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腹腔镜下胆道镜联合钬激光碎石术与传统开腹手术治疗胆管结石效果比较的Meta分析
DOI: 10.3969/j.issn.1001-5256.2023.10.021
利益冲突声明：本文不存在任何利益冲突。
作者贡献声明：牛向东、余静、汪旭云负责课题设计，资料分析，撰写论文；陈一锋、马世勋、丁国淦、苗长丰参与收集数据，修改论文；王晓鹏、苏河负责拟定写作思路，指导撰写文章并最后定稿。牛向东、余静为共同第一作者；王晓鹏、苏河为共同通信作者。
Efficacy of laparoscopic choledochoscopy combined with holmium laser lithotripsy versus traditional laparotomy in treatment of bile duct stones： A Meta－analysis
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摘要:
目的 通过Meta分析系统评价腹腔镜下胆道镜联合钬激光碎石术的有效性及安全性。 方法 本研究根据PRISMA指南完成，PROSPERO注册号：CRD42023406221。计算机检索中国知网、万方、维普等中文数据库以及PubMed、Embase、Cochrane Library、Web of Science等外文数据库中比较传统开腹手术与腹腔镜联合胆道镜钬激光治疗胆管结石的原始文献，通过优势比（OR）和95%可信区间（95%CI）评估二分类变量，通过加权平均差（WMD）和95%CI评估连续性变量，并对异质性较高结局指标进行敏感性分析。Begg检验和Egger检验用于评估发表偏倚。应用Stata 15.0软件和Review Manager 5.3软件进行统计分析。 结果 纳入来自中国的29项回顾性研究，共2 511例患者。Meta分析结果显示，与传统开腹手术相比，腹腔镜联合胆道镜钬激光治疗胆管结石的手术时间（WMD＝－1.26，95%CI：－1.36～－1.16，P<0.001）、住院时间（WMD＝－1.93，95%CI：－2.64～－1.12，P<0.001）及肠道功能恢复时间（WMD＝－1.52，95%CI：－1.68～－1.35，P<0.001）更短，术中出血量更少（WMD＝－1.79，95%CI：－1.93～－1.66，P<0.001），术中残石率更低（OR＝0.15，95%CI：0.11～0.20，P<0.001），并发症更少（OR＝0.17，95%CI：0.13～0.23，P<0.001）。 结论 相比于传统开腹手术治疗胆管结石，腹腔镜联合胆道镜钬激光治疗胆管结石显示出更好的有效性。 Abstract:Objective To systematically review the efficacy and safety of laparoscopic choledochoscopy combined with holmium laser lithotripsy through a meta－analysis. Methods This study was conducted based on PRISMA guidelines， with a PROSPERO registration number of CRD42023406221. Chinese databases including CNKI， Wanfang Data， and VIP and foreign language databases such as PubMed， Embase， the Cochrane Library， and Web of Science were searched for original articles on traditional laparotomy versus laparoscopic choledochoscopy combined with holmium laser lithotripsy in the treatment of bile duct stones. Dichotomous variables were assessed by odds ratio （OR） and 95% confidence interval （CI）， while continuous variables were assessed by weighted mean difference （WMD） and 95%CI， and a sensitivity analysis was performed for outcome measures with relatively high heterogeneity. The Begg test and Egger test were used to evaluate publication bias. Stata 15.0 and Review Manager 5.3 were used to perform the statistical analysis. Results A total of 26 retrospective studies from China were included in this study， with 2 238 patients in total. The meta－analysis showed that compared with traditional laparotomy for the treatment of bile duct stones， laparoscopic choledochoscopy combined with holmium laser lithotripsy had significantly shorter time of operation （WMD＝－1.26， 95%CI： －1.36 to －1.16， P<0.001）， length of hospital stay （WMD＝－1.93， 95%CI： －2.64 to －1.12， P <0.001）， and time to bowel function recovery （WMD＝－1.52， 95%CI： －1.68 to －1.35， P<0.001）， significantly less intraoperative blood loss （WMD＝－1.79， 95%CI： －1.93 to －1.66， P<0.001）， a significantly lower rate of intraoperative residual stone （OR＝0.15， 95%CI： 0.11－0.20， P<0.001）， and significantly fewer complications （OR＝0.17， 95%CI： 0.13－0.23， P<0.001）. Conclusion Compared with traditional laparotomy， laparoscopic choledochoscopy combined with holmium laser lithotripsy shows better efficacy in the treatment of bile duct stones. -
Key words:
- Gallstones /
- Laparoscopy /
- Lasers， Solid－State /
- Treatment Outcome /
- Meta－Analysis
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图 4 术后残石率的Meta分析结果
Figure 4. Meta－analysis result of postoperative residual stone rate
图 9 术后残石率发表偏倚
注： a，Begg检验；b，Egger检验。
Figure 9. Publication bias： Postoperative residual stone rate
表 1 纳入文献基本特征及NOS评分
Table 1. Basic characteristics and NOS score of the included study
第一作者 发表年份 研究类型 样本量（例） 年龄（岁） 男/女（例） 结局指标 NOS评分 试验组 对照组 试验组 对照组 试验组 对照组 王建［11］ 2013 回顾性研究 34 31 28～721） 28/371） c，d 5 赵守和［12］ 2013 回顾性研究 40 40 46.00±13.19 47.70±16.13 18/22 16/24 a，b，c，d，e，f 7 唐滔［13］ 2013 回顾性研究 60 64 46.5±4.2 48.5±3.5 36/24 42/22 a，c，d，e 6 叶进军［14］ 2014 回顾性研究 84 79 20～81 22～79 53/31 43/36 a，c，d，e 7 田志强［15］ 2014 回顾性研究 55 55 56.2±7.4 54.7±5.2 25/30 26/29 a，c，d，e，f 9 程伟［16］ 2014 回顾性研究 55 55 45.62±9.16 45.13±9.21 32/23 33/22 a，b，c，d 7 刘汉东［17］ 2014 回顾性研究 25 25 22～76 23～74 14/11 13/12 a，c，d，e 6 刘国生［18］ 2015 回顾性研究 56 56 42.1±4.2 42.5±4.3 30/26 31/25 a，b，c，d，e 8 徐键［19］ 2015 回顾性研究 30 30 47.9±3.6 47.8±3.5 17/13 16/14 a，c，d，e 8 廖文鹏［20］ 2015 回顾性研究 40 38 65～83 65～83 42/361） a，c，d，e 6 李信［21］ 2015 回顾性研究 37 37 46.8±5.21） 43/311） a，b，c，d，e 8 何恒正［22］ 2015 回顾性研究 64 64 56.2±4.7 54.7±5.2 39/25 39/25 a，b，c，d 7 温志华［23］ 2017 回顾性研究 50 50 47±7 49±6 30/20 28/22 a，b，c，d 8 陈季云［24］ 2016 回顾性研究 30 30 44.3±4.11） 32/281） a，b，c，d，f 7 郑红军［25］ 2016 回顾性研究 37 37 48.5±4.2 46.5±3.5 17/20 19/18 a，c，d，e 7 张文培［26］ 2016 回顾性研究 54 54 42.9±4.11） 68/401） c，d 6 景东帅［27］ 2017 回顾性研究 25 20 51.12±6.13 49.25±7.55 16/9 12/8 a，b，c，d，e 9 吕述明［28］ 2017 回顾性研究 30 30 49.5±2.5 49.2±2.7 17/13 16/14 a，b，c，d 8 孙大华［29］ 2018 回顾性研究 33 33 55.19±10.37 56.17±11.03 14/19 13/20 a，b，c，d，e 7 刘旸［30］ 2018 回顾性研究 70 70 52.34±13.35 53.34±13.49 45/25 43/27 a，c，d，e 9 贺志敬［31］ 2020 回顾性研究 33 32 22～75 21～74 21/12 18/14 a，b，c，d，e，f 8 罗泽斌［32］ 2020 回顾性研究 45 45 49.70±10.02 50.78±9.39 28/17 25/20 a，b，c，d，e，f 8 姚伟旗［33］ 2021 回顾性研究 47 46 56.58±6.31 55.62±6.17 33/14 31/15 a，b，c，d，e，f 8 张国军［34］ 2021 回顾性研究 36 37 46.41±7.17 46.37±7.22 19/17 18/19 c，d 8 李林峰［35］ 2022 回顾性研究 23 20 46.11±10.89 47.25±10.75 10/13 7/13 a，b，c，d，f 7 王海平［36］ 2022 回顾性研究 34 33 49.76±11.73 49.47±12.36 22/12 20/13 a，b，c，d，f 8 何圣敏［37］ 2022 回顾性研究 54 49 47.11±8.35 45.63±11.73 33/21 29/20 a，b，d，e，f 7 尚宾［38］ 2022 回顾性研究 65 60 52.38±9.49 52.37±9.74 26/39 24/36 a，b，c，d，e，f 6 邱伟［39］ 2022 回顾性研究 25 25 55.73±5.21 55.62±5.30 15/10 13/12 a，b，c，e 6 注：1）纳入文献中未分组描述年龄或男女例数；a，手术时间；b，术中出血量；c，术后残石率；d，总并发症；e，住院时间；f，肛门排气时间。 
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