摘要
目的探讨胆道镜探查及影像学检查在胆道残留结石诊断与治疗中的应用价值。方法采用回顾性描述性研究方法。收集2014年4月至2018年9月郑州大学第一附属医院618例肝胆管结石病术后行胆道镜探查及影像学检查患者的临床资料;男300例,女318例;年龄为(58±12)岁,年龄范围为19~89岁。观察指标:(1)行胆道镜探查及影像学检查明确胆道残留结石情况。(2)肝胆管结石病患者取石情况。正态分布的计量资料以Mean±SD表示,偏态分布的计量资料以M(范围)表示。计数资料以绝对数或百分比表示,比较采用χ^2检验或Fisher确切概率法。结果(1)行胆道镜探查及影像学检查明确胆道残留结石情况:618例患者均行胆道镜探查,其中505例患者胆道镜检查前行影像学检查。①单项影像学检查中行超声检查者72例,假阴性率为29.17%(21/72);行CT检查者37例,假阴性率为10.81%(4/37);行T管造影检查者33例,假阴性率为39.39%(13/33)。②两项联合影像学检查中行超声+CT检查者61例,假阴性率为8.20%(5/61);行超声+T管造影检查者129例,假阴性率为12.40%(16/129);行CT+T管造影检查者52例,假阴性率为5.77%(3/52)。③三项联合影像学(超声+CT+T管造影)检查者121例,假阴性率为7.44%(9/121)。7组影像学检查(超声、CT、T管造影、超声+CT、超声+T管造影、CT+T管造影与超声+CT+T管造影)假阴性率比较,差异有统计学意义(χ^2=40.83,P<0.05)。进一步分析,单项影像学检查组间比较,差异有统计学意义(χ^2=7.70,P<0.05)。两项联合影像学检查组间比较,差异无统计学意义(χ^2=2.10,P>0.05)。三项联合影像学检查与超声、T管造影检查比较,差异均有统计学意义(χ^2=16.23,21.62,P<0.05),与CT、CT+T管造影检查比较,差异均无统计学意义(P>0.05),与超声+CT、超声+T管造影检查比较,差异均无统计学意义(χ^2=0.33,1.71,P>0.05)。71例患者影像学检查未发现胆道结石,但经胆道镜探查发现结石,其中分布于胆总管下端附近36例、肝内细小胆道31例,左右肝管、肝总管及余下胆总管4例。(2)肝胆管结石病患者取石情况:618例患者中,经1、2、3、4、5、6、7、8、9、10次取尽胆道残留结石的分别为392、116、48、39、9、6、3、2、2、1例。平均每例患者取尽胆道残留结石次数为1.73次,63.43%(392/618)的患者能1次取尽胆道残留结石,96.28%(595/618)的患者能≤4次取尽胆道残留结石。结论胆道镜影像学检查结果阴性不可作为评估胆道结石取尽的标准,结合胆道镜探查明确是否存在胆道残留结石并取尽是最佳选择。
ObjectiveTo investigate the application value of choledochoscopy and imaging examination in the diagnosis and treatment of residual bile duct stones.MethodsThe retrospective descriptive study was conducted. The clinical data of 618 patients who underwent choledochoscopy and imaging examination after operation of hepatolithiasis in the First Affiliated Hospital of Zhengzhou University between April 2014 and September 2018 were collected, including 300 males and 318 females, aged from 19 to 89 years, with an average age of (58±12)years. Observation indicators: (1) situations of residual bile duct stones diagnosed by choledochoscopy and imaging examination;(2) stone extraction situations of patients with hepatolithiasis. Measurement data with normal distribution were represented as Mean±SD, and measurement data with skewed distribution were described as M (range). Count data were represented as absolute number or percentage, and analyzed using the chi-square test or Fisher exact propability.Results(1) Situations of residual bile duct stones diagnosed by choledochoscopy and imaging examination: all the 618 patients underwent choledochoscopy, and 505 of them underwent the imaging examination before choledochoscopy. ① Of patients undergoing single imaging examination, 72 received ultrasonography, with false-negative rate of 29.17%(21/72);37 received CT examination, with false-negative rate of 10.81%(4/37);33 received T-tube cholangiography, with false-negative rate of 39.39%(13/33). ② Of patients undergoing combined two imaging examinations, 61 received ultrasonography+ CT, with false-negative rate of 8.20%(5/61);129 received ultrasonography+ T-tube cholangiography, with false-negative rate of 12.40%(16/129);52 received CT+ T-tube cholangiography, with false-negative rate of 5.77%(3/52). ③ There were 121 receiving ultrasound+ CT+ T-tube cholangiography, with false-negative rate of 7.44% (9/121). There were statistically significant differences in the false-negative rates of combined two or three examinations of ultrasound+ CT+ T-tube cholangiography and single imaging examination (χ^2=40.83, P<0.05). The further analysis showed a statistically significant difference among the single imaging examination (χ^2=7.70, P<0.05). There was no statistically significant difference among the combined two of imaging examinations (χ^2=2.10, P>0.05). There were statistically significant differences in the combined three examinations of ultrasound+ CT+ T-tube cholangiography and ultrasound and T-tube cholangiography examination respectively (χ^2=16.23, 21.62, P<0.05). There was no statistically significant difference in the combined three of imaging examinations and CT examination and combination of CT+ T-tube cholangiography respectively (P>0.05). There was no statistically significant difference in the combined three of imaging examinations and combination of ultrasound+ CT examinations and combination of ultrasound+ T-tube cholangiography (χ^2=0.33, 1.71, P>0.05). Seventy-one patients without residual bile duct stone by preoperative imaging examination were detected residual bile duct stones by intraoperative choledochoscopy, and residual bile duct stones of 36, 31 and 4 patients are respectively distributed around the distal common bile duct, small intrahepatic bile duct, left and right hepatic ducts, common hepatic duct and remaining common bile duct. (2) Stone extraction situations of patients with hepatolithiasis: of 618 patients, cases with 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10 times of residual bile duct stones clearance were respectively 392, 116, 48, 39, 9, 6, 3, 2, 2 and 1. Residual bile duct stones clearance frequency of patients was an average of 1.73 times. There were 63.43%(392/618) and 96.28%(595/618) of patients had stone clearance with once and ≤ 4 times of stone extraction, respectively.ConclusionThe negative results of preoperative imaging examinations cannot be as standards of bile duct stone clearance before choledochoscopy, and the best choice is to detect whether there are residual bile duct stones and remove the stones combined with choledochoscopy.
作者
陈昆仑
李仁锋
周闯
陆旭
宋盛平
薛建锋
翟文龙
Chen Kunlun;Li Renfeng;Zhou Chuang;Lu Xu;Song Shengping;Xue Jianfeng;Zhai Wenlong(Department of Hepatobiliary and Pancreatic Surgery,the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052,China)
出处
《中华消化外科杂志》
CAS
CSCD
北大核心
2019年第2期165-168,共4页
Chinese Journal of Digestive Surgery
基金
国家自然科学基金项目(81702863).
