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首页> 外文期刊>Surgical Endoscopy >Appropriate management of common bile duct stones: a RAND Corporation/UCLA Appropriateness Method statistical analysis.
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Appropriate management of common bile duct stones: a RAND Corporation/UCLA Appropriateness Method statistical analysis.

机译：胆总管结石的适当管理：RAND Corporation / UCLA适当方法统计分析。

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BACKGROUND: Bile duct stones affect 10% of patients who undergo a cholecystectomy and therefore represent a major health problem. Laparoscopic common bile duct exploration, endoscopic sphincterotomy, and open surgical choledocholithotomy are the three available methods for dealing with choledocholithiasis. Though many trials and reviews have compared all three strategies, a list of indications for defined patient profiles is lacking. METHODS: We employed the RAND Corporation/UCLA Appropriateness Method (RAM) to evaluate the three procedures for bile duct stone clearance. An expert panel judged appropriateness after a comprehensive bibliography review, a first-round private rating of 108 different clinical situations, a consensus meeting, and a second round of definitive rating. A list of indications for each procedure was statistically calculated. RESULTS: A consensus was reached for 41 indications (38%). The endoscopic approach was always appropriate for preoperatively diagnosed bile duct stones and inappropriate for patients with single intraoperative detected stones causing cholangitis and bile duct dilatation. Laparoscopic bile duct exploration was appropriate for preoperatively diagnosed choledocholithiasis if patients had not undergone a previous cholecystectomy and no signs of cholangitis were detected. The laparoscopic approach was also appropriate for intraoperatively incidentally detected stones, except for septic patients with poor performance status and multiple calculi. Laparoscopic bile duct clearance was judged inappropriate for septic patients with poor performance status and absence of bile duct dilatation. Open surgery was appropriate in all patients with intraoperative diagnosis of choledocholithiasis and cholangitis and in septic patients with bile duct dilatation. There was no clinical situation in which open surgery was appropriate when bile duct stones were preoperatively diagnosed. CONCLUSIONS: There is still uncertainty with respect to the management of choledocholithiasis, showing the need for further investigation. The RAM helps to elucidate appropriateness for the different treatment options in specific clinical settings.
机译：背景：胆管结石会影响接受胆囊切除术的患者的10％，因此是一个主要的健康问题。腹腔镜胆总管探查术，内窥镜括约肌切开术和开放式胆总管结石切开术是治疗胆总管结石症的三种可用方法。尽管许多试验和评论都对这三种策略进行了比较，但仍缺乏定义患者概况的适应症清单。方法：我们采用RAND Corporation / UCLA适当方法（RAM）评估了三种清除胆管结石的方法。专家小组在对书目进行了全面审查，对108种不同临床情况进行的第一轮私人评级，共识会议以及第二轮确定性评级之后，判断适当性。统计计算每个程序的适应症清单。结果：41个适应症（38％）达成共识。内窥镜检查方法始终适合于术前诊断的胆管结石，而不适用于术中发现单个结石导致胆管炎和胆管扩张的患者。如果患者以前未进行过胆囊切除术且未检测到胆管炎的迹象，则腹腔镜胆管探查适合于术前诊断的胆总管结石。腹腔镜手术方法也适用于术中偶然发现的结石，除了脓毒症患者的表现状态差和结石多。腹腔镜检查胆道间隙被认为不适用于表现状态差且没有胆管扩张的脓毒症患者。对于所有术中诊断为胆总管结石和胆管炎的患者以及脓毒症胆管扩张的患者，均应行开放手术。在术前诊断胆管结石时，没有临床情况适合进行开放手术。结论：胆总管结石的治疗仍存在不确定性，表明需要进一步研究。 RAM有助于阐明特定临床设置中不同治疗方案的适用性。

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