Comparison of treatments for hepatolithiasis: hepatic resection versus cholangioscopic lithotomy

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.

Clinical characteristics and prognosis of primary hepatolithiasis in hospitalized children

The purpose of this study is to evaluate the clinical characteristics and prognosis of primary hepatolithiasis in hospitalized children. This retrospective cohort study included 106 hospitalized patients with primary hepatolithiasis at Beijing Children's Hospital. Clinical data were derived from electronic inpatient (2010-2021) and outpatient (2016-2021) medical records. The prognosis was evaluated by outpatient ultrasounds after discharge and telephone interviews performed in December 2022. Intrahepatic bile duct stones in patients enrolled in the study were all found incidentally by abdominal ultrasound during hospitalization, with an incidence of 1.7 per 10,000 hospitalized children. The mean age at diagnosis was 9.3 ± 3.6 years, with male predominance (69/106, 65.1%). The right lobe of the liver (80/106, 75.5%) was preferentially affected. All patients underwent conservative observation. Seventy-eight patients (78/106, 73.6%) were followed up with a mean follow-up age of 17.1 ± 5.0 years, and 4 (4/78, 5.1%) had intermittent abdominal pain. From 2016 to 2021, 32 patients were diagnosed with primary hepatolithiasis, and follow-up abdominal ultrasounds were performed in 20 of them (20/32, 60.0%) with a median time of 2.1 (0.1, 3.5) years. The stones were present in 17 patients (17/20, 85.0%).

CONCLUSION

Primary hepatolithiasis in hospitalized children is rare, almost found accidentally; mostly affects the right lobe of the liver; and can be conservatively observed without surgical treatment in childhood.

WHAT IS KNOWN

• Primary hepatolithiasis in adults often presents with severe clinical symptoms and requires hepatectomy.. • There are few studies on primary hepatolithiasis in children.

WHAT IS NEW

• Primary hepatolithiasis in children is mostly found accidentally by abdominal ultrasound without associated symptoms during hospitalization. • Children with accidental primary hepatolithiasis can be conservatively observed without surgical treatment in childhood.

The value of three-dimensional visualization techniques in hepatectomy for complicated hepatolithiasis: A propensity score matching study

OBJECTIVE

The present study aimed to investigate the safety, feasibility, and efficacy of three-dimensional visualization technique (3DVT)-guided hepatectomy in the treatment of complicated hepatolithiasis.

METHODS

The clinical and follow-up data of 279 patients with complicated hepatolithiasis were retrospectively analyzed. The patients were divided into a 3DVT group (group A, 66 cases) and a non-3DVT group (group B, 213 cases). After baseline data were balanced using propensity score matching (PSM), the clinical characteristics and follow-up data of the two groups were observed.

RESULTS

After 1:1 PSM, 58 patients in each group were successfully matched with each other. When the groups were compared, the surgical duration (p = 0.033) and intraoperative blood loss (p = 0.002) of group A were lower than those of group B. The immediate stone clearance rate (91.4% vs. 75.9%, p = 0.024) and quality of life outcome (p = 0.034) of group A were significantly higher than those of group B. Logistic regression analysis showed that history of two or more biliary tract operations (odds ratio [OR] = 6.544, 95% confidence interval [CI] = 1.193-35.890, p = 0.031), bilateral stone distribution (OR = 4.198, 95% CI = 1.186-14.854, p = 0.026), and Geng grade III or IV (OR = 12.262, 95% CI = 2.224-67.617, p = 0.004) were independent risk factors for poor outcomes in patients with complicated hepatolithiasis.

CONCLUSION

Compared to conventional imaging examinations, 3DVT can be used to guide and achieve accurate preoperative diagnosis of complicated hepatolithiasis and has good safety, feasibility, and efficacy.

Diagnosis and management of hepatolithiasis in an adult patient: A case report

Hepatolithiasis or intrahepatic calculi are common in South East Asia but are rare in Western nations. The primary symptom of the condition is recurrent pain in the upper abdomen. Stones in the cystic duct or common bile duct are also common findings. Recurrent pyogenic cholangitis is the most frequent complication. Radiological studies and percutaneous procedures are vital for diagnosing and managing this condition. The primary goal in treating the condition is to decrease the chance of developing cholangitis and to stop the progression of the disease, which may lead to biliary cirrhosis.

•

Hepatolithiasis or intrahepatic calculi are common in South East Asia but are rare in Western nations.

•

The primary symptom of the condition is recurrent pain in upper abdomen.

•

It is essential to practice an interdisciplinary approach to best treat and manage these patients.

•

Early diagnosis is crucial; and treatment should be multidisciplinary and complete to avoid recurrence and complications.

Hepatolithiasis: A Retrospective Analysis of Surgical Management Options in a Tertiary Care Centre in Southern India

Introduction: Hepatolithiasis (HL) is the presence of stones in the bile ducts proximal to the confluence of the hepatic ducts. This study aims to analyse the case presentations of HL in a tertiary care centre in South India and define the role of hepatic resection in these cases and their outcomes.

Methods: Retrospective data of all patients operated on for HL from 2012 to 2021 were analysed with regard to clinical parameters, biochemical parameters, and different types of surgical management. Descriptive data analyses were done.

Results: A total of 42 patients underwent surgical treatment for HL between 2012 and 2021 in our institution. Of the patients, 64% were females. A total of 50% of patients were affected by bilateral HL. Of the patients, 95% had abdominal pain, 57% had a fever, and 29% presented with jaundice. A total of 38% of patients had a history of previous biliary surgery. Atrophy was present in 38% of cases. Choledochoduodenostomy was performed in 26%, and hepatic resection with bilio-enteric anastomosis was done in 36% of patients. Endoluminal access loop was done in 21%. Hepaticojejunostomy alone was done in 14%. On follow-up visits (mean: 61.5 months), 60% of patients were asymptomatic with no recurrence. There was nil 30-day postoperative mortality.

Conclusion: The treatment options for HL were based on the extent of liver involvement. The bilio-enteric anastomosis was done after the clearance of stones for uncomplicated HL. Complicated HL may need liver resection with hepaticojejunostomy, with an endoluminal access loop for a good outcome.

Clinical online nomogram for predicting prognosis in recurrent hepatolithiasis after biliary surgery: A multicenter, retrospective study

BACKGROUND

Methods for predicting the prognosis of patients undergoing surgery for recurrent hepatolithiasis after biliary surgery are currently lacking.

AIM

To establish a nomogram to predict the prognosis of patients with recurrent hepatolithiasis after biliary surgery.

METHODS

In this multicenter, retrospective study, data of consecutive patients in four large medical centers who underwent surgery for recurrent hepatolithiasis after biliary surgery were retrospectively analyzed. We constructed a nomogram to predict the prognosis of recurrent hepatolithiasis in a training cohort of 299 patients, following which we independently tested the nomogram in an external validation cohort of 142 patients. Finally, we used the concordance index (C-index), calibra-tion, area under curve, decision curve analysis, clinical impact curves, and visual fit indices to evaluate the accuracy of the nomogram.

RESULTS

Multiple previous surgeries [2 surgeries: Odds ratio (95% confidence interval), 1.451 (0.719-2.932); 3 surgeries: 4.573 (2.015-10.378); ≥ 4 surgeries: 5.741 (1.347-24.470)], bilateral hepatolithiasis [1.965 (1.039-3.717)], absence of immediate clearance [2.398 (1.304-4.409)], neutrophil-to-lymphocyte ratio ≥ 2.462 [1.915 (1.099-3.337)], and albumin-to-globulin ratio ≤ 1.5 [1.949 (1.056-3.595)] were found to be independent factors influencing the prognosis. The nomogram constructed on the basis of these variables showed good reliability in the training (C-index: 0.748) and validation (C-index: 0.743) cohorts. Compared with predictions using traditional classification models, those using our nomogram showed better agreement with actual observations in the calibration curve for the probability of endpoints and the receiver operating characteristic curve. Dichloroacetate and clinical impact curves showed a larger net benefit of the nomogram.

CONCLUSION

The nomogram developed in this study demonstrated superior performance and discriminative power compared to the three traditional classifications. It is easy to use, highly accurate, and shows excellent calibration.

Percutaneous Transhepatic Cholangioscopy and Stone Extraction in a Patient with Recurrent Cholangitis Following Liver Trauma

Percutaneous transhepatic cholangioscopy (PTCS) is a safe and effective treatment for obstructive biliary stones, when endoscopic retrograde cholangiopancreatography (ERCP) is unsuccessful or unavailable. Once percutaneous access is gained into the biliary tree by an interventional radiologist, the biliary ducts can be directly visualized and any biliary stones can be managed with lithotripsy, mechanical fragmentation, and/or percutaneous extraction. We report a case of a 45-year-old man who sustained a traumatic liver laceration and associated bile duct injury, complicated by bile duct ectasia and intrahepatic biliary stone formation. Despite undergoing a cholecystectomy, multiple ERCPs, and percutaneous transhepatic cholangiogram with drain placement, the underlying problem was not corrected leading to recurrent bouts of gallstone pancreatitis and cholangitis. He was ultimately referred to an interventional radiologist who extracted the impacted intrahepatic biliary stones that were thought to be causing his recurrent infections through cholangioscopy. This is the first case of PTCS with biliary stone extraction in the setting of recurrent biliary obstruction and cholangitis due to traumatic bile duct injury.

Application of Laparoscopic Technique in the Treatment of Hepatolithiasis

Hepatolithiasis is commonly encountered in Southeastern and East Asian countries, and its incidence is increasing in Western countries. For symptomatic hepatolithiasis or asymptomatic hepatolithiasis with signs of liver atrophy or malignancy, surgical intervention is needed, especially when peroral cholangioscopy and percutaneous transhepatic cholangioscopic lithotomy are not suitable or fail to be performed. Currently, laparoscopic surgery is gradually replacing traditional open surgery and becoming a better option. Various types of laparoscopic surgeries, including laparoscopic hepatectomy, laparoscopic biliary exploration through the common bile duct or the hepatic duct stump, and robotic-assisted laparoscopic surgery, have been developed for the treatment of simple hepatolithiasis, hepatolithiasis concomitant with choledocholithiasis, recurrent hepatolithiasis, and complicated hepatolithiasis. The related clinical experience is gradually accumulating. In this review, the laparoscopic applications and their advantages will be summarized. In most cases, the laparoscopic technique could provide the advantages of less trauma, reduced blood loss, and faster postoperative recovery.

Ultra-mini Percutaneous Hepatolithotomy in Patients With Large and Multiple Hepatolithiasis

BACKGROUND

In this study, we applied the ultra-mini percutaneous hepatolithotomy (UM-PHL) technique on hepatolithiasis patients with multiple and large stones on which other minimally invasive methods failed, and our aim was to report its results, sharing in series for the first time.

MATERIALS AND METHODS

Preoperative and postoperative data, laboratory parameters, radiologic findings, and preoperative and postoperative details were recorded for a total of 14 patients for whom the UM-PHL technique was applied between April 2017 and December 2019. As all patients had multiple stones and extreme stone load and had bile duct surgery, they did not have a normal anatomy. All patients were radiologically confirmed to have had preprocedural magnetic retrograde cholangiopancreatography.

RESULTS

Operation duration of the patients was 137.6±44.9 minutes, while intraoperative blood loss was 69.2±24.9 mL, drainage catheter removal time was 2.85±0.86 days, and the hospitalization time was 4.28±2.55 days. Intraoperative balloon dilation was applied to enlarge the stricture area in 5 patients (35.7%). On the basis of the Clavien-Dindo classification, grade 2 complication was observed in 2 patients (14.2%) due to postoperative cholangitis. Patients were followed up for an average of 15 months, and nonsymptomatic radiologic stone recurrence was detected in the 12th month control of 1 patient (7.1%).

CONCLUSION

The UM-PHL technique is a successful method that facilitates stone clearance by providing minimal dilatation through percutaneous intervention and by using instruments with small diameter, and it can safely be applied with its low complication level, low recurrence ratio, and short hospitalization time.

Risk of malignancy in Caroli disease and syndrome: A systematic review

BACKGROUND

Congenital intrahepatic bile duct dilatation without fibrosis is called Caroli disease (CD), and is called Caroli syndrome (CS) when it has fibrotic and cirrhotic liver morphology. The development of intrahepatic carcinoma is described in both conditions, but the reported incidence varies extensively. Potential risk factors for the malignant transformation were not described. Furthermore, conservative or surgical treatment is performed depending on the extent of cystic malformation, hepatic dysfunction and structural hepatic changes, but little is known about which treatment should be offered to patients with CD or CS and cancer.

AIM

To further investigate the malignant transformation in these conditions.

METHODS

A systematic review of the current literature until January 2019 was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. A search using Medline (PubMed) was performed using a combination of Medical Subject Headings terms “caroli disease”, “caroli syndrome”, “tumor”, “malignant”, and “cholangiocarcinoma”. Only human studies published in English were used for this systematic review. The following parameters were extracted from each article: year of publication, type of study, number of patients, incidence of malignant tumor, duration of symptoms, age, sex, diagnostics, identification of tumor, surgical therapy, survival and tumor recurrence.

RESULTS

Twelve retrospective studies reporting the courses of 561 patients (53% females) were included in this systematic review. With a mean age of 41.6 years old (range 23 to 56 years old), patients were younger than other populations undergoing liver surgery. Depending on the size of the study population the incidence of cholangiocarcinoma varied from 2.7% to 37.5% with an overall incidence of 6.6%. There were only few detailed reports about preoperative diagnostic work-up, but a multimodal work-up including ultrasound of the liver, computed tomography, magnetic resonance imaging and endoscopic retrograde cholangiopancreatography was used in most studies. Disease duration was variable with up to several years. Most patients had episodes of cholangitis, sepsis, fever or abdominal pain. Tumor detection was an incidental finding of the surgical specimen in most cases because it is currently often impossible to detect tumor manifestation during preoperative diagnostics. Liver resection or liver transplantation was performed depending on the extent of the biliary pathology and additional alterations of the liver structure or function. No postoperative adjuvant chemotherapy was reported, but chemotherapy was administered in selected cases of tumor recurrence. Overall survival rates after one year were low at 36% and a high recurrence rate of up to 75% during the observation period.

CONCLUSION

Only few retrospective studies reported a low tumor incidence. Despite the high rate of mortality and tumor recurrence, definite surgical treatment should be offered as soon as possible.

Hepatectomy and intrahepatic hepaticocutaneous jejunostomy for bilateral primary hepatolithiasis: Case report

•

Primary hepatolithiasis is a rare disease in western countries.

•

Primary intrahepatic stones are associated with repeated attacks of acute cholangitis.

•

Primary bilateral hepatolithiasis can be managed with partial hepatectomy with an intrahepatic hepaticocutaneous jejunostomy.

Introduction

Primary hepatolithiasis is a rare disease in western countries and it is associated with repeated attacks of acute cholangitis. Without proper treatment, hepatolithiasis can lead to progressive biliary strictures and secondary biliary cirrhosis.

Presentation of case

A 40 years old male was admitted due to recurrent cholangitis during the last 18 years. Bilateral primary hepatolithiasis was diagnosed and treated by left hepatectomy with an intrahepatic hepaticocutaneous jejunostomy. There were no postoperative complications and the patient was discharged after 7 days.

Discussion

The management of patients with primary hepatolithiasis remains a challenging task due to the high incidence of residual and recurrent stones after treatment.

Conclusion

Primary bilateral hepatolithiasis is a complex disease that can be managed with partial hepatectomy with an intrahepatic hepaticocutaneous jejunostomy.

New management of hepatolithiasis: Can surgery be avoided? (with video)

BACKGROUND

The presence of hepatolithiasis (HL) is prevalent in eastern countries. It is a clinical entity which is rarely reported in non-surgical series because the standard treatment is the surgical option. Currently, treatment has evolved, with the use of endoscopic techniques being increased and the number of hepatectomies being decreased. SpyGlass™ is a small-calibre endoscopic direct cholangiopancreatoscopy developed to explore and perform procedures in the bile and pancreatic ducts. Single-operator peroral cholangioscopy (POC) is an endoscopic technique useful for treating difficult bile duct stones.

AIMS

To assess the usefulness, efficacy, and safety of POC with the SpyGlass™ system in patients with HL.

PRIMARY OBJECTIVES

to achieve technical success of the procedure and clinical success of patients with HL.

STUDY DESIGN AND PATIENTS

Retrospective, single-centre cohort study of patients with HL from April 2012 to August 2018. SpyGlass™ was chosen in symptomatic patients referred from the surgery unit as the first-line procedure. To perform electrohydraulic lithotripsy (EHL), we used a Northgate Autolith IEHL generator with a 0.66-mm biliary probe.

RESULTS

We performed a total of 13 procedures in 7 patients with HL. The mean age was 46 years (range 35-65) and 3/7 of patients were female. We achieved technical success in 5/7 cases (71.4%) and clinical success in 4/7 cases (57%).

DISCUSSION

SpyGlass™ is safe and effective in the treatment of HL. With these results, we confirm the need for management of patients with HL in a multidisciplinary team. When the endoscopic approach is the option, this procedure must be performed by experts in advanced endoscopy.

Intrahepatic bile duct exploration lithotomy is a useful adjunctive hepatectomy method for bilateral primary hepatolithiasis: an eight-year experience at a single centre

Background

To evaluate the perioperative and long-term results of intrahepatic bile duct exploration lithotomy (IHBDIL) combined with hepatectomy for patients with complicated bilateral primary hepatolithiasis.

Methods

A study was conducted involving 56 patients with complicated bilateral primary hepatolithiasis who underwent IHBDIL combined with hepatectomy at our hospital from January 2006 to December 2014. The perioperative and long-term outcomes that were retrospectively analysed included the stone clearance rate, operative morbidity and mortality, and stone recurrence rate. Patients with a preoperative diagnosis of cholangiocarcinoma were excluded.

Results

In all 56 patients, hepatic duct stones were located in the bilateral IHBD. The surgical method was IHBDIL combined with hepatectomy. Postoperative complications occurred in 15 patients (26.8%), 14 patients responded to conservative management, and there was 1 case of postoperative mortality because of hepatic failure. The overall initial success rate of stone clearance was 85.7%, and the final clearance rate was 92.9% following postoperative choledochoscopic lithotripsy. The stone recurrence rate was 13.5%, and the occurrence of postoperative cholangitis was 10.9% during the follow-up period.

Conclusion

IHBDIL combined with hepatectomy is a safe, effective, and promising treatment for patients with complicated bilateral primary hepatolithiasis. The perioperative and long-term outcomes are satisfactory for complicated bilateral primary hepatolithiasis.

Electronic supplementary material

The online version of this article (10.1186/s12893-019-0480-1) contains supplementary material, which is available to authorized users.

Hepatico-jejuno-duodenal access loop – a modified biliary reconstruction technique for facilitated endoscopic access to biliary tree following surgery for hepatolithiasis

Aims: Management of hepatolithiasis is complicated by residual and recurrent disease, and endoscopic access to biliary tree in such patients enables therapeutic interventions thereby avoiding the morbidity associated with relaparotomy. In this study we assess a modified biliary reconstruction in the form of hepaticojejuno- duodenal access loop (HJDA) with regard to the feasibility of endoscopic access to intrahepatic ducts with follow-up. Methods: From August 2011 till December 2016, all patients treated for hepatolithiasis with bilateral disease, nondilated extrahepatic biliary system or extensive intrahepatic strictures underwent HJDA. After completion of hepaticojejunostomy (HJ), the free end of the Roux loop was anastomosed to the first part of duodenum in a side to side fashion. In the fourth week postoperatively, endoscopy with conventional forward viewing endoscope was performed to explore the possibility of accessing the biliary system. Results: Endoscopic access to the intrahepatic bile ducts through the HJDA was possible in all the patients and mean time taken to access the HJ was 3.5 minutes (2-7 minutes). There were no complications pertinent to construction of the HJDA. One patient had bile leak from HJ, which settled with conservative management and surgical site infection was seen in four. We did not have any mortality in our series. During the follow up, three of our patients (30%) subsequently presented with cholangitis at a mean period of 22 months and were successfully managed with endoscopic procedures alone. One patient required balloon dilatation of the HJ stricture, while the other two were managed by endoscopic removal of calculi. Overall, five endoscopic procedures were required in three patients with recurrent cholangitis in the follow up period with rate of 1.67 procedures per patient. Conclusion: HJDA is a modified biliary reconstruction technique which facilitates endoscopic access to the biliary system for removal of recurrent/residual intrahepatic stones. It is therefore recommended in patients with complicated hepatolithiasis like bilateral disease, recurrence, multiple intrahepatic strictures and for those in whom future endoscopic access to biliary tree is deemed necessary.

Biliary tract exploration through a common bile duct incision or left hepatic duct stump in laparoscopic left hemihepatectomy for left side hepatolithiasis: which is better?: A single-center retrospective case-control study

Laparoscopic left hemihepatectomy (LLH) followed by biliary tract exploration is used to treat left-sided hepatolithiasis (LSH). The purpose of this study was to compare the efficacy of 2 methods of biliary tract exploration in LLH:biliary tract exploration through a common bile duct (CBD) incision (with T-tube drainage) or through the left hepatic duct (LHD) stump (without T-tube drainage).LSH patients (113 patients) were recruited retrospectively in our hospital from December 2008 to January 2016. To compare different methods of biliary tract exploration during LLH, the patients were divided into 2 groups: 41 patients underwent biliary tract exploration through the LHD stump (LHD group), and 72 patients underwent biliary tract exploration through a CBD incision (CBD group). Baseline characteristics, surgical outcomes, surgery-related complications, postoperative hospital stay (PHS) and long-term results were compared between the 2 groups.There was no unplanned reoperation in the 2 groups. One patient in the CBD group had a residual stone, which was removed by choledochoscopy 2 months postoperation. Two patients in the LHD group and 3 patients in the CBD group had bile leakage and were cured with abdominal drainage. There were no significant differences in the total operation time, incidence of residual stones and bile leakage between the 2 groups (P > .05). The PHS and the incidence of hypokalemia or hyponatremia in the LHD group were significantly lower than those in the CBD group (P < .05). T-tube-related complications occurred in 13.9% (10/72) of the CBD patients. The mean follow-up period was 37.2 ± 13.8 months. There were no significant differences in the incidence of recurrence stones or cholangitis (P > .05) between the 2 groups.Exploration of the biliary tract through the LHD stump without T-tube drainage is safe with satisfactory short- and long-term results for selected LSH patients.

A clinical study of choledochoscopic holmium laser lithotripsy for multiple intrahepatic calculi within ERAS programs

OBJECTIVES

Multiple intrahepatic calculi, especially calculi in both sides of the liver, cannot be completely resolved by traditional surgery. In addition, morbidity after liver resection remains high. ERAS programs have been suggested that could relieve surgical stress and accelerate postoperative recovery. This study aimed to evaluate the safety and efficacy of choledocholithotomy combined with holmium laser lithotripsy in the treatment of multiple intrahepatic calculi within ERAS programs.

METHODS

In all, 109 patients with multiple intrahepatic calculi were enrolled between January 2012 and September 2016, 42 of whom received choledocholithotomy combined with holmium laser lithotripsy. The remaining 67 patients underwent choledocholithotomy combined with choledochoscopic mechanical lithotripsy. Perioperative outcomes were compared and analyzed.

RESULTS

Patient characteristics and preoperative details were similar between the groups (P > 0.05). The implementation of holmium laser lithotripsy could reduce the calculi residual rate (7.1% vs. 22.4%, P = 0.037), and even the liver resection rate (16.7% vs. 35.8%, P = 0.031). Additionally, holmium laser lithotripsy did not result in a higher morbidity (11.9% vs. 16.4%, P = 0.517), readmission rate (0% vs. 6%, P = 0.158), hospital stay (P = 0.189), hospital cost (P = 0.998), transfusion rate (P = 0.576), or operative time (P = 0.638).

CONCLUSIONS

Holmium laser lithotripsy is feasible and efficient for treating multiple intrahepatic calculi within ERAS programs, which could reduce the liver resection rate and render refractory hepatic calculi easy to eliminate. In addition, holmium laser lithotripsy could be well coupled to the ERAS program to relieve surgical stress and accelerate postoperative recovery. Lasers Surg. Med. 51:161-166, 2019. © 2018 Wiley Periodicals, Inc.

Major hepatectomy for primary hepatolithiasis: a comparative study of laparoscopic versus open treatment

Background

Due to higher technical requirements, laparoscopic major hepatectomy (LMH) for primary hepatolithiasis have been limited to a few institutions. This retrospective study was performed to evaluate the therapeutic safety, and perioperative and long-term outcomes of LMH versus open major hepatectomy (OMH) for hepatolithiasis.

Methods

From January 2012 to December 2016, 61 patients with hepatolithiasis who underwent major hepatectomy were enrolled, including 29 LMH and 32 OMH. The perioperative outcomes and postoperative complications, as well as long-term outcomes, including the stone clearance and recurrence rate, were evaluated.

Results

There was no difference of surgical procedures between the two groups. The mean operation time was (262 ± 83) min in the LMH group and (214 ± 66) min in the OMH group (p = 0.05). There is no difference of intra-operative bleeding (310 ± 233) ml versus (421 ± 359) ml (p = 0.05). In the LMH group, there were shorter time to postoperative oral intake ((1.1 ± 0.6) days versus (3.1 ± 1.8) days, p = 0.01) and shorter hospital stay [(7.2 ± 2.3) days versus (11.8 ± 5.5) days, p = 0.03] than the open group. The LMH group had comparable stone clearance rate with the OMH group during the initial surgery (82.8% vs. 84.4%, p = 0.86).

Conclusions

LMH could be an effective and safe treatment for selected patients with hepatolithiasis, with an advantage over OMH in the field of less intra-operative blood loss, less intra-operative transfusion, less overall complications, and faster postoperative recovery.

Recurrent pyogenic cholangitis: a review of imaging findings and clinical management

Recurrent pyogenic cholangitis (RPC) is an infective process involving the biliary tree typified by pigmented intraductal calculi with dilatation of the intra- and extrahepatic biliary tree. Previously endemic to South-east Asia, RPC can now be seen in Western countries with the increasing access to international travel and immigration. Affected patients are often plagued by recurrent bouts of cholangitis, and commonly suffer from complications such as abscess formation and biliary strictures. In severe cases, cirrhosis with portal hypertension may develop. The disease is also a known risk factor for cholangiocarcinoma, and can be seen in up to 5% of affected patients. Its exact etiology is unknown, but parasitic infections such as Clonorchis sinensis and Ascaris lumbricoides, ascending bacterial infection with gut flora (Escherichia coli) and low socioeconomic status have been associated strongly with it. This paper reviews the imaging features of the disease, as well as the roles of interventional radiology and surgery with respect to management of the condition.

Incidence of underlying biliary neoplasm in patients after major hepatectomy for preoperative benign hepatolithiasis

Backgrounds/Aims

Despite hepatolithiasis being a risk factor for biliary neoplasm including cholangiocarcinoma, the incidence of underlying biliary neoplasm is unknown in patients with preoperative benign hepatolithiasis. The aim of this study was to evaluate the incidence of underlying biliary neoplasm in patients who underwent major hepatectomy for preoperative benign hepatolithiasis.

Methods

Between March 2005 and December 2015, 73 patients who underwent major hepatectomy for preoperative benign hepatolithiasis were enrolled in this study. The incidence and pathological differentiation of concomitant biliary neoplasm were retrospectively determined by review of medical records. Postoperative complications after major hepatectomy were evaluated.

Results

Concomitant biliary neoplasm was pathologically confirmed in 20 patients (27.4%). Biliary intraepithelial neoplasia (BIN) was detected in 12 patients (16.4%), and 1 patient (1.4%) had intraductal papillary mucinous neoplasm (IPMN), as the premalignant lesion. Cholangiocarcinoma was pathologically confirmed in 7 patients (9.6%). Preoperative imaging of the 73 patients revealed biliary stricture at the first branch of bile duct in 31 patients (42.5%), and at the second branch of bile duct in 39 patients (53.4%). Postoperative complications developed in 14 patients (19.1%). Almost all patients recovered from complications, including intra-abdominal abscess (9.6%), bile leakage (4.1%), pleural effusion (2.7%), and wound infection (1.4%). Only 1 patient (1.4%) died from aspiration pneumonia.

Conclusions

The incidence of underlying biliary neoplasm was not negligible in the patients with hepatolithiasis, despite meticulous preoperative evaluations.

Comparison Between Percutaneous Transhepatic Rigid Cholangioscopic Lithotripsy and Conventional Percutaneous Transhepatic Cholangioscopic Surgery for Hepatolithiasis Treatment

Background:

Percutaneous transhepatic cholangioscopy (PTCS) is one option for treating hepatolithiasis without surgical resection. This approach can use conventional biliary drainage methods over a long period, but a shorter procedure needs to be evolved.

Objective:

To evaluate the short-term and the long-term therapeutic outcomes of percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) in comparison with conventional PTCS.

Methods:

In this retrospective study, 118 patients with hepatolithiasis were enrolled who underwent treatment in our hospital between March 2007 and July 2014. About 67 of them received PTCSL and the remaining 51 patients received conventional PTCS. Preoperative data, surgical operation-related records, the postoperative therapeutic effect, and the long-term hepatolithiasis recurrence rate were collected for comparison between the 2 groups.

Results:

The age, sex, and surgical history were similar between the 2 groups, but there was a significant difference in the Child-Pugh score, with more grade 3 patients in the PTCS group (P=0.002). However, the operation time, intraoperative blood infusion, and the blood loss were similar between the 2 groups. The final clearance ratio of calculus in the PTCSL group was significantly better than in the PTCS group after multivariate analysis (P=0.021; OR=0.201; 95% CI, 0.051-0.785). Calculus recurrence was 9% (PTCSL) and 22% (PTCS). The postoperative hospital stay was significantly shorter in the PTCSL group (P=0.001; OR=1.337; 95% CI, 1.132-1.58).

Conclusions:

PTCSL was a satisfactory therapeutic option for hepatolithiasis treatment, with less operation time and a superior long-term therapeutic effect compared with conventional PTCS.

Outcome of surgery for recurrent pyogenic cholangitis: a single center experience

BACKGROUND

Although, recurrent pyogenic cholangitis (RPC) is prevalent in several parts of India, there is paucity of published literature from India. The aim of this study was to report on the short and long-term outcomes of surgery for RPC.

METHODS

All the patients, who underwent surgery for RPC between August 2007 and February 2016 in the Department of Surgical gastroenterology, Institute of Postgraduate Medical Education and Research, Kolkata, India were retrospectively reviewed.

RESULTS

Of the total 94 patients, 66 (70%) were women. The median age at presentation was 40 years. Left lobe was solely involved in 49% of patients. Left hepatectomy was performed in 23/44 (52%) patients who underwent liver resection. Thirty two postoperative complications developed in 27 patients (29%). Complete stone clearance was possible in 83% of patients after primary surgery. Over a median follow up of 36 months, seventy one of 87 patients (81%) remained free of stones. Recurrent cholangitis occurred 10 of 87 patients (11%).

CONCLUSIONS

Surgery plays an important role in the management of RPC achieving excellent short and long-term outcomes.

Endoscopy Lithotomy for Intrahepatic Gallstones: A Meta-Analysis

BACKGROUND

Endoscopy lithotomy (percutaneous transhepatic cholangioscopic lithotomy or through a T-tube track) has become a well-established treatment for intrahepatic gallstones. However, the relationship between strictures and the results of this treatment is still controversial.

MATERIALS AND METHODS

We searched PubMed, EMBASE, Cochrane Library databases, clinicaltrails, CBM, and Google scholar systematically for all articles. The rate of complete clearance, the recurrence rate, and major complications were analyzed. A meta-analysis was performed by RevMan 5.2.

RESULTS

Thirteen studies were included. In patients with intrahepatic duct stricture, the rate of complete clearance was significantly lower, but the rate of recurrence was significantly higher. The morbidity rate of major complications was significantly lower in complete stone removal patients.

CONCLUSIONS

Intrahepatic biliary stricture is a major cause of treatment failure for intrahepatic stones and stone recurrence. To prevent recurrent cholangitis or cholangiocarcinoma, complete removal of intrahepatic gallstones is very important.

Hepatolithiasis and intrahepatic cholangiocarcinoma: A review

Although the incidence of hepatolithiasis is decreasing as the pattern of gallstone disease changes in Asia, the prevalence of hepatolithiasis is persistently high, especially in Far Eastern countries. Hepatolithiasis is an established risk factor for cholangiocarcinoma (CCA), and chronic proliferative inflammation may be involved in biliary carcinogenesis and in inducing the upregulation of cell-proliferating factors. With the use of advanced imaging modalities, there has been much improvement in the management of hepatolithiasis and the diagnosis of hepatolithiasis-associated CCA (HL-CCA). However, there are many problems in managing the strictures in hepatolithiasis and differentiating them from infiltrating types of CCA. Surgical resection is recommended in cases of single lobe hepatolithiasis with atrophy, uncontrolled stricture, symptom duration of more than 10 years, and long history of biliary-enteric anastomosis. Even after resection, patients should be followed with caution for development of HL-CCA, because HL-CCA is an independent prognostic factor for survival. It is not yet clear whether hepatic resection can reduce the occurrence of subsequent HL-CCA. Furthermore, there are no consistent findings regarding prediction of subsequent HL-CCA in patients with hepatolithiasis. In the management of hepatolithiasis, important factors are the reduction of recurrence of cholangitis and suspicion of unrecognized HL-CCA.

Clinical features of hepatolithiasis: analyses of multicenter-based surveys in Japan

Background

Hepatolithiasis is a calculus disease of the liver with no known cause that is relatively uncommon, and is characterized by a refractory nature and high frequency of recurrence. Hepatolithiasis is one of the diseases listed by the Ministry of Health, Labour and Welfare of Japan under Research on Intractable Diseases, and it requires further research on the pathogenesis as well as the therapeutic strategy. It is also included in the clinical guidelines for cholelithiasis of the Japanese Society of Gastroenterology, which suggest guiding principles for the treatment of hepatolithiasis.

Methods

we performed questionnaire surveys of hepatolithiasis twice in 2010 and in 2012. Verification of the evidence-based clinical practice guidelines a questionnaire survey of 22 facilities in 2010 and 25 facilities in 2012 across Japan that provided cooperation, which enabled us to assess 210 new cases over a two-year period.

Conclusions

Comparison with two surveys that have been carried out previously revealed the main factor associated with hepatolithiasis was a history of biliary tract surgery, which was noted in the majority of cases. In addition, there was an increase of patients in whom balloon endoscopy was performed using transduodenal approach. This method is not included in the treatment options of the current clinical guidelines for cholelithiasis, so there may be a need to take it into consideration when the guidelines are revised.

Comparison of laparoscopic versus open left-sided hepatectomy for intrahepatic duct stones

BACKGROUND

Laparoscopic hepatectomy for intrahepatic duct (IHD) stones is limited by technical difficulties caused by adhesion to adjacent tissue or distorted anatomy resulting from recurrent inflammation. This study compared perioperative and clinical outcomes in patients undergoing laparoscopic and open hepatectomy for left IHD stones.

METHODS

From January 2002 to December 2013, 40 patients underwent laparoscopic left-sided hepatectomy [left hemihepatectomy (n = 7) or left lateral sectionectomy (n = 33)] and 54 patients without combined operations and previous operation histories underwent open left-sided hepatectomy [left hemihepatectomy (n = 24) or left lateral sectionectomy (n = 30)]. Their perioperative and clinical outcomes were compared, including stone clearance rates, stone recurrence rates, and median follow-up duration.

RESULTS

There was no difference in age (56.8 ± 8.2 vs. 55.6 ± 9.6 years, p = 0.531), sex (1.0:4.0 vs. 1.0:1.8 male:female, p = 0.108), or BMI (22.8 ± 2.8 vs. 22.9 ± 3.0 kg/m(2), p = 0.802) between the laparoscopic and open hepatectomy groups. Lateral sectionectomy was more frequent in the laparoscopic group (33/40 vs. 30/54, p = 0.010). Operation time (174.2 ± 56.6 vs. 210.4 ± 51.6 min, p = 0.002) and postoperative hospital stay (7.9 ± 2.6 vs. 14.3 ± 5.5 days, p < 0.001) were shorter in the laparoscopic group, and complication rate (17.5 vs. 40.7%, p = 0.016), in particular surgical site infection rate (5.0 vs. 18.5%, p = 0.052), was lower in the laparoscopic group than in the open hepatectomy group. Similar results were observed in the hemihepatectomy and lateral sectionectomy subgroups. There was no operation-related mortality. There were no significant differences in follow-up periods (48 ± 33.6 vs. 59.2 ± 41.7 months, p = 0.235) and rates of initial stone clearance (87.5 vs. 75.9%, p = 0.159), final clearance (100 vs. 94.4%, p = 0.130), and stone recurrence (2.5 vs. 5.6%, p = 0.468).

CONCLUSION

Laparoscopic hepatectomy is safe and effective for well-selected patients with left IHD stones, when performed by experienced surgeons. Laparoscopic hepatectomy resulted in shorter operation time and postoperative hospital stay, and a lower postoperative morbidity rate, than open hepatectomy.

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.

Surgical management of recurrent pyogenic cholangitis: 10 years of experience in a tertiary referral centre in Hong Kong

BACKGROUND

Recurrent pyogenic cholangitis (RPC) is common in Asia. Its management differs from centre to centre.

METHODS

A retrospective review of 80 patients undergoing surgery for RPC was performed. Immediate and longterm outcomes were analysed.

RESULTS

All patients underwent hepaticocutaneousjejunostomy (HCJ) for biliary drainage and stone removal. Additional hepatectomy was performed in 38 patients with intrahepatic ductal stricture or liver segmental atrophy. Twenty-three patients had residual stones and 25 had recurrent stones. All patients with residual stones underwent repeated choledochoscopy (median: four sessions) for stone removal and obtained confirmation of ductal clearance. Four patients developed cholangiocarcinoma, of which two died. The complication rate was 17.5%. Most of the complications were wound infections. No mortality related to surgery occurred. Multivariate analysis found that gender, disease extent (unilobar versus bilobar) and surgery type (HCJ alone versus HCJ with hepatectomy) were not associated with increased risk for residual or recurrent stones. A raised preoperative bilirubin level was the only risk factor identified as associated with an increased risk for recurrent stones (P < 0.001); it was not associated with an increased risk for residual stones.

CONCLUSIONS

Recurrent pyogenic cholangitis is a distinct disease, the management of which requires a high level of surgical expertise. Hepaticojejunostomy is recommended as the primary drainage procedure, but hepatectomy should be reserved for complicated RPC.

Management of intrahepatic stones: the role of subcutaneous hepaticojejunal access loop. A prospective cohort study

BACKGROUND

Patients with intrahepatic stones usually present with recurrent cholangitis, biliary sepsis and intrahepatic abscesses, may develop liver atrophy and may progress to cholangiocarcinoma. Treatment of intrahepatic stones is difficult and the disease progresses in most patients even after adequate treatment. Surgical removal of stones has been the standard management but residual stones and stone recurrence occur frequently whatever the technique. Because of the need for repeated biliary instrumentation, long-term access routes involving percutaneous transhepatic cholangioscopic lithotripsy (PTCSL), hepaticocutaneousjejunostomy (HCJ) and subparietal hepaticojejunal access loop to permit stone retrieval or stricture dilatation have been developed.

PURPOSE

The aim of this work was to evaluate the outcome of subcutaneous hepaticojejunal access loop in the management of intrahepatic stones.

PATIENTS AND METHODS

Between January 2009 and January 2013, 42 patients with intrahepatic stones underwent surgical treatment at the Gastrointestinal Surgery Unit, Main Alexandria University Hospital. Demographic data, details of operative findings, follow up details, and treatment of recurrent stones were analyzed. After approval of local ethics committee, all patients included in the study were informed well about the procedure and an informed written consent was obtained from every patient before carrying the procedure.

RESULTS

Forty-two patients (17 males and 25 females) with intrahepatic stones underwent surgery with construction of a subcutaneous hepaticojejunal access loop. Stones were confined to the left lobe in 25 patients, the right lobe in 3 patients and bilobar in 14 patients. Associated extrahepatic stones were found in 33 patients. Twenty-two patients had associated intrahepatic duct strictures. Five patients with atrophy of segments II and III underwent hepatic resection at the time of access loop formation. The mean operation time was 4.9 h and mean blood loss was 440 mL. Mean postoperative hospital stay was 10 days. Wound infection was the commonest complication, occurring in 5 (12%) patients. There were no specific complications attributable to the construction of the access loop. The subcutaneous access loop was used to gain access to the biliary tree in 28 patients with residual or recurrent stones. A total of 55 procedures (range 1-5) were attempted with successful access achieved in all cases and successful stone clearance in 21 of the 28 patients, and all of them were symptom free for at least 12 months after the last procedure. Partial stone clearance was achieved in the remaining seven patients. These seven patients had different degrees of biliary strictures.

CONCLUSION

The subcutaneous access loop offers the advantage of permanent access for the successful management of retained or re-formed intrahepatic stones with minimal morbidity since it permitted easy access to intrahepatic ducts using the conventional forward-viewing endoscope or the choledochoscope, without the additional morbidity of a biliary-cutaneous fistula or transhepatic access.

Endoscopic or laparoscopic approach for hepatolithiasis in the era of endoscopy in China

BACKGROUND

Many endoscopic procedures have been used to treat hepatolithiasis, including as laparoscopic hepatectomy (LH), laparoscopic intrahepatic duct exploration (LIDE), and endoscopic retrograde cholangiopancreatography (ERCP). However, long-term results of such treatments are rarely reported. The series aimed to evaluate the immediate outcomes and long-term results of these treatments and their optimal indications.

METHODS

From January 2002 to April 2010, a total of 124 continuous patients with hepatolithiasis were primarily treated with endoscopic surgery, including LH (LH group, n = 37), LIDE (LIDE group n = 41), and ERCP (ERCP group, n = 46) at our two institutes. These cases were retrospectively reviewed. The patients' demographic variables, operative outcomes, complete clearance rate, and cholangitis recurrence rate were analyzed.

RESULTS

Complete stone clearance was achieved in 94.6 % of LH, 78.0 % of LIDE, and 67.4 % of ERCP patients. After a median follow-up period of 5.0 years (rang 2-8 years), we observed stone recurrence in 26.6 % (33/124) of patients and recurrent cholangitis in 24.2 % (30/124) of patients. Stricture, stones in both lobes, and non-hepatectomy treatments were significant risk factors for incomplete stone clearance on multivariate analysis. In addition, recurrent cholangitis was associated with non-hepatectomy therapy, Sphincter of Oddi dysfunction, residual stones, and intrahepatic bile strictures.

CONCLUSION

In this study with 2-8 years of follow-up, residual stones, biliary stricture, Sphincter of Oddi dysfunction, and ERCP therapy were associated with recurrent stones and/or cholangitis after treatment, indicating that the modification of Sphincter of Oddi function and maintaining its normal pressure are very important.

Oriental cholangiohepatitis - is our surgery appropriate?

Oriental cholangiohepatitis, or recurrent pyogenic cholangitis is only noted in certain parts of the world, especially South East Asia. Due to increasing immigration the disease is now being seen in western countries also. Treating physicians may face difficulty in managing such cases due to lack of exposure. Furthermore management of such cases is not standardized because of lack of a universally accepted classification system. Here we review the disease and share our long experience with management of these patients.

Outcomes of hepatectomy for hepatolithiasis based on 3-dimensional reconstruction technique

BACKGROUND

The aim of our study was to evaluate the perioperative and long-term outcomes of hepatectomy based on 3-dimensional reconstruction technique for hepatolithiasis by comparing it with traditional hepatectomy.

STUDY DESIGN

From December 2005 to September 2012, 56 consecutive patients underwent hepatectomy based on 3-dimensional reconstruction technique for hepatolithiasis in our hospital (group A). During the same period, 42 patients with hepatolithiasis who met the inclusion criteria for hepatectomy were selected for traditional hepatectomy (group B). All operations were performed by the authors. There was no significant difference in preoperative data between the 2 groups statistically.

RESULTS

Compared with patients in group B, those in group A had a significantly lower stone residual rate (intermediate rate, 3.6% vs 19.0%; final rate, 0% vs 9.5%) and stone recurrence rate (3.6% vs 23.8%), a lower intrahepatic duct stricture residual rate (1.8% vs 14.3%), and a faster operating time (218.8 ± 55.5 minutes vs 254.7 ± 65.6 minutes). Intraoperative blood transfusion, intraoperative blood loss, postoperative hospital stay, and recurrent cholangitis rate were similar. No significant dominance was found in group A with respect to serum aminotransferase level, serum bilirubin level, serum albumin level, and prothrombin time. There was a significant dominance in group A for serum hemoglobin level (116.3 ± 16.0 g/L vs 108.0 ± 13.9 g/L; p < 0.05). Twenty-two complications occurred, 10 in group A and 12 in group B. Neither group had any perioperative mortality.

CONCLUSIONS

Hepatectomy for hepatolithiasis based on 3-dimensional reconstruction technique is feasible and safe in selected patients. Compared with traditional hepatectomy, it is more effective for diagnosis and treatment of hepatolithiasis.

Incidence of Cholangiocarcinoma with or without Previous Resection of Liver for Hepatolithiasis

BACKGROUND/AIMS

To investigate the incidence of cholangiocarcinoma in patients with hepatolithiasis with or without previous resection of liver.

METHODS

From 2002 to 2009, we retrospectively reviewed 117 patients who were diagnosed and treated for hepatolithiasis in Korea University Guro Hospital. Among the 117 patients, 55 patients who were lost during follow-up were excluded, and 62 patients were eligible for analysis. The hepatic resection group (n=25) included patients who underwent left hemihepatectomy (n=2); left lateral segmentectomy (n=10); left lobectomy (n=9); right lobectomy (n=3); or wedge resection (n=1). The nonhepatic resection group (n=37) included transhepatic cholangiographic lithotomy and endoscopic retrograde cholangiopancreatography-treated patients. The mean follow-up period was 47 months.

RESULTS

The incidence of cholangiocarcinoma while patients were followed for hepatolithiasis was 12.9% (8/62) (hepatic resection group, three cases [12%] vs nonhepatic resection group, five cases [13.5%]; p=1.000). The mean follow-up period was 53 months (47±11 months) until the diagnosis of cholangiocarcinoma.

CONCLUSIONS

There was no difference in the incidence of cholangiocarcinoma according to previous liver resections. Patients with hepatolithiasis should be carefully followed up for detection of cholangiocarcinoma even after a previous liver resection.

Management hepatolithiasis with operative choledochoscopic FREDDY laser lithotripsy combined with or without hepatectomy

BACKGROUND

Hepatolithiasis is very common in East Asia. It is benign in nature, but has a high recurrence rate. It is likely to lead to biliary cirrhosis and increase the risk of cholangiocarcinoma. Hence, the treatment of hepatolithiasis is difficult but vital. In this report, we present a novel approach to manage hepatolithiasis using the choledochoscopic Frequency-Doubled Double pulse Nd:YAG (FREDDY) laser lithotripsy combined with or without hepatectomy.

METHODS

Between July 2009 and October 2012, 45 patients underwent choledochoscopic FREDDY laser lithotripsy combined with or without hepatectomy (laser lithotripsy group). Forty-eight patients underwent a traditional operation (traditional method group) from January 2009 to June 2009. Comparative analysis was made of demographic and clinical characteristics of the two groups.

RESULTS

The final stone clearance rate of the laser lithotripsy group was 93.3%, whereas that of the traditional method group was 85.4% (P=0.22). In the laser lithotripsy group, 2 patients experienced hemobilia and 3 patients had acute cholangitis. In the traditional method group, 3 patients had intraoperative hemorrhage, 1 patient had bile leakage, 6 patients had acute cholangitis, and 1 patient died of liver failure. Moreover, the operative time in the traditional method group was significantly longer than that in the laser lithotripsy group (P=0.01). The mean hospital stay of the patients in the traditional method group was longer than that in the laser lithotripsy group (9.8 vs 8.2 days, P=0.17). Recurrent intrahepatic bile duct stones were not found during the follow-up period in the two groups.

CONCLUSION

Operative choledochoscopic FREDDY laser lithotripsy combined with or without hepatectomy may be an effective and safe treatment for hepatolithiasis.

Classification and management of hepatolithiasis: A high-volume, single-center's experience

Hepatolithiasis is endemic to East Asia, but immigration from the region means that this rare but emerging disease will pose a therapeutic challenge to doctors in the West as well. Curative management of hepatolithiasis is difficult since its etiology has not been fully elucidated. Hepatectomy is the best approach to treating hepatolithiasis. Here, we propose a novel classification of hepatolithiasis and describe features of each type. We then relate our experience with various forms of hepatectomy to treat different types of hepatolithiasis. Surgery should be indicated for all cases of hepatolithiasis. The proposed classification will help to determine surgical strategies. Better selection of which patients should undergo a hepatectomy will lead to better outcomes.

Hepatic resection for bilateral hepatolithiasis: a 20-year experience

BACKGROUND

There is increasing evidence showing that hepatic resection is probably the best definitive treatment for unilateral hepatolithiasis. However, the role of hepatic resection for bilateral hepatolithiasis is rarely mentioned in the literature.

METHODS

We retrospectively reviewed 197 patients who underwent hepatic resection for hepatolithiasis in Changhua Christian Hospital from December 1987 to December 2007. A total of 156 patients with unilateral hepatolithiasis were defined as the UNI group (control group), and 41 patients with bilateral hepatolithiasis were defined as the BI group (study group). The short- and long-term outcomes were measured.

RESULTS

The BI group had longer operating time (200 min versus 173 min, P = 0.006), lower immediate stone clearance rate (56.1% versus 91.7%, P < 0.001), lower final stone clearance rate (75.6% versus 94.9%, P = 0.001), higher rate of stone recurrence (22.6% versus 6.1%, P = 0.009) and higher disease-related mortality (19.5% versus 5.1%, P = 0.006). Thirty patients with bilateral peripheral stones were indicated for bilateral hepatectomy, but only 20 (66.7%) of them actually underwent the proposed procedure. Of the patients who did not achieve immediate stone clearance, bilateral peripheral stones represented 88.9% (P = 0.044). Of the patients who had stone recurrence, patients less than 35 years old represented 42.9% (P = 0.007).

CONCLUSION

Bilateral hepatolithiasis has worse outcomes than unilateral hepatolithiasis after being treated with hepatic resection. Regarding bilateral peripheral stones, there is often a discrepancy between the extent of stone-affected parenchyma and that of final liver resection, resulting in a lower immediate stone clearance rate. A higher stone recurrence rate was observed among younger population.

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.

Selection of surgical treatment types for intrahepatic duct stones

Backgrounds/Aims

Complete elimination of intrahepatic duct (IHD) stones is difficult and IHD stone disease is frequently associated with various complications, recurrence and sometimes cholangiocarcinoma. Therefore, we analyzed the long-term surgical results and evaluated the management currently considered appropriate.

Methods

Overall 110 patients who had been diagnosed with benign IHD stone disease and who underwent surgical treatment were enrolled in this study. The patients were categorized into three groups according to the type of surgery performed; liver resection (LR) group, intrahepatic duct exploration (IHDE) group and hepaticoenterostomy (HE) group. We compared and analyzed the results of these three groups.

Results

The number of cases in the LR group, IHDE group and HE group were 77, 25 and 8 respectively. The LR group required a longer operation time (p=0.000), more frequent transfusion (p=0.028) and had higher morbidity (p=0.049). However, the LR group had a higher clearance rate (90.9%) (p=0.000) than the other groups. In addition, there were a total of 22 cases of IHD stone recurrence during the follow-up, but there was no statistically significant difference among the three groups. The location of IHD stones was related to a risk factor for incomplete stone removal, but not for recurrence.

Conclusions

The fundamental principle for the treatment of IHD stone disease should be liver resection. However, it can lead to a longer operative time and higher rate of complications than the other procedures. There is also no difference in the IHD stone recurrence rate among the procedures. Therefore, these alternative and minor procedures could also be taken into account for patients with poor preoperative condition.

Does bilioenteric anastomosis impair results of liver resection in primary intrahepatic lithiasis?

AIM: To evaluate the long-term results of liver resection for the treatment of primary intrahepatic lithiasis. Prognostic factors, especially the impact of bilioenteric anastomosis on recurrence of symptoms were assessed.

METHODS: Forty one patients with intrahepatic stones and parenchyma fibrosis/atrophy and/or biliary stenosis were submitted to liver resection. Resection was associated with a Roux-en-Y hepaticojejunostomy in all patients with bilateral stones and in those with unilateral disease and dilation of the extrahepatic biliary duct (> 2 cm). Late results and risk factors for recurrence of symptoms or stones were evaluated.

RESULTS: There was no operative mortality. After a mean follow-up of 50.3 mo, good late results were observed in 82.9% of patients; all patients submitted to liver resection alone and 58.8% of those submitted to liver resection and hepaticojejunostomy were free of symptoms (P = 0.0006). Patients with unilateral and bilateral disease showed good late results in 94.1% and 28.6%, respectively (P < 0.001).

CONCLUSION: Recurrence of symptoms in patients with hepaticojejunostomy showed that this may not be the ideal solution. Further studies are needed to establish the best treatment for patients with bilateral stones or unilateral disease and a dilated extrahepatic duct.

Surgical treatment of complicated hepatolithiasis using the ultrasound-guided fiberoptic choledochoscope

BACKGROUND

The residual stones of postsurgical intrahepatic calculi have been among the most difficult problems in hepatobiliary surgery. Intraoperative ultrasound can clearly display the morphology of intrahepatic bile ducts and the distribution of calculi as well as the position of the choledochoscope and the calculus extraction instruments. Therefore, intraoperative ultrasound can guide the choledochoscope and its auxiliary equipment for calculus extraction. It is necessary to evaluate the effectiveness and safety of surgeries using an ultrasound-guided fiberoptic choledochoscope for the treatment of complicated hepatolithiasis.

METHODS

The 56 cases in group A were selected from patients who had complicated hepatolithiasis treated with calculus extraction therapy using an ultrasound-guided fiberoptic choledochoscope in the authors' hospital between January 2006 and June 2009. The 63 cases of complicated hepatolithiasis in group B were chosen from patients treated with calculus extraction surgeries using a fiberoptic choledochoscope without the guidance of ultrasound from September 2001 through December 2005. Transabdominal ultrasound, T-tube cholangiography, and computed tomography (CT) examination were performed on day 15 after the surgery to compare the complete stone clearance rate, the residual stone rate, and the incidence rate of postoperative complications between groups A and B.

RESULTS

The intrahepatic calculi were completely removed in 53 group A cases. The complete stone clearance rate was 94.6%, and the residual stone clearance rate was 5.4%. In group B, 51 cases had complete stone removal, for a stone clearance rate of 81% and a residual stone rate of 19%. The difference in the residual stone rates between the two groups is statistically significant (p=0.025). No hemobilia, biliary perforation, or other complications were observed in either group.

CONCLUSION

Use of the intraoperative ultrasound-guided fiberoptic choledochoscope in the treatment of complicated hepatolithiasis can significantly reduce the residual stone rate of intrahepatic biliary calculi and significantly improve the treatment effect of hepatolithiasis.

Efficacy of antisense gene therapy for proliferative cholangitis

AIM: To compare the effects of short hairpin RNAs (shRNAs) targeting the proliferating cell nuclear antigen (PCNA), c-Myc and cdc2 k genes on the hyperplastic behavior and lithogenic potential of proliferative cholangitis (PC), and to select the best target for antiproliferative treatment of PC.

METHODS: A rat model of PC was developed by retrogradely inserting a nylon thread into the common bile duct. Using the nylon thread as the guide wire, an intralumenal injection of PCNA, c-Myc and cdc2 k shRNAs into the common bile duct was performed in three different groups of model rats, respectively.

RESULTS: Compared to the c-Myc and cdc2 k shRNA treatment groups, the degree of hyperplasia of biliary epithelium and collagen fibers in the bile duct wall in the PCNA shRNA treatment group were significantly decreased. In addition, the protein expression and secretion of mucin from the hyperplastic biliary epithelium and peribiliary gland were remarkably reduced in the PCNA shRNA treatment group.

CONCLUSION: PCNA shRNA possesses more strong inhibitory effects on collagen fiber hyperplasia in and mucin secretion from the bile duct wall of rats with experimental PC than c-Myc and cdc2 k shRNAs. Therefore, PCNA shRNA holds more promise for prevention of postoperative biliary restenosis and stone recurrence in PC patients.

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.