Hepatectomy for bilateral primary hepatolithiasis: a cohort study

Laparoscopic Left Hemihepatectomy for Left-sided Hepatolithiasis

INTRODUCTION

Hepatolithiasis is a prevalent disease in the southeastern coastal regions of China. Partial hepatectomy is the most definitive treatment for hepatolithiasis. This study evaluated the safety and efficacy of the laparoscopic left hemihepatectomy (LLH) for left-sided hepatolithiasis.

METHODS

The clinical data of 37 consecutive patients who underwent pure LLH for left-sided hepatolithiasis at Yinzhou Second Hospital between March 2009 and December 2013 were reviewed retrospectively.

RESULTS

Pure LLH was performed successfully in 36 patients. Because of severe adhesions from previous choledochotomy, 1 patient was converted to open procedure. The mean operative time was 257.9 minutes (range, 188 to 396 min). The mean duration of postoperative hospital stay was 11.7 days (range, 8 to 21 d). There were 2 (5.4 %) cases of postoperative bile leakage, 2 (5.4%) cases of intra-abdominal fluid collection, and 1 (2.7%) case of incisional infection, which were successfully managed conservatively. Residual stones were observed in 2 (5.4%) patients. The residual stones were located in the common bile duct in these cases and were removed through the T-tube tract by choledochoscopy. During a mean follow-up of 31.3 months (range, 6 to 63 mo), recurrent stones were detected in 2 (5.4%) patients and were successfully treated with endoscopic sphincterotomy.

CONCLUSIONS

LLH for left-sided hepatolithiasis is feasible and safe in selected patients.

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.

Oddi sphincter preserved cholangioplasty with hepatico-subcutaneous stoma for hepatolithiasis

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

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

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

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

Choledochoscopic high-frequency needle-knife electrotomy as an effective treatment for intrahepatic biliary strictures

BACKGROUND AND AIM

Hepatolithiasis is associated with the presence of intrahepatic biliary strictures, and balloon dilatation is the main approach. However, this method is difficult to implement if the bile duct distal to the stricture is blocked by stones. Therefore, alternative methods need to be explored to effectively treat hepatolithiasis. The aim of this study is to investigate the feasibility and effectiveness of choledochoscopic high-frequency needle-knife electrotomy for the treatment of intrahepatic biliary strictures.

METHODS

Clinical data of 58 patients suffering from intrahepatic bile duct strictures from January 2011 to January 2013 were retrospectively analyzed. Choledochoscopic electrotomy was used to resolve the strictures.

RESULTS

One hundred thirty-four sites of intrahepatic bile duct strictures were discovered. The average operating time of electrotomy is 5.6 min (range, 1 ∼ 15 min). Structured bile duct tissue bleeding occurred in eight sites (8/134, 6.0%) but were resolved by endoscopic high-frequency electric cautery. After the operations, 14 cases of cholangitis (14/58, 24.1%), three cases of delayed hemobilia, one case of liver abscess (1/58, 1.7%), and seven cases of stenting exodus (7/58, 12.1%) were observed despite conservative treatment and stenting reset. The average supporting time was 7.0 months (6 ∼ 9 months). No abnormal bile duct structure or presence of stone was found according to choledochoscopy. The follow-up period ranged from 12 to 48 months. Hepatolithiasis recurred in five (5/58, 8.6%) patients, and the cumulative recurrent probability of intrahepatic bile duct stricture was 5.2% (7/134).

CONCLUSIONS

Choledochoscopic high-frequency needle-knife electrotomy could be considered as a simple, safe, and effective complementary approach for treating intrahepatic biliary strictures.

Segmental Bile Duct-Targeted Liver Resection for Right-Sided Intrahepatic Stones

Hepatectomy is a safe and effective treatment for intrahepatic stones (IHSs). However, the resection plane for right-sided stones distributed within 2 segments is obstacle because of atrophy-hypertrophy complex formation of the liver and difficult dissection of segmental pedicle within the Glissonean plate by conventional approach. Thus, we devised segmental bile duct-targeted liver resection (SBDLR) for IHS, which aimed at completely resection of diseased bile ducts. This study aimed to evaluate the outcomes of SBDLR for right-sided IHSs. From January 2009 to December 2013, 107 patients with IHS treated by SBDLR in our center were reviewed in a prospective database. Patients' intermediate and long-term outcomes after SBDLR were analyzed. A total of 40 (37.4%) patients with localized right-sided stone and 67 (62.7%) patients with bilateral stones underwent SBDLR alone and SBDLR combined with left-sided hepatectomy, respectively. There was no hospital mortality of this cohort of patients. The postoperative morbidity was 35.5%. The mean intraoperative blood loss was 414  mL (range: 100-2500). Twenty-one (19.6%) patients needed red blood cells transfusion. The intermediate stone clearance rate was 94.4%; the final clearance rate reached 100% after subsequent postoperative cholangioscopic lithotomy. Only 2.8% patients developed stone recurrence in a median follow-up period of 38.3 months. SBDLR is a safe and effective treatment for right-sided IHS distributed within 2 segments. It is especially suitable for a subgroup of patients with bilateral stones whose right-sided stones are within 2 segments and bilateral liver resection is needed.

Laparoscopic versus open left hemihepatectomy for hepatolithiasis

BACKGROUND

Partial hepatectomy is the most definitive treatment for hepatolithiasis. Laparoscopic liver resection, however, presents unique technical challenges. The objectives of this study were to evaluate and compare the safety and perioperative and long-term outcomes of laparoscopic left hemihepatectomy (LLH) versus open left hemihepatectomy (OLH) for left intrahepatic duct stones.

METHODS

From March 2009-October 2014, 97 consecutive patients with left intrahepatic duct stones who underwent LLH (n = 46) or OLH (n = 51) were evaluated. We retrospectively reviewed the clinical outcomes and the stone clearance rates of the 97 patients in this study.

RESULTS

The median surgical procedure times were 254 min (188-396 min) in the LLH group and 236 min (192-395 min) in the OLH group. No significant difference was found in the surgical procedure times between the two groups. The intraoperative blood loss of the LLH group was less than the OLH group (332 mL [247-914 mL] versus 369 mL [221-996 mL], P = 0.13), but there was no statistical significance. A shorter length of postoperative hospital stay was noticed in laparoscopy group (11 d [8-21 d] versus 12 d [9-24 d], P = 0.01). Postoperative complications were observed in six of the 46 patients (13.0%) after LLH and in 11 of the 51 patients (21.6%) after OLH (P = 0.27). Laparoscopy was comparable with laparotomy in the effectiveness of stone clearance during the first attempt (93.5% versus 94.1%, P = 1.00).

CONCLUSIONS

In left-sided hepatolithiasis, LLH was safe and effective: it resulted in low postoperative morbidity, no mortality, and a high stone clearance rate. The potential benefit of LLH was a shorter hospital stay. If consideration is given to the appropriate indication criteria, including the extent of hepatectomy and the location and distribution of lesions, LLH may be an excellent choice for treatment of left-sided hepatolithiasis.

Roles of sphincter of Oddi motility and serum vasoactive intestinal peptide, gastrin and cholecystokinin octapeptide

AIM: To investigate roles of sphincter of Oddi (SO) motility played in pigment gallbladder stone formation in model of guinea pigs.

METHODS: Thirty-four adult male Hartley guinea pigs were divided randomly into two groups: the control group and pigment stone group. The pigment stone group was divided into 4 subgroups with 6 guinea pigs each according to time of sacrifice, and were fed a pigment lithogenic diet and sacrificed after 3, 6, 9 and 12 wk. SO manometry and recording of myoelectric activity of the guinea pigs were obtained by multifunctional physiograph at each stage. Serum vasoactive intestinal peptide (VIP), gastrin and cholecystokinin octapeptide (CCK-8) were detected at each stage in the process of pigment gallbladder stone formation by enzyme-linked immunosorbent assay.

RESULTS: The incidence of pigment gallstone formation was 0%, 0%, 16.7% and 66.7% in the 3-, 6-, 9- and 12-wk group, respectively. The frequency of myoelectric activity decreased in the 3-wk group. The amplitude of myoelectric activity had a tendency to decrease but not significantly. The frequency of the SO decreased significantly in the 9-wk group. The SO basal pressure and common bile duct pressure increased in the 12-wk group (25.19 ± 7.77 mmHg vs 40.56 ± 11.81 mmHg, 22.35 ± 7.60 mmHg vs 38.51 ± 11.57 mmHg, P < 0.05). Serum VIP was significantly elevated in the 6- and 12-wk groups and serum CCK-8 was decreased significantly in the 12-wk group.

CONCLUSION: Pigment gallstone-causing diet may induce SO dysfunction. The tension of the SO increased. The disturbance in SO motility may play a role in pigment gallstone formation, and changes in serum VIP and CCK-8 may be important causes of SO dysfunction.

Laparoscopic hepaticoplasty using gallbladder as a subcutaneous tunnel for hepatolithiasis

AIM: To investigate the feasibility, efficacy and safety of laparoscopic hepaticoplasty using gallbladder as subcutaneous tunnel and sphincter-of-Oddi preservation for hepatolithiasis.

METHODS: From January 2010 to July 2013, six patients with hepatolithiasis were treated at our institution. All the patients underwent laparoscopic surgery. The procedures included common hepatic duct exploration, stone clearance by fiberoptic choledochoscopy, hilar bile duct hepaticoplasty with preservation of the sphincter of Oddi, anastomosis between the hilar bile duct and neck of the gallbladder, and establishment of a subcutaneous tunnel with the gallbladder. Two patients underwent left lateral hepatectomy simultaneously. Clinical data including operation time, intraoperative blood loss, operative morbidity, hospital mortality, stone clearance, and recurrence rate were analyzed.

RESULTS: All patients successfully completed laparoscopic surgery. The mean length of hospital stay was 4.5 ± 0.9 d (range: 3-6 d). The mean blood loss of the hepatectomy was 450 mL (range: 200-700 mL), and the blood loss of the other four was 137 ± 151 mL (range: 50-400 mL). The mean operative time was 318 ± 68 min (range: 236-450 min). The operative morbidity and hospital mortality were zero. The immediate stone clearance rate was 100%. All patients were followed up for an average of 17 mo (range: 7-36 mo). One of the six patients had abdominal mass with pain, and subcutaneous tunnel cholangiography showed severe gallbladder-biliary anastomotic stricture at 4 mo postoperatively. There was no stone recurrence and no cholangitis during follow-up.

CONCLUSION: Laparoscopic hepaticoplasty using gallbladder with a subcutaneous tunnel and preserving the sphincter of Oddi is feasible, safe and effective for hepatholithiasis.

Risk factors of surgical site infection after hepatic resection

A study of 7,388 consecutive patients after hepatic resection between 2011 and 2012 identified hepatolithiasis, cirrhosis, and intraoperative blood transfusion as the only independent risk factors of both incisional and organ/space surgical site infection (SSI). Patients with these conditions should be cared for with caution to lower SSI rates.

Comparison of laparoscopic versus open left hemihepatectomy for left-sided hepatolithiasis

PURPOSE

The purpose of this study was to evaluate and compare the perioperative and long-term outcomes of open versus laparoscopic left hemihepatectomy (OLH vs. LLH) for left-sided hepatolithiasis.

METHODS

Between October 2007 and June 2012, 149 patients with left-sided hepatolithiasis who underwent LLH (n = 37) or OLH (n = 112) were evaluated. The perioperative and long-term outcomes that were reviewed included the stone clearance rate, operative morbidity and mortality, and the stone recurrence rate.

RESULTS

The mean operative time of the LLH group was significantly longer than that of the OLH group (257±50.4 minutes vs. 237±75.5 minutes, p = 0.022), but the mean hospital stay was significantly shorter (8.8±4.10 vs. 14.1±4.98 days, p < 0.001). Postoperative complications were noted in four and twenty cases among LLH and OLH patients, respectively (p = 0.982). The initial clearance rate of intrahepatic duct (IHD) stones was 100% and 96.4% in the LLH and OLH groups, respectively, but all remnant stones (n = 4, OLH group) were resolved postoperatively. There were two cases of recurrence of IHD stones in OLH patients, but none in LLH patients (p = 0.281).

CONCLUSIONS

In left-sided hepatolithiasis, LLH was safe and effective: it resulted in low postoperative morbidity, no mortality and a high stone clearance rate, and there were no incidences of recurrence in our study. The potential benefits of LLH include a shorter hospital stay and a faster return to oral intake. If consideration is given to the appropriate indication criteria, including the extent of hepatectomy and the location and distribution of lesions, LLH may be an excellent choice for treatment of left-sided hepatolithiasis.

Applying chemical bile duct embolization to achieve chemical hepatectomy in hepatolithiasis: a further experimental study

BACKGROUND

Hepatolithiasis is the presence of calculi within the bile ducts of the liver. It represents a significant problem for hepatobiliary surgery because of its high recurrence rate and the associated risk for partial hepatectomy. This study was designed to explore the long-term efficacy of chemical biliary duct embolization (CBDE) to treat recurrent hepatolithiasis.

MATERIALS AND METHODS

A rabbit model of hepatolithiasis was established, and CBDE was achieved using oxybenzene and N-butyl-cyanoacrylate. The short-term (6 wk) and long-term (12 wk) efficacy of CBDE treatment was compared by observing the degree of atrophy, fibrosis, proliferation of collagen fibers, and apoptosis of hepatocytes and hepatic stellate cells in the embolized hepatic lobe. Biochemical measurement of β-glucuronidase was also evaluated to determine the effect of CBDE on stone formation.

RESULTS

Six weeks after CBDE, there was liver cell destruction, collagen accumulation, and bile duct proliferation only in the peripheral part of the target lobe. Twelve weeks after CBDE, "self-cut" chemical hepatectomy was achieved, as manifested by the destruction of almost all the hepatocytes in the target lobe, bile duct proliferation, and collagen fiber accumulation. The β-glucuronidase activity was markedly lower in the embolized lobe than in the nonembolized lobe. In contrast, bax, caspase-3, caspase-9, and α-smooth muscle actin expression was substantially higher in the embolized lobe than in the sham-operation group at 6 wk, but was lower at 12 wk.

CONCLUSIONS

CBDE is a potentially effective therapeutic approach for treating and preventing the recurrence of hepatolithiasis.

Lithotomy using cholangioscopy via the left hepatic duct orifice versus the common bile duct in laparoscopic treatment of left-sided hepatolithiasis: a comparative study

OBJECTIVE

Laparoscopic hepatectomy is widely used in the surgical treatment of left-sided hepatolithiasis (LSH). Lithotomy using a cholangioscope usually is required for the treatment of concurrent right-sided hepatolithiasis or choledocholithiasis. The primary objective of this study was to evaluate the effectiveness and safety of gallstone elimination using cholangioscopy through the left hepatic duct (LHD) orifice versus the common bile duct (CBD).

PATIENTS AND METHODS

Eligible LSH patients (n=41) were scheduled for laparoscopic left lateral segmentectomy or left hemihepatectomy with intraoperative biliary exploration using cholangioscopy through the LHD orifice (LHD group, n=23) or the CBD (CBD group, n=18) at the discretion of patients. Laparoscopic T-tube insertion was performed in selected patients. Patients were regularly followed up at monthly intervals or more frequently in the presence of any symptom. The primary outcome measures included overall operative time, duration of the cholangioscopy procedure, volume of blood loss, length of hospital stay, and frequency of procedure-related complications.

RESULTS

The two groups were comparable in sex, age, symptoms, site of lesion, and gallstone comorbidities (P>.05). Of the 18 patients in the CBD group, 12 (66.7%) patients had a T-tube inserted in contrast to 1 (4.5%) patient in the LHD group. The two groups were comparable in cholangioscopy duration and volume of blood loss (P>.05), whereas the LHD group had a significantly shorter operative time than the CBD group (221.4 ± 58.6 minutes versus 171.2 ± 63.5 minutes; P<.05). The postoperative duration of hospitalization was significantly shorter in the LHD group than in the CBD group (7.5 ± 2.2 days versus 4.2 ± 1.9 days; P<.05). No patient showed any recurrence of gallstones or cholangitis during the follow-up period.

CONCLUSIONS

As an effective and safe technique that is comparable to choledochotomy, LHD cholangioscopy is a preferred alternative to choledochotomy in the laparoscopic treatment of LSH because it offers patients shorter operative duration and length of hospitalization.

Percutaneous transhepatic cholangioscopy: does its role still exist?

Percutaneous transhepatic cholangioscopy (PTCS) is the most widely used modality for diagnosis and treatment of biliary disease. Although many other novel technologies have been developed based on recent advances in endoscopy, PTCS has its own role. In diagnostics, PTCS is used for evaluation of indeterminate biliary strictures, bile duct tumors, and postoperative biliary strictures that cannot be reached by a peroral approach. In therapeutics, the removal of bile duct stones, dilatation of bile duct strictures including postoperative anastomosis site strictures, and local tumor therapy are indications of PTCS. Especially in a therapeutic role, PTCS has the advantage of maneuverability due to a shorter endoscopic length compared to other cholangioscopic modalities. Hence, PTCS has its own indispensable diagnostic and therapeutic roles.

Acute iatrogenic Budd-Chiari syndrome following hepatectomy for hepatolithiasis: A report of two cases

Budd-Chiari syndrome (BCS) is defined as hepatic venous outflow obstruction at any level from the small hepatic veins to the junction of the inferior vena cava (IVC) and the right atrium, regardless of the cause of obstruction. We present two cases of acute iatrogenic BCS and our clinical management of these cases. The first case was a 43-year-old woman who developed acute BCS following the implantation of an IVC stent for the correction of stenosis in the IVC after hepatectomy for hepatolithiasis. The second case was a 61-year-old woman with complete obstruction of the outflow of hepatic veins during bilateral hepatectomy for hepatolithiasis. Acute iatrogenic BCS should be considered a rare complication following hepatectomy for hepatolithiasis. Awareness of potential hepatic outflow obstructions and timely management are critical to avoid poor outcomes when performing hepatectomy for hepatolithiasis.

Recurrent pyogenic cholangitis: disease characteristics and patterns of recurrence

Recurrent pyogenic cholangitis (RPC) is characterized by repeated infections of the biliary system with the formation of stones and strictures. The management aims are to treat acute cholangitis, clear the biliary ductal debris and calculi, and eliminate predisposing factors of bile stasis. Operative options include hepatectomy and biliary drainage procedures or a combination of both; nonoperative options include endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography (PTC) guided procedures. This current study compares the operative and the nonoperative management outcomes in patients with RPC in 80 consecutive patients. In addition, we aim to evaluate our approach to the management of RPC over the past decade, according to the various degrees of severity and extent of the disease, and identify the patterns of recurrence in this complex clinical condition. Initial failure rate in terms of residual stone of operative compared with nonoperative treatment was 10.2% versus 32.3% (P = 0.020). Long-term failure rate for operative compared with non-operative treatment was 20.4% versus 61.3% (P = 0.010). Based on multivariate logistic regression, the only significant factors associated with failure were bilaterality of disease (OR: 8.101, P = 0.007) and nonoperative treatment (OR: 26.843, P = 0.001). The median time to failure of the operative group was 48 months as compared to 20 months in the nonoperative group (P < 0.010). Thus operative treatment is a durable option in long-term resolution of disease. Hepatectomy is the preferred option to prevent recurrent disease. However, biliary drainage procedures are also an effective treatment option. The utility of nonoperative treatment can achieve a reasonable duration of disease free interval with minimal complications, albeit inferior to operative management.

Left hepatic trisectionectomy for hepatolithiasis with occluded left and right anterior branches of the portal vein: report of a case

A 64-year-old male was admitted to a local hospital with epigastric pain. Diagnostic imaging revealed hepatolithiasis in the atrophic left lobe. However, endoscopic intervention was impossible because of the presence of many large stones. He was referred to our hospital for surgical treatment. Enhanced multidetector-row computed tomography revealed that the right posterior portal vein (PV) was branched from the portal trunk as a first-order branch, and the bile duct of segment 3 ran caudally to the umbilical portion of the left PV. Furthermore, the umbilical portion of the left PV, which was located between the dilated bile ducts of segment 2 and segment 3, and also the right anterior PV, was occluded with thrombus. Based on these findings, he underwent left hepatic trisectionectomy. Although the indications for left hepatic trisectionectomy for hepatolithiasis are limited, it is therefore extremely important to determine the most appropriate surgical procedure based on the anatomy and findings of hepatic hilus in individual cases.

Comparison of concomitant and subsequent cholangiocarcinomas associated with hepatolithiasis: Clinical implications

AIM: To compare the outcomes of concomitant cholangiocarcinoma (C-CCA) and subsequent cholangiocarcinoma (S-CCA) associated with hepatolithiasis.

METHODS: From December 1987 to December 2007, 276 patients underwent hepatic resection for hepatolithiasis in Changhua Christian Hospital. Sixty-five patients were excluded due to incomplete medical records and the remaining 211 patients constituted our study population base. Ten patients were diagnosed with C-CCA based on the preoperative biopsy or postoperative pathology. During the follow-up period, 12 patients developed S-CCA. The diagnosis of S-CCA was made by image-guided biopsy or by pathology if surgical intervention was carried out. Patient charts were reviewed to collect clinical information. Parameters such as CCA incidence, interval from operation to CCA diagnosis, interval from CCA diagnosis to disease-related death, follow-up time, and mortality rate were calculated for both the C-CCA and S-CCA groups. The outcomes of the C-CCA and S-CCA groups were mathematically compared and analysed.

RESULTS: Our study demonstrates the clinical implications and the survival outcomes of C-CCA and S-CCA. Among the patients with unilateral hepatolithiasis, the incidence rates of C-CCA and S-CCA were fairly similar (4.8% vs 4.5%, respectively, P = 0.906). However, for the patients with bilateral hepatolithiasis, the incidence rate of S-CCA (12.2%) was higher than that of C-CCA (4.7%), although the sample size was limited and the difference between two groups was not statistically significant (P = 0.211). The average follow-up time was 56 mo for the C-CCA group and 71 mo for the S-CCA group. Regard to the average time intervals from operation to CCA diagnosis, S-CCA was diagnosed after 67 mo from the initial hepatectomy. The average time intervals from the diagnoses of CCA to disease-related death was 41 mo for the C-CCA group and 4 mo for the S-CCA group, this difference approached statistical significance (P = 0.075). Regarding the rates of overall and disease-related mortality, the C-CCA group had significantly lower overall mortality (70% vs 100%, P = 0.041) and disease-related mortality (60% vs 100%, P = 0.015) than the S-CCA group. For the survival outcomes of two groups, the Kaplan-Meier curves corresponding to each group also demonstrated better survival outcomes for the C-CCA group (log rank P = 0.005). In the C-CCA group, three patients were still alive at the time of data analysis, all of them had free surgical margins and did not have pathologically proven lymph node metastasis at the time of the initial hepatectomy. In the S-CCA group, only one patient had chance to undergo a second hepatectomy, and all 12 S-CCA patients had died at the time of data analysis.

CONCLUSION: C-CCA has better outcomes than S-CCA. The first hepatectomy is crucial because most patients with recurrent CCA or S-CCA are not eligible for repeated surgical intervention.

Treatment of hepatolithiasis with bile duct stenosis

Hepatolithiasis is a disease prevalent in Southeast Asian countries that is characterized by the presence of stones in the intrahepatic bile ducts proximal to the confluence of the right and left hepatic ducts. The goals of management include efficient elimination of stones and stasis, relief of strictures, total biliary drainage, maximum protection of functional liver tissue, and reduction of surgical complications. The diagnosis can be best established by direct cholangiography such as percutaneous transhepatic cholangiography or endoscopic retrograde cholangiography. Magnetic resonance cholangiography can delineate detailed information on the bile ducts, which is useful in the planning of treatment for hepatolithiasis. Though non-operative biliary decompression by endoscopy and interventional radiology is effective in controlling infection, surgery by multiple methods remains the mainstay for the treatment of stones and strictures. The bile duct stricture carries a high risk for postsurgical intrahepatic calculi; hence, permanent relief of stricture in hepatobiliary surgery is mandatory. The aggressive resection strategy is recommended for an atrophic segment resulting from hepatolithiasis to achieve complete clearance of the stones and relief of bile stasis. For therapeutic purposes, we recommend a combination of multimodal treatments to improve results. It is necessary to choose the most suitable and optimal therapeutic approaches in selective cases in the treatment of complicated hepatolithiasis.

Caudate lobe-sparing subtotal hepatectomy for primary hepatolithiasis

BACKGROUND

Patients with frequent and life-threatening attacks of cholangitis due to bilateral primary hepatolithiasis with atrophy of the main liver and giant hypertrophy of the caudate lobe were assessed for caudate lobe-sparing subtotal hepatectomy.

METHODS

This was a retrospective study of prospectively collected data from patients who underwent subtotal hepatectomy with sparing of the caudate lobe (resection of 7 liver segments, leaving only the caudate lobe) between March 2003 and December 2009. All patients had concomitant bile duct exploration and choledochoscopy. Perioperative and long-term outcomes were analysed.

RESULTS

Immediate stone clearance was obtained in all 12 patients enrolled in the study. Two patients had strictureplasty of the strictured caudate bile duct. There was no hospital mortality and six complications developed in three patients. At a mean follow-up of 51 months, one patient had developed recurrent stones in the caudate lobe bile ducts at 8 months and died from acute purulent cholangitis, 17 months after surgery. The remaining 11 patients were symptom-free with no further attacks of acute cholangitis.

CONCLUSION

In selected patients with bilateral primary hepatolithiasis, caudate lobe-sparing subtotal hepatectomy is a safe and effective treatment.

Laparoscopic hepatectomy is associated with a higher incident frequency in hepatolithiasis patients

PURPOSES

The primary concern regarding laparoscopic hepatectomy in hepatolithiasis patients is surgical safety, which may be high in current practice.

METHODS

Hepatolithiasis patients who underwent laparoscopic and laparotomic hepatectomies were retrospectively studies after being matched for age, location of gallstones, liver resection and underlying liver conditions at a ratio of 1:1 (n = 44 in each group). The rates of intraoperative incidents and postoperative complications were examined using validated classification and grading systems. The primary outcome measure was the procedure-related complication/mortality rate.

RESULTS

Laparoscopy was converted to open surgery in three patients (6.8 %). The length of the operation for laparoscopic hepatectomy was significantly longer than that for laparotomic hepatectomy (277.5 min [range, 190-410 min] vs. 212.5 min [140-315 min], P < 0.001). The two groups had similar intraoperative blood loss (367.5 mL [150-1200 mL] vs. 392.5 mL [200-1400 mL], P > 0.05) and transfusion frequencies (13.6 vs. 18.2 %, P > 0.05). The laparoscopy group had a higher percentage of patients with at least one intraoperative incident compared with the laparotomy group (22.7 vs. 6.8 %; P < 0.05). Vascular events occurred in nine patients (20.5 %) undergoing laparoscopy and two patients (4.5 %) undergoing laparotomy (OR 5.4 [95 %CI, 1.1-26.7], P < 0.05).

CONCLUSIONS

Laparoscopic hepatectomy is associated with a higher risk of intraoperative vascular incidents in hepatolithiasis patients compared wit laparotomy.

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.

Laparoscopic left hemihepatectomy for left intrahepatic duct stones

Purpose

The feasibility of laparoscopic left hemihepatectomy for the management of intrahepatic duct (IHD) stones was evaluated.

Methods

The clinical data of 26 consecutive patients who underwent total laparoscopic left hemihepatectomy for IHD stones at Gyeongsang National University Hospital between January 2009 and June 2011 were reviewed retrospectively.

Results

The mean operation time was 312.1 ± 63.4 minutes and the mean postoperative hospital stay was 11.8 ± 5.0 days. There were 2 cases of postoperative bile leakage and 3 cases of intra-abdominal fluid collection, which were successfully managed conservatively. Remnant stones were detected in 2 patients. The initial success rate of stone clearance was 92.3% (24 of 26). The remnant stones were located in the common bile duct in both cases and were removed by endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy. Therefore, the final success rate of stone clearance was 100% (26 of 26). During a mean follow-up of 22 months (range, 7 to 36 months), there was no patient with recurrent stone.

Conclusion

Laparoscopic surgery could be an effective treatment modality for the management of IHD stones in select patients.

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.

Laparoscopic vs open left hepatectomy for hepatolithiasis

AIM

To explore the feasibility and therapeutic effect of total laparoscopic left hepatectomy (LLH) for hepatolithiasis.

METHODS

From June 2006 to October 2009, 61 consecutive patients with hepatolithiasis who met the inclusion criteria for LLH were treated in our institute. Of the 61 patients with hepatolithiasis, 28 underwent LLH (LLH group) and 33 underwent open left hepatectomy (OLH group). Clinical data including operation time, intraoperative blood loss, postoperative complication rate, postoperative hospital stay time, stone clearance and recurrence rate were retrospectively analyzed and compared between the two groups.

RESULTS

LLH was successfully performed in 28 patients. The operation time of LLH group was longer than that of OLH group (158 +/- 43 min vs 132 +/- 39 min, P < 0.05) and the hospital stay time of LLH group was shorter than that of OLH group (6.8 +/- 2.8 d vs 10.2 +/- 3.4 d, P < 0.01). No difference was found in intraoperative blood loss (180 +/- 56 mL vs 184 +/- 50 mL), postoperative complication rate (14.2% vs 15.2%), and stone residual rate (intermediate rate 17.9% vs 12.1% and final rate 0% vs 0%) between the two groups. No perioperative death occurred in either group. Fifty-seven patients (93.4%) were followed up for 2-40 mo (mean 17 mo), including 27 in LLH group and 30 in OLH group. Stone recurrence occurred in 1 patient of each group.

CONCLUSION

LLH for hepatolithiasis is feasible and safe in selected patients with an equal therapeutic effect to that of traditional open hepatectomy.

Laparoscopic vs open left hepatectomy for hepatolithiasis

AIM: To explore the feasibility and therapeutic effect of total laparoscopic left hepatectomy (LLH) for hepatolithiasis.

METHODS: From June 2006 to October 2009, 61 consecutive patients with hepatolithiasis who met the inclusion criteria for LLH were treated in our institute. Of the 61 patients with hepatolithiasis, 28 underwent LLH (LLH group) and 33 underwent open left hepatectomy (OLH group). Clinical data including operation time, intraoperative blood loss, postoperative complication rate, postoperative hospital stay time, stone clearance and recurrence rate were retrospectively analyzed and compared between the two groups.

RESULTS: LLH was successfully performed in 28 patients. The operation time of LLH group was longer than that of OLH group (158 ± 43 min vs 132 ± 39 min, P < 0.05) and the hospital stay time of LLH group was shorter than that of OLH group (6.8 ± 2.8 d vs 10.2 ± 3.4 d, P < 0.01). No difference was found in intraoperative blood loss (180 ± 56 mL vs 184 ± 50 mL), postoperative complication rate (14.2% vs 15.2%), and stone residual rate (intermediate rate 17.9% vs 12.1% and final rate 0% vs 0%) between the two groups. No perioperative death occurred in either group. Fifty-seven patients (93.4%) were followed up for 2-40 mo (mean 17 mo), including 27 in LLH group and 30 in OLH group. Stone recurrence occurred in 1 patient of each group.

CONCLUSION: LLH for hepatolithiasis is feasible and safe in selected patients with an equal therapeutic effect to that of traditional open hepatectomy.