| Background and objective:Choledocholithiasis and cholecystolithiasis are common diseases in today’s world.With the improvement of people’s living standard and the increase of the aging society,the incidence of choledocholithiasis is on the rise.Laparoscopic cholecystectomy has long been the preferred treatment for gallstones.However,as an important digestive organ,the gallbladder is basically responsible for protecting the liver,gastric mucosa,gallbladder and colon from the effects of hepatotoxicity and hydrophobic bile acids,and regulating serum lipid levels.Some patients will develop post-cholecystectomy syndrome,including dyspepsia,diarrhea,bile reflux gastritis,etc.,and have a slightly increased risk of small intestine and colon tumors.Preserving a functioning gallbladder has positive implications for patients.In addition,a variety of small incision gallbladder gallblades-preserving lithotomy techniques are also emerging.Although the gallbladder is preserved by these techniques,it is inevitable to cut the gallbladder,and Cajal-like cells are distributed throughout the gallbladder.Transwall gallblades-preserving lithotomy(GPC)cuts a window into the gallbladder,and later scar repair of the incision may affect the movement function of the gallbladder to a certain extent.The normal movement of gallbladder plays an important role in preventing excessive cholesterol from crystallizing and precipitating in gallbladder bile.In order to preserve gallbladder structural integrity and protect gallbladder function to the maximum extent while preserving gallbladder stones,this study has adopted endoscopic retrograde cholangiopancreatography(ERCP)since December 2018 to treat choledocholithiasis and gallbladder stones simultaneously for patients with choledocholithiasis combined with gallstones,preserving gallbladder and removing gallstones.Prospectively,48 patients with choledocholithiasis combined with cholecystolithiasis,some with acute pancreatitis,were treated with ERCP for simultaneous removal of choledocholithiasis and cholecystolithiasis to evaluate its efficacy and safety.Meanwhile,the short-term and long-term effects of ERCP choledocholithiasis combined with cholecystolithiasis and ERCP choledocholithiasis combined with cholecystolithiasis were compared and studied.In addition,based on previous studies,the feasibility of ERCP combined with extracorporeal shock wave lithotripsy(ESWL)in the treatment of choledocholithiasis combined with large gallbladder stones was discussed by expanding indications.Method:1.The effectiveness and safety of ERCP for simultaneous extraction of choledocholithiasis and gallbladder stonesForty-eight patients with cholecystolithiasis combined with choledocholithiasis with or without acute biliary pancreatitis underwent gallbladder-preserving lithotomy via cholecystectomy based on endoscopic retrograde cholangiopancreatography(ERCP)to observe the technical and clinical success rate of this novel minimally invasive treatment,observe intraoperative and postoperative complications,and observe the changes of liver function and other indicators before and after treatment.Patients were followed up to evaluate the feasibility,safety,and efficacy of ERCP for simultaneous removal of choledocholithiasis and gallbladder stones.2.To compare the clinical efficacy of ERCP choledocholithiasis combined with cholecystolithiasis and ERCP choledocholithiasis combined with cholecystolithiasisRetrospective analysis was conducted on the data of choledocholithotomy with ERCP,and 34 patients who were clinically successful in removing calculi and receiving follow-up were selected,and 28 patients who were admitted to the Department of Gastroenterology during the same period and requested to be transferred to the Department of General surgery for laparoscopic cholecystectomy after removal of choledocholithiasis with ERCP were matched.To compare the clinical efficacy,short-term and long-term complications of ERCP and ERCP+LC in the treatment of choledocholithiasis combined with cholecystolithiasis.3.Application of ERCP combined with ESWL in the treatment of choledocholithiasis combined with large gallbladder stonesThe ERCP gallbladder-preserving lithotomy carried out in the early stage proved that it was feasible to take the stone of gallbladder stones less than 1cm in size.In this part,we intend to apply ERCP combined with ESWL to patients with gallbladder stones over 1cm,who meet the indications of gallbladder-preserving and have the intention of gallbladder-preserving,to explore its feasibility.Results:1.The effectiveness and safety of ERCP for simultaneous extraction of choledocholithiasis and gallbladder stones(1)The 48 patients included in the study included 23 males and 25 females,with an average age of 46.3±14.6 years old(21-77 years old).28 patients were diagnosed with choledocholithiasis and cholecystolithiasis(group A),and 20 patients were diagnosed with acute pancreatitis,choledocholithiasis and cholecystolithiasis(group B).(2)48 patients,technical success rate of 92.86%(44/48),clinical success rate of 77.27%(34/44);(3)There were no significant differences in demographic data,preoperative liver function and complicated chronic diseases between group A and group B(P > 0.05).There were no significant differences in technical success rate,clinical success rate and complication rate between group A and Group B(P > 0.05).(4)Postoperative liver function of all patients was significantly improved compared with that before surgery,with statistical significance(P < 0.05).(5)Overall complications: intraoperative gallbladder perforation occurred in 1 case,with an incidence of 2.08%(1/48);Pancreatitis occurred in 2 cases(4.17%),acute cholangitis occurred in 1 case(2.08%),and the incidence of postoperative complications was 6.25%(3/48).(6)Follow-up: A total of 34 patients achieved clinical success,with an average follow-up of 27 months(6-40).All patients showed significant improvement in postoperative clinical symptoms,including 1 case of diarrhea during the follow-up,which improved after 1 week after oral administration of probiotics(Bacillus subtilis combined with viable bacteria enteric-soluble capsules,2 capsules/time,3 times a day).No reflux cholangitis,no new disease,a total of 5 cases(14.7%)of gallstone recurrence,no new gallbladder disease,12 months,18 months,24 months,30 months and 36 months of recurrence rates were 0,2.94%,5.88%,11.76% and 14.7%,respectively,4 patients with gallstone recurrence no symptoms.1 case felt dull pain and discomfort in the right upper abdomen.2.To compare the clinical efficacy of ERCP gallbladder-preserving lithotomy and ERCP+LC in the treatment of choledocholithiasis combined with cholecystolithiasis(1)ERCP gallbladder preservation group: 34 patients with stone removal and follow-up were clinically successful,including 14 males and 20 females,aged 21 ～71 years old,with an average age of(47.2±13.7)years old.14 patients were complicated with acute biliary pancreatitis before surgery,and 20 patients without pancreatitis before surgery.(ERCP+LC)group: Twenty-eight patients admitted to the Department of Gastroenterology and admitted to the Department of Gastroenterology for removal of choledocholithiasis after ERCP were transferred to the Department of general surgery for laparoscopic cholecystectomy and successful surgery were performed,including 12 males and 16 females,aged 25-69 years old,with an average age of(46.8±14.2)years old.11 patients were combined with acute biliary pancreatitis before surgery,and 17 patients without pancreatitis before surgery.(2)There was no bile duct injury in the ERCP group,and there was 1 case of bile duct injury in the ERCP+LC group,but the difference was not statistically significant(P>0.05);The total hospitalization expenses of the two groups were(3.98±0.52)Yuan and(4.03±0.63)Yuan,respectively,and the difference was not statistically significant(P>0.05);The mean length of hospital stay in the ERCP group was(11.56±2.67)days and the mean length of hospital stay in the ERCP+LC group was(13.29±1.62)days,the difference was statistically significant(P<0.05);Recent postoperative complications included 1 case of postoperative pancreatitis in the ERCP gallbladder-preserving group and 1 case of postoperative incision infection in the ERCP-LC group,with no statistically significant difference(P>0.05);(3)Occurrence of long-term complications in the two groups:After 2 years of follow-up,there were 1 case of diarrhea in the ERCP gallbladder conservation group and 4 cases in the ERCP+LC group,and the difference was statistically significant(P>0.05);There were 0 cases of reflux cholangitis in the ERCP group and 1 case of reflux cholangitis in the(ERCP+LC)group,the difference was not statistically significant.0.05);No intestinal obstruction occurred during the period.There were 2 cases(5.88%)of cholecystolithiasis recurrence in the ERCP gallbladder conservation group,and no choledocholithiasis recurrence in the(ERCP+LC)group,but there was no statistical significance in the overall biliary stone recurrence.0.05);There were no case of bile duct stenosis in the ERCP group and 2 cases in the ERCP+LC group,the difference was statistically significant(P<0.05);No small bowel cancer,colon cancer or liver cancer occurred in ERCP group and ERCP+LC group.3.Application of ERCP combined with ESWL in the treatment of choledocholithiasis combined with large gallbladder stones(1)There were 5 patients,including 2 males and 3 females,with an average age of 45.2±19.0 years(23-67 years).Four cases were diagnosed with choledocholithiasis and cholecystolithiasis,and one case was diagnosed with acute biliary pancreatitis(mild),choledocholithiasis and cholecystolithiasis.(2)All 5 patients achieved technical and clinical success,with a success rate of 100%.(3)Postoperative liver function was significantly improved in all patients.(4)Complications: 1 case of pancreatitis.Conclusion:1.ERCP-based choledocholithiasis combined with cholecystolithiasis is feasible,safe and effective,and can avoid complications related to cholecystectomy,completely preserve the structure of the gallbladder,and effectively protect the function of the gallbladder.2.For patients with acute biliary disease,the operation difficulty will not be increased under the condition of stable pancreatitis,and there is no significant statistical difference in the technical success rate,clinical success rate and complication rate compared with the group without pancreatitis.Early removal of gallstones can reduce the occurrence of related complications in the window of waiting for surgery.3.There was no statistical difference in hospital costs,intraoperative and postoperative complications between the ERCP and the(ERCP+LC)groups.The hospital stay in ERCP group was shorter than that in ERCP+LC group,and the incidence of diarrhea and bile duct stenosis in ERCP+LC group was lower than that in ERCP+LC group.4.For patients with choledocholithiasis combined with large cholecystolithiasis(> 1.0cm),ERCP combined with ESWL is feasible. |
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