胆囊切除术后原发性胆总管结石复发患者的临床特征分析

Abstract

目的 分析原发性胆总管结石复发患者的总体情况、膳食因素等临床特征，为积极预防结石复发提供依据。 方法 回顾性收集2013年1月—2023年12月内蒙古自治区人民医院肝胆胰脾外科因胆石病行胆囊切除治疗的23 730例患者临床资料，其中术后复发334例。按性别分类，对复发患者的复发率、复发周期、复发年龄、复发结石类别，以及一般资料、疾病资料、影像学资料和膳食因素资料进行汇总分析。计量资料2组间比较采用成组t检验，计数资料2组间比较采用χ²检验。 结果 胆囊切除术后原发性胆总管结石复发率为1.41%，复发周期频数最高集中在术后10年，男、女性复发周期差异有统计学意义 (t=5.238，P<0.001) 。首次诊断为单纯胆囊结石和胆囊合并胆总管结石者其术后结石复发率分别为1.23%和2.76%，差异有统计学意义 (χ²=42.104，P<0.001) 。复发者中年龄>60岁在总计及男、女性中均占比最高，92%为汉族居民；10%的复发者有胆囊结石家族史；合并症中以伴高血压者占比最高。复发者中吸烟和饮酒者占比分别为76.7%和10.3%。63.8%的复发者BMI正常、23.2%为超重，且距第1次胆囊手术时体质量相比，60.1%的复发者体质量下降，22.9%体质量增加。不同性别复发者的年龄构成、民族分布、居住地类型、合并症、吸烟、饮酒、BMI分类、体质量变化差异均有统计学意义 (P值均<0.001) 。复发结石类型中多发、单发、泥沙样结石的比例为74∶15∶11；结石大小<1 cm、1～2 cm、>2 cm的占比分别为40.5%、48.8%和10.6%；手术方式为开腹和腹腔镜的比例分别为66.1%和33.9%；各类型血脂异常的比例均低于30%。不同性别复发者的初次结石种类、结石类型、结石大小、手术方式及高密度脂蛋白异常占比差异均有统计学意义 (P值均<0.001) 。影像学资料分析发现胆道结构异常者仅4例，表现为胆囊管长而弯曲，术后73.1%者伴有胆总管扩张。膳食因素随访发现55.8%的复发者平素饮食不规律。平素饮食结构以肉类和主食为主者分别占比43.8%和37.8%，且有性别差异，男性以肉类为主、女性以主食为主；64.1%的复发者平素有高盐高油的饮食习惯；59.8%的患者第1次结石术后饮食有改变，其中80%的患者能将饮食调整为规律 (即饮食规律者可提高至92%) 。 结论 本地区原发性胆总管结石复发率较低且无性别差异，复发高峰在术后10年，60岁以上人群是结石复发的集中群体。膳食因素及临床特征分析有助于医、患进一步认识原发性胆总管结石复发的特点，为后续采取针对性的预防提供基础依据。

Alternate abstract:

Objective To investigate the general situation, dietary factors, and clinical features of patients with recurrent primary common bile duct stones, and to provide a basis for effective prevention of stone recurrence. Methods A retrospective analysis was performed for 23 730 patients who underwent cholecystectomy due to cholelithiasis in Department of Hepatobiliary, Pancreatic and Spleen Surgery, Inner Mongolia People’s Hospital, from January 2013 to December 2023, and according to the presence or absence of recurrence of primary common bile duct stones after surgery, 334 patients were divided into recurrence group. The recurrence group was further analyzed based on sex in terms of recurrence rate, recurrence cycle, recurrence age, recurrence type, and general, disease, imaging, and dietary factors. The independent-samples t test was used for comparison of continuous data between two groups, the chi-square test was used for comparison of categorical data between two groups. Results There were 334 cases of recurrence of primary bile duct stones after cholecystectomy, with a recurrence rate of 1.41%, and the highest frequency of recurrence cycle was observed in 10 years after surgery, with a significant difference in recurrence cycle between the male and female patients (t=5.238, P<0.001). There was a significant difference in the recurrence rate of stones after surgery between the patients with simple gallstones and those with gallbladder and common bile duct stones at initial diagnosis (1.23% vs 2.76%, χ²=42.104, P<0.001). The patients with recurrence aged >60 years accounted for the highest proportion in the whole population and in both male and female populations, and 92% were Han residents; 10% of the patients with recurrence had a family history of gallstones, and as for comorbidities, the patients with hypertension accounted for the highest proportion. Among the patients with recurrence, the patients with smoking or drinking accounted for 76.7% and 10.3%, respectively. As for body weight, 63.8% of the patients with recurrence had a normal body mass index (BMI), and 23.2% of the patients were overweight; compared with body weight at the time of the first gallbladder surgery, a reduction in body weight was observed in 60.1% of the patients with recurrence, while an increase in body weight was observed in 22.9% of the patients with recurrence. There were significant differences between the male and female patients with recurrence in age composition, ethnicity, the type of place of residence, comorbidities, smoking, drinking, BMI, and the change in body weight (all P<0.001). As for the type of stone recurrence, the ratio of multiple stones, solitary stones, and muddy stones was 74∶15∶11, and the stone size of <1 cm, 1-2 cm, and >2 cm accounted for about 40.5%, 48.8%, and 10.6%, respectively. As for the surgical procedure, the patients undergoing laparotomy accounted for 66.1%, and those undergoing laparoscopy accounted for 33.9%. The patients with various types of dyslipidemia accounted for a percentage of<30%. There were significant differences between the male and female patients with recurrence in the type of stones at initial onset, the type and size of stones, and surgical procedure (all P<0.001). Imaging data showed that 4 patients had an abnormal structure of the bile duct, manifesting as long and curve cystic ducts, and 73.1% of the patients had common bile duct dilatation after surgery. The follow-up of dietary factors showed irregular diets in 55.8% of the patients with recurrence. As for the dietary structure, meat and staple food accounted for 43.8% and 37.8%, respectively, which showed a sex difference, with meat in male patients and staple food in female patients; 64.1% of the patients with recurrence had a high-salt and high-oil diet; 59.8% of the patients had changes in diet after the first surgery for stones, among whom 80% were able to have a regular diet, and the patients with a regular diet accounted for 92%. Conclusion There is a relatively low recurrence rate of primary common bile duct stones in this area, and there is no sex difference. The peak of recurrence is 10 years after surgery, and recurrence of stones is mainly observed in the population aged >60 years. The analysis of dietary and clinical features can help doctors and patients to further understand the characteristics of the recurrence of primary common bile duct stones and provide a basis for subsequent targeted prevention.