背景:合并胆囊和胆总管(CBD)结石,被称为胆囊胆总管结石症,在临床上很普遍。目前对顺序管理方法和同步管理方法没有共识,and,如果同时,采用哪种方法。这项荟萃分析评估了一期腹腔镜胆囊切除术(LC)加术中内镜逆行胰胆管造影术(ERCP)与二期ERCP联合LC治疗胆囊结石和CBD结石的安全性和有效性。
方法:在五个数据库中进行了全面的文献检索,PubMed,Embase,WebofScience,VIP,还有万方,对于所有随机对照试验(RCT),截至2024年2月发表的队列和回顾性研究。数据提取由两名审阅者独立进行。主要结果是CBD结石清除率和术后并发症发生率。次要结果包括转换为其他程序和住院时间。使用R(v.4.3.2)进行统计分析,计算连续变量和二分变量的加权平均差和比值比(OR),分别,95%置信区间(CI)。
结果:共纳入17项研究,涉及2120名患者,898例患者接受单阶段治疗,1222例患者接受两阶段治疗。在这些研究中,9项RCTs,8项为回顾性队列研究。一阶段组在CBD结石清除率方面表现出更好的结果(OR=2.07,p=0.0004),总发病率(OR=0.35,p<0.0001),术后胰腺炎(OR=0.49,p=0.006),转换为其他程序(OR=0.38,p=0.0006),和住院时间(MD=-2.6456,95%CI-3.5776;-1.7136,p<0.0001)。术后胆管炎无显著差异(OR=0.44,p=0.12),术后出血(OR=0.76,p=0.47),或胆漏(OR=1.28,p=0.54)。
结论:对于合并胆囊结石和CBD结石的患者,结合ERCP和LC的一阶段方法似乎更安全、更有效,优点包括较高的结石清除率,减少术后并发症(尤其是胰腺炎),缩短住院时间,更少残留的石头,减少了对额外程序的需求。然而,我们还需要更多高质量的临床试验,以确定适合不同患者情况的最佳治疗方法.
BACKGROUND: Concomitant gallbladder and common bile duct (CBD) stones, known as cholecystocholedocholithiasis, are clinically prevalent. There is currently no consensus on sequential versus simultaneous management approaches, and, if simultaneous, which approach to adopt. This meta-analysis evaluates the safety and efficacy of one-stage laparoscopic cholecystectomy (
LC) with intraoperative endoscopic retrograde cholangiopancreatography (ERCP) versus two-stage ERCP followed by
LC for treating concomitant gallbladder and CBD stones.
METHODS: A comprehensive literature search was conducted in five databases, PubMed, Embase, Web of Science, VIP, and Wanfang, for all randomized controlled trials (RCTs), cohort and retrospective studies published up to February 2024. Data extraction was performed independently by two reviewers. The primary outcomes were CBD stone clearance rate and postoperative complications morbidity. Secondary outcomes included conversion to other procedures and length of hospital stay. Statistical analyses were performed using R (v.4.3.2) with weighted mean differences and odds ratios (ORs) calculated for continuous and dichotomous variables, respectively, with 95% confidence intervals (CIs).
RESULTS: A total of 17 studies involving 2120 patients have been included, with 898 patients receiving single-stage and 1222 patients undergoing two-stage treatment. Of these studies, 9 were RCTs and 8 were retrospective cohort study. The one-stage group demonstrated superior outcomes in terms of CBD stone clearance (OR = 2.07, p = 0.0004), overall morbidity (OR = 0.35, p < 0.0001), post-operative pancreatitis (OR = 0.49, p = 0.006), conversion to other procedures (OR = 0.38, p = 0.0006), and length of hospital stay (MD = - 2.6456, 95% CI - 3.5776; - 1.7136, p < 0.0001). No significant differences were observed in post-operative cholangitis (OR = 0.44, p = 0.12), post-operative bleeding (OR = 0.76, p = 0.47), or bile leakage (OR = 1.28, p = 0.54).
CONCLUSIONS: For patients with concomitant gallbladder and CBD stones, the one-stage approach combining ERCP and
LC appears safer and more effective, with advantages including higher stone clearance rates, reduced postoperative complications (particularly pancreatitis), shorter hospital stays, fewer residual stones, and decreased need for additional procedures. However, additional high-quality clinical trials are needed to establish the optimal treatment approach for various patient scenarios.