联合应用利胆排石药物治疗胆总管细小结石可行性分析
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摘要
目的探讨联合应用利胆、排石药物对胆总管细小结石的治疗作用,以期提高其非手术治疗效果。方法回顾性分析2014年11月至2018年1月北京电力医院联合应用利胆(33%硫酸镁)、排石(颠茄片、山莨菪碱)药物治疗41例胆总管细小结石(直径≤8 mm,数量≤3个)患者的临床资料。结果 41例患者排石成功率为73.17%(30/41),其中排石成功组30例(合并急性胆囊炎2例,6.67%),排石数量为1～3(1.1±0.4)个,排石时间为3～16(6.0±3.7) d,住院时间为3～23(12.7±5.2) d,排石失败组11例(合并急性胆囊炎5例,45.45%),排石数量为1～2(1.2±0.4)个,排石时间为5～14(9.4±3.5)d,住院时间为10～23(15.8±4.1)d,两组排石数量及住院时间对比,差异无统计学意义(t=0.086,P=0.032;t=2.014,P=0.051),但排石失败组合并急性胆囊炎比例较高,排石时间明显延长(χ~2=6.033,P=0.024;t=2.522,P=0.016)。排石成功组患者排石后的肝功能指标如丙氨酸氨基转移酶(ALT)、天门冬氨酸氨基转移酶(AST)、总胆红素(TBil)、结合胆红素(DBil)、γ-谷氨酰转肽酶(GGT)、碱性磷酸酶(ALP),均较排石前显著降低(t=3.369、4.957、5.112、5.231、2.264、2.422,均P<0.05)。随访6～18个月,41例患者肝功能正常,均无胆总管结石复发或再生。结论联合应用利胆、排石药物可促进胆总管细小结石排入十二指肠,降低手术治疗胆总管细小结石概率,既可作为胆总管细小结石的非手术治疗方法,又可作为胆总管结石的术前准备措施,以期最大限度地简化治疗手段,减轻患者痛苦,减少治疗隐患。
Objective To explore the therapeutic effects of small choledocholithiasis treated with the combination of choleretic and calculus-removal drugs, so as to improve the effect of non-operative treatment of small choledocholithiasis. Methods The clinical data of forty-one patients with common bile duct calculi(diameter≤8 mm, number≤3) treated with choleretic(33% magnesium sulfate) and lithotripsy(belladonna tablets, anisodamine) in Beijing Electric Power Hospital from November 2014 to January2018 were retrospectively analyzed. Results The successful rate of stone removal in 41 patients was73.17%(30/41), of which 30 cases(including 2 cases with acute cholecystitis) were successful group, and 11 cases(including 5 cases with acute cholecystitis) were failure group. Comparison of two groups with acute cholecystitis, stone discharge, stone discharge time and hospital stay showed no significant differences in stone discharge [1-3(1.1±0.4) vs 1-2(1.2±0.4), t=0.086, P=0.032] and hospital stay [3-23(12.7±5.2) d vs 10-23(15.8±4.1) d, t=2.014, P=0.051], while the failure group had a higher proportion of acute cholecystitis(45.45% vs 6.67%, χ~2=6.033, P=0.024) and the time of lithotripsy was significantly prolonged[5-14(9.4±3.5) d vs 3-16(6.0±3.7) d, t=2.522, P=0.016]. The liver function indexes such as alanine aminotransferase(ALT), aspartate aminotransferase(AST), total bilirubin(TBil), conjugated bilirubin(DBil),gamma-glutamyltransferase(GGT) and alkaline phosphatase(ALP) after lithotripsy in the successful group were significantly lower than those before lithotripsy(t=3.369, 4.957, 5.112, 5.231, 2.264, 2.422; all P<0.05).After 6-18 months of follow-up, all 41 patients had normal liver function and no recurrence or regeneration of common bile duct stones. Conclusion The combined administration of choleretic and lithagogue drugs can promote the small choledocholithiasis into duodenum, reduce the chance of surgical treatment of small choledocholithiasis, not only as a non-operative treatment for the small choledocholithiasis, but also as a preoperative preparatory measure for the choledocholithiasis, so as to maximize the simplification of treatment, reduce patient pain, decrease treatment risks and avoid unnecessary surgery.
Objective To explore the therapeutic effects of small choledocholithiasis treated with the combination of choleretic and calculus-removal drugs, so as to improve the effect of non-operative treatment of small choledocholithiasis. Methods The clinical data of forty-one patients with common bile duct calculi(diameter≤8 mm, number≤3) treated with choleretic(33% magnesium sulfate) and lithotripsy(belladonna tablets, anisodamine) in Beijing Electric Power Hospital from November 2014 to January2018 were retrospectively analyzed. Results The successful rate of stone removal in 41 patients was73.17%(30/41), of which 30 cases(including 2 cases with acute cholecystitis) were successful group, and 11 cases(including 5 cases with acute cholecystitis) were failure group. Comparison of two groups with acute cholecystitis, stone discharge, stone discharge time and hospital stay showed no significant differences in stone discharge [1-3(1.1±0.4) vs 1-2(1.2±0.4), t=0.086, P=0.032] and hospital stay [3-23(12.7±5.2) d vs 10-23(15.8±4.1) d, t=2.014, P=0.051], while the failure group had a higher proportion of acute cholecystitis(45.45% vs 6.67%, χ~2=6.033, P=0.024) and the time of lithotripsy was significantly prolonged[5-14(9.4±3.5) d vs 3-16(6.0±3.7) d, t=2.522, P=0.016]. The liver function indexes such as alanine aminotransferase(ALT), aspartate aminotransferase(AST), total bilirubin(TBil), conjugated bilirubin(DBil),gamma-glutamyltransferase(GGT) and alkaline phosphatase(ALP) after lithotripsy in the successful group were significantly lower than those before lithotripsy(t=3.369, 4.957, 5.112, 5.231, 2.264, 2.422; all P<0.05).After 6-18 months of follow-up, all 41 patients had normal liver function and no recurrence or regeneration of common bile duct stones. Conclusion The combined administration of choleretic and lithagogue drugs can promote the small choledocholithiasis into duodenum, reduce the chance of surgical treatment of small choledocholithiasis, not only as a non-operative treatment for the small choledocholithiasis, but also as a preoperative preparatory measure for the choledocholithiasis, so as to maximize the simplification of treatment, reduce patient pain, decrease treatment risks and avoid unnecessary surgery.
引文
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[15]周迈,郭晏同,常迎彬,等.山莨菪碱和加贝酯对胆总管结石术后胆道动力的影响[J].世界华人消化杂志, 2009, 17(26):2748-2751.
[16]李浩航,汪建初,罗宗将,等.胆囊结石并肝外胆管结石个体化微创治疗初探[J].肝胆胰外科杂志, 2017, 29(5):417-419.
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[18]冯变喜.肝胆胰外科理论与实践[M].北京:科学技术出版社,2001.
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[20] Lefemine V, Morgan RJ. Spontaneous passage of common bile duct stones in jaundiced patients[J]. Hepatobiliary Pancreat Dis Int,2011, 10(2):209-213.
[2]张宗明,苑海明,张翀.双镜联合同期治疗胆囊结石合并胆总管结石的策略[J].中华消化外科杂志, 2015, 14(4):280-283.
[3]Kim TH, Kim JH, Seo DW, et al. International consensus guidelines for endoscopic papillary large-balloon dilation[J].Gastrointest Endosc, 2016, 83(1):37-47.
[4]Nussinson E, Shibli F, Shahbari A. The combined laparoscopic and endoscopic treatment for concomitant gallstones and common bile duct stones:two stage or single stage management?[J]. Harefuah,2015, 154(10):649-652, 675.
[5]Liu JG, Wang YJ, Shu GM, et al. Laparoscopic versus endoscopic management of choledocholithiasis in patients undergoing laparoscopic cholecystectomy:a meta-analysis[J]. Laparoendosc Adv Surg Tech A, 2014, 24(5):287-294.
[6]Sato Y, Okamura S, Nakasono M, et al. Evaluation of serum amylase and gabexate mesilate with endoscopic papillary balloon dilatation[J]. Med Invest, 2007, 54:65-71.
[7]张强,吴硕东,王伟.吗啡、山莨菪碱及硫酸镁对Oddi括约肌压力的影响[J].解剖科学进展, 2008, 14(2):161-164.
[8]周良,吴国兴.硫酸镁治疗胆道蛔虫病36例观察[J].热带病与寄生虫学, 2001, 30(1):48.
[9]金俊哲,吴硕东,张强,等.山莨菪碱等对Oddi括约肌作用的临床测压研究[J].岭南现代临床外科, 2002, 2(4):229-231.
[10]张展峰,朱社教.硫酸镁合用丹参注射液治疗胆绞痛和肾绞痛78例[J].中国中西医结合急救杂志, 2005, 12(2):96.
[11]张晨阳,陈耀,林斯航.大剂量硫酸镁治疗胆囊疾病腹痛52例的效果[J].右江医学, 2002, 30(5):443-444.
[12]杨宝峰.药理学[M]. 6版.北京:人民卫生出版社, 2005.
[13]林志彬,金有豫.医用药理学基础[M]. 4版.北京:世界图书出版公司北京公司, 1998.
[14]吴林海,王照东,耿鑫,等.自拟调胆理气汤治疗腹腔镜胆囊切除术后奥迪氏括约肌功能紊乱的临床研究[J].卫生职业教育, 2013, 31(18):148-149.
[15]周迈,郭晏同,常迎彬,等.山莨菪碱和加贝酯对胆总管结石术后胆道动力的影响[J].世界华人消化杂志, 2009, 17(26):2748-2751.
[16]李浩航,汪建初,罗宗将,等.胆囊结石并肝外胆管结石个体化微创治疗初探[J].肝胆胰外科杂志, 2017, 29(5):417-419.
[17]吴孟超,吴在德.黄家驷外科学[M]. 7版.北京:人民卫生出版社, 2008.
[18]冯变喜.肝胆胰外科理论与实践[M].北京:科学技术出版社,2001.
[19]石继伟.山莨菪碱对有症状的单个直径≤10 mm胆总管结石排出的促进作用[D].承德:承德医学院, 2017.
[20] Lefemine V, Morgan RJ. Spontaneous passage of common bile duct stones in jaundiced patients[J]. Hepatobiliary Pancreat Dis Int,2011, 10(2):209-213.
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