| Background:The incidence of cholelithiasis after gastrectomy will increase.ERCP and laparoscopic bile duct exploration are widely used for extraction of common bile duct stones(CBDS)in patients with cholelithiasis.However,alteration in the anatomical structure of the biliary tract and abdominal adhesion after gastrectomy have increased the difficulty of the operation.At present,there are few studies comparing the safety and effectiveness between various surgical methods in patients who have undergone a gastrectomy.Objective:To compare the effectiveness,safety and economic analysis of ERCP,laparoscopic bile duct exploration and open surgery in patients with common bile duct stones after gastrectomy.Methods:Patients with CBDS after a gastrectomy who treated in the First Affiliated Hospital of Nanchang University from January 2005 to December 2019 were retrospectively reviewed and enrolled in analysis after fulfilling selection criteria.They were divided into ERCP group,laparoscopic group and open surgery group according to the surgical methods patients taken.Then we analyzed and compared the treatment success rate,postoperative adverse events(fever,abdominal pain),postoperative complications(bile fistula,bleeding,perforation,infection,postoperative pancreatitis,hyperamylasemia),the time of antibiotic using,length of hospital stay,total hospitalization cost(surgical treatment fee,non-surgical treatment fee,medicine fee).Follow-up for 3 years.Results:A total of 318 patients with biliary stones after gastrectomy were hospitalized in our hospital,194 patients were finally included in the study,including the ERCP group(n=82,male / female = 68/14,mean age 67.8 ± 10.44 years),laparoscopicgroup(n=55,male/female=43/12,mean age 65.7 ± 10.10 years),open surgery group(n =42,male/female = 37/5,mean age 63.5 ± 8.15years)and 15 patients in the ERCP group were excluded because duodenal papilla could not be found under endoscope.1.The successful intubation rate of the endoscope to reach the duodenal papilla was 84.5%(82/97).The success rate of selective cannulation and completing the expected intervention were 93.9%(77/82)and 86.6%(71/82),respectively.The total success rate of ERCP was 73.2%(71/97).2.The overall success rate of ERCP group,laparoscopic group,open surgery group were 86.6%(71/82),94.5%(52/55)and 100%(42/42),respectively.The success rate in surgery group was higher than that in ERCP operation group(P <0.05),and there was no significant difference between the other groups.The conversion laparotomy rate in laparoscopic group(18.2%)was significantly higher than that of the other two groups(P <0.05).The total complication rates in the ERCP group,laparoscopy group,and open surgery group were 23.2%,16.4% and 26.2%,respectively.There was no statistical difference in the complication rate between three groups(P> 0.05).The mean length of hospital stay between the three groups showed an increasing trend(8.6±5.42 d vs.15.8±7.22 d vs.24.8±13.16d),and the difference has statistically significant(P<0.001).The mean total hospitalization costs in open surgery group was higher than that in ERCP group(25346.1±16865.05 ?vs.33768.3±13717.21 ?,P=0.004).While,there was no significant difference in the mean total hospitalization costs between the others groups(P>0.05).3.The mean total hospitalization costs of patients in the ERCP group,laparoscopy group,and open surgery group were 25346.1±16865.05 yuan ?29493.3±13401.60 yuan?33768.3±13717.21 yuan,respectively.Regarding the cost of non-surgical treatment,surgical treatment and the medicine,the ERCP surgery,laparoscopic surgery,and open surgery showed an increasing trend((1693.1±1324.49 vs.2459.9±1625.20 vs.3504.5±1933.9yuan),(5005.6±2107.65 vs.5829.3±1929.67 vs.6861.3±2327.13yuan)and(4133.1±3512.36 vs.9781.7±6744.46 vs.14078.7±7811.28yuan)).the difference between the three groups has statistically significant(P<0.001).Conclusions:1.For patients with bile duct stones after gastrectomy,ERCP is difficult to operate,but still can achieve a high success rate.The main reason for failure of stone removal under ERCP,is that duodenal papillae cannot be found under endoscope.EPBD combined with EST can significantly increase the rate of stone removal and reduce the residual stone rate.2.In patients with bile duct stones after gastrectomy,ERCP and laparoscopic surgery can achieve similar success rates,and there was no differences in postoperative complications,But the rate of conversion to open surgery in laparoscopic surgery is higher.Compared with minimally invasive surgery,laparotomy has a longer hospital stay and significantly longer antibiotic use.3.In terms of economic benefit analysis,laparoscopic surgery and open surgery cost more money for surgery and medication.The mean total hospitalization costs of patients in the ERCP group was lower than open surgery group.4.In the long-term follow-up,it was found that there was no difference in the recurrence rate of stone in the three groups within three years. |
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