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[摘要] 目的 探討应用腹腔镜胆总管探查术（LCBDE） 腹腔镜胆囊切除术（LC）与内镜逆行胰胆管造影（ERCP）/内镜下十二指肠乳头括约肌切开术（EST） LC治疗胆囊结石并胆总管结石的胆源性轻症急性胰腺炎的疗效及安全性。方法 将我院2015年1月～2019年6月收治的276例胆囊结石并胆总管结石的胆源性轻症急性胰腺炎的患者按治疗方案随机分为两组：LCBDE LC组及ERCP/EST LC组。比较两组手术时间、术中出血量、完全取石率、中转开腹率、术后排气时间、下床时间、住院费用、住院时间、总胆红素、丙氨酰氨基转移酶、天门冬氨酸氨基转移酶、血淀粉酶的变化趋势及并发症发生率。 结果 与LCBDE LC组相比，ERCP/EST LC组手术时间和术中出血量、术后排气时间、下床时间和胆瘘发生率显著性减少;而住院费用和重症急性胰腺炎发生率显著性增加;两组住院时间、完全取石率、中转开腹率、术后总胆红素、丙氨酰氨基转移酶、天门冬氨酸氨基转移酶、血淀粉酶、消化道穿孔和腹腔感染的发生率比较差异无统计学意义（P>0.05）。 结论 早期应用LCBDE LC组与ERCP/EST LC组均能有效治疗胆囊结石并胆总管结石的胆源性轻症急性胰腺炎，具体实施应根据患者实际病情及医院条件，个性化选择最合适的微创治疗方式。
[关键词] 胆囊结石;胆总管结石;腹腔镜胆总管探查术;内镜逆行胰胆管造影;急性胰腺炎
[Abstract] Objective To explore the efficacy and safety of laparoscopic common bile duct exploration（LCBDE） laparoscopic cholecystectomy（LC） and endoscopic retrograde cholangiopancreatography（ERCP）/endoscopic sphincterotomy（EST） LC in the treatment of mild biliary acute pancreatitis induced by gallstones complicated with common bile duct stones. Methods 276 patients with mild biliary acute pancreatitis induced by gallstones complicated with common bile duct stones who were admitted in our hospital from January 2015 to June 2019 were randomly divided into two groups according to the treatment plan： LCBDE LC group and ERCP/EST LC group. The surgery time， intraoperative blood loss， complete stone removal rate， transfer laparotomy rate， postoperative exhaust time， time to get out of bed， hospitalization cost， length of hospital stay， total bilirubin， alanyl aminotransferase， aspartate aminotransferase， blood amylase change trends and the incidence rate of complications were compared between the two groups. Results Compared with the LCBDE LC group， the surgery time， intraoperative blood loss， postoperative exhaust time， time to get out of bed and the incidence of biliary leakage were significantly less than those in the ERCP/EST LC group; the hospitalization costs and the incidence rate of severe acute pancreatitis were increased significantly; there were no statistically significant differences in the length of hospital stay， complete stone removal rate， transfer laparotomy rate， postoperative total bilirubin， alanyl aminotransferase， aspartate amino transferase， blood amylase，digestive tract perforation and the incidence rate of abdominal infection between the two groups（P>0.05）. Conclusion Early application of LCBDE LC group and ERCP/EST LC group can effectively treat mild biliary acute pancreatitis induced by gallstones complicated with common bile duct stones. The specific implementation should be based on the patient’s actual conditions and hospital conditions to carry out personalized selection of the most appropriate minimally invasive treatment. [Key words] Gallstones; Common bile duct stones; Laparoscopic common bile duct exploration（LCBDE）; Endoscopic retrograde cholangiopancreatography（ERCP）; Acute pancreatitis
胆囊结石的发病率约占10%，继发性胆总管结石的发生率占胆囊结石的15%～18%，是胆囊结石最常见的并发症。胆囊结石经胆囊管排入胆总管内后，并发细菌感染时易诱发急性胰腺炎，称之为胆源性胰腺炎[1，2]。胆石症在西方国家则作为第二常见的胰腺炎病因，在中国目前则为最常见的胰腺炎病因。胆源性胰腺炎的诊断和后续处理十分重要，尤其要警惕胆道微结石的可能[3]，而胆源性胰腺炎发生发展的机制在于迁移的胆结石对Vater壶腹的阻碍。造成管内高压并导致胰腺分泌物的回流，从而导致胰蛋白酶原异常激活，并引起胰腺自消化。在此基础上引发机体的炎症反应，释放细胞因子进入全身循环导致毛细血管通透性增加，从而导致毛细血管渗漏综合征、胰腺坏死等情况[4，5]。微创手术清除胆管结石解除梗阻和切除胆囊是治疗的关键，手术方式有两种，一种为一次性行胆总管探查术 胆囊切除术（LCBDE LC）（一步法）;另一种为内镜逆行胰胆管造影/内镜下十二指肠乳头括约肌切开术 胆囊切除术（ERCP/EST LC）（二步法）[6，7]。本研究比较LCBDE LC与ERCP/EST LC早期治疗胆囊结石并胆总管结石的胆源性轻症急性胰腺炎疗效及安全性，现报道如下。
1 资料与方法
1.1 一般资料
前瞻性研究我院2015年1月～2019年6月收治的胆囊结石并胆总管结石的胆源性轻症急性胰腺炎患者。纳入标准[8]：（1）所有患者入院均有典型急性胰腺炎临床表现，包括腹痛、腹胀、白细胞、血淀粉酶、C反应蛋白（C-reactive protein，CRP）的升高;急性生理与慢性健康评分-Ⅱ（Acute Physiology and Chronic Health Evaluation-Ⅱ，APACHE-Ⅱ）<8分，Ranson评分<3分;（2）影像学证实胆囊结石、胆总管结石、胰腺水肿、渗出;（3）丙氨酰氨基转移酶（Alanylaminotransferase，ALT）
[关键词] 胆囊结石;胆总管结石;腹腔镜胆总管探查术;内镜逆行胰胆管造影;急性胰腺炎
[Abstract] Objective To explore the efficacy and safety of laparoscopic common bile duct exploration（LCBDE） laparoscopic cholecystectomy（LC） and endoscopic retrograde cholangiopancreatography（ERCP）/endoscopic sphincterotomy（EST） LC in the treatment of mild biliary acute pancreatitis induced by gallstones complicated with common bile duct stones. Methods 276 patients with mild biliary acute pancreatitis induced by gallstones complicated with common bile duct stones who were admitted in our hospital from January 2015 to June 2019 were randomly divided into two groups according to the treatment plan： LCBDE LC group and ERCP/EST LC group. The surgery time， intraoperative blood loss， complete stone removal rate， transfer laparotomy rate， postoperative exhaust time， time to get out of bed， hospitalization cost， length of hospital stay， total bilirubin， alanyl aminotransferase， aspartate aminotransferase， blood amylase change trends and the incidence rate of complications were compared between the two groups. Results Compared with the LCBDE LC group， the surgery time， intraoperative blood loss， postoperative exhaust time， time to get out of bed and the incidence of biliary leakage were significantly less than those in the ERCP/EST LC group; the hospitalization costs and the incidence rate of severe acute pancreatitis were increased significantly; there were no statistically significant differences in the length of hospital stay， complete stone removal rate， transfer laparotomy rate， postoperative total bilirubin， alanyl aminotransferase， aspartate amino transferase， blood amylase，digestive tract perforation and the incidence rate of abdominal infection between the two groups（P>0.05）. Conclusion Early application of LCBDE LC group and ERCP/EST LC group can effectively treat mild biliary acute pancreatitis induced by gallstones complicated with common bile duct stones. The specific implementation should be based on the patient’s actual conditions and hospital conditions to carry out personalized selection of the most appropriate minimally invasive treatment. [Key words] Gallstones; Common bile duct stones; Laparoscopic common bile duct exploration（LCBDE）; Endoscopic retrograde cholangiopancreatography（ERCP）; Acute pancreatitis
胆囊结石的发病率约占10%，继发性胆总管结石的发生率占胆囊结石的15%～18%，是胆囊结石最常见的并发症。胆囊结石经胆囊管排入胆总管内后，并发细菌感染时易诱发急性胰腺炎，称之为胆源性胰腺炎[1，2]。胆石症在西方国家则作为第二常见的胰腺炎病因，在中国目前则为最常见的胰腺炎病因。胆源性胰腺炎的诊断和后续处理十分重要，尤其要警惕胆道微结石的可能[3]，而胆源性胰腺炎发生发展的机制在于迁移的胆结石对Vater壶腹的阻碍。造成管内高压并导致胰腺分泌物的回流，从而导致胰蛋白酶原异常激活，并引起胰腺自消化。在此基础上引发机体的炎症反应，释放细胞因子进入全身循环导致毛细血管通透性增加，从而导致毛细血管渗漏综合征、胰腺坏死等情况[4，5]。微创手术清除胆管结石解除梗阻和切除胆囊是治疗的关键，手术方式有两种，一种为一次性行胆总管探查术 胆囊切除术（LCBDE LC）（一步法）;另一种为内镜逆行胰胆管造影/内镜下十二指肠乳头括约肌切开术 胆囊切除术（ERCP/EST LC）（二步法）[6，7]。本研究比较LCBDE LC与ERCP/EST LC早期治疗胆囊结石并胆总管结石的胆源性轻症急性胰腺炎疗效及安全性，现报道如下。
1 资料与方法
1.1 一般资料
前瞻性研究我院2015年1月～2019年6月收治的胆囊结石并胆总管结石的胆源性轻症急性胰腺炎患者。纳入标准[8]：（1）所有患者入院均有典型急性胰腺炎临床表现，包括腹痛、腹胀、白细胞、血淀粉酶、C反应蛋白（C-reactive protein，CRP）的升高;急性生理与慢性健康评分-Ⅱ（Acute Physiology and Chronic Health Evaluation-Ⅱ，APACHE-Ⅱ）<8分，Ranson评分<3分;（2）影像学证实胆囊结石、胆总管结石、胰腺水肿、渗出;（3）丙氨酰氨基转移酶（Alanylaminotransferase，ALT）