内镜和外科手术治疗迟发性医源性胆管损伤效果的倾向性评分匹配研究  

The comparison between endoscopic and surgical treatment of delayed iatrogenic bile duct injury by propensity score matching

作　　者：韩恒通 岳平[1] 孟文勃[1] 张磊[1] 朱克祥[1] 朱晓亮[1] 苗龙[1] 王正峰[1] 王海平[1] 李汛[1] Han Hengtong;Yue Ping;Meng Wenbo;Zhang Lei;Zhu Kexiang;Zhu Xiaoliang;Miao Long;Wang Zhengfeng;Wang Haiping;Li Xun(The First School of Clinical Medicine,Lanzhou University Department of General Surgery and Surgical Endoscopy Center,the First Hospital of Lanzhou University Institute of Hepatobiliary and Pancreatic Surgery of Gansu Province Key Laboratory Biotherapy and Regenerative Medicine of Gansu Province,Lanzhou 730030,China)

机构地区：[1]兰州大学第一临床医学院、兰州大学第一医院普通外科、外科内镜中心、甘肃省肝胆胰外科研究所、甘肃省生物治疗与再生医学重点实验室,兰州730030

出　　处：《中华外科杂志》2023年第10期871-879,共9页Chinese Journal of Surgery

基　　金：国家自然科学基金(82060119);甘肃省省级重点人才项目(甘组通字[2020]9号)。

摘　　要：目的比较内镜和外科手术治疗胆管损伤严重程度(SG)1~2级的迟发性医源性胆管损伤(DBDI)患者的安全性及临床效果。方法回顾性收集2007年11月至2021年11月于兰州大学第一医院成功接受内镜或外科手术治疗的129例SG 1~2级DBDI患者的临床资料。男性46例, 女性83例;年龄[M(IQR)]54(22)岁(范围:21~82岁)。采用倾向性评分匹配法对两组患者的基线资料进行1∶1匹配(卡钳值为0.2)。采用独立样本t检验、秩和检验、χ^(2)检验或Fisher 确切概率法对匹配后两组患者的资料进行分析。结果匹配后内镜治疗组和外科手术组各有48例患者, 两组一般资料的差异均无统计学意义(P值均>0.05)。匹配后两组患者的胆管损伤-修复间隔时间、术中麻醉并发症的差异均无统计学意义(P值均>0.05)。与外科手术组相比, 内镜治疗组患者的手术时间[50(30)min比185(100)min, Z=7.675, P<0.01]和术后住院时间[5(5)d比12(7)d, Z=5.848, P<0.01]明显缩短。安全性方面, 两组Clavien-Dindo并发症分级系统<Ⅲ级的术后近期并发症发生率的差异无统计学意义(P>0.05);外科手术组术后严重并发症(Clavien-Dindo并发症分级系统≥Ⅲ级)的发生率高于内镜治疗组, 差异有统计学意义(P=0.012)。内镜治疗组和外科手术组患者的术后远期并发症发生率(28.1%比20.7%)的差异无统计学意义(P=0.562)。疗效方面, 匹配后两组患者术后肝功能指标均较术前有明显改善, 恢复至正常或接近正常水平;两组术后感染指标呈上升趋势, 但均处于正常范围内。两组96例患者中, 61例获得随访, 随访时间为(89.4±48.0)个月(范围:3~165个月), 两组患者随访时间的差异无统计学意义(P=0.079)。内镜治疗组和外科手术组患者术后远期随访优良率(78.1%比86.2%)的差异无统计学意义(P=0.412)。在Strasberg-Bismuth分型E1型患者中, 与外科手术组相比, 内镜治疗组的远期随访优良率[13/14比2/5, P=0.037]更�Objective To compare the safety and clinical efficacy of endoscopic and surgical treatment of patients with delayed iatrogenic bile duct injury(DBDI)with severity(SG)grade 1 to 2.Methods The clinical data of 129 patients with SG grade 1 to 2 DBDI who received endoscopic or surgical treatment in the First Hospital of Lanzhou University from November 2007 to November 2021 were retrospectively collected.There were 46 males and 83 females,aged(M(IQR))54(22)years(range:21 to 82 years).The baseline data of the two groups were matched 1∶1 by propensity score matching(caliper value was 0.2).Independent sample t test,rank sum test,χ^(2) test or Fisher exact probability test were used to analyze the data of the two matched groups.Results There were 48 patients in each of the endoscopic treatment and surgical groups after matching,and there was no difference in general information between the two groups(both P>0.05).The bile duct injury-repair interval and intraoperative anesthesia complications were not statistically significant between the two groups after matching(all P>0.05).Compared with the surgical group,patients in the endoscopic treatment group had significantly shorter operative time(50(30)minutes vs.185(100)minutes,Z=7.675,P<0.01)and postoperative hospital stay(5(5)days vs.12(7)days,Z=5.848,P<0.01).For safety,there was no statistical difference in the incidence of immediate postoperative complications between the two groups with Clavien-Dindo classification of surgical complications<Ⅲ;the incidence of serious postoperative complications(Clavien-Dindo classification of surgical complications≥Ⅲ)was significantly higher in the surgical group than in the endoscopic treatment group(P=0.012).The incidence of long-term postoperative complications was not statistically different between the two groups(28.1%vs.20.7%,P=0.562).In terms of efficacy,the postoperative liver function indexes of patients in both groups improved significantly compared with the preoperative period and returned to normal or near normal lev

关 键 词：外科手术 手术中并发症 迟发性 医源性 胆管损伤 经内镜逆行性胰胆管造影 胆肠吻合 

分 类 号：R657.4[医药卫生—外科学]