Surgical therapy for hepatolithiasis: a Western experience

Evidence-based clinical practice guidelines for cholelithiasis 2021

The Japanese Society of Gastroenterology first published evidence-based clinical practice guidelines for cholelithiasis in 2010, followed by a revision in 2016. Currently, the revised third edition was published to reflect recent evidence on the diagnosis, treatment, and prognosis of cholelithiasis conforming to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Following this revision, the present English version of the guidelines was updated and published herein. The clinical questions (CQ) in the previous version were reviewed and rearranged into three newly divided categories: background questions (BQ) dealing with basic background knowledge, CQ, and future research questions (FRQ), which refer to issues that require further accumulation of evidence. Finally, 52 questions (29 BQs, 19 CQs, and 4 FRQs) were adopted to cover the epidemiology, pathogenesis, diagnosis, treatment, complications, and prognosis. Based on a literature search using MEDLINE, Cochrane Library, and Igaku Chuo Zasshi databases for the period between 1983 and August 2019, along with a manual search of new information reported over the past 5 years, the level of evidence was evaluated for each CQ. The strengths of recommendations were determined using the Delphi method by the committee members considering the body of evidence, including benefits and harms, patient preference, and cost-benefit balance. A comprehensive flowchart was prepared for the diagnosis and treatment of gallbladder stones, common bile duct stones, and intrahepatic stones, respectively. The current revised guidelines are expected to be of great assistance to gastroenterologists and general physicians in making decisions on contemporary clinical management for cholelithiasis patients.

The Difficult Path to Correct Diagnosis of Hepatolithiasis: A Case Report

Hepatolithiasis is a benign disease, where stones are localized proximal to the confluence of hepatic ducts. The clinical picture may differ depending on whether the stones cause complete, partial, or intermittent biliary obstruction. The course can vary from asymptomatic to fatal, thus, early diagnosis and treatment is critical for a good prognosis. The gold standard in imaging is magnetic resonance cholangiopancreatography (MRCP). However, correct diagnosis can be challenging due to atypical clinical picture and laboratory findings. We present a case where hepatolithiasis was misdiagnosed initially due to incomplete reporting and documentation of MRCP. Choledocholithiasis was diagnosed based on initial MRCP, and endoscopic stone extraction was indicated. However, an unusual post-interventional course and signs of obstructive cholangitis led to an endoscopic re-intervention, which confirmed absence of pathology in extrahepatic biliary ducts. The cholangitis recurrence required intensive antibiotic treatment, and CT examination revealed intrahepatic S3 bile duct dilatation. Thus, a re-evaluation of initial MRCP and repeated MRCP confirmed hepatolithiasis. Further, laparoscopic bisegmentectomy was chosen as the definitive treatment due to the location of the lesion. The patient recovered and remained symptom free upon a 12 month follow up.

One-Step Multichannel Percutaneous Transhepatic Cholangioscopic Lithotripsy Applied in Bilateral Hepatolithiasis

BACKGROUND

The aim of this study was to compare the outcomes of one-step multichannel percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) with traditional PTCSL in the treatment of bilateral hepatolithiasis.

METHODS

From February 2011 to June 2015, 156 patients with bilateral hepatolithiasis received surgical treatment in our department. Among these patients, 81 received one-step multichannel PTCSL (group A), and the remaining 75 received traditional PTCSL (group B).

RESULTS

Compared with group B, group A was characterized by a significantly shorter operation time (83.7 ± 28.5 min vs 118.1 ± 41.5 min; P = 0.000), hospital stay (11.1 ± 3.4 d vs 17.8 ± 5.6 d; P = 0.034), and postoperative hospital stay (6.9 ± 3.1 d vs 9.6 ± 4.5 d; P = 0.026). In addition, the immediate clearance (62.9% vs 45.3%, P = 0.027) and final clearance (90.1% vs 78.7%, P = 0.048) rates were higher in group A than in group B. During the follow-up period, stone recurrence was significantly less common in group A than in group B (13.6% vs 26.7%, P = 0.041). Multivariate Cox analysis showed that the PTCSL method (HR = 2.32, 95% confidence interval [CI] = 1.09-4.90, P = 0.028), bilateral biliary stricture (HR = 4.17, 95% CI = 1.73-10.03, P = 0.001), and stones located in segments I (HR = 7.75, 95% CI = 3.67-16.38, P = 0.000) were independent predictors of recurrence.

CONCLUSIONS

Compared with traditional PTCSL, one-step multichannel PTCSL was more efficient and effective in the treatment of bilateral hepatolithiasis.

Surgical resection for non-Asian intrahepatic lithiasis: The Brazilian experience

BACKGROUND

Intrahepatic lithiasis (IHL) is a rare disease in the western world. Complications associated with IHL include acute cholangitis, liver atrophy, secondary biliary cirrhosis, and risk for intrahepatic cholangiocarcinoma. Liver resection is considered the treatment of choice for IHL. The objective of this study was to analyze patients who underwent liver resection for non-Asian hepatolithiasis.

METHODS

127 patients with symptomatic non-Asian hepatolithiasis underwent resection in six institutions. Demographic data, clinical presentation, diagnosis, classification according to stone location, presence of atrophy, bile duct stricture, biliary cirrhosis, incidence of cholangiocarcinoma, treatment and postoperative course were evaluated.

RESULTS

52 patients (40.9%) were male and the mean age was 46.1 years. Sixty-six patients (51.9%) presented with history of cholangitis. Stones were located in the left lobe in 63 (49.6%), and right lobe in 28 patients (22.0%). Atrophy was observed in 31 patients (24.4%) and biliary stenosis in 18 patients (14.1%). The most common procedure performed was left lateral sectionectomy in 63 (49.6%) patients, followed by left hepatectomy in 36 (28.3%), right hepatectomy in 19 (15.0%), and associated hepaticojejunostomy in 28 (22.0%). Forty-two patients (33.0%) presented postoperative complications and the most common were biliary fistula (13.3%) and surgical site infection (7.0%). Postoperative mortality was 0.7%. Intrahepatic cholangiocarcinoma was observed in 2 patients (1.5%). Recurrence was identified in 10 patients (7.8%), mostly with bilateral stones and/or hepaticojejunostomy.

CONCLUSION

Liver resection is the standard treatment for symptomatic unilateral or complicated IHL with good operative results. Risk of cholangiocarcinoma was low in non-Asian patients.

Outcomes of reoperation for hepatolithiasis with 3D imaging individualized preoperative planning technique: a single-center experience

BACKGROUND

A detailed assessment of biliary tract anatomy is necessary for the successful reoperation for hepatolithiasis. This study aimed to evaluate the feasibility of preoperative individualized surgical planning with three-dimensional (3D) imaging technique for reoperation of hepatolithiasis.

METHODS

This was a retrospective matched case-control study. From January 2011 to December 2018, 56 patients receiving reoperation according to the individualized preoperative plan based on 3D imaging at our center were included (group A). Meanwhile, 54 patients receiving traditional imaging guided reoperation matched by age, gender and distribution of hepatobiliary stones to each case were selected as controls (group B). The perioperative and long-term follow-up outcomes were compared between the two groups.

RESULTS

There was no significant difference in demographic characteristics between groups. Compared with group B, the group A had a significantly shorter operation time (245.7±56.2 min vs. 305.2±79.9 min, P<0.001), a significantly higher surgical plan implementation rate (SPIR, 92.9% vs. 66.7%, P=0.001) and a lower incidence-of severe complications (Clavien-Dindo grade>II, 1.8% vs. 14.8%, P=0.015). The incidences of initial residual stone (7.1% vs. 44.4%, P<0.001) and repeated cholangitis (3.6% vs. 33.3%, P<0.001) were significantly lower in group A than in group B. After postoperative choledochoscopic lithotripsy, the incidence of final residual stones was significantly lower in group A than in group B. (1.8% vs. 20.4%, P=0.002).

CONCLUSIONS

The preoperative 3D imaging assisted surgical planning is feasible and safe for reoperation of hepatolithiasis which can effectively improve surgical plan implementation rate and reduce the incidence of postoperative complications as compared with conventional surgical planning.

Combined lithotripsy of mechanical clamping and electrohydraulics in facilitating endoscopic management of refractory residual biliary calculi after surgery

Although postoperative cholangioscopy (POC) guided electrohydraulic lithotripsy (EHL) is considered to be a conventional technique for residual biliary calculi, its efficacy still needs to be improved to fit in the managemet of refractory calculi. This study evaluated the efficacy and safety of combined lithotripsy of mechanical clamping and electrohydraulics in fragmentation and removal of refractory calculi. Totally, 281 patients, who suffered from residual biliary calculi after hepatectomy and underwnet POC from August 2016 to June 2018 were involved. The first 128 patients were subjected to conventional EHL, and later consective 153 to combined lithotripsyof mechanical clamping and EHL. Perioperative data, technical information, treatment outcomes and follow-up results were collected. Clinical characteristics were statistically comparable (P > 0.05). The overall POC interventional sessions (2.0 ± 0.65 vs. 2.9 ± 1.21 sessions), average operating time (99.1 ± 34.88 vs. 128.6 ± 72.87 minutes), incidence of intraoperative hemobilia (4.58% vs. 10.93%), cholangitis (6.54% vs. 14.06%), postoperative complications (10.45% vs. 21.87%), T-tube retaining time after first POC (20.7 ± 5.35 vs. 28.1 ± 8.28 days), and treatment costs ($2375 ± 661.72 vs. $3456.7 ± 638.07) were significantly lower in the combined lithotripsy group than those in the EHL group (P < 0.05). There were no differences between the two groups in calculi recurrence at half-a year, or one year follow-up. In conclusion, combined lithotripsy of mechanical clamping and electrohydraulics can safely and effectively benefit postoperative patients along with refractory residual biliary calculi.

Routine guidewire application facilitates cholangioscopy in the management of postoperative residual hepatolithiasis

BACKGROUND AND AIM

Although postoperative cholangioscopy (POC) is considered to be an effective treatment for residual hepatolithiasis after surgery, its security and validity still need to be improved. This study compared wire-guided POC (WG-POC) versus traditional POC (T-POC) in the management of patients with residual hepatolithiasis.

METHODS

This retrospective study included a total of 203 patients who suffered from hepatolithiasis and underwent hepatectomy as initial intervention from 1 January 2016 to 1 January 2017. After surgery, 110 patients were subjected to T-POC and 93 to WG-POC for eliminating residual hepatolithiasis. Perioperative course and follow-up outcomes were retrospectively analyzed.

RESULTS

No significant differences in clinical characteristics or distribution of residual hepatolithiasis between the WG-POC and T-POC groups were observed (P > 0.05). However, overall POC interventional sessions (2.9 ± 0.85 vs 4.0 ± 1.21 times), average operating time (264.8 ± 103.61 vs 389.4 ± 136.26 min), overall complications rate (18.28% vs 32.73%), and overall T-tube retaining time (21.8 ± 6.20 vs 28.8 ± 8.09 days) were lower in the WG-POC group than in the T-POC group (P < 0.05). In addition, there were no significant differences between the two groups (WG-POC vs T-POC) in recurrence (4.30% vs 4.55%) and residual calculi (8.60% vs 6.36%) at half-a-year follow up (P > 0.05).

CONCLUSIONS

Routine wire guidance may improve the outcome of cholangioscopy in managing complicated residual hepatolithiasis, being associated with clear advantages such as shorter operating time and number of POC interventions, reduced T-tube retaining time, and fewer postoperative complications.

Nerve growth factor upregulates sirtuin 1 expression in cholestasis: a potential therapeutic target

This study investigated the regulatory role of nerve growth factor (NGF) in sirtuin 1 (SIRT1) expression in cholestatic livers. We evaluated the expression of NGF and its cognate receptors in human livers with hepatolithiasis and the effects of NGF therapy on liver injury and hepatic SIRT1 expression in a bile duct ligation (BDL) mouse model. Histopathological and molecular analyses showed that the hepatocytes of human diseased livers expressed NGF, proNGF (a precursor of NGF), TrkA and p75NTR, whereas only p75NTR was upregulated in hepatolithiasis, compared with non-hepatolithiasis livers. In the BDL model without NGF therapy, p75NTR, but not TrkA antagonism, significantly deteriorated BDL-induced liver injury. By contrast, the hepatoprotective effect of NGF was abrogated only by TrkA and not by p75NTR antagonism in animals receiving NGF therapy. Intriguingly, a positive correlation between hepatic SIRT1 and NGF expression was found in human livers. In vitro studies demonstrated that NGF upregulated SIRT1 expression in mouse livers and human Huh-7 and rodent hepatocytes. Both NGF and proNGF induced protective effects against hydrogen peroxide-induced cytotoxicity in Huh-7 cells, whereas inhibition of TrkA and p75NTR activity prevented oxidative cell death. Mechanistically, NGF, but not proNGF, upregulated SIRT1 expression in human Huh-7 and rodent hepatocytes via nuclear factor (NF)-κB activity, whereas NGF-induced phosphoinositide-3 kinase/Akt, extracellular signal–regulated kinase and NF-κB signaling and SIRT1 activity were involved in its hepatoprotective effects against oxidative injury. These findings suggest that pharmacological manipulation of the NGF/SIRT1 axis might serve as a novel approach for the treatment of cholestatic disease.

Step-by-step strategy in the management of residual hepatolithiasis using post-operative cholangioscopy

Hepatolithiasis is the presence of calculi within the intrahepatic bile duct specifically located proximal to the confluence of the left and right hepatic ducts. The ultimate goal of hepatolithiasis treatment is the complete removal of the stone, the correction of the associated strictures and the prevention of recurrent cholangitis. Although hepatectomy could effectively achieve the above goals, it can be restricted by the risk of insufficient residual liver volume, and has a 15.6% rate of residual hepatolithiasis. With improvements in minimally invasive surgery, post-operative cholangioscopy (POC), provides an additional option for hepatolithiasis treatment with higher clearance rate and fewer severe complications. POC is very safe, and can be performed repeatedly until full patient benefit is achieved. During POC three main steps are accomplished: first, the analysis of the residual hepatolithiasis distribution indirectly by imaging methods or directly endoscopic observation; second, the establishment of the surgical pathway to relieve the strictures; and third, the removal of the stone by a combination of different techniques such as simple basket extraction, mechanical fragmentation, electrohydraulic lithotripsy or laser lithotripsy, among others. In summary, a step-by-step strategy of POC should be put forward to standardize the procedures, especially when dealing with complicated residual hepatolithiasis. This review briefly summarizes the classification, management and complications of hepatolithiasis during the POC process.

Simple resection of the lesion bile duct branch for treatment of regional hepatic bile duct stones

To evaluate the effectiveness and safety of simple resections of bile duct branch lesions for the treatment of regional hepatic bile duct stones.A retrospective analysis of the clinical data from patients in our hospital from November 2008 to November 2015, who only underwent a simple resection of the lesion bile duct branch. The patients' clinical characteristics, surgical features, postoperative complications, stone clear rate, residual stone rate, and recurrence stone rate were analyzed.This study of 32 patients included 13 males and 19 females with intrahepatic bile duct stones confined to the right hepatic bile duct branch. The intraoperative blood loss, operation time, and postoperative hospital stay were 478.0 ± 86.5, 210.7 ± 6.6, and 10.8 ± 3.5, respectively. Postoperative complications occurred in 6 patients (18.8%), all of whom recovered with conservative management. There were no deaths during hospitalization. The intraoperative stone clearance rate was 95.8%. Three patients had a recurrence of stones at a mean of 22 months of follow-up (range, 4-36 months).Simple resection of bile duct branch lesions is safe and feasible for patients who have regional hepatic bile duct stones limited to the right hepatic bile duct branches.

Evidence-based clinical practice guidelines for cholelithiasis 2016

Cholelithiasis is one of the commonest diseases in gastroenterology. Remarkable improvements in therapeutic modalities for cholelithiasis and its complications are evident. The Japanese Society of Gastroenterology has revised the evidence-based clinical practice guidelines for cholelithiasis. Forty-three clinical questions, for four categories-epidemiology and pathogenesis, diagnosis, treatments, and prognosis and complications-were selected, and a literature search was performed for the clinical questions with use of the MEDLINE, Cochrane, and Igaku Chuo Zasshi databases for the period between 1983 and June 2012. The guidelines were developed with use of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. This article preferentially describes the clinical management of cholelithiasis and its complications. Following description of the diagnosis performed stepwise through imaging modalities, treatments of cholecystolithiasis, choledocholithiasis, and hepatolithiasis are introduced along with a flowchart. Since there have been remarkable improvements in endoscopic treatments and surgical techniques, the guidelines ensure flexibility in choices according to the actual clinical environment. The revised clinical practice guidelines are appropriate for use by clinicians in their daily practice.

Liver Resection for Primary Intrahepatic Stones: Focus on Postoperative Infectious Complications

BACKGROUND

Primary intrahepatic lithiasis is defined by the presence of gallstones at the level of cystic dilatations of the intrahepatic biliary tree. Liver resection is considered the treatment of choice, with the purpose of removing stones and atrophic parenchyma, also reducing the risk of cholangiocarcinoma. However, in consequence of the considerable incidence of infectious complications, postoperative morbidity remains high. The current study was designed to evaluate the impact of preoperative bacterial colonization of the bile ducts on postoperative outcome.

METHODS

The clinical records of 73 patients treated with liver resection were reviewed and clinical data, operative procedures, results of bile cultures, and postoperative outcomes were examined.

RESULTS

Left hepatectomy (38 patients) and left lateral sectionectomy (19 patients) were the most frequently performed procedures. Overall morbidity was 38.3 %. A total of 133 microorganisms were isolated from bile. Multivariate analysis identified previous endoscopic or percutaneous cholangiography (p = 0.043) and preoperative cholangitis (p = 0.003) as the only two independent risk factors for postoperative infectious complications.

CONCLUSIONS

Postoperative morbidity was strictly related to the preoperative biliary infection. An effective control of infections should be always pursued before liver resection for intrahepatic stones and an aggressive treatment of early signs of sepsis should be strongly emphasized.

The impact of body mass index on short-term surgical outcomes after laparoscopic hepatectomy, a retrospective study

Background

Surgeons may expect technical difficulties and worse outcomes when performing laparoscopic hepatectomy (LH) on obese patients. The aim of this study is to assess the impact of body mass index (BMI) on short-term surgical outcomes and to verify risk factors of conversion rate and complications of LH.

Methods

Data were collected from 551 patients who underwent attempted LH between August 1998 and April 2013. Patients were classified into four groups depending on their BMI according to the WHO’s definition of obesity for Asia-Pacific region: underweight <18.5 kg/m² (Group1); normal 18.5–23.9 kg/m² (Group2); overweight 24–27.9 kg/m² (Group3); obese ≥ 28 kg/m² (Group4) respectively. Short-term surgical outcomes were compared across the BMI categories. Possible risk factors concerned conversion rate and complications were analyzed.

Results

The overall conversion rate of the 551 patients was 13.07 %. Conversion rate for Group 1, 2, 3, and 4 were 14.3 % (n = 5), 11.2 % (n = 38), 13.0 % (n = 19), and 34.5 % (n = 10) respectively. Patients within the obese group had a much higher conversion rate. The overall complications rate was 11.98 %, where the complication for Group 1, 2, 3, and 4 were 22.9 % (n = 8), 12.7 % (n = 43), 18.2 % (n = 12), and 10.3 % (n = 3) respectively. Patients within the underweight group had a higher complication rate, but it did not reach statistic difference. Obesity and surgical site of left lobe were independent risk factors of conversion. Age, abdominal surgery history, and type of left and right lobe resection were independent risk factors for complications.

Conclusions

In China, obesity increases risk of conversion rate but it dose not affect surgical complications and other short-outcomes after LH.

Electronic supplementary material

The online version of this article (doi:10.1186/s12871-016-0194-1) contains supplementary material, which is available to authorized users.

Liver transplantation for hepatolithiasis: Is terminal hepatolithiasis suitable for liver transplantation?

Hepatolithiasis, originally as oriental cholangiohepatitis, especially prevails in Asia, but globalization and intercontinental migration have also converted the endemic disease dynamics around the world. Characterized by its high incidence of ineffective treatment and recurrence, hepatolithiasis, always, poses a therapeutic challenge to global doctors. Although the improved surgical and non-surgical techniques have evolved over the past decade, incomplete clearance and recurrence of calculi are always so common and disease-related mortality from liver failure and concurrent cholangiocarcinoma still exists in the treatment of hepatolithiasis. In the late stage of hepatolithiasis, is it suitable for liver transplantation (LT)? Herein, we propose a comprehensive review and analysis of the LTx currently in potential use to treat hepatolithiasis. In our subjective opinion, and as is objective from the literatures so far, also given the strict indications, LT remains one of the definitive treatments for terminal hepatolithiasis.

Oddi sphincter preserved cholangioplasty with hepatico-subcutaneous stoma for hepatolithiasis

AIM: To evaluate the long-term outcomes of Oddi sphincter preserved cholangioplasty with hepatico-subcutaneous stoma (OSPCHS) and risk factors for recurrence in hepatolithiasis.

METHODS: From March 1993 to December 2012, 202 consecutive patients with hepatolithiasis underwent OSPCHS at our department. The Oddi sphincter preserved procedure consisted of common hepatic duct exploration, stone extraction, hilar bile duct plasty, establishment of subcutaneous stoma to the bile duct. Patients with recurrent stones can undergo stone extraction and/or biliary drainage via the subcutaneous stoma which can be incised under local anesthesia. The long-term results were reviewed. Cox regression model was employed to analyze the risk factors for stone recurrence.

RESULTS: Ninety-seven (48.0%) OSPCHS patients underwent hepatic resection concomitantly. The rate of surgical complications was 10.4%. There was no perioperative death. The immediate stone clearance rate was 72.8%. Postoperative cholangioscopic lithotomy raised the clearance rate to 97.0%. With a median follow-up period of 78.5 mo (range: 2-233 mo), 24.8% of patients had recurrent stones, 2.5% had late development of cholangiocarcinoma, and the mortality rate was 5.4%. Removal of recurrent stones and/or drainage of inflammatory bile via subcutaneous stoma were conducted in 44 (21.8%) patients. The clearance rate of recurrent stones was 84.0% after subsequent choledochoscopic lithotripsy via subcutaneous stoma. Cox regression analysis showed that residual stone was an independent prognostic factor for stone recurrence.

CONCLUSION: In selected patients with hepatolithiasis, OSPCHS achieves excellent long-term outcomes, and residual stone is an independent prognostic factor for stone recurrence.

The role of endoscopy in the management of recurrent pyogenic cholangitis: a review

Recurrent pyogenic cholangitis (RPC) is a clinical syndrome characterized by repeated episodes of suppurative cholangitis due to hepatolithiasis and extrahepatic stones in the biliary ducts. It is now recognized as a distinct syndrome with a different natural history and pathoetiology than spontaneously occurring liver abscesses. Most commonly seen in East Asian populations, this syndrome is growing increasingly common in Western Nations due to migration patterns. The exact pathogenesis of RPC remains elusive; although colonization of the biliary tract with particular enteric bacterial species, in combination with possible dietary factors, has been attributed as causative factors. Hepatobiliary surgery, in particular segmental hepatectomy, is often described as the definitive treatment of choice for RPC. The exact role of endoscopic intervention has been less clearly described in the literature. This review focuses on the management of RPC while highlighting situations in which endoscopic retrograde cholangiopancreatography may be preferred over surgery as an initial or salvage therapeutic measure.

Hepatectomy with primary closure of common bile duct for hepatolithiasis combined with choledocholithiasis

AIM: To evaluate the feasibility of hepatectomy and primary closure of common bile duct for intrahepatic and extrahepatic calculi.

METHODS: From January 2008 to May 2013, anatomic hepatectomy followed by biliary tract exploration without biliary drainage (non-drainage group) was performed in 43 patients with intrahepatic and extrahepatic calculi. After hepatectomy, flexible choledochoscopy was used to extract residual stones and observe the intrahepatic bile duct and common bile duct (CBD) for determination of biliary stricture and dilatation. Function of the sphincter of Oddi was determined by manometry of the CBD. Primary closure of the CBD without T-tube drainage or bilioenteric anastomosis was performed when there was no biliary stricture or sphincter of Oddi dysfunction. Dexamethasone and anisodamine were intravenously injected 2-3 d after surgery to prevent postoperative retrograde infection due to intraoperative bile duct irrigation, and to maintain relaxation of the sphincter of Oddi, respectively. During the same period, anatomic hepatectomy followed by biliary tract exploration with biliary drainage (drainage group) was performed in 48 patients as the control group. Postoperative complications and hospital stay were compared between the two groups.

RESULTS: There was no operative mortality in either group of patients. Compared to intrahepatic and extrabiliary drainage, hepatectomy with primary closure of the CBD (non-drainage) did not increase the incidence of complications, including residual stones, bile leakage, pancreatitis and cholangitis (P > 0.05). Postoperative hospital stay and costs were nevertheless significantly less in the non-drainage group than in the drainage group. The median postoperative hospital stay was shorter in the non-drainage group than in the drainage group (11.2 ± 2.8 d vs 15.4 ± 2.1 d, P = 0.000). The average postoperative cost of treatment was lower in the non-drainage group than in the drainage group (29325.6 ± 5668.2 yuan vs 32933.3 ± 6235.1 yuan, P = 0.005).

CONCLUSION: Hepatectomy followed by choledochoendoscopic stone extraction without biliary drainage is a safe and effective treatment of hepatolithiasis combined with choledocholithiasis.

Application of hepatic resection in hepatolithiasis

AIM: To investigate the value of hepatic resection in the treatment of hepatolithiasis.

METHODS: The clinical data for 130 patients with hepatolithiasis who underwent hepatectomy from June 2005 to May 2014 were retrospectively analyzed.

RESULTS: Left lateral hepatic lobectomy was performed in 87 patients, left hepatectomy in 19 patients, quadrate lobe resection in 9 patients, regular hepatic resection in 8 patients, partial right lobe resection with left lateral lobectomy in 3 patients, right hepatectomy with left lateral lobectomy in 1 patient, and left medial hepatic resection in 3 patients. The stone clearance rate was 87%. Fifteen patients were discovered to have cholangiocarcinoma, and 13 cases had residual stones. Postoperative complications included incision infection, bile leakage, pneumonia, and pleural effusion. One patient died of liver failure preoperatively.

CONCLUSION: Hepatectomy is a safe and effective treatment for hepatolithiasis. Adequate preoperative evaluation and reasonable surgical procedure can help reduce or avoid biliary tract reoperation.

Surgical treatment of intrahepatic cholangiocarcinoma in the USA

Cholangiocarcinoma (CC) is a malignancy that arises from the epithelial cells of the biliary system (ductules as well as large ducts, and likely from progenitor cells, as well). Intrahepatic CC (ICC) is the second most common primary hepatic malignancy after hepatocellular carcinoma (HCC), and accounts for 10-15% of primary liver cancers. ICC differs from both extrahepatic and CC and HCC and has unique risk factors, histological features, genetic alterations and clinical outcomes. The natural history and results of surgical intervention are not well described as ICC is a relatively uncommon tumor, especially in the USA. This article reviews the literature relevant to the surgical management and outcome of patients with ICC in the USA.

Application of three-dimensional reconstruction and visible simulation technique in reoperation of hepatolithiasis

BACKGROUND AND AIM

Hepatolithiasis often requires repeated operations in East Asia. This study aims to evaluate the clinical application of three-dimensional reconstruction and visible simulation techniques for repeated operation in patients with intrahepatic calculi.

METHODS

A medical image processing system was used for modeling, segmentation, and three-dimensional reconstruction of intrahepatic stones in 20 patients, consisting of 7 males and 13 females who were subjected to repeated surgical treatment from May 2010 to November 2011. The three-dimensional models of the liver and bile ducts in a standard template library format were then processed by the FreeForm Modeling System. Accurate digital information about the bile duct system, lesions, calculi distribution, and surrounding organs obtained from all directions, multiple angles, and multistrata were used to decide the rational surgical modality. Virtual operations were then performed on the models with virtual surgical instruments in the FreeForm Modeling System. The results were used to guide and were compared with the real surgical procedures performed.

RESULTS

The surgical outcomes of all patients in this study were satisfactory. Three-dimensionally reconstructed models provided clear and strong relief perception and a user-friendly interface. Visible simulation surgery performed based on three-dimensionally reconstructed models led to an optimal operation plan that had great resemblance to the actual surgeries for cases with intrahepatic stones.

CONCLUSIONS

Three-dimensional reconstruction and visible simulation techniques had unique value in optimizing repeated operation plans and in guiding actual surgical procedures for patients with recurrent intrahepatic calculi.

Anatomic hepatectomy as a definitive treatment for hepatolithiasis: a cohort study

BACKGROUND

Treatment requirements in hepatolithiasis may vary and may involve a multidisciplinary approach. Surgical resection has been proposed as a definitive treatment.

OBJECTIVES

This study aimed to evaluate the clinical results of anatomic liver resection among Chilean patients with hepatolithiasis.

METHODS

An historical cohort study was conducted. Patients who underwent hepatectomy as a definitive treatment for hepatolithiasis from January 1990 to December 2010 were included. Patients with a preoperative diagnosis of cholangiocarcinoma were excluded. Preoperative, operative and postoperative variables were evaluated.

RESULTS

A total of 52 patients underwent hepatectomy for hepatolithiasis. The mean ± standard deviation patient age was 49.8 ± 11.8 years (range: 24-78 years); 65.4% of study subjects were female. A total of 75.0% of subjects had a history of previous cholecystectomy. The main presenting symptom was abdominal pain (82.7%). Hepatic involvement was noted in the left lobe in 57.7%, the right lobe in 34.6% and bilaterally in 7.7% of subjects. The rate of postoperative clearance of the biliary tree was 90.4%. Postoperative morbidity was 30.8% and there were no postoperative deaths. Three patients had recurrence of hepatolithiasis, which was associated with Caroli's disease in two of them. Overall 5-year survival was 94.5%.

CONCLUSIONS

Anatomic liver resection is an effective treatment in selected patients with hepatolithiasis and is associated with low morbidity and no mortality. At longterm follow-up, anatomic hepatectomy in these patients was associated with a lower rate of recurrence.

[An Asian man with recurrent abdominal pain]

Recurrent pyogenic cholangitis (RPC), or oriental cholangiohepatitis, is characterized by intrabiliary pigment stone formation, whose main manifestation consists of recurrent episodes of cholangitis, although other biliopancreatic complications can also occur. RPC develops mainly in Asian patients, in whom this entity is one of the main causes of acute abdominal pain. The differential diagnosis should be established with all other entities associated with intrahepatic stone formation, which is more common in Asian countries compared with the predominance of gallstone formation in the West. The diagnostic and therapeutic approach requires collaboration among gastroenterologists, radiologists and gastrointestinal surgeons. We review the most important clinical, diagnostic and therapeutic features of this entity, which, although clearly predominant in Asia, is increasingly diagnosed in our setting.

Hepatocellular Carcinomas and Primary Liver Tumors as Predictive Factors for Postoperative Mortality after Liver Resection: A Meta-Analysis of More than 35,000 Hepatic Resections

Liver resection is considered the therapeutic gold standard for primary and metastatic liver neoplasms. The reduction of postoperative complications and mortality has resulted in a more aggressive approach to hepatic malignancies. For the most part, results of liver surgery have been published by highly experienced institutions, but the observations of highly specialized units results may not reflect the current status of hepatic surgery, underestimating mortality and complications. The objective of this study is to evaluate morbidity and mortality as a result of liver resection for primary and metastatic lesions, analyzing a large number of studies with a meta-analytic process taking into account the overdispersion of data. An extensive literature search has been conducted, and 148 papers published between January 2000 and April 2008, including a total of 36,629 patients from both high-volume and low volume institutions, were included in the meta-analysis. A beta binomial model was used to provide a robust estimate of the summary event rate by pooling overdispersion binomial data from different studies. Overall morbidity and mortality after liver surgery were 29.32 per cent and 3.15 per cent, respectively. Significantly higher postoperative mortality was observed after liver resection for hepatocellular carcinomas and primary hepatic tumors. The application of a beta binomial model to correct for overdispersion of liver surgery data showed significantly higher postoperative mortality rates in patients with hepatocellular carcinomas or primary hepatic tumors after liver resection.

Right hepatolithiasis and abnormal hepatic duct confluence: more than a casual relation?

BACKGROUND

Hepatolithiasis (HL) is a rare disease in Western countries. The aim of our study was to investigate a possible relation between the development of right HL and abnormalities of the hepatic duct confluence.

MATERIAL AND METHODS

Fourteen patients who presented with localized right-sided HL were included in this study. The anatomy of hepatic duct confluence in this group of patients was analyzed and compared with the anatomy of hepatic duct confluence in the general population.

RESULTS

The Presence of a shift of 1 of the 2 sectorial right ducts was significantly associated with right-sided HL (P = .003).

CONCLUSIONS

The shift of a sectorial right duct must be considered as one of the anatomic causes of HL. This finding must be considered when surgical treatment of HL is planned.

Liver resection for intrahepatic stones in congenital bile duct dilatation

OBJECTIVE

This study reports our clinical experience with liver resection for congenital dilatation of the intrahepatic bile duct and intrahepatic gallstones to evaluate results and define indications for treatment.

PATIENTS AND METHODS

We studied the clinical data of patients who underwent hepatic resection for intrahepatic lithiasis from January 1992 to December 2008 and assessed the immediate and long-term results of these interventions.

RESULTS

Of 49 treated patients, 47 underwent liver resection. In the majority of cases, the disease was limited to the left lobe and left hepatectomy was the most commonly performed surgical procedure. The operative mortality was zero with morbidity in 24.5% of patients. Cholangiocarcinoma was diagnosed in six cases (12.2%). In 91.6% of cases the long-term results were good or satisfactory.

CONCLUSION

Treatment goals in all cases should be the elimination of intrahepatic stones, the prevention of recurrent lithiasis, and prevention or cure of cholangiocarcinoma. Surgical excision is the best possible treatment for symptomatic patients with localized disease and atrophy of the affected liver.

An appraisal of anatomical and limited hepatectomy for regional hepatolithiasis

Aim. Determination of first line treatment with limited hepatectomy or Anatomical hepatectomy provides better clinical outcome. Methods. Immediate and long-term outcomes of 106 patients who underwent partial hepatectomy for RH at our institution from January 2001 to February 2005 were analyzed retrospectively. Clinical end-points included time to recovery of hepatic function, residual stones, infection of the liver remnant, bile leakage, recurrent stones, morbidity, and mortality. Results. LH was performed in 59 patients and AH in 47 patients as first-line treatment. The time of hepatic function recovery was not statistically different between the two groups (P > .05). However, Patients in AH group suffered from less residual stones (P < .05), less infection of the raw surface of liver remnant (P < .05), and less bile leakage (P < .05), with a median follow-up of 40.3 ± 0.8 months (range 3–48), and AH group suffered a less recurrent stone rate (P < .05). No difference in morbidity, and mortality rates between the two groups. Conclusion. AH is a safe and effective treatment for RH, with a fair rate of surgical complications, it should be considered as first-line treatment of RH.

Sphincter of Oddi laxity: An important factor in hepatolithiasis

AIM: To evaluate the importance of sphincter of Oddi laxity (SOL) in hepatolithiasis (HL).

METHODS: Subjects included 98 patients diagnosed with HL between 2002 and 2007. Detailed histories were taken and the subjects were monitored until July 2008. HL patients were divided into two groups: Group I included 45 patients with SOL, and Group II included 53 patients without. Recurrence and reoperation indices of both groups were calculated and compared.

RESULTS: The recurrence index was 0.135 in Group I and 0.018 in Group II (P < 0.001). The reoperation index was 0.070 in Group I and 0.010 in Group II (P < 0.001). The mean frequency of biliary operation was 2.07 in Group I and 1.21 in Group II (P = 0.001). Differences between the two groups are significant.

CONCLUSION: HL patients with SOL tend to have a higher risk of recurrence and a larger demand for reoperation than those without this condition.

Hepatectomy for bilateral primary hepatolithiasis: a cohort study

OBJECTIVE

This study aimed to evaluate the perioperative and long-term results of partial hepatectomy for patients with complicated bilateral primary hepatolithiasis.

SUMMARY BACKGROUND DATA

Hepatolithiasis is best managed by a multidisciplinary approach. Definitive treatment can be offered using endoscopic, percutaneous, laparoscopic, or open surgical approaches. Partial hepatectomy is only indicated for recurrent, troublesome, localized, and severe disease affecting the liver.

METHODS

From January 2000 to December 2006, 136 consecutive patients who underwent bilateral (n = 54) or unilateral (n = 82) hepatectomy for biliary strictures and bilateral primary hepatolithiasis in our center were included in this study. All patients had concomitant bile duct exploration. Their perioperative and long-term outcomes were analyzed.

RESULTS

The immediate stone clearance rates after bilateral and unilateral hepatectomy were 81.5% and 65.9%, respectively. Additional postoperative choledochoscopic lithotripsy raised the clearance rates to 85.2% and 81.7%, respectively. The hospital mortality rates were 5.6% and 0%, respectively, and the complication rates were 46.3% and 46.3%, respectively. The 5-year overall survival rates were 98% and 91.5%, respectively.

CONCLUSION

In selected patients with biliary strictures and bilateral hepatolithiasis, partial hepatectomy associated with choledochoscopic lithotripsy is a safe and efficacious treatment, with a high immediate stone clearance rate, a low long-term stone recurrence rate and good long-term survival.

Laparoscopic approach of surgical treatment for primary hepatolithiasis: a cohort study

BACKGROUND

The aim of the current study was to evaluate the perioperative and long-term outcome of a laparoscopic approach for management of primary hepatolithiasis.

METHODS

From January 1995 to June 2008, 55 consecutive patients with primary hepatolithiasis who underwent laparoscopic partial hepatectomy and laparoscopic bile duct exploration were analyzed. Immediate outcomes included stone clearance rate, operative morbidity, and mortality. Long-term outcomes included stone recurrence rate and hepatolithiasis-related mortality.

RESULTS

Nineteen patients underwent laparoscopic left lateral sectionectomy and 36 patients underwent laparoscopic bile duct exploration. Twenty-five patients also underwent concomitant laparoscopic choledochoduodenostomy bypass. The operative morbidity and mortality rates were 25.5% and 1.8%, respectively. Four procedures needed open conversion. The immediate stone clearance rate was 90.9%, and the final stone clearance rate was 94.5% after subsequent choledochoscopic treatment. With a mean follow-up of 59 +/- 30 months, recurrent stones developed in 3 patients. One patient died of advanced cholangiocarcinoma.

CONCLUSIONS

In selected patients with primary hepatolithiasis, a laparoscopic approach of definitive treatment is safe and effective with good immediate and long-term outcomes.

Surgical management of hepatolithiasis

BACKGROUND

Globalization and intercontinental migration have not just changed the socioeconomic status of regions, but have also altered disease dynamics across the globe. Hepatolithiasis, although still rare, is becoming increasingly evident in the West because of immigration from the Asia-Pacific region, where the disease prevails in endemic proportions. Such rare but emerging diseases pose a therapeutic challenge to doctors.

METHODS

Here, we briefly introduce the topic of hepatolithiasis and describe features of intrahepatic stones, the aetiology of hepatolithiasis and the symptoms and sequelae of the condition. We then provide a comprehensive review of the various management modalities currently in use to treat hepatolithiasis.

CONCLUSIONS

In our opinion, and as is evident from the literature, surgery remains the definitive treatment for hepatolithiasis. However, non-surgical procedures such as cholangiography, although limited in their therapeutic capabilities, play a vital role in diagnosis and preoperative evaluation.

Is Oddi sphincterotomy an indication for hepatolithiasis?

BACKGROUND

The purpose of treatment for hepatolithiasis is reducing recurrent cholangitis. This study was designed to determine the long-term outcome of Oddi sphincterotomy for hepatolithiasis.

METHODS

Thirty-two consecutive hepatolithiasis patients, including 15 cases that had undergone conventional open surgical transduodenal sphincteroplasty (COSTS) and 17 cases with endoscopic sphincterotomy (EST), were followed up for a long term. We compared the post-treatment rates of recurrent cholangitis and acute cholangitis severe type (ACST) with the ones of pretreatment in each group, respectively. Paired chi(2) test was used.

RESULTS

In the COSTS group, neither the post-operative rate of recurrent cholangitis (86.7%, 13/15 vs. 100%, 15/15) nor ACST (26.7%, 4/15 vs. 46.7%, 7/15) decreased (p > 0.05) compared with before the operation. In the EST group, the situation was the same: neither the rate of post-EST recurrent cholangitis (76.5%, 13/17 vs. 82.4%, 14/17) nor ACST (29.4%, 5/17 vs. 23.5%, 4/17) were reduced significantly (p > 0.05).

CONCLUSIONS

Both eradication of hepatobiliary lesions and keeping Oddi sphincter intact should be emphasized in the management of hepatolithiasis. Neither COSTS nor EST is an effective method or can achieve the goal of reducing cholangitis for hepatolithiasis.

Pre-operative evaluation and management of bile duct re-operation

AIM: To discuss the preoperative evaluation and management of bile duct re-operation.

METHODS: Clinical data obtained from 127 patients underwent bile duct re-operation in our hospital from January 2003 to March 2007 were investigated retrospectively.

RESULTS: The main cause for bile duct re-operation was residual or recurrent stones in intra- and extra-hepatic bile ducts which occurred in 66.9% of the reviewed patients. The secondary causes were rudimentary gallbladder, lower bile duct stricture, and biliary leakage. The main bile duct re-operation procedures included partial hepatectomy with Roux-en-Y cholangiojejunostomy and T tube drainage. The complication rate of bile duct re-operation was 10.2%. Portal hypertension and bleeding (over 800-1500 mL) occurred in 7 patients during operation.

CONCLUSION: Sufficient preoperative preparation and evaluation, careful exploration, rational choice of surgical procedures and post-operation treatment can reduce bile duct re-operation.

[Hepaticolithiasis. Rare benign disease of the intrahepatic bile ducts]

Hepaticolithiasis is a rare disease of the intrahepatic bile ducts endemic to east Asia which also is known as oriental cholangiohepatitis. Beside strictures and metabolic disturbance, the main cause of intrahepatic stones is acquired or congenital malformation of the intrahepatic biliary ducts. In the following we show a case of hepaticolithiasis and concurrent pancreatic metaplasia.