The Effect On Therapeutic Pattern Of Laparoscopic Common Bile Duct Exploration Combined With Intraoperative Choledochoscopy Dealing With Common Bile Duct Stones Complicating Cholecystolithiasis

The morbidity rate of adult cholecystolithiasis is 7%~10% in our country[1]. There are 10 %~14 % cholecystolithiasis patients complicating common bile duct stones simultaneously[2].The traditional therapeutic pattern of cholecystolithiasis complicating common bile duct stones are opening cholecystectomy and common bile duct exploration and T - tube drainage.This method can act out well and perform conveniently.But it also has large insult,slow postoperative recovery and long length of stay. Now LC is becoming the gold standard management of benign lesion of cholecystis[3]. But there is controversy about that which mehtod is performed on patients with common duct stones complicating cholecystolithiasis[4].With maturation of minimal invasion technic,laparoscopic cholecystectomy(LC) combined with endoscopic sphincterotomy (EST) postoperation or preoperation and laparoscopic common bile duct exploration (LCBDE) can minimize the insult,shorten the length of stay and relieve the suffering of patients. They become the main method of common duct stones[5,6]. The calculus removed by EST is faced with the complication resulted from sphincterotomy such as early pancreatitis,perforation,bleeding and laterly stenosis of duodenal ampulla,chronic infection of biliary tract and induced primary bile duct stone and increased opportunity of malignant change of biliary ducts. Above these,there is 4.4 to 10 percent of failed performance[7]. In the mean while,some scholar[8]presume that multiple hepatic exterior and interior calculus of bile duct and suppurative cholangitis are the relative contraindications. Performing ERCP to remove the common duct stones,before or after the laparoscopic cholecystectomy,need select patients rigorously and the patient have to suffer twice operations. And ERCP request doctors posses exquisite techniques about laparoscopic operation,perfectly grasp LC and endoscopic diagnosis and therapeutic measure of endoscopy such as ERCP,EST,endoscopic nasobiliary drainage(ENBD),endoscopic retrograde biliary drainage(ERBD),endoscopic papillary balloon dilatation,(EPBD) and so on[6].Many cases with common duct stones complicating cholecystolithiasis are dealt with laparoscopic common bile duct exploration combined with choledochoscopy are reported recently.Using LCBDE to resect cholecyst can cure cholelithiasis and common duct stones simultaneously. This method , has many merits of laparoscopic cholecystectomy, can keep integrity of Oddi musculus sphincter ,do not increase complications of the operation. Above all , choledochoscope is performed euthyphorialy,which reduce the incidence of injury of biliary tract and duodenum.[9]。Objective:LCBDE combined choledochoscope were performed to treat common duct stones complicating cholecystolithiasis, compared with homeochronous traditional operation group.So as to study the effect of this method on the treatment pattern to deal with common duct stones complicating cholecystolithiasis,and provid theoretical and practical basis to estimating the clinical evluation and practicability of this method.Methods:(1)The clinical data that 11 cases of choledoch cholelithiasis treated with LCBDE combined with choledochoscopy were analyzed and compared with homeochronous open surgery group of 11 cases.(2)Collect the data including mortality of the operation,operating time,bleeding flow of the operation,time of stomach intestine functional recovery,time of out-of-bed activity,drainage flow after operation,time of extubation,complication and time to be in hospital after operation of the two group.(3)Using rank sum test among two independent sample data,analyze the significance of all the data above of the two group. The measurement data are not contented with Gaussian distribution and indicated with median.(4)Choledochoscope was performed to exam whether there is retained calculus.Results:(1)All the 22 cases were managed successfully. There is no complication such as henorrhea and bile leakage. All the patients discharged with fully recover.(2)Compare with OS group,the patients of LCBDE have obviously shorter time to be in hospital after operation:LCBDE 7(6,8)d,OS 8(7,9)d(p<0.05),obviously reduce bleeding flow in operation:LCBDE 20(18,25)ml,OS150(58,180ml)(p<0.05).But operating time: LCBDE125(114,160)min,OS105(80,130)min,drainage flow after operation: LCBDE 30(11,72)ml,OS50(12,108)ml and time of extubation :LCBDE d,OS(3,5)d have no significant difference(p>0.05).Conclusions:(1)Compared with open surgery,LCBDE combined with choledochoscopy to treatment of choledoch cholelithiasis is a method with traditional operation,little bleeding during operation,fast recovery and little complication.(2)With the improvement of surgical instruments and advancement of scope technology,LCBDE is used generally.It maybe displace traditional operation gradually,and even become surgical therapy gold standard of cholelithiasis of choledoch combined with benign lesion of cholecystis.