经不同部位胆管切开取石联合LC治疗胆总管结石合并胆囊结石的效果观察OACSTPCD

Objective To observe the clinical efficacy of choledocholithotomy through various incision sites combined with laparoscopic cholecystectomy(LC)in the treatment of choledocholithiasis and cholecystolithiasis,and to explore the practicality of selection criteria for bile duct incision sites.Methods One hundred and twenty seven patients diagnosed with choledocholithiasis and cholecystolithiasis,who were admitted in Beijing Jishuitan Hospital from Jun.2021 to Jan.2024 were retrospectively analyzed.Preoperative MRCP imaging was used to evaluate the size and number of choledocholithiasis,to determine the site of bile duct incision for exploration and stone removal.The specific strategy for choosing the bile duct incision was as follows:(1)For stones,the number≤3 and the maximum diameter≤1 cm,the cystic duct was incised and dilated,followed by choledochoscopy for stone removal;if the cystic duct was too narrow for choledochoscopy,or if stones could not be removed,or if the common hepatic duct could not be explored via choledochoscopy to confirm the presence of residual stones,a partial sidewall bile duct incision and enlargement were performed,converting to combined cystic duct and micro-incision common bile duct exploration and stone removal;(2)For stones,the number>3 and the maximum diameter>1 cm,or in cases of severe cholangitis,or if the cystic duct entered posteriorly,the anterior wall of the common bile duct was incised for stone removal.Results Among the 127 patients,65 cases with 1 common bile duct stone,14 cases with 2-3 stones,and 48 cases with more than 3 stones;with stone diameter ranging from 0.5 to 2.5 cm.Sixty-nine patients underwent cystic duct exploration,successfully removing stones in 48 cases(cystic duct stone removal group),and the remaining 21 cases required additional micro-incision common bile duct exploration(combined cystic duct and micro-incision group).There was no statistically significant difference in postoperative hospitalization time between the two groups[(3.6±1.0)d vs(4.2±2.9)d,P>0.05].Fifty-eight patients underwent anterior wall common bile duct incision and stone removal,of which 35 patients required T-tube placement and 23 patients required primary suture closure of the bile duct incision.Compared with patients underwent primary suture closure,patients with T-tube placement had significantly higher preoperative liver function level(GGT),longer postoperative hospitalizattion time,and higher hospitalization costs(all P<0.05).Conclusion Cystic duct incision and stone removal,combined cystic duct and micro-incision common bile duct stone removal,and anterior wall common bile duct incision and stone removal are all safe and effective laparoscopic procedures for the intraoperative management of choledocholithiasis.Preoperative precise assessment of the number and size of bile duct stones,which can facilitate individualized surgical approach selection,and can ensure efficacy while accelerating patient recovery.