肝切除术治疗肝内结石354例

目的探讨肝切除术治疗肝内结石的效果。方法分析１０年来采用肝切除术治疗３５４例肝内结石患者的临床表现、结石的部位和分布情况、手术方式、手术后并发症及结石残留等情况,并将１９９０年以后与１９９０年前的资料进行比较。结果肝内结石以左肝较多（３２３例）,肝切除仍以左外叶及左半肝切除为主。１３．８％的病例有结石残留;６０例出现手术后并发症;手术死亡４例。１９９０年以后再次手术的病例、术后残石率均比以前下降。治疗效果优良者占８８％。结论肝切除手术是治疗肝内结石的主要方法,为减少结石的残留和复发,应根据结石情况同时行肝内狭窄胆管切开整形、胆管空肠吻合治疗。     

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目的 分析胆肠吻合术治疗肝内胆管结石并胆道狭窄的选择和疗效。方法 对１９９１年９月至１９９８年１２月６９例行胆肠吻合术的肝内胆管结石并胆道狭窄病例进行总结,包括临床表现、结石部位、狭窄情况、手术方式和治疗效果等。结果 胆管狭窄主要位于１￣２级胆管内。５１例（７３．９％）行肝胆管空肠Ｒｏｕｘ－ｅｎ－Ｙ吻合术,１８例（２６．１％）采用胆总管十二指肠吻合术,随访结果表明,肝胆管空肠Ｒｏｕｘ－ｅｎ－Ｙ吻合     

Choledochoscopic lithotripsy is a useful adjunct to laparoscopic common bile duct exploration for hepatolithiasis: a cohort study

Background

This study aims to investigate the role of combining choledochoscopic lithotripsy with laparoscopic common bile duct exploration for hepatolithiasis in patients who are not suitable for hepatectomy.

Methods

From March 2009 to March 2013, 86 patients with hepatolithiasis irrespective of whether they underwent a choledochoscopic plasma shock wave lithotripsy or not were analyzed.

Results

Sixty-two patients underwent lithotripsy and 24 patients underwent basket lithoextraction intraoperatively. Plasma shock wave lithotripsy did not lengthen the operating time, but decreased the postoperative residual stone rate and reduced the frequency of postoperative choledochoscopic lithotomy for patients with remnant stones. The overall final stone clearance rate was 98.8%. During a mean follow-up of 26.2 months, recurrent stones and cholangiocarcinoma developed in 1 patient, respectively.

Conclusion

Laparoscopic common bile duct exploration combined with choledochoscopic lithotripsy is a definitive procedure for hepatolithiasis in patients who are not candidates for hepatectomy.     

Recurrence of intrahepatic stones after an end-to-side choledochojejunostomy

The risk factors for the recurrence of intrahepatic stones after an end-to-side choledochojejunostomy were investigated, along with the outcome following the treatment of such stones. Thirty-two patients with intrahepatic stones underwent an end-to-side choledochojejunostomy, and a complete lithotomy was achieved in 26 of them. The follow-up which ranged from 5-19 years after surgery revealed that eight patients developed a recurrence of intrahepatic stones, and their clinical and cholangiographic findings were thus reviewed. Recurrent stones were associated with onset of symptoms at a younger age and were predominantly located in the intrahepatic bile ducts. Recurrence was also associated with severe intrahepatic bile duct dilatation. Six of the eight patients developed recurrent stones more than 5 years after a complete lithotomy. One of these patients died of liver cirrhosis while two died of acute obstructive suppurative cholangitis. Five patients underwent cholangioscopic lithotomy through the jejunostomy for their recurrent stones, and a complete lithotomy was accomplished in three of them. These findings indicate the necessity of performing a hepatectomy in such patients whenever possible, and also emphasize the need for a long-term follow-up after a complete lithotomy with an end-to-side choledochojejunostomy. In addition, any recurrent stones should be treated promptly by a cholangioscopic lithotomy through a jejunostomy.     

Intrahepatic Segmental Portal Vein Thrombosis After Living-Related Donor Liver Transplantation

Background

Intrahepatic segmental portal vein thrombosis after living-related liver transplantation (LRLT) is uncommon. The cause remains unclear.

Methods

After providing written informed consent, 25 recipients receiving LRLT at our institution from January 2011 to September 2013 were enrolled in this study. We performed triphase computerized tomographic (CT) study of the liver graft of each recipient 1 month after LRLT. The patencies of hepatic artery, portal vein, and hepatic vein were evaluated in detail. The triphase CT scans of the liver of each donor before transplantation also were reviewed. Thrombosis of the intrahepatic segmental portal vein was defined as the occlusion site of the portal vein being intrahepatic. Extrahepatic portal vein thrombosis was excluded in this study.

Results

Among the 25 patients, 2 (8%) developed thrombosis of intrahepatic segmental portal vein. One 47-year-old man received LRLT for hepatitis B viral infection–related liver cirrhosis (Child-Pugh class C) with 3 hepatocellular carcinomas (total tumor volume <8 cm). Another 53-year-old man received LRLT for alcoholic liver cirrhosis (Child-Pugh class C). Both had developed progressive jaundice and cholangitis 1 month after surgery. Intrahepatic biliary stricture was found on the follow-up magnetic resonance images. However, liver triphase CT study demonstrated occlusion of intrahepatic portal vein of segment 8 in each patient. Radiologic interventions and balloon dilatation therapy via percutaneous transhepatic biliary drainage route improved the symptoms and signs of cholangitis and obstructive jaundice for both.

Conclusions

Thrombosis of intrahepatic segmental portal vein is not common but is usually associated with complications of intrahepatic bile duct. Early detection is important, and follow-up CT study of liver is suggested.     

Liver transplantation for hepatolithiasis

Hepatolithiasis is frequently encountered in Asia, but is relatively uncommon in Western societies. The improved surgical and stone fragmentation techniques that have evolved over the past decade have reduced the incidence of retained or recurrent stones with a consequent reduction in progressive liver damage and cirrhosis. Nonetheless, disease-related mortality from liver failure, bleeding oesophageal varices and cholangiocarcinoma still exists and a proportion of patients are cirrhotic at their initial presentation. There have been good long-term results following liver transplantation for a variety of cholestatic liver diseases, but transplantation for hepatolithiasis has seldom been reported. This paper reports four patients who underwent successful liver transplantation for hepatolithiasis with secondary biliary cirrhosis.     

胆管空肠吻合联合空肠盲袢固定标记在复发肝胆管结石治疗中应用研究

目的 探讨胆管空肠Roux-en-Y吻合联合腹膜下空肠盲袢固定标记法在肝胆管结石病术后及其伴随的胆管狭窄治疗中的价值。方法 回顾性分析2009年1月至2017年12月在北京大学第一医院接受胆管空肠Roux-en-Y吻合联合腹膜下空肠盲袢固定标记术的113例肝胆管结石病病人的临床资料。并对术后经肠袢胆道镜治疗肝内胆管结石和狭窄的情况进行总结。结果 113例病人全部完成胆肠吻合及盲袢固定标记术并在术后行胆道镜检查，其中79例行胆道镜取石治疗；49例行胆道镜下球囊扩张肝内胆管狭窄，7例发现有术后近期吻合口狭窄而行球囊扩张，71例证实结石取净或狭窄缓解后结束治疗。16例在治疗结束后因肝内胆管结石复发而在局麻下打开空肠盲袢，其中15例顺利完成再次治疗。结论 空肠盲袢固定标记法便于在胆管空肠Roux-en-Y吻合后进一步治疗肝内胆管结石及狭窄，并使多数复发病例避免了再次开放手术，对于易复发的肝胆管结石病是一种可供选择的治疗方法。     

Living Donor Liver Transplantation for Progressive Familial Intrahepatic Cholestasis Type 1: Two Reported Cases

Background

Progressive familial intrahepatic cholestasis type 1 (PFIC1) is an inherited disease characterized by cholestatic features. We report two patients with PFIC1 who underwent liver retransplantation.

肝切除术治疗区域性肝胆管结石

目的 探讨肝切除术治疗区域性肝胆管结石的效果。方法 分析12年来采用肝切除术治疗儿2例区域性肝胆管结石患者的临床表现、结石的部位和分布情况、手术方式、手术后并发症及结石残留等情况。结果 肝内结石以左肝较多(108例),肝切除仍以左外叶及左半肝切除为主。10．8％的病例有结石残留；13例出现手术后并发症；无手术死亡。治疗效果优良者占93％。结论 肝切除手术是治疗区域性肝胆管结石的主要方法，为减少结石的残留和复发，应根据结石情况同时行肝内狭窄胆管切开整形、胆管空肠吻合治疗。     

肝移植治疗肝内胆管结石和肝包虫病

目的探讨肝移植治疗合并胆汁性肝硬化的广泛肝内胆管结石和不能手术治疗的肝包虫病的效果。方法对2例广泛肝内胆管结石伴胆汁性肝硬化和4例不能手术切除的肝包虫病(泡球蚴病)患者施行原位肝移植，术后定期随访，评价疗效。结果2例胆管结石患者已存活2年多：4例肝包虫病患者，除1例术后3个月死于心力衰竭外，其余3例已分别存活9个月、15个月及2年；存活患者均恢复了正常生活和工作。结论肝移植可作为治疗广泛肝内胆管结石和不能手术治疗的肝包虫病的有效手段。     

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。     

Efficacy and safety of entecavir and/or tenofovir for prophylaxis and treatment of hepatitis B recurrence post-liver transplant

Aims

To establish the efficacy and safety of entecavir (ETV) and/or tenofovir (TDF) in the treatment and prevention of hepatitis B virus (HBV) recurrence after liver transplantation.

Patients and methods

Eight patients (four men) received treatment with ETV and/or TDF after liver transplantation as prophylaxis for HBV recurrence or as posttransplant treatment of HBV. Four liver transplants were in patients with HBV-associated cirrhosis who had received prior nucleos(t)ide analogue treatment until HBV DNA became undetectable. After transplantation, two of these four were treated with ETV + TDF and the other two with just TDF. All received intramuscular hepatitis B immunoglobulins. The reasons for the other four liver transplants were primary biliary cirrhosis in two cases, alcoholic cirrhosis, and hepatitis C virus. Two of the patients were donor anti-HBcAb-positive/recipient anti-HBcAb-negative. They received no anti-HBV prophylaxis so they had a recurrence of HBV. These four patients required treatment with ETV + TDF for the HBV DNA to become negative.

Results

The mean age was 60 (39-67) years. The mean follow-up was 9.5 (3-20) months. The mean follow-up of the patients who received prophylaxis was 8.2 (3-19) months. These had no HBV recurrence. The mean follow-up of the patients who received treatment for HBV recurrence was 12 (3-19) months. ETV combined with TDF was necessary for the HBV DNA to become undetectable because this was not possible using different nucleos(t)ide analogues. There were no significant adverse effects from these drugs and no alteration of renal function during the follow-up period.

Conclusions

Therapy with ETV and/or TDF seems to be efficient and safe when used in the prophylaxis and treatment of HBV recurrence after liver transplantation. They are well tolerated and seem to have no interactions with immunosuppressive medication.     

肝胆管结石病肝移植(附4例报告)

目的 探讨肝胆管结石终末期病变肝移植的适应证及术中技术和围手术期处理的改进方法。方法 回顾性分析我科近年来施行的肝胆管结石终末期病变肝移植4例。结果 3例均为肝胆管结石继发胆汁性肝硬化失代偿期。病例1行先转流后游离肝脏的原位肝移植，病例2、3行不转流的改良背驮式肝移植，病例4行不转流的原位肝移植。平均手术时间7．9h，失血800ml。4例手术均成功。病例1术后第6天出现消化道出血，经保守治疗痊愈；病例2术后第44天并发消化道出血和胆肠吻合口漏，经治疗痊愈；病例4术后第8天和第10天并发肝动脉吻合口出血，经再次手术治疗，痊愈出院。术后病理结果为胆汁性肝硬化。所有病例均随访，健康存活。结论 肝胆管结石继发胆汁性肝硬化失代偿期是肝移植适应证。先转流后游离肝脏及改良背驮式肝移植技术的应用可以减少术中出血、降低术后并发症。     

Biliary Complications in 108 Consecutive Recipients With Duct-to-Duct Biliary Reconstruction in Living-Donor Liver Transplantation

Background

Biliary complications remain the leading cause of postoperative complications after living-donor liver transplantation (LDLT) in patients undergoing duct-to-duct choledochocholedochostomy. The aim of this study was to analyze the causes of these complications.

Methods

One hundred eight patients who underwent LDLT with duct-to-duct biliary reconstruction at Mie University Hospital were enrolled in this study. The mean follow-up time was 58.4 months (range, 3–132). The most recent 18 donors underwent indocyanine green (ICG) fluorescence cholangiography for donor hepatectomy. The development of biliary complications was retrospectively analyzed. Biliary complications were defined as needing endoscopic or radiologic treatment.

Results

Biliary leakages and strictures occurred in 6 (5.6%) and 15 (13.9%) of the recipients, respectively, and 3 donors (2.7%) experienced biliary leakage. However, since the introduction of ICG fluorescence cholangiography, we have not encountered any biliary complications in either donors or recipients. Biliary leakage was an independent risk factor for the development of biliary stricture (P = .013). Twelve (80%) of the 15 recipients with biliary stricture had successful nonoperative endoscopic or radiologic management, and 3 patients underwent surgical repair with hepaticojejunosotomy.

Conclusions

Biliary leakage was an independent factor for biliary stricture. ICG fluorescence cholangiography might be helpful to reduce biliary complications after LDLT in both donors and recipients.     

肝叶切除术治疗肝内结石254例临床分析

为探讨肝内切除术治疗肝内结石的效果，分析７年来采用肝切除术治疗２５４例肝内结石的术前检查、结石的部位和分布情况，手术方式、手术后并发症及结石残留等情况，加以归纳总结。结果表明，肝内结石以左肝较多（１５９例），全肝结石其次（７８例）；肝切除仍以左外叶及左半肝切除为主（９０％）；有１８．９％的病例有结石残留；４９例出现手术后并发症；手术死亡２例，占０．７９％；４例伴有胆管癌变；全组治疗效果良好。肝切除     

A study on postoperative bile duct stricture with intrahepatic stones

From January 1976 through December 1988 we encountered ninety nine cases of intrahepatic stones. Eight of them were complicated with postoperative bile duct strictures which were formed on cholangiojejunostomy in 5 cases, cholangioduodenostomy, hepatic hilum and common hepatic duct in 1 case, respectively. Six cases of them are anastomotic strictures. The stones were mainly composed of bilirubin calcium. We guessed that the bile duct stricture resulted from cholangiojejunostomy without Roux-en-Y in 1 case and anastomotic insufficiency in 5 cases. Intrahepatic stones were removed by percutaneous transhepatic cholangioscopy (PTCS), and the treatment for the stricture was cholangiojejunostomy in 1 case and the dilatation by PTCS in 5 cases, including 3 endoprostheses by pig-tail silicone catheter and 2 internal-external biliary drainage. Two patients who did not undergo cholangioscopic dilatation died of sepsis due to cholangitis. Three of 5 patients who underwent endoscopic dilatation by PTCS could return to social life without recurrence of gallstones. In other two cases an endoprosthetic catheter was removed by PTCS because of dislodgement or obstruction of the catheter after confirming anastomotic strictures had improved. Authors recommended that PTCS should be applied for postoperative bile duct stricture complicated with intrahepatic stone.     

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

BackgroundIntrahepatic lithiasis (IHL) is a rare disease in the western world. Complications associated with IHL include acute cholangitis, liver atrophy, secondary biliary cirrhosis, and risk for intrahepatic cholangiocarcinoma. Liver resection is considered the treatment of choice for IHL. The objective of this study was to analyze patients who underwent liver resection for non-Asian hepatolithiasis.Methods127 patients with symptomatic non-Asian hepatolithiasis underwent resection in six institutions. Demographic data, clinical presentation, diagnosis, classification according to stone location, presence of atrophy, bile duct stricture, biliary cirrhosis, incidence of cholangiocarcinoma, treatment and postoperative course were evaluated.Results52 patients (40.9%) were male and the mean age was 46.1 years. Sixty-six patients (51.9%) presented with history of cholangitis. Stones were located in the left lobe in 63 (49.6%), and right lobe in 28 patients (22.0%). Atrophy was observed in 31 patients (24.4%) and biliary stenosis in 18 patients (14.1%). The most common procedure performed was left lateral sectionectomy in 63 (49.6%) patients, followed by left hepatectomy in 36 (28.3%), right hepatectomy in 19 (15.0%), and associated hepaticojejunostomy in 28 (22.0%). Forty-two patients (33.0%) presented postoperative complications and the most common were biliary fistula (13.3%) and surgical site infection (7.0%). Postoperative mortality was 0.7%. Intrahepatic cholangiocarcinoma was observed in 2 patients (1.5%). Recurrence was identified in 10 patients (7.8%), mostly with bilateral stones and/or hepaticojejunostomy.ConclusionLiver resection is the standard treatment for symptomatic unilateral or complicated IHL with good operative results. Risk of cholangiocarcinoma was low in non-Asian patients.     

Indication and procedure for treatment of hepatolithiasis

HYPOTHESIS: Because of its complicated clinicopathologic features, hepatolithiasis is difficult to treat, and there is no established method of treating patients with intrahepatic stones. DESIGN: Retrospective case-control study. SETTING: Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan (January 1, 1971-December 31, 2000). PATIENTS: Eighty-nine patients treated for hepatolithiasis (43 male; median age, 56.9 years). MAIN OUTCOME MEASURES: The rate of residual stones and complications after the treatments of hepatolithiasis. RESULTS: Between 1971 and 1985, 17 patients (41%) had stones located in the left or right intrahepatic duct, and 25 patients (60%) had stones located in the bilateral intrahepatic duct. From 1986 through 2000, 32 patients (68%) had stones located in the left or right intrahepatic duct, and 15 patients (32%) had stones located in the bilateral intrahepatic duct (P =.009). The rate of residual stones after surgical and nonsurgical treatment was 41% (17 of 42 patients) in 1971 through 1985, but decreased to 11% (5 of 47 patients) in 1986 through 2000 (P =.001). The rate of residual stones after cholangioenterostomy or T-tube insertion was 43.8% (21 of 48 patients), but the rate of residual stones after hepatectomy or percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) was 2.4% (1 of 41 patients, P<.001). In cases treated by PTCSL, we used a holmium (Ho):YAG laser in 3 cases since 1999. To our knowledge, there have been no reports describing the use of Ho:YAG lasers to treat hepatolithiasis. Also, board-shaped stones can be sufficiently pulverized without inducing hemorrhage from the bile duct wall. CONCLUSIONS: According to the current therapeutic strategy for hepatolithiasis, hepatectomy seems to be the most effective treatment for selected patients with isolated left hepatolithiasis if other surgical procedures cannot remove all the related lesions. In addition, PTCSL seems to be performed first in isolated right hepatolithiasis and bilateral lobe type hepatolithiasis. In PTCSL procedures, favorable results have been obtained using the Ho:YAG laser for fracturing intrahepatic stones.     

Protective effect of glutamine-enriched early enteral nutrition on intestinal mucosal barrier injury after liver transplantation in rats

Background

The effect of glutamine-enriched early enteral nutrition (Gln-EEN) on intestinal mucosal barrier injury after liver transplantation (LT) remains uncertain.

Methods

The Wistar-to-Wistar rat LT model was used to explore the protective effect of Gln-EEN. Morphologic changes of intestinal mucosa, levels of intestinal malondialdehyde and secretory immunoglobulin (sIgA), plasma endotoxin, D-lactic acid, serum tumor necrosis factor-α (TNF-α), rates of bacterial translocation, and expression of intestinal nuclear factor-κB, TNF-α, and intercellular adhesion molecule-1 were determined.

Results

After LT, intestinal mucosa was damaged seriously. At 12, 24, and 48 hours posttransplantation, levels of intestinal sIgA were decreased; levels of malondialdehyde, endotoxin, D-lactic acid, and TNF-α, the ratio of bacterial translocation, and the expression of intestinal nuclear factor-κB, TNF-α, and intercellular adhesion molecule-1 all were increased. However, changes in earlier-mentioned parameters in recipients treated with Gln-EEN were attenuated remarkably at 24 to 48 hours.

Conclusions

Our data show that Gln-EEN is a potent protectant against intestinal mucosal barrier injury after LT.     

Alemtuzumab induction in deceased donor kidney transplantation

Purpose

Alemtuzumab (Campath-1H), a humanized monoclonal antibody directed against CD52, is a lymphocyte-depleting agent currently being evaluated as an induction agent in solid organ transplantation. This study analyzed the clinical outcomes and effects on peripheral blood lymphocyte subset counts in adult deceased donor renal transplant recipients who received an alemtuzumab-based induction protocol.

Methods

Eleven kidney alone or simultaneous pancreas-kidney transplant recipients received 20 mg alemtuzumab on postoperative days 0 and 1, followed by calcineurin inhibitor-based maintenance immunosuppression after postoperative day 5. We collected 1-year data including recipient and donor demographic features, renal function and adverse events including endocrine impact, incidence of acute rejection episodes, infections or malignancies as well as hematologic and late immunologic parameters for correlation with patient or graft survival.

Results

Mean HLA mismatch was 3.6 and 8/11 deceased donors were of the extended criteria type. Only 2 (18%) recipients displayed delayed graft function with a failure of the serum creatinine to decrease by 25% on the first day; however, their long-term outcomes were similar to other nonaffected patients. Serious adverse events were absent; there was no hyperlipidemia or new-onset diabetes. We failed to observe an acute rejection. The 3 (27%) recipients with infectious complications experienced pericardial tuberculosis, urinary tract infection, or invasive pulmonary aspergillosis. Two (18%) cases of posttransplantation lymphoproliferative disease were diagnosed in this study during the follow-up. Overall patient and graft survival rates were both 91%.

Conclusion

This study demonstrated that preconditioning with antibody-depletion using alemtuzumab was efficient with satisfactory patient and graft survivals at 1 year. Alemtuzumab induction was safe even for recipients of extended criteria donor renal transplantation.