù)組(25例)延期手術(shù)組(14例)t值或χ2值P值Ranson評(píng)分(x±s)1.0±0.51.5±0.818.3390.026手術(shù)時(shí)間(min,x±s)56.4±18.063.6±18.626.2340.254中轉(zhuǎn)開(kāi)腹(例)00術(shù)后并發(fā)癥(例)00術(shù)后恢復(fù)時(shí)間(d,x±s)4.8±1.44.3±0.532.4210.076總住院天數(shù)(d,x±s)14.0±2.818.1±3.323.7610.001住院總費(fèi)用(元,x±s)17899±346123710±323028.674<0.001

討論

膽源性胰腺炎占AP總數(shù)的比例各個(gè)中心報(bào)道結(jié)果不同，在我國(guó)大于50%。膽源性胰腺炎多數(shù)為膽囊內(nèi)小結(jié)石通過(guò)膽總管下移至Vater壺腹而發(fā)病[3]。本研究39例行膽囊切除術(shù)的膽源性胰腺炎病例中，術(shù)前B超或CT、MRCP提示38例為膽囊多發(fā)小結(jié)石，僅1例為膽囊單發(fā)較大結(jié)石。文獻(xiàn)報(bào)道，若不切除膽囊，膽源性胰腺炎的復(fù)發(fā)率為29%～63%[7]。因此，對(duì)于膽源性胰腺炎，切除多發(fā)小結(jié)石的膽囊是治療和預(yù)防再次復(fù)發(fā)的重要手段。

膽源性胰腺炎若膽管有梗阻，以膽管炎癥狀為主的患者應(yīng)急診手術(shù)解除膽道梗阻，行膽總管切開(kāi)取石+T管引流術(shù)；膽囊未切除者同時(shí)切除膽囊[8]。對(duì)SAP患者，特別是高齡，全身情況差，病情危重，合并心、肺、腎等重要臟器功能障礙的患者，因難以耐受開(kāi)腹手術(shù)，可早期行ERCP，明確病因后行Oddi括約肌切開(kāi)以快速緩解膽道淤積、解除胰管高壓，抑制病情的進(jìn)一步發(fā)展，待胰腺炎癥狀緩解后再擇期手術(shù)治療膽道結(jié)石[1]。

對(duì)于輕癥膽源性胰腺炎患者，手術(shù)切除膽囊和(或)膽總管切開(kāi)取石并引流的時(shí)機(jī)目前仍有爭(zhēng)議。早期的一些研究認(rèn)為，早期膽囊切除術(shù)相較于延期手術(shù)，在MAP時(shí)并無(wú)優(yōu)勢(shì)，卻能增加SAP患者的并發(fā)癥發(fā)生率及病死率，因此更傾向于在胰腺炎完全控制后再擇期行手術(shù)治療[9]。但在近期，特別是腹腔鏡技術(shù)的發(fā)展及廣泛應(yīng)用后，發(fā)現(xiàn)似乎沒(méi)有必要等到胰腺炎癥完全控制后再行手術(shù)切除膽囊。延期手術(shù)反而會(huì)增加再發(fā)胰腺炎的概率，延長(zhǎng)患者的住院時(shí)間及費(fèi)用，且并不能減少圍手術(shù)期的并發(fā)癥發(fā)生率[10]。

Morris等[11]匯總了2011年至2012年英國(guó)國(guó)民醫(yī)療保障體系中膽源性胰腺炎的治療費(fèi)用，發(fā)現(xiàn)早期和延期手術(shù)治療的平均費(fèi)用分別為2 748英鎊和3 752英鎊。 Taylor等[12]報(bào)道，早期手術(shù)能顯著降低患者的住院天數(shù)，而不會(huì)增加術(shù)中及術(shù)后的并發(fā)癥發(fā)生率。本組資料顯示，早期手術(shù)組的平均住院費(fèi)用顯著低于延期手術(shù)組，患者住院總天數(shù)也顯著短于延期手術(shù)組。這是因?yàn)槟懺葱砸认傺捉?jīng)1周左右非手術(shù)治療后癥狀得到控制，大多數(shù)膽囊周?chē)装Y粘連已明顯減輕，因此早期手術(shù)并不會(huì)增加手術(shù)難度及手術(shù)風(fēng)險(xiǎn)，也不會(huì)延長(zhǎng)術(shù)后恢復(fù)時(shí)間。

近來(lái)有學(xué)者提出膽源性胰腺炎發(fā)病48 h內(nèi)，血清淀粉酶開(kāi)始下降，腹部癥狀體征開(kāi)始好轉(zhuǎn)后即可行腹腔鏡下膽囊切除術(shù)[13]。但也有學(xué)者認(rèn)為早期膽囊切除術(shù)并不適用于重型膽源性胰腺炎患者，Ranson評(píng)分常常需要到發(fā)病48 h后，48 h內(nèi)尚不能完整評(píng)估胰腺炎的嚴(yán)重程度，尚需進(jìn)一步臨床數(shù)據(jù)支持[14]。

總之，應(yīng)該根據(jù)膽道結(jié)石類(lèi)型選擇合適的處理方法，手術(shù)時(shí)機(jī)應(yīng)個(gè)體化對(duì)待。對(duì)于輕型急性膽源性胰腺炎，早期手術(shù)能減少住院時(shí)間及費(fèi)用，而不增加手術(shù)時(shí)間及手術(shù)并發(fā)癥，因而更適用于輕癥患者。重癥急性膽源性胰腺炎患者則不推薦早期手術(shù)，應(yīng)在AP控制后再進(jìn)一步評(píng)估病情，考慮手術(shù)時(shí)機(jī)。

參考文獻(xiàn)

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(本文編輯：呂芳萍)