The effect of decreased portal blood flow on the biliary system

A disturbance in the regional portal blood flow adjacent to the dilated bile duct in the liver is often observed in patients with hepatolithiasis. The effects of this disturbed portal blood flow on the biliary system, with or without cholangitis, were therefore investigated. Young rabbits were divided into the following four groups; (1) controls that had a laparotomy only (n = 3), (2) those that had a ligation of the portal branch of the right posterior lobe (RP lobe) (PL) (n = 10), (3) those that had tubing inserted into the bile duct through the duodenal papilla (BS) (n = 10), and (4) PL + BS (n = 10). Despite marked atrophy of the RP lobe, no distinct changes were seen in the biliary systems of groups 1 or 2. In groups 3 and 4, however, infiltration of inflammatory cells and glandular proliferation in the wall of the markedly dilated extrahepatic bile duct (proliferative cholangitis (PC), characteristic to hepatolithiasis) were seen. Findings of PC were also noted in the intrahepatic bile duct of the atrophied RP lobes of these 2 groups. The incidence of PC was 20 per cent in group 3 and 60 per cent in group 4, respectively, but the PC of the intrahepatic bile ducts in group 3 was more localized than in group 4. Goblet cell metaplasia was seen in the epithelial cells of PC. Bacteriologically, bile samples were aseptic in groups 1 and 2, however, samples of bile from groups 3 and 4 were all contaminated with Escherichia coli or Streptococcus Faecalis. The biliary contents of phospholipids, total cholesterol and total bile acid were significantly decreased in groups 3 and 4, when compared with groups 1 and 2. In conclusion, a disturbance in portal blood flow, accompanied by cholangitis and segmental liver atrophy, may play an important role in the clinical course of hepatolithiasis.     

肝胆管结石并发复发性胆管炎时择期手术处理的关键

目的 探讨提高肝胆管结石并发复发性胆管炎病人治疗水平的方法。方法 报告3例肝胆管结石并发复发性胆管炎病人的手术中发现及胆树的主要梗阻部位。结果 例1是右后肝管与右前肝管汇入左肝管横部的胆管变异致右肝管狭窄继以结石形成、右肝叶萎缩；例2胆树的主要梗阻部位是肝尾叶结石及右肝动脉对肝总管的压迫性狭窄；例3总肝管狭窄及嵌顿结石是主要的梗阻部位，并采用了相应的手术方式治疗。结论 掌握影像诊断如BUS、CT、ERCP、MRCP提供的资料，术中仔细探查胆道，加上术中胆道镜运用，消除与胆管炎密切相关的主要梗阻是手术处理肝胆管结石并发复发性胆管炎病人的关键。     

肝门胆管良性狭窄个体化治疗的临床研究

目的 前瞻性地评价肝门胆管良性狭窄的处理方式与近远期疗效的关系。方法 前瞻性观察了按病因不同分为4组的25例患者,分别以不同方式治疗所取得的近远期疗效。结果 肝门胆管空肠吻合术治疗良性医源性肝门胆管狭窄疗效确切,随访期间返流性胆管炎1例,发生率较低,仅为10%,肝门胆管原位整形保持了胆管生理学的完整性,惟需可用的良好的自体修补组织及合理的手术设计两个因素;含石的萎缩右半肝切除加肝门胆管整形既达到了清除病灶的目的,又保持了胆管的通畅性及生理功能的完整性;气囊扩张虽对轻度环形狭窄有良效,但继发性硬化性胆管炎伴肝门管状狭窄气囊扩张疗效欠佳。结论 根据不同病因选择各异的治疗方案（个体化）,处理肝门胆管良性狭窄可获近远期良效。     

The practical value of applying chemical biliary duct embolization to chemical hepatectomy for treatment of hepatolithiasis

BACKGROUND: The high recurrence rate of hepatolithiasis, together with the high operative risk of hepatectomy for specifically located stones, has not been effectively settled until now. Thus, the aim of this study was to investigate the feasibility and effectiveness of using chemical biliary duct embolization (CBDE) to achieve chemical hepatectomy in a rabbit model of hepatolithiasis. MATERIALS AND METHODS: The animal model of hepatolithiasis was established using the methods of obstruction plus infection. Seven days later, the left hepatic ducts were embolized using phenol plus cyanoacrylate or absolute ethanol plus cyanoacrylate. Subsequently, the influence of CBDE on bile duct, liver, and stone formation was analyzed by histology, RT-PCR for procollagen, biochemistry, and enzymatic histochemistry for beta-glucuronidase (beta-G). RESULTS: CBDE resulted in the entire ablation of the diseased biliary duct mucosa and the complete occlusion of the diseased biliary duct lumen, thus effectively eradicating chronic proliferative cholangitis and preventing stone formation. More importantly, CBDE also resulted in the complete fibrosis and "self-cut" in the periphery of the embolized lobe, thus achieving chemical hepatectomy. Also of note, the embolized lobe exhibited a much lower level of endogenous beta-G than the nonembolized lobe, indicating an inhibitory effect of CBDE on beta-G. Besides, the mRNA level of procollagen I in the embolized bile duct wall of phenol embolization group was significantly higher than the ethanol embolization group. CONCLUSION: Chemical biliary duct embolization, especially using phenol plus cyanoacrylate, may prevent the recurrence of intrahepatic stone and concurrently achieve the effect of chemical hepatectomy.     

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??Surgical treatment of hepatolithiasis in right lobe of liver: a report of 102 cases HE Ling??LI Wen-mei. Department of General Surgery??Affiliated Hospital of Xuzhou Medical College??Xuzhou 221002??China
Corresponding author??LI Wen-mei??E-mail??L5748036@126.com
Abstract Objective To explore the surgical treatment of hepatolithiasis in right lobe of liver. Methods Retrospective analysis the surgical treatment methods and efficacy of the 102 cases of hepatolithiasis in right lobe of liver in affiliated hospital of Xuzhou medical college from January 2000 to December 2008. Results 30 cases in this group underwent hepatic segmentectomy; and the remaining 72 cases underwent resection of the liver lobi, and incided common bile duct???? and ?? grade bile duct and removed the stones??Of which 20 cases were placed directly T-tube or U-tube drainage??33 cases were formed the narrow bile ducts and placed T-tube or U-tube drainage??and 19 cases received choledochojejunostomy. 42 cases combined common bile duct stones which underwent incision of common bile duct and removed the stones. All cases of postoperative jaundice subsided gradually, and liver function improved. Postoperative bile leakage occurred in 6 cases (5.9%), residual calculi happened in 5 cases(4.9%), cholangitis happened in 3 cases??2.9%??received cholecystojejunostomy??8 cases (7.8%) recurrent hepatolithiasis. Conclusion Hepatic segmentectomy or resection of the liver lobi ??incision of the secondary bile duct and removing the stones??forming the narrow bile duct??and placing T-tube or U-tube drainage or choledochojejunostomy for hepatolithiasis in right lobe of liver can obtain a good therapeutic effect. In addition??Forming bile duct stenosis, and placing T-tube or U-tube drainage can reduce the occurrence of postoperative complications, and more conducive to deal with complications.     

Intractable Biliary Strictures After Living Donor Liver Transplantation: A Case Series

BackgroundBiliary stricture (BS) is a severe complication after liver transplantation. It is difficult to treat, especially after living donor liver transplantation (LDLT). We successfully treated 4 patients for intractable BS after LDLT. All patients had developed cholangitis with stenosis of bile ducts anastomosis.Case 1. A 65-year-old woman underwent LDLT with right lobe graft and duct-to-duct biliary reconstruction. Internal plastic stents inserted by endoscopic retrograde cholangiography (ERC) were changed quarterly for the next 2 years.Case 2A 55-year-old man underwent LDLT with right lobe graft and duct-to-duct biliary reconstruction. Insertion of internal plastic stents by ERC was attempted; however, the posterior bile duct branch showed complete obstruction. After percutaneous transhepatic biliary drainage (PTCD), the stents were inserted using the rendezvous technique of ERC and were changed by ERC quarterly for the next 3 years.Case 3A 22-year-old man underwent LDLT with left lobe graft and hepaticojejunostomy. An external drainage tube was inserted by PTCD, and stents were changed quarterly for the next 2 years.Case 4A 60-year-old man underwent LDLT with right lobe graft and hepaticojejunostomy. An external drainage tube was inserted by PTCD, and changed to a metallic stent after 1 year. Three months later the stent was extracted using the rendezvous technique of double balloon enteroscopy.ConclusionBS of complete obstruction type after LDLT is difficult to treat. Appropriate procedures should be chosen based on the types of strictures and biliary reconstruction methods.     

肝胆管结石合并胆道感染的诊断及处理

肝胆管结石合并胆道感染是胆道外科的常见病,但如何合理、规范、彻底的治疗却是难题。须根据病人的临床表现,实验室检查和影像学检查做出临床诊断,准确评估病情,选择合适的治疗方案。肝胆管结石合并胆道感染,须在炎症完全控制后再实施确定性手术治疗。轻度急性胆管炎抗感染治疗可缓解症状,待炎症控制后进行确定性手术。中度急性胆管炎可先予以保守治疗,严密观察病情变化,如有加重,及时行胆道减压引流。重度急性胆管炎需尽早行胆管减压引流。胆道引流可选择内镜下引流、经皮经肝胆管引流（PTBD）或手术引流,待炎症完全控制后进行彻底性手术治疗。确定性手术治疗方式可选择肝段/肝叶切除,同时整复狭窄的胆管行胆道重建,必要时尚须行胆肠吻合。对合并慢性胆道感染,在取净肝内胆管结石需同时切除病变的肝组织。     

Treatment of hepatolithiasis by chemical bile duct embolization: report on 2 cases

The high recurrence of hepatolithiasis has not been settled effectively until now, which lead us to present a new therapy of the chemical bile duct embolization to resolve it. In our selected 2 patients, multiple biliary calculi, complicated by biliary stricture, were found in the inferior branch of left lateral bile duct via preoperative cholangiography. After the choledochoscopic cholelithotomy, the combination of absolute ethanol and N-butyl-cyanoacrylate were injected into the diseased biliary duct lumen. Two months later, their T-tube cholangiography demonstrated that the targeted biliary ducts were completely embolized, thus effectively preventing the calculous recurrence. Twelve and 15 months later, their computed tomography scan showed that the inferior segments of left lateral lobes were almost completely atrophied and disappeared, thus successfully achieving the chemical "resection" of the diseased hepatic lobe. Chemical bile duct embolization may be a feasible and safe technique to prevent the calculous recurrence and concurrently achieve the effect of chemical hepatectomy for highly selected hepatolithiasis cases.     

规则性肝段切除术治疗肝内胆管结石病

目的 总结采用肝段切除术治疗肝内胆管结石病的经验。方法 回顾性分析1975年1月至1998年12月间采用肝段切除术治疗514例肝内胆管结石的临床资料及远期疗效。结果 肝内胆管结石的分布：左外叶64例、左肝叶176例、右前叶10例、右后叶24例、右肝叶31例、双侧肝叶209例。合并症：合并有显著肝段或肝叶萎缩者280例，肝脓肿17例，胆瘘7例，胆管癌8例。265例有1-5次胆道手术史。手术方法：根据肝内结石的分布决定肝段或联合肝段切除的范围，其中S2－3切除284例、切除98例、切除26例、切除37例、双侧肝叶部分切除23例。附加术式包括经肝门胆管切开取石217例，经肝实质肝内胆管切开取石11例，胆管空肠Roux-en-Y吻合296例。术后并发症有胆漏15例（2.9%）、膈下感染23例(4.5%)、腹腔脓肿2例（0.4%）和肝衰3例（0.6%）等。11例（2.1%）术后死于肝衰竭。随访10个月到25年，75.9%症状消失，14.5%偶而有轻度胆管炎发作，9.6%仍反复发作严重胆道感染。49例手术效果差的主要原因是肝脏切除范围不够兖分而遗留病变的肝胆管。结论 规则性肝叶切除术是清除病灶的最有效手段。     

Liver transplantation for “mass-forming” sclerosing cholangitis after laparoscopic cholecystectomy

INTRODUCTIONChronic biliary obstruction consequence of a bile duct injury may require liver transplantation (LT) in case of secondary biliary cirrhosis, intractable pruritus or reiterate episodes of cholangitis. “Mass-forming” sclerosing cholangitis leading to secondary portal vein thrombosis and pre-sinusoidal portal hypertension has not been reported so far.PRESENTATION OF CASEWe present the case of a patient who underwent laparoscopic cholecystectomy for Mirizzi syndrome. The persistent bile duct obstruction due to a residual gallstone fragment was treated by a prolonged biliary stenting. Following repeated bouts of cholangitis, a fibrous centrohepatic scar developed, conglobating and obstructing the main branches of the portal vein and of the biliary tree. The patient developed secondary portal vein thrombosis and portal hypertension. After an extensive diagnostic work-up, including surgical exploration to rule out malignancy, the case was successfully managed by liver transplantation.DISCUSSIONMass-forming sclerosis of the bile duct and biliary bifurcation may develop as a consequence of chronic biliary obstruction and prolonged stenting. Secondary portal vein thrombosis and pre-sinusoidal portal hypertension represents an unusual complication, mimicking Klatskin tumor.CONCLUSIONA timely and proper management of post-cholecystectomy complications is of mainstay importance. Early referral to a specialized hepato-biliary center is strongly advised.     

腹腔镜与开腹胆总管探查术144例对比研究

目的 探讨胆囊结石合并胆总管结石行胆总管探查术的术式选择。方法 回顾性分析144例胆囊结石合并胆总管结石患者行腹腔镜与开腹胆总管探查术的临床资料。根据手术方式分为腔镜组（n=78）和开腹组（n=66）。结果 腔镜组一期缝合39例,T管引流32例,经胆囊管探查2例,中转开腹5例;术后胆漏7例,胆管炎4例,残余结石2例,肠穿孔1例,MODS 1例,电解质紊乱5例,伤口感染2例。开腹组术后胆漏合并胸、腹腔积液1例,胆管炎1例,残余结石2例,术后出血再次手术1例,电解质紊乱4例,伤口感染4例,肝肾功能不全2例,死亡1例。两组在术后并发症发生率方面比较差别无统计学意义（P＞0.05）。结论 与开腹手术比较,腹腔镜胆总管探查取石术具有微创、术中失血少、术后恢复快、术后住院时间短等优点,但尚不能完全替代传统开腹手术。     

Common bile duct pressure in patients with common bile duct stones with or without acute suppurative cholangitis

Resting common bile duct pressure was measured in three groups of patients: group 1, 53 patients with gallstones but without common duct stones; group 2, 35 patients with common bile duct stones unaccompanied by cholangitis; and group 3, 36 patients with common duct stones and acute suppurative cholangitis. A significantly higher pressure in the common bile duct was documented in patients with cholangitis when compared with the other two groups. Twenty-four patients with cholangitis had common duct pressure values above 20 cm H2O, the maximal values of normal. Additionally, patients with cholangitis with pressure values over 30 cm H2O (nine patients) showed absence of green bile in the extrahepatic biliary tract, suggesting cessation of bile excretion into biliary duct. In all these cases, an impacted stone at the distal end of the common bile duct was documented.     

Unusual cases of acute cholecystitis and cholangitis: Tokyo Guidelines

Unusual cases of acute cholecystitis and cholangitis include (1) pediatric biliary tract infections, (2) geriatric biliary tract infections, (3) acalculous cholecystitis, (4) acute and intrahepatic cholangitis accompanying hepatolithiasis (5) acute biliary tract infection accompanying malignant pancreatic-biliary tumor, (6) postoperative biliary tract infection, (7) acute biliary tract infection accompanying congenital biliary dilatation and pancreaticobiliary maljunction, and (8) primary sclerosing cholangitis. Pediatric biliary tract infection is characterized by great differences in causes from those of adult acute biliary tract infection, and severe cases should be immediately referred to a specialist pediatric surgical unit. Because biliary tract infection in elderly patients, who often have serious systemic conditions and complications, is likely to progress to a serious form, early surgery or biliary drainage is necessary. Acalculous cholangitis, which often occurs in patients with serious concomitant conditions, such as those in intensive care units (ICUs) and those with disturbed cardiac, pulmonary, and nephric function, has a high mortality and poor prognosis. Cholangitis accompanying hepatolithiasis includes recurrent pyogenic cholangitis, an epidemic disease in Southeast Asia. Biliary tract infections, which often occur after a biliary tract operation and treatment of the biliary tract, may have a fatal outcome, and should be carefully observed. The causes of acute cholangitis associated with pancreaticobiliary maljunction differ before and after operation. Direct cholangiography is most useful in the diagnosis of primary sclerosing cholangitis. If cholangiography visualizes a typical bile duct, differentiation from acute pyogenic cholangitis is easy. This article discusses the individual characteristics, diagnostic criteria, treatment guidelines, and prognosis of these unusual types of biliary tract infection.     

深低温对肝脏胆管系统三级以上分支的影响

目的探讨深低温对肝脏胆管系统三级以上分支的影响。方法本研究采用30只小猪,随机分为4组。用平底冷冻头分别对A组动物第一肝门部、B组动物左肝外叶的Glisson管道、C组动物左肝外叶Glisson管道的主要分支区域进行3分钟的直接深低温冷冻(冷冻时阻断肝门);对照组:仅阻断肝门3分钟。术后通过血清学、核素扫描、彩色多谱勒和病理学等方法了解肝组织及管道系统变化。结果A组动物肝门部的胆管系统在冷冻后出现严重损伤,表现为进行性、不可逆的胆管坏死、狭窄、胆瘘、化脓性胆管炎等并发症;在B、C组,冷冻可造成受冻部位肝实质、胆管及门静脉分支管壁的坏死,而肝动脉分支不受影响,术后8周原冷冻区的肝动脉、门静脉分支的管腔依然保持通敞,所在肝叶萎缩、纤维化。结论如对第一肝门部进行直接深低温冷冻,应注意避免损伤胆管系统。机体可耐受对部分肝叶胆管系统二、三级分支区域的直接深低温冷冻;冷冻可造成受冻部位肝实质的坏死,达到外科治疗目的。     

腹腔镜肝切除术治疗左肝内胆管结石的临床应用

目的 探讨腹腔镜肝切除术治疗左肝内胆管结石的技术与疗效。 方法 回顾性分析2011年1月至2016年12月完成67例腹腔镜肝切除术治疗左肝内胆管结石临床及随访资料。 结果 全部67例患者合并左半肝或左外叶肝萎缩,腔镜手术方式包括左外叶肝切除48例、左半肝切除19例。其他腹腔镜下联合术式包括：胆囊切除术52例、胆总管探查术43例、T管引流术39例,胆总管一期修补术4例。手术切口长度（4.67±1.26）cm。术后发生胆漏3例,均经引流观察后自愈;1例因术后腹腔大出血合并胆瘘再手术治愈;肝脓肿1例,膈下脓肿1例,均经穿刺引流治愈。 结论 腹腔镜肝切除术治疗左肝内胆管结石安全可靠,术中应尽量取净其他胆道残余结石并连续紧密缝合左肝管残端。如结石已被取净胆总管的探查和T管引流并非必需。     

肝胆管结石的微创手术治疗进展

肝胆管结石(hepatolithiasis)是指位于左、右肝管分叉以上的胆管结石。肝胆管结石常合并反复发作的胆管炎,导致肝胆管狭窄、肝实质萎缩,继发性胆汁性肝硬化甚至胆管癌。肝胆管结石病变复杂,术后并发症多、结石残余率及复发率均较高,其治疗一直是肝胆外科的难题。手术微创化是当今国际外科学发展的一大趋势,肝胆管结石的微创手术治疗方法及疗效也有了很大的进步。本文将近年来肝胆管结石的微创手术治疗进展作简要综述。     

规则性肝段切除结合胆道镜治疗肝内胆管结石

目的 研究规则性肝段切除结合胆道镜治疗肝内胆管结石的优越性及有效性。方法 根据289例患者肝内胆管结石的分布情况(左外叶138例．左肝叶96例,右前叶6例,右后叶12例,右肝叶25例。双侧肝叶12例;合并有显著肝段或肝叶萎缩98例,肝脓肿8例,胆瘘3例,胆管癌5例)行肝段或联合肝段切除。其中S2～S3切除181例,S2～4切除56例．S6～S7切除18例,S5～8切除12例,双侧肝叶切除12例。附加术式包括经肝门部胆管切开取石186例,经肝实质胆管切开取石8例,胆管空肠Roux-en-Y吻合196例(10例输出空肠拌皮下埋植)。术中胆道镜经胆总管途径186例,肝断面胆管途径103例,术后胆道镜经T管途径186例,皮下输出空肠袢途径10例。结果 随访10个月至10年,89．5％(259／289)症状消失,7．9％(23／289)偶有轻度胆管炎发作,2．6％(7／289)仍反复发作严重胆道感染。术后并发症有胆漏8例(2．8％)．膈下感染12例(4．2％)．腹腔脓肿1例(0．35％)．3例(1．03％)术后死于肝衰竭。结论 规则性肝段切除术结合胆道镜技术是治疗肝内胆管结石的最有效手段。     

Suppression of proliferative cholangitis in a rat model by local delivery of paclitaxel

Background. Proliferative cholangitis (PC) leads to biliary stricture, which is the main cause of hepatolithiasis, recurrent cholangitis, and biliary cirrhosis. The aim of this study was to determine whether local delivery of paclitaxel, which inhibits cell proliferation by overstabilization of microtubules, prevents PC in a rat model.Methods. PC was induced by introducing a fine nylon thread into the bile duct in a rat. Paclitaxel (100µl of 10, 100, and 1000µmol/l) or solvent vehicle was administered into the bile duct for 15min. One week after treatment, histopathologic examination and 5-bromodeoxyuridine (BrdU) labeling of the bile duct were performed.Results. In comparison with the control, the mean thickness of the bile duct was reduced by 29% in the 1000µmol/l paclitaxel-treated group (2.61 ± 0.31µm vs 3.67 ± 0.25µm, P 0.05). The luminal area increased (P 0.0001) and the grade of epithelial–glandular proliferation was decreased (P 0.01) as the dose of paclitaxel increased. Ductal fibrosis and inflammatory cell infiltration were similar in both groups. The BrdU labeling index was significantly lower in the paclitaxel-treated group (P 0.05).Conclusions. Local delivery of paclitaxel suppressed PC in a rat model by the inhibition of epithelial–glandular proliferation and may offer an effective therapeutic option for biliary stricture.     

Management of gallstone cholangitis in the era of laparoscopic cholecystectomy

HYPOTHESIS: The combined endoscopic and laparoscopic approach is safe and effective in managing gallstone cholangitis in the era of laparoscopic cholecystectomy (LC). DESIGN: Retrospective case series. SETTING: University teaching hospital. PATIENTS: One hundred eighty-four consecutive patients with gallstone cholangitis treated between January 1995 and December 1998. INTERVENTIONS: The main treatments were endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) followed by interval LC. Open or laparoscopic common bile duct exploration (OCBDE or LCBDE) was used when ERCP or ES failed. MAIN OUTCOME MEASURES: Success of various interventions, morbidity and mortality, and long-term incidence of recurrent biliary symptoms. RESULTS: Endoscopic retrograde cholangiopancreatography was successful in 175 patients (95%), with bile duct stones found in 147 (84%). Endoscopic stone clearance by ES was achieved in 132 patients (90%). Morbidity rate after ERCP or ES was 4.0% (n = 7), and overall mortality rate from cholangitis was 1.6% (n = 3). After bile duct stone clearance, 82 patients underwent LC with a conversion rate of 9.8% (n = 8) and a morbidity rate of 3.6% (n = 3). Eighteen patients underwent OCBDE with a morbidity rate of 33% (n = 6), and 3 underwent LCBDE with 1 conversion and no morbidity. There was no operative mortality. Seventy-eight patients were managed conservatively after endoscopic clearance of bile duct stones. Follow-up data were available in 101 patients with cholecystectomy and 73 patients with gallbladder in situ. During a median follow-up of 24 months, recurrent biliary symptoms occurred in 5.9% (n = 6) and 25% (n = 18), respectively (P =.001). In both groups, the most common recurrent symptom was cholangitis (n = 5 and n = 14, respectively). Gallbladder in situ (risk ratio, 4.16; 95% confidence interval, 1.39-12.50; P =.01) and small-size papillotomy (risk ratio, 2.94; 95% confidence interval, 1. 07-8.10; P =.04) were significant risk factors for recurrent biliary symptoms. CONCLUSIONS: Endoscopic sphincterotomy for biliary drainage and stone removal, followed by interval LC, is a safe and effective approach for managing gallstone cholangitis. Patients with gallbladder left in situ after ES have an increased risk of recurrent biliary symptoms. Laparoscopic cholecystectomy should be recommended after endoscopic management of cholangitis except in patients with prohibitive surgical risk.33333333333333333333333