Liver resection for intrahepatic stones

HYPOTHESIS: Long-term outcome is good for a selected group of patients with hepatolithiasis treated with liver resection. Liver resection should also be offered to patients with complex hepatolithiasis such as bilateral stones or those with strictures. DESIGN: Retrospective study. SETTING: Regional hospital. PATIENTS: A total of 174 patients with hepatolithiasis (201 procedures) treated between January 1, 1989, and September 30, 2003. INTERVENTIONS: Liver resection (52 procedures) or removal of stones primarily by percutaneous choledochoscopy (149 procedures). MAIN OUTCOME MEASURE: Recurrence of cholangitis. RESULTS: Most patients in the liver resection group had stones localized to the left side. The overall success rate in this group was 98.0% (49 of 50 patients, excluding 2 patients found to have cholangiocarcinoma). The chance of biliary sepsis at 5 years after resection was 13.3%. The overall success rate of stone removal primarily by percutaneous choledochoscopy was 70.5%. The bilaterality of stones, the presence of stricture, and the presence of atrophy were found to be significant risk factors for a poor long-term outcome after stone removal alone. The chance of biliary sepsis at 5 years was 26.4% and 43.2% for those without and with stricture, respectively. CONCLUSIONS: The long-term outcome after liver resection for hepatolithiasis was excellent for a selected group of patients. Poor outcomes were recorded for patients whose intrahepatic stones were removed primarily by percutaneous choledochoscopy, especially those with strictures. The indication for liver resection for hepatolithiasis should be extended to patients with strictures and those with bilateral stones. A combination of different treatment modalities is necessary to improve the outcome of these patients.     

肝叶切除治疗肝胆管结石

原发性肝内胆管结石主要是以胆色素为主的泥砂样结石。由于其病理变化十分复杂,手术常无定式,故处理起来比胆固醇结石要困难得多。许多病人往往经过多次手术仍不能彻底解除病痛。肝胆管结石的确定性治疗原则首先是先去除肝内结石,然后处理胆管狭窄（后者是造成肝内胆管...     

Clinical significance of intrahepatic biliary stricture in efficacy of hepatic resection for intrahepatic stones

In the Far East, hepatic resection is the definitive treatment for complicated intrahepatic stones (IHS). However, many investigators have reported that the associated intrahepatic biliary stricture is the main cause of treatment failure. A retrospective comparative study was undertaken to clarify the long-term efficacy of hepatic resection for treatment of IHS and to investigate the clinical significance of intrahepatic biliary stricture in treatment failure after hepatic resection performed in 44 patients with symptomatic IHS. The patients were divided into two study groups: group A, with intrahepatic biliary stricture (n = 28) and group B, without stricture (n = 16). Residual or recurrent stones, recurrence of intrahepatic biliary stricture, late cholangitis, and final outcomes were analyzed and compared statistically between the two groups. The patients were followed up for a median duration of 65 months after hepatectomy. The overall incidence of residual or recurrent stones was 36% and 11%, respectively, in groups A and B. The initial treatment failure rate was 50% in group A and 31% in group B. Intrahepatic biliary stricture recurred in 46% of patients in group A, while none of the group B patients had biliary stricture recurrence (P = 0.001). More than two-thirds of the restrictures in group A were identified at the primary site. The incidence of late cholangitis was higher in group A (54%) than in group B (6%) (P = 0.002). Three-quarters of the patients with cholangitis in group A had severe cholangitis, that was recurrent, and related to stones and strictures (n = 11). They and 2 asymptomatic patients in group B required secondary procedures done at a median of 12 months after hepatectomy. Final outcomes after hepatectomy with or without secondary management were good in 80%, fair in 16%, and poor in 4% of our 44 patients. Most recurrent cholangitis after hepatectomy in patients with IHS was related to recurrent intrahepatic ductal strictures. Therefore, to be effective, hepatic resection should include the strictured duct. However, with hepatectomy alone it is difficult to clear the IHS or relieve the ductal strictures completely, particularly in patients with bilateral IHS, so perioperative team approaches that include both radiologic and cholangioscopic interventions should be combined for the effective management of IHS. Received for publication on Oct. 15, 1997; accepted on Feb. 2, 1998     

肝内胆管结石的腹腔镜治疗

目的探讨腹腔镜治疗肝内胆管结石的方法。方法2000年3月~2005年3月,57例肝内胆管结石在腹腔镜下将肝总管高位切开至左右肝管汇合部,显露左右肝管的开口,在腹腔镜监视下,用取石钳、取石网篮、加压冲洗等方法将左右肝管内结石取出,进而利用扩张的左右肝管,显露二级胆管的开口,取出二级胆管结石,在二级胆管明显扩张时,还可以看到三级胆管内的结石,并将其取出。存在较多泥沙样结石时,导尿管反复冲洗胆道。结果中转开腹3例(5.3%,3/57)。57例手术时间75~275 m in,(136±54)m in。49例(86.0%,49/57)术后仍有残石,需要1~4次胆道镜取石。术后胆漏5例(8.8%,5/57),经腹腔引流治愈。43例随访0.5~5年,(2.3±1.5)年,优38例(88.4%),良3例(7.0%),差2例(4.6%)。结论腹腔镜下肝内胆管结石可通过肝总管高位切开的方法较好地显露一、二级胆管,甚至三级胆管,在腹腔镜监视下将结石取出。     

Partial hepatectomy for intrahepatic stones

Fifty partial hepatectomies were performed in 49 patients as the definitive treatment for symptomatic intrahepatic stones. The part of the liver containing the strictured ducts and stones was resected. In 39 patients, it was done as the primary procedure, and in 11, it was done when an initial procedure (including one left hepatic lobectomy) had failed. Partial hepatectomy was the preferred method of management when the patients had 1 or more of the following conditions: stones confined to one segment or one lobe of the liver; destruction of the portion of the liver harboring the stones from repeated episodes of obstruction and infection; and multiple strictures of the ducts in the involved portion of the liver. The operative mortality was 2%. Long-term follow-up on 44 patients at a median of 7 years showed that 82% were symptom free, 7% had occasional mild attacks of cholangitis, and 11% had severe cholangitis requiring surgical intervention. At reoperation for severe cholangitis, 2 were found to have sphincteroplasty strictures and 3 had stones and ductal strictures. The low operative mortality rate and the overall good results show that partial hepatectomy can be considered as the primary treatment of choice for selected patients with intrahepatic stones.

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Resumen Cincuenta hepatectomías parciales han sido realizadas como la forma definitiva de tratamiento en 49 pacientes con cálculos intrahepáticos sinomáticos. La parte del hígado que contenía los canales hepáticos estenosados y con cálculos fue resecada, en 39 casos como el procedimiento primario y en 11 cuando el procedimiento inicial (incluyendo una hepatectomía lobar izquierda) había fallado. La hepatectomía parcial fue escogida en preferencia sobre otras modalidades de manejo en aquellos pacientes que exhibían una o más de las condiciones siguientes: cálculos confinados a un segmento o a un lóbulo del hígado; destrucción de la porción del hígado que albergaba los cálculos por episodios repetidos de obstrucción e infección; y presencia de estenosis multiples en los canales de la porción afectada del hígado. La tasa de mortalidad operatoria fue 2%. El seguimiento a largo plazo sobre 44 pacientes, con un promedio de 7 años, mostró que el 82% se mantuvo libre de síntomas, 7% presentó ataques levés y ocasionales de colangitis y 11% tuvo colangitis severa que requirió intervención quirÚrgica. En la reoperación por colangitis severa se encontró que 2 pacientes presentaban estenosis de la esfinteroplastia y que 3 tenían cálculos y estenosis de los canales. La baja mortalidad operatoria y los buenos resultados globales demuestran que la hepatectomía parcial puede ser considerada como el tratamiento primario de escogencia en pacientes seleccionados con cálculus intrahepáticos.

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Résumé Cinquante hépatectomies partielles ont été pratiquées pour assurer la guérison d'une lithiase biliaire intrahépatique s'exprimant par des troubles. Le segment du foie ou siégeaient les rétrécissements et les calculs a été réséqué. Chez 39 sujets elle a été pratiquée d'emblée et chez 11 de seconde main après échec de la première intervention (1 cas concernait une lobectomie gauche). L'hépatectomie partielle a été préférée quand les malades présentaient une ou plusieurs de conditions pathologiques suivantes: calculs localisés dans un segment ou dans un lobe du foie; destruction d'une partie du parenchyme hépatique à la suite d'épisodes répétés d'obstruction et d'infection; et rétrécissements multiples des canaux biliaires intrahépatiques au niveau de la partie du parenchyme intéressé par la lithiase. La mortalité opératoire a été de 2%. Quarante-quatre malades ont été suivis longtemps; 7 ans en moyenne. Dans 82% des cas ils n'ont présenté aucune manifestation pathologique, 7% ont subi des poussées légères d'angiocholite, 11% ont accusé une angiocholite grave imposant une nouvelle opération. Au cours de celle-ci il a été observé 2 cas de sténose après sphinctéroplastie et 3 cas où des rétrécissements et de calculs étaient présents. Le taux faible de la mortalité et les bons résultats à long terme montrent que l'hépatectomie partielle peut Être considérée comme l'opération de choix pour traiter la lithiase biliaire intrahépatique.

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Presented at the 8th World Congress of the Collegium Internationale Chirurgiae Digestivae at Amsterdam, The Netherlands, September 1984.     

硬质胆道镜碎石取石术

正【内容简介】随着近年来胆道镜技术的广泛应用和手术器械设备的发展,肝内外胆管结石的治疗水平不断提高。该手术视频清晰直观地演示了用硬质胆道镜治疗肝内胆管结石的全过程:经鞘管插入硬质胆道镜,探查肝内胆管或胆总管结石。遇到小于鞘管直径的结石用取石钳钳夹,较大结石可用鞘管碾压切割,或用气压弹道等碎石工具击碎后用水流经鞘管冲出。该术式使用鞘管建立直观路径,简化操作,方便高效,同时兼顾经济、安全、并发症少的优点,利于临床推广。     

Liver resection as the definitive treatment for unilateral non-oriental primary intrahepatic lithiasis

BACKGROUND: The current study sought to evaluate the results of liver resection as the treatment for unilateral non-oriental primary intrahepatic lithiasis (PHIL). METHODS: Twenty-seven symptomatic patients (mean age 42 years) were submitted to liver resection; the indications were parenchymal fibrosis/atrophy in 22 and biliary stenosis in 5. Resection was associated with a Roux-en-Y hepaticojejunostomy in patients with a significant degree of dilation of the extrahepatic biliary duct. RESULTS: There was no operative mortality and the morbidity rate was 7.4% (2 patients with biliary fistula). After a median follow-up of 41.2 months, the overall rate of good results was 92.6%. All patients submitted to liver resection alone presented good late results, while 80% of those with associated hepaticojejunostomy did not have complications (P = .12). Late complications were observed in 2 patients (7.4%): 1 with a liver abscess and 1 with cholangitis and recurrent stones. There was no mortality during long-term follow-up. CONCLUSIONS: Liver resection showed low incidence of complications and good long-term results. None of the patients with unilateral disease without associated extrahepatic bile duct dilation presented complications and they were considered cured. We believe that resection indications should be expanded and the procedure should be indicated as routine in patients with unilateral PHIL even in the absence of parenchymal fibrosis/atrophy or biliary stenosis.     

纤维胆道镜联合肝切除术治疗肝内胆管结石的临床研究

目的:探讨纤维胆道镜联合肝切除术治疗肝内胆管结石的临床疗效。方法:将2011年1月至2012年12月收治的70例肝内胆管结石患者按手术方式分为观察组(n=35例)与对照组(n=35例),两组均行胆管切开纤维胆道镜取石,观察组在对照组的基础上切除病变部位肝段,观察并对比两组手术有效率、术后并发症发生率、术后残石率、术后复发率。所得数据采用χ2检验。结果:观察组手术有效率为88.57%,显著高于对照组(65.71%),两组差异有统计学意义(P<0.05)。观察组手术并发症发生率低于对照组,但差异无统计学意义(P>0.05)。观察组患者术后残石率(5.71%)、复发率(5.71%)均显著低于对照组,差异有统计学意义(P<0.05)。结论:纤维胆道镜联合肝切除术治疗肝内胆管结石疗效显著,安全性肯定,是较理想的治疗手术。     

Treatment of bilateral intrahepatic stones with high duct strictures through selective central hepatic resection

Bilateral intrahepatic duct stones with strictures, more common in the Orient than elsewhere, are difficult to access surgically. The results of surgical procedures have not been generally successful and are attended by a high postoperative complication and recurrence rate. We report the treatment of 30 patients with intrahepatic calculi and high duct strictures by means of selective central hepatic resection without dissection of the major vessels at the hilum. Central hepatic resection provided satisfactory access to the primary and secondary confluences of the intrahepatic ducts, allowed removal of residual stones and ascariasis, and permitted correction of multiple strictures. Twenty-nine patients so treated were followed for a mean of 32 months after operation. No patients developed recurrent fever, biliary colic, or jaundice after the operation. The technique is therefore recommended as an effective alternative to extensive hepatic lobectomy in the treatment of the intrahepatic calculi with multiple strictures.     

Current management of intrahepatic stones

A high incidence of intrahepatic stones occurs in East Asia. The surgical management of intrahepatic stones is problematic because it is difficult to locate and remove all the stones and relieve the accompanying biliary strictures. Consequently, the rate of recurrent cholangitis is high. Many new techniques have been introduced to locate, fragment, and retrieve gallstones. Operative procedures to relieve biliary strictures have also undergone development. These new procedures and techniques have been applied to intrahepatic stones. The initial results are good. Whether these good results can be maintained in the long-term remains to be seen.

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Resumen En el Asia Oriental se presenta una elevada incidencia de cálculos intrahepáticos. El manejo quirúrgico de los cálculos intrahepáticos es problemático por cuanto es difícil localizar y extraer la totalidad de los cálculos y corregir las estrecheces biliares asociadas. En consecuencia, es alta la tasa de colangitis recurrente. Se han descrito numerosa nuevas técnicas para localizar, fragmentar, y extraer los cálculos. También han tenido novedoso desarrollo los procedimientos operatorios para corregir las estenosis biliares. Tales procedimientos y técnicas innovativas han sido aplicados al tratamiento de los cálculos intrahepáticos. Los resultados iniciales son buenos, pero habrá que ver si tales buenos resultados persisten en el seguimiento a largo plazo.

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Résumé La lithiase intrahépatique est fréquente en Asie de l'Est. Le traitement chirurgical des calculs intrahépatiques pose des problèmes car il est difficile de localiser les calculs, de tous les enlever et de pallier la sténose concomitante des voies biliares. Ainsi le taux de récidive d'angiocholite est fort. On a trouvé de nombreuses techniques nouvelles pour localiser, fractionner et extraire les calculs biliaires ainsi que des procédés efficaces pour traiter la sténose des voies biliaires. On a appliqué ces techniques et procédés nouveaux aux calculs intrahépatiques. Les premiers résultats sont bons. Reste à voir si ces bons résultats resteront valables à long terme.

     

Long-term results of surgical treatment for intrahepatic stones

One hundred and nineteen patients with intrahepatic stones treated surgically in Nagasaki University Hospital from 1969 to 1984 were reviewed. The patients were divided into four types according to location of the stones and the presence or absence of stenotic lesions and/or localized dilatation of the intrahepatic bile ducts. Types I and II patients were treated with choledocholithotomy or choledochojejunostomy, while type III patients underwent hepatic resection and type IV patients were treated by partial hepatic resection with bilioenteric anastomosis, including extended hepaticocholedochojejunostomy. The majority of operative or early deaths belonged to type IV and residual stones were present in almost all patients. The longterm results for the 88 patients revealed that the rate of improvement was 100 per cent for type I, 87 per cent for type II, 83 per cent for type III and 84 per cent for type IV. In type IV, the most excellent results (92 per cent) were obtained by extended hepaticocholedochojejunostomy, especially with hepatectomy. It is suggested that extended hepaticocholedochojejunostomy with partial hepatic resection is a reasonable procedure for treating patients with type IV intrahepatic stones.     

Long-term results of surgical treatment for intrahepatic stones

One hundred and nineteen patients with intrahepatic stones treated surgically in Nagasaki University Hospital from 1969 to 1984 were reviewed. The patients were divided into four types according to location of the stones and the presence or absence of stenotic lesions and/or localized dilatation of the intrahepatic bile ducts. Types I and II patients were treated with choledocholithotomy or choledochojejunostomy, while type III patients underwent hepatic resection and type IV patients were treated by partial hepatic resection with bilioenteric anastomosis, including extended hepatico-choledochojejunostomy. The majority of operative or early deaths belonged to type IV and residual stones were present in almost all patients. The long-term results for the 88 patients revealed that the rate of improvement was 100 per cent for type I, 87 per cent for type II, 83 per cent for type III and 84 per cent for type IV. In type IV, the most excellent results (92 per cent) were obtained by extended hepaticocholedochojejunostomy, especially with hepatectomy. It is suggested that extended hepaticocholedochojejunostomy with partial hepatic resection is a reasonable procedure for treating patients with type IV intrahepatic stones.     

The significance of hepatectomy for primary intrahepatic stones

(Received for publication on Aug. 13, 1998; accepted on Mar. 11, 1999)     

肝切除治疗肝胆管结石(附644例报告)

分析肝切除治疗肝胆管结石的疗效。方法报告１９７５年至１９９９年１１月６４４例肝内胆管结石病人采用肝切除治疗的术式,并发症及随访情况,结果本组治疗方式中合并的肝切除率为５２％;６４４例中６２．９％经历过１－５次手术,其中２０．５％,合并不同类型的胆肠吻合。肝切除术式：左外叶切除３７８例（５８．７％）;左半肝切除１３２例（２０．５％）;右半肝切除３１例（４．８％）;多段切除６６例（１０．３％）;肝方叶     

Postoperative choledochofiberscopic removal in intrahepatic stones

An endoscopic approach for the diagnosis and treatment of intrahepatic stones is presented based on the experience of 4 cases, in which complete removal of intrahepatic stones was done by postoperative choledochoscopy. Postoperative choledochoscopy for the diagnosis and treatment of gall-stone disease is not difficult to perform. The choledochofiberscope is inserted into the bile duct via choledochal fistula 3 weeks after the operation. Stones are crushed or grasped with forceps under direct vision. In some cases, the stricture in the intrahepatic biliary tree is dilated with the use of a high frequency waves cutting knife to facilitate stone removal. In fact, over 410 stones were successfully removed in one case by 28 postoperative choledochoscopies without any complications. The details of the choledochofiberscope developed by us with the close cooperation of Machida Company of Tokyo was presented. Postoperative choledochoscopy seems to be a safe and simple procedure and is useful in the treatment of intrahepatic stones.     

肝胆管结石的诊断和治疗

肝胆管结石是我国常见和难治的胆道疾病。由于其在治疗上的复杂性及常合并严重并发症和晚期的肝损害，肝胆管结石仍然是外科医生经常需要面对的棘手问题，有必要对其诊断和治疗进行进一步规范。