Outcomes of Hepatectomy for Hepatolithiasis

Clinical and economic comparison of laparoscopic versus open hepatectomy for primary hepatolithiasis: a propensity score-matched cohort study

BACKGROUND

It is unclear whether laparoscopic hepatectomy (LH) for hepatolithiasis confers better clinical benefit and lower hospital costs than open hepatectomy (OH). This study aim to evaluate the clinical and economic value of LH versus OH.

METHODS

Patients undergoing OH or LH for primary hepatolithiasis at Yijishan Hospital of Wannan Medical College between 2015 and 2022 were divided into OH group and LH group. Propensity score matching (PSM) was used to balance the baseline data. Deviation-based cost modelling and weighted average median cost (WAMC) were used to assess and compare the economic value.

RESULTS

A total of 853 patients were identified. After exclusions, 403 patients with primary hepatolithiasis underwent anatomical hepatectomy (OH n=143; LH n=260). PSM resulted in 2 groups of 100 patients each. Although LH required a longer median operation duration compared with OH (285.0 versus 240.0 min, respectively, P<0.001), LH patients had fewer wound infections, fewer pre-discharge overall complications (26 versus 43%, respectively, P=0.009), and shorter median postoperative hospital stays (8.0 versus 12.0 days, respectively, P<0.001). No differences were found in blood loss, major complications, stone clearance, and mortality between the two matched groups. However, the median overall hospital cost of LH was significantly higher than that of OH (CNY¥52,196.1 versus 45,349.5, respectively, P=0.007). Although LH patients had shorter median postoperative hospital stays and fewer complications than OH patients, the WAMC was still higher for the LH group than for the OH group with an increase of CNY¥9,755.2 per patient undergoing LH.

CONCLUSION

The overall clinical benefit of LH for hepatolithiasis is comparable or even superior to that of OH, but with an economic disadvantage. There is a need to effectively reduce the hospital costs of LH and the gap between costs and diagnosis-related group reimbursement to promote its adoption.

Total laparoscopic partial hepatectomy versus open partial hepatectomy for primary left-sided hepatolithiasis: study protocol for a randomized controlled trial

BACKGROUND

The advantages of laparoscopic left-sided hepatectomy (LLH) for treating hepatolithiasis in terms of the time to postoperative length of hospital stay (LOS), morbidity, long-term abdominal wall hernias, hospital costs, residual stone rate, and recurrence of calculus have not been confirmed by a randomized controlled trial. The aim of this trial is to compare the safety and effectiveness of LLH with open left-sided hepatectomy (OLH) for the treatment of hepatolithiasis.

METHODS

Patients with hepatolithiasis eligible for left-sided hepatectomy will be recruited. The experimental design will produce two randomized arms (laparoscopic and open hepatectomy) at a 1:1 ratio and a prospective registry. All patients will undergo surgery in the setting of an enhanced recovery after surgery (ERAS) programme. The prospective registry will be based on patients who cannot be randomized because of the explicit treatment preference of the patient or surgeon or because of ineligibility (not meeting the inclusion and exclusion criteria) for randomization in this trial. The primary outcome is the LOS. The secondary outcomes are percentage readmission, morbidity, mortality, hospital costs, long-term incidence of incisional hernias, residual stone rate, and recurrence of calculus. It will be assumed that, in patients undergoing LLH, the length of hospital stay will be reduced by 1 day. A sample size of 86 patients in each randomization arm has been calculated as sufficient to detect a 1-day reduction in LOS [90% power and α = 0.05 (two-tailed)]. The trial is a randomized controlled trial that will provide evidence for the merits of laparoscopic surgery in patients undergoing liver resection within an ERAS programme.

CONCLUSIONS

Although the outcomes of LLH have been proven to be comparable to those of OLH in retrospective studies, the use of LLH remains restricted, partly due to the lack of short- and long-term informative RCTs pertaining to patients with hepatolithiasis in ERAS programmes. To evaluate the surgical and long-term outcomes of LLH, we will perform a prospective RCT to compare LLH with OLH for hepatolithiasis within an ERAS programme.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03958825. Registered on 21 May 2019.

Evidence-based clinical practice guidelines for cholelithiasis 2021

The Japanese Society of Gastroenterology first published evidence-based clinical practice guidelines for cholelithiasis in 2010, followed by a revision in 2016. Currently, the revised third edition was published to reflect recent evidence on the diagnosis, treatment, and prognosis of cholelithiasis conforming to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Following this revision, the present English version of the guidelines was updated and published herein. The clinical questions (CQ) in the previous version were reviewed and rearranged into three newly divided categories: background questions (BQ) dealing with basic background knowledge, CQ, and future research questions (FRQ), which refer to issues that require further accumulation of evidence. Finally, 52 questions (29 BQs, 19 CQs, and 4 FRQs) were adopted to cover the epidemiology, pathogenesis, diagnosis, treatment, complications, and prognosis. Based on a literature search using MEDLINE, Cochrane Library, and Igaku Chuo Zasshi databases for the period between 1983 and August 2019, along with a manual search of new information reported over the past 5 years, the level of evidence was evaluated for each CQ. The strengths of recommendations were determined using the Delphi method by the committee members considering the body of evidence, including benefits and harms, patient preference, and cost-benefit balance. A comprehensive flowchart was prepared for the diagnosis and treatment of gallbladder stones, common bile duct stones, and intrahepatic stones, respectively. The current revised guidelines are expected to be of great assistance to gastroenterologists and general physicians in making decisions on contemporary clinical management for cholelithiasis patients.

EASL-ILCA Clinical Practice Guidelines on the management of intrahepatic cholangiocarcinoma

Intrahepatic cholangiocarcinoma (iCCA) develops inside the liver, between bile ductules and the second-order bile ducts. It is the second most frequent primary liver cancer after hepatocellular carcinoma, and its global incidence is increasing. It is associated with an alarming mortality rate owing to its silent presentation (often leading to late diagnosis), highly aggressive nature and resistance to treatment. Early diagnosis, molecular characterisation, accurate staging and personalised multidisciplinary treatments represent current challenges for researchers and physicians. Unfortunately, these challenges are beset by the high heterogeneity of iCCA at the clinical, genomic, epigenetic and molecular levels, very often precluding successful management. Nonetheless, in the last few years, progress has been made in molecular characterisation, surgical management, and targeted therapy. Recent advances together with the awareness that iCCA represents a distinct entity amongst the CCA family, led the ILCA and EASL governing boards to commission international experts to draft dedicated evidence-based guidelines for physicians involved in the diagnostic, prognostic, and therapeutic management of iCCA.

Liver resection for hepatolithiasis: A multicenter experience in Latin America

BACKGROUND

Hepatolithiasis is a prevalent disease in Asia but rare in Western countries. An increasing number of cases have been reported in Latin America. Liver resection has been proposed as a definitive treatment for complete stone clearance. The aim of this study was to evaluate the postoperative outcomes of liver resection for the treatment of hepatolithiasis in 2 large hepatobiliary reference centers from South America.

METHODS

We conducted a retrospective descriptive analysis from patients with hepatolithiasis who underwent liver resection between November 1986 and December 2018, in 2 Latin-American centers in Chile and Brazil.

RESULTS

One hundred forty-nine patients underwent liver resection for hepatolithiasis (72 in Chile, 77 in Brazil). The mean age was 49 years and most patients were female (62.4%). Hepatolithiasis was localized in the left lobe (61.7%), right lobe (24.2%), and bilateral lobe (14.1%). Bilateral lithiasis was associated with higher incidence of preoperative and postoperative cholangitis (81% vs 46.9% and 28.6% vs 6.1%) and need for hepaticojejunostomy (52.4%). In total, 38.9% of patients underwent major hepatectomy and 14.1% were laparoscopic. The postoperative stone clearance was 100%. The 30-day morbidity and mortality rates were 30.9% and 0.7%, respectively. Cholangiocarcinoma was seen in 2 specimens, and no postoperative malignancy were seen after a median follow-up of 38 months. Fourteen patients (9.4%) had intrahepatic stones recurrence.

CONCLUSIONS

Liver resection is an effective and definitive treatment for patients with hepatolithiasis. Bilateral hepatolithiasis was associated with perioperative cholangitis, the need for hepaticojejunostomy, and recurrent disease. Resection presents a high rate of biliary tree stone clearance and excellent long-term results, with low recurrence rates and low risk of malignancy.

Outcome of percutaneous transhepatic biliary interventions in the management of biliary enteric anastomotic strictures with hepatolithiasis

AIM

To evaluate percutaneous transhepatic biliary interventions (PTBI) using the ADDFREE (Access-Drain-Dilate-Flush-REpeat periodically-Evaluate and remove) technique and its outcomes in patients with biliary enteric anastomotic strictures (BEAS) and hepatolithiasis.

MATERIAL AND METHODS

A retrospective review was undertaken of patients having hepatolithiasis with BEAS who underwent PTBI with a therapeutic intent (from January 2010 to January 2021) was performed. The technical and clinical successes of PTBI were analysed. Technical success was divided into duct access, crossing of BEAS, stricture resolution, and calculi clearance. Improvement of liver function tests, resolution of leucocytosis and presenting complaints were considered as clinical success. The patients were followed-up for a minimum duration of 6-months.

RESULTS

Eighteen patients received PTBI in form of the ADDFREE technique. Hepatolithiasis was bilobar (44.4%), unilobar in multiple ducts (unilobar-m; 27.8%) and unilobar in a single duct (unilobar-s; 27.8%) along with anastomotic stricture. The average number of sessions of stone clearance for bilobar, unilobar-m, and unilobar-s was 4.4 (±1.6), 3.6 (±2.4), and 1.5 (±0.5), respectively. Clinical success was observed in 14 (77.8%), while one patient had recurrence of calculi and received repeat treatment. Bile culture was positive for bacterial organisms in 17 (94.4%) patients. No major complication were seen while minor complication were seen in five patients consisting of self-limiting haemobilia (n=1), per-catheter bile leak (n=2) and aggravation of cholangitis (n=2).

CONCLUSION

PTBI, consisting of bile duct access, cholangioplasty, and calculi clearance, is a safe and effective technique for the treatment of patients having hepatolithiasis secondary to BEAS.

Predictive factors for subsequent intrahepatic cholangiocarcinoma associated with hepatolithiasis: Japanese National Cohort Study for 18 years

BACKGROUND

Predictive factors for intrahepatic cholangiocarcinoma in long-term follow-up of hepatolithiasis are unknown. We thus conducted a cohort study to investigate the predictive factors for developing intrahepatic cholangiocarcinoma in hepatolithiasis.

METHODS

This cohort is comprised of 401 patients registered in a nationwide survey of hepatolithiasis for 18 years of follow-up. Cox regression analysis was used to elucidate predictive factors for developing intrahepatic cholangiocarcinoma.

RESULTS

The median follow-up period of patients was 134 months. Twenty-two patients developed intrahepatic cholangiocarcinoma and all died. Identified independent significant factors were as follows: age 63 years or older (hazard ratio [HR] 3.344), residual stones at the end of treatment (HR 2.445), and biliary stricture during follow-up (HR 4.350). The incidence of intrahepatic cholangiocarcinoma in patients with three factors was significantly higher than that in patients with one or two factors. The incidence in the groups with one or two predictive factors was not different. In 88.9% of patients with both biliary stricture and intrahepatic cholangiocarcinoma, the duration between the diagnoses of biliary stricture and intrahepatic cholangiocarcinoma was ≥ 5 years. However, once intrahepatic cholangiocarcinoma developed, 77.8% of patients died within 1 year. Of 24 patients with no symptoms, no previous choledocoenterostomy, no signs of malignancy, no biliary stricture, and no treatment for hepatolithiasis during follow-up, only one developed intrahepatic cholangiocarcinoma.

CONCLUSIONS

Regarding carcinogenesis, complete stone clearance and releasing biliary stricture can prevent the development of intrahepatic cholangiocarcinoma and improve the prognosis of hepatolithiasis.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Laparoscopic middle-hepatic-vein-guided anatomical hemihepatectomy in the treatment of hepatolithiasis: a 10-year case study

BACKGROUND

This retrospective 10-year case study evaluated the perioperative results and long-term efficacy of laparoscopic middle-hepatic-vein-guided hemihepatectomy (L-MHV-H) and traditional anatomical hemihepatectomy (TAH) in the treatment of hepatolithiasis (HL).

METHODS

From January 2010 to December 2019, 99 patients with regional HL underwent laparoscopic anatomical hemihepatectomy (LAH) at our centre, including 43 patients in the L-MHV-H group and 56 patients in the TAH group.

RESULTS

All patients in both groups were Child-Pugh grade A before operation. No significant between-group differences in general information, stone distribution, comorbidities, history of previous abdominal surgery or co-occurrence of gallstones and common bile duct stones were observed. The L-MHV-H group exhibited a higher intraoperative stone clearance rate (95.3% vs. 75.0%, p = 0.014) and a lower postoperative complication rate (10.1% vs. 48.2%, p = 0.005) compared with the TAH group. In the median follow-up time of 60 months (range 6-125 months), the L-MHV-H group had lower stone recurrence (2.3% vs. 19.6%, p = 0.013) and cholangitis recurrence (2.3% vs. 17.9%, p = 0.034) rates. No significant between-group differences in the other results were observed.

CONCLUSIONS

L-MHV-H is safe and feasible for HL with certain advantages over TAH in improving the intraoperative stone clearance rate, reducing postoperative complication incidence and reducing stone and cholangitis recurrence rates.

[Management of Intrahepatic Duct Stone]

Intrahepatic duct (IHD) stone is the presence of calculi within the intrahepatic bile duct specifically located proximal to the confluence of the left and right hepatic ducts. This stone is characterized by its intractable nature and frequent recurrence, requiring multiple therapeutic interventions. Without proper treatment, biliary strictures and retained stones can lead to repeated episodes of cholangitis, liver abscesses, secondary biliary cirrhosis, portal hypertension, and death from sepsis or hepatic failure. The ultimate treatment goals for IHD stones are complete removal of the stone, the correction of the associated strictures, and the prevention of recurrent cholangitis. A surgical resection can satisfy the goal of treatment for hepatolithiasis, i.e., complete removal of the IHD stones, stricture, and the risk of cholangiocarcinogenesis. On the other hand, in some cases, such as bilateral IHD stones, surgery alone cannot achieve these goals. Therefore, the optimal treatments require a multidisciplinary approach, including endoscopic and radiologic interventional procedures before and/or after surgery. Percutaneous transhepatic cholangioscopic lithotomy (PTCS-L) is particularly suited for patients at poor surgical risk or who refuse surgery and those with previous biliary surgery or stones distributed in multiple segments. PTCS-L is relatively safe and effective for the treatment of IHD stones, and complete stone clearance is mandatory to reduce the sequelae of IHD stones. An IHD stricture is the main factor contributing to incomplete clearance and stone recurrence. Long-term follow-up is required because of the overall high recurrence rate of IHD stones and the association with cholangiocarcinoma.

Incidence and Prognosis of Subsequent Cholangiocarcinoma in Patients with Hepatic Resection for Bile Duct Stones

BACKGROUND AND AIM

Cholangiocarcinoma (CCA) often develops after the hepatic resection for hepatolithiasis as well as indwelling it. We studied the incidence and prognosis of subsequent CCA in patients with hepatolithiasis in South Korea.

METHODS

We identified individuals with diagnosed CCA at the time of or after surgery, during 2002-2016, from the Korean National Health Insurance. The incidences and survival rates of subsequent CCA were analyzed and compared with concomitant CCA. The standardized incidence ratios (SIRs) of CCA in this cohort were evaluated in the standard Korean population. All data were stratified by the presence of intrahepatic or extrahepatic CCA, age and sex.

RESULTS

Of the 7852 patients with hepatectomy for BDS, 433 (5.84%) had concomitant CCA. Over the 12-year follow-up, 107 of 7419 (1.98%) patients were diagnosed with subsequent CCA. Patients with hepatic resection for BDS revealed higher SIRs for subsequent CCA (12.89, 95% CI 10.96-15.15) in cases of both intrahepatic CCA (13.40, 10.55-17.02) and extrahepatic CCA (12.42, 9.98-15.46). The median survival time for subsequent CCA was 0.87 years, while that for concomitant CCA was 2.79 years. Having subsequent CCA (HR 2.71, 95% CI 2.17-3.40) and being male (HR 1.28, 1.05-1.57) were related to a shorter survival time. The CCA site and age at CCA diagnosis were not related to prognoses.

CONCLUSIONS

Subsequent CCA developed in 2% of the patients with hepatic resection for benign BDS until 10 years and was associated with poorer prognoses than concomitant CCA. Future studies focused on the long-term surveillance for CCA in such patients are needed.

Robotic-assisted laparoscopic surgery for complex hepatolithiasis: a propensity score matching analysis

BACKGROUND

The indication for laparoscopic treatment of hepatolithiasis is early-stage regional hepatolithiasis. Open surgery (OS) is the traditional treatment for complex hepatolithiasis. Robotic-assisted laparoscopic surgery (RLS) overcomes the limitations of the traditional laparoscopic approach in terms of the visual field, instruments, and operational flexibility. RLS is thus theoretically indicated for the treatment of complicated hepatolithiasis. This study aimed to evaluate the safety, efficacy, and feasibility of RLS for the treatment of complicated hepatolithiasis.

METHODS

From October 2010 to August 2017, 26 consecutive patients who underwent RLS and 287 consecutive patients who underwent OS for the treatment of complicated hepatolithiasis at our center were included in this study. We performed a propensity score matching (PSM) analysis between patients who underwent RLS and patients who underwent OS at a ratio of 1:2. Twenty-six patients were included in the RLS group, and 52 patients were included in the OS group.

RESULTS

The groups exhibited no differences with respect to age, sex, location of stones, liver function, history of previous surgery, or Child-Pugh classification. There were no differences in the postoperative complication rates (46.2% vs. 63.5%, p = 0.145), intraoperative stone clearance rates (96.2% vs. 90.4%, p = 1.000), or final stone clearance rates (100% vs. 98.1%, p = 0.652) between the two groups. The RLS group had less blood loss (315.38 ± 237.81 vs. 542.88 ± 518.70 ml, p = 0.037), a lower transfusion rate (15.4% vs. 46.2%, p = 0.008), shorter oral intake times (3.50 ± 1.30 vs. 5.88 ± 4.00 days, p = 0.004), and shorter postoperative hospital stays (13.54 ± 6.54 vs. 17.81 ± 7.49 days, p = 0.016) than the OS group. At a median follow-up of 48 months (range 7-90 months), there were no differences in stone recurrence rate (3.8% vs. 13.5%, p = 0.356) or recurrent cholangitis rate (3.8% vs. 3.8%, p = 1.000) between RLS and OS patients.

CONCLUSION

RLS for complicated hepatolithiasis is safe and feasible with advantages over OS in terms of intraoperative blood loss, transfusion rate, duration of hospital stays, and postoperative recovery.

Robotic Liver Resection For Primary Hepatolithiasis: Is It Beneficial?

BACKGROUND

Primary hepatolithiasis is a disease characterized by primary biliary ductal abnormality with stone formation predominantly within the intrahepatic bile ducts. Its management is difficult, but liver resection has emerged as a promising treatment option.

METHODS

Robotic liver resection (RLR) has been adopted in our center for the management of patients with hepatolithiasis. The operative and short-term outcomes of this cohort of patients were compared with a historical cohort of patients using open approach (OLR). A subgroup analysis was performed for left lateral sectionectomy.

RESULTS

Between September 2010 and April 2015, 15 RLRs were performed on patients with primary hepatolithiasis. The historical cohort consisted of 42 OLRs with operation done between January 2005 and January 2014. No differences were found in patient demographics, disease characteristics, or types of resection. No operative deaths occurred, and no difference was seen in complication rates. RLR had significantly less blood loss (100 vs. 235 ml; p = 0.011) and shorter hospital stays (6 vs. 8 days; p = 0.003). After a median follow-up of 19.4 months for RLRs and 79.2 months for OLRs (p < 0.001), there were no differences in residual stone rate, recurrent stone rate, or rate of recurrent cholangitis. Subgroup analysis of lateral sectionectomy (10 RLRs vs. 27 OLRs) revealed similar outcomes, i.e., less blood loss and shorter hospital stays in RLR.

CONCLUSIONS

Robotic liver resection reduces blood loss and shortens hospital stays compared with OLR. A longer follow-up is needed to assess the long-term outcomes of RLR regarding prevention of recurrent stones and cholangitis.

Risk Factors for Cholangiocarcinoma After Initial Hepatectomy for Intrahepatic Stones

BACKGROUND

Aggressive hepatectomy is effective in treating intrahepatic stones and may minimize the deleterious consequences of subsequent cholangiocarcinoma (S-CCA). The risk factors of S-CCA after different methods of hepatectomy may vary with the resection scope of stone-affected segments.

METHODS

We reviewed the records of 981 patients of primary intrahepatic stones with elective hepatectomy from January 2000 to December 2010. The clinical characteristics of patients in the S-CCA group (n = 55) and the control group (n = 926) were compared. The uniformity between extent of liver resection (ELR) with stone-affected segments (SAS) was segmented into 2 varieties: ELR = SAS with ELR < SAS according to the different hepatic resection scopes. Cox regression model with forward selection was used to identify the risk factors of S-CCA.

RESULTS

In the univariate analysis, significant differences were observed between the S-CCA and control groups concerning stone location (unilateral 43.6 and 65.2 %, bilateral 56.4 and 34.8 %), residual stones (32.7 and 11.6 %), hepaticojejunostomy (43.6 and 30.9 %), and uniformity between ELR with SAS (ELR = SAS 20.0 and 42.6 %, ELR < SAS 80.0 and 57.4 %). Residual stones [hazard ratio (HR) 2.101, P = 0.016], hepaticojejunostomy (HR 1.837, P = 0.026) and uniformity between ELR and SAS (HR 2.442, P = 0.013) were independent prognostic factors for S-CCA by a Cox regression analysis with forward selection. In the subsection of ELR = SAS group, the 5- and 10-year postoperative tumor occurrence rates of unilateral and bilateral stones group were 0.9 versus 1.9 % and 3.0 versus 4.1 %, respectively (P = 0.663, log-rank). In the other subsection of ELR < SAS group, the 5- and 10-year postoperative tumor occurrence rates of unilateral and bilateral stones group were 3.4 versus 3.9 % and 6.8 versus 13.2 %, respectively (P = 0.047, log-rank), and the 5- and 10-year postoperative tumor occurrence rates of residual stones and non-residual stones group were 5.8 versus 3.0 % and 16.0 versus 7.9 %, respectively (P = 0.015, log-rank).

CONCLUSIONS

Patients who underwent aggressive hepatectomy and had ELR = SAS had better outcomes than those with ELR < SAS. In the patients with ELR = SAS, the S-CCA rates of unilateral and bilateral stones were low and comparable. However, patients with ELR < SAS and bilateral intrahepatic or residual stones should be monitored more carefully for high-risk factors of S-CCA.

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

Backgrounds/Aims

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

Methods

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

Results

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

Conclusions

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Liver Resection for Primary Intrahepatic Stones: Focus on Postoperative Infectious Complications

BACKGROUND

Primary intrahepatic lithiasis is defined by the presence of gallstones at the level of cystic dilatations of the intrahepatic biliary tree. Liver resection is considered the treatment of choice, with the purpose of removing stones and atrophic parenchyma, also reducing the risk of cholangiocarcinoma. However, in consequence of the considerable incidence of infectious complications, postoperative morbidity remains high. The current study was designed to evaluate the impact of preoperative bacterial colonization of the bile ducts on postoperative outcome.

METHODS

The clinical records of 73 patients treated with liver resection were reviewed and clinical data, operative procedures, results of bile cultures, and postoperative outcomes were examined.

RESULTS

Left hepatectomy (38 patients) and left lateral sectionectomy (19 patients) were the most frequently performed procedures. Overall morbidity was 38.3 %. A total of 133 microorganisms were isolated from bile. Multivariate analysis identified previous endoscopic or percutaneous cholangiography (p = 0.043) and preoperative cholangitis (p = 0.003) as the only two independent risk factors for postoperative infectious complications.

CONCLUSIONS

Postoperative morbidity was strictly related to the preoperative biliary infection. An effective control of infections should be always pursued before liver resection for intrahepatic stones and an aggressive treatment of early signs of sepsis should be strongly emphasized.

Liver transplantation for hepatolithiasis: Is terminal hepatolithiasis suitable for liver transplantation?

Hepatolithiasis, originally as oriental cholangiohepatitis, especially prevails in Asia, but globalization and intercontinental migration have also converted the endemic disease dynamics around the world. Characterized by its high incidence of ineffective treatment and recurrence, hepatolithiasis, always, poses a therapeutic challenge to global doctors. Although the improved surgical and non-surgical techniques have evolved over the past decade, incomplete clearance and recurrence of calculi are always so common and disease-related mortality from liver failure and concurrent cholangiocarcinoma still exists in the treatment of hepatolithiasis. In the late stage of hepatolithiasis, is it suitable for liver transplantation (LT)? Herein, we propose a comprehensive review and analysis of the LTx currently in potential use to treat hepatolithiasis. In our subjective opinion, and as is objective from the literatures so far, also given the strict indications, LT remains one of the definitive treatments for terminal hepatolithiasis.

Pathogenesis and Management of Hepatolithiasis: A Report of Two Cases

Hepatolithiasis or primary intrahepatic stones are prevalent in the Far-East countries such as Korea, Japan and Taiwan. It has been associated with helminthiasis, bacterial infections, environmental and dietary factors. Despite high prevalence of helminthiasis like ascariasis, poor environmental condition and low protein diet, India and Middle-East countries have a low incidence of hepatolithiasis. We report two cases of hepatolithiasis associated with bacterial infections and were surgically managed. The first case is a 45-year-old female presenting with upper abdominal pain and fever. She had multiple calculi in intrahepatic biliary radicles, common bile duct, common hepatic duct and gall bladder. She was managed by cholecystectomy, left lateral liver sectionectomy, choledochoscopy assisted stone clearance of the residual liver and Roux-en-Y hepatico-jejunostomy. The second case is a 60-year-old female presenting with epigastric pain and fever and past history of cholecystectomy for cholelithiasis. She had multiple right and left intrahepatic calculi and managed by left lateral liver sectionectomy with excision of CBD and Roux-en-Y hepatico-jejunostomy. Both the cases showed growth of bacteria in the culture of the intraoperatively collected bile.

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.

The role of endoscopy in the management of recurrent pyogenic cholangitis: a review

Recurrent pyogenic cholangitis (RPC) is a clinical syndrome characterized by repeated episodes of suppurative cholangitis due to hepatolithiasis and extrahepatic stones in the biliary ducts. It is now recognized as a distinct syndrome with a different natural history and pathoetiology than spontaneously occurring liver abscesses. Most commonly seen in East Asian populations, this syndrome is growing increasingly common in Western Nations due to migration patterns. The exact pathogenesis of RPC remains elusive; although colonization of the biliary tract with particular enteric bacterial species, in combination with possible dietary factors, has been attributed as causative factors. Hepatobiliary surgery, in particular segmental hepatectomy, is often described as the definitive treatment of choice for RPC. The exact role of endoscopic intervention has been less clearly described in the literature. This review focuses on the management of RPC while highlighting situations in which endoscopic retrograde cholangiopancreatography may be preferred over surgery as an initial or salvage therapeutic measure.

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.

Hepatectomy with primary closure of common bile duct for hepatolithiasis combined with choledocholithiasis

AIM: To evaluate the feasibility of hepatectomy and primary closure of common bile duct for intrahepatic and extrahepatic calculi.

METHODS: From January 2008 to May 2013, anatomic hepatectomy followed by biliary tract exploration without biliary drainage (non-drainage group) was performed in 43 patients with intrahepatic and extrahepatic calculi. After hepatectomy, flexible choledochoscopy was used to extract residual stones and observe the intrahepatic bile duct and common bile duct (CBD) for determination of biliary stricture and dilatation. Function of the sphincter of Oddi was determined by manometry of the CBD. Primary closure of the CBD without T-tube drainage or bilioenteric anastomosis was performed when there was no biliary stricture or sphincter of Oddi dysfunction. Dexamethasone and anisodamine were intravenously injected 2-3 d after surgery to prevent postoperative retrograde infection due to intraoperative bile duct irrigation, and to maintain relaxation of the sphincter of Oddi, respectively. During the same period, anatomic hepatectomy followed by biliary tract exploration with biliary drainage (drainage group) was performed in 48 patients as the control group. Postoperative complications and hospital stay were compared between the two groups.

RESULTS: There was no operative mortality in either group of patients. Compared to intrahepatic and extrabiliary drainage, hepatectomy with primary closure of the CBD (non-drainage) did not increase the incidence of complications, including residual stones, bile leakage, pancreatitis and cholangitis (P > 0.05). Postoperative hospital stay and costs were nevertheless significantly less in the non-drainage group than in the drainage group. The median postoperative hospital stay was shorter in the non-drainage group than in the drainage group (11.2 ± 2.8 d vs 15.4 ± 2.1 d, P = 0.000). The average postoperative cost of treatment was lower in the non-drainage group than in the drainage group (29325.6 ± 5668.2 yuan vs 32933.3 ± 6235.1 yuan, P = 0.005).

CONCLUSION: Hepatectomy followed by choledochoendoscopic stone extraction without biliary drainage is a safe and effective treatment of hepatolithiasis combined with choledocholithiasis.

Preliminary study of a new pathological evolution-based clinical hepatolithiasis classification

AIM: To investigate clinical features, treatment strategies and outcomes of patients with hepatolithiasis (HL) undergoing surgical treatment, using a new clinical classification.

METHODS: Sixty-eight HL patients were hospitalized and treated surgically from August 2011 to December 2012 and they were classified into four HL types according to pathological evolution of the disease. These four HL types included type I primary type (defined as no previous biliary tract surgery), type II inflammatory type (with previous biliary tract surgery and cholangitis), type III mass-forming type (HL complicated by hepatic mass-forming lesion), and type IV terminal type (with secondary biliary cirrhosis and resultant portal hypertension). The perioperative data including general information, imaging data, postoperative complications, and immediate and final stone clearance rate were obtained and analyzed.

RESULTS: In all 68 patients, the proportion of HL type I-IV was 50% (34/68), 36.8% (25/68), 10.3% (7/68) and 2.8% (2/68), respectively. Abdominal pain was the main clinical manifestation in type I (88.2%), fever was predominant in type II (52.0%), the malignancy rate in type III was high (71.4%), and portal hypertension and spleen enlargement were common in type IV (2/2, 100.0%). Liver resection rate for types I-III was 79.4%, 72.0% and 71.4%, respectively. The overall incidence of postoperative complications was 23.5% (16/68). There were no perioperative deaths. The average length of hospital stay was 12.7 ± 7.3 d. Immediate and final stone clearance rate was 73.5% (50/68) and 89.7% (61/68), respectively. Fifty-nine of 68 patients (86.8%) were followed- up for > 1 year after surgery, and 96.6% of these patients (57/59) had a good quality of life according to a criterion recommended for postoperative evaluation of quality of life.

CONCLUSION: The pathological evolution-based clinical classification of HL has a role in optimizing treatment strategy, and patients can benefit from this classification when it is used properly.

Application of hepatic resection in hepatolithiasis

AIM: To investigate the value of hepatic resection in the treatment of hepatolithiasis.

METHODS: The clinical data for 130 patients with hepatolithiasis who underwent hepatectomy from June 2005 to May 2014 were retrospectively analyzed.

RESULTS: Left lateral hepatic lobectomy was performed in 87 patients, left hepatectomy in 19 patients, quadrate lobe resection in 9 patients, regular hepatic resection in 8 patients, partial right lobe resection with left lateral lobectomy in 3 patients, right hepatectomy with left lateral lobectomy in 1 patient, and left medial hepatic resection in 3 patients. The stone clearance rate was 87%. Fifteen patients were discovered to have cholangiocarcinoma, and 13 cases had residual stones. Postoperative complications included incision infection, bile leakage, pneumonia, and pleural effusion. One patient died of liver failure preoperatively.

CONCLUSION: Hepatectomy is a safe and effective treatment for hepatolithiasis. Adequate preoperative evaluation and reasonable surgical procedure can help reduce or avoid biliary tract reoperation.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Hepatolithiasis: analysis of Japanese nationwide surveys over a period of 40 years

The aims of the present study are to clarify the changes in clinicopathologic features, diagnosis and treatment for hepatolithiasis, and propose an appropriate management strategy in Japan. The research group conducted nationwide surveys seven times in the past over a period of 40 years. Furthermore, a cohort was followed up in 2010. We analyzed the clinical features, diagnosis tools, treatment procedures, outcomes, and predictive factors for cholangiocarcinoma. Surgery was the primary method for hepatolithiasis up to 1998, and the frequency of its use has decreased since then. In 2011, 66.7% of hepatolithiasis patients were treated using nonsurgical approaches. In addition, endoscopic retrograde cholangiography (ERC) with stone extraction was the most frequently performed procedure (22.7%). However, the incidences of residual stone and recurrent stone after ERC with stone extraction were higher than those after percutaneous transhepatic cholangioscopic lithotomy and surgery. Bile duct stricture and dilatation during follow up were significant risk factors for stone recurrences. In the cohort study, stone removal only and age >65 years were significant factors for the development of cholangiocarcinoma. In patients without a history of cholangioenterostomy, left-lobe-type stones were a risk factor, and hepatectomy reduced the risk of the development of cholangiocarcinoma significantly. Nonsurgical treatment may be performed as the first-line treatment for hepatolithiasis. Surgery should be performed on patients who were treated incompletely after nonsurgical treatment. However, hepatectomy may be recommended for patients with left-lobe-type stones and without a history of cholangioenterostomy.

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.

Laparoscopic hepatectomy with bile duct exploration for the treatment of hepatolithiasis: an experience of 116 cases

BACKGROUND

An increasing number of patients with hepatolithiasis were diagnosed at an early stage in China. Laparoscopic surgery has introduced new methods of treating this condition.

AIM

To investigate the patient selection, operative technique, and efficacy of laparoscopic hepatectomy with bile duct exploration for the treatment of hepatolithiasis.

PATIENTS AND METHODS

The clinical data of 116 patients who underwent laparoscopic hepatectomy (laparoscopic group) and 78 patients who underwent open hepatectomy (open group) for hepatolithiasis were retrospectively analyzed, and were compared with the recent reports.

RESULTS

The laparoscopic group had a longer duration of operation (323.3 ± 103.0 min vs. 272.8 ± 66.8 min, p<0.05) and shorter postoperative hospital stay (13.1 ± 5.6 days vs. 16.5 ± 8.4 days, p<0.05) than the open group. There were no significant differences between the two groups in intraoperative blood loss or transfusion rate, postoperative complications, calculus clearance, calculus recurrence, or recurrent cholangitis (p>0.05 for all). Efficacy in the laparoscopic group was similar to that in other recently reported studies.

CONCLUSIONS

Laparoscopic hepatectomy with bile duct exploration is safe and feasible for early stage localized hepatolithiasis, with an efficacy similar to that of open surgery. Anatomic hepatectomy is important for achieving good therapeutic outcomes.

Application of three-dimensional reconstruction and visible simulation technique in reoperation of hepatolithiasis

BACKGROUND AND AIM

Hepatolithiasis often requires repeated operations in East Asia. This study aims to evaluate the clinical application of three-dimensional reconstruction and visible simulation techniques for repeated operation in patients with intrahepatic calculi.

METHODS

A medical image processing system was used for modeling, segmentation, and three-dimensional reconstruction of intrahepatic stones in 20 patients, consisting of 7 males and 13 females who were subjected to repeated surgical treatment from May 2010 to November 2011. The three-dimensional models of the liver and bile ducts in a standard template library format were then processed by the FreeForm Modeling System. Accurate digital information about the bile duct system, lesions, calculi distribution, and surrounding organs obtained from all directions, multiple angles, and multistrata were used to decide the rational surgical modality. Virtual operations were then performed on the models with virtual surgical instruments in the FreeForm Modeling System. The results were used to guide and were compared with the real surgical procedures performed.

RESULTS

The surgical outcomes of all patients in this study were satisfactory. Three-dimensionally reconstructed models provided clear and strong relief perception and a user-friendly interface. Visible simulation surgery performed based on three-dimensionally reconstructed models led to an optimal operation plan that had great resemblance to the actual surgeries for cases with intrahepatic stones.

CONCLUSIONS

Three-dimensional reconstruction and visible simulation techniques had unique value in optimizing repeated operation plans and in guiding actual surgical procedures for patients with recurrent intrahepatic calculi.

The safety and feasibility of reoperation for the treatment of hepatolithiasis by laparoscopic approach

BACKGROUND

Hepatolithiasis removal is associated with high rates of postoperative residual and recurrence, which in some cases may require multiple surgeries. The progress and development of laparoscopic techniques introduced a new way of treating hepatolithiasis. However, the selection criteria for laparoscopic hepatolithiasis surgery, particularly among patients with a history of biliary surgery, remain undetermined. This study aimed to evaluate the safety, feasibility, and efficacy of reoperation for the treatment of hepatolithiasis via a laparoscopic approach.

METHODS

A retrospective analysis of the perioperative course and outcomes was performed on 90 patients who underwent laparoscopic procedures for hepatolithiasis between January 1, 2008, and December 31, 2012. Thirty-eight patients had previous biliary tract operative procedures (PB group) and 52 patients had no previous biliary tract procedures (NPB).

RESULTS

There was no significant difference in operative time (342.3 ± 101.0 vs. 334.1 ± 102.7 min), intraoperative blood loss (561.2 ± 458.8 vs. 546.3 ± 570.5 ml), intraoperative transfusion (15.8 vs. 19.2 %), postoperative hospitalization (12.6 ± 4.2 vs. 13.4 % ± 6.3 days), postoperative complications (18.4 vs. 23.1 %), conversion to open laparotomy (10.5 vs. 9.6 %), or intraoperative stone clearance rate (94.7 vs. 90.4 %). There was also no significant difference in stone recurrence (7.9 vs. 11.5 %) and recurrent cholangitis (5.3 vs. 13.5 %) at a mean of 19 months of follow-up (range, 3-51 months) for PB patients compared to NPB patients. The final stone clearance rate was 100 % in both groups.

CONCLUSIONS

Reoperation for hepatolithiasis by laparoscopic approach is safe and feasible for selected patients who have undergone previous biliary operations.

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

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

Left-sided hepatic resection for hepatolithiasis: a longitudinal study of 110 patients

BACKGROUND

Hepatolithiasis affecting the left hepatobiliary system is common in the Asia Pacific region. This aim of this study was to describe an experience with the diagnosis and treatment of patients with isolated left-sided hepatolithiasis.

METHODS

One hundred and ten patients with isolated left-sided hepatolithiasis who underwent a left-sided hepatic resection between January 1999 and February 2010 were included for further analysis. The clinical profile, cholangiograms, operative procedures and early and late results were examined.

RESULTS

Analysis of magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) findings revealed left hepatic ductal anatomical details in 101 patients. Three types of left hepatic ductal variations were observed (type 1 in 90.1%, type 2 in 5.9% and type 3 in 4.0% patients). Eighty-four (76.4%) patients had the presence of strictures in the left hepatic ductal system and in 26 (23.6%) patients no strictures could be seen. Out of 84 patients with strictures, 78 could be classified (type I in 89.7% and type II in 10.3%). Of the 110 patients, 75 (68.2%) underwent a left lateral sectionectomy, 33 (30%) a left hepatectomy and 2 (1.8%) patients were treated with a left hepatectomy combined with a caudate lobe resection. Of the patients who underwent a left hepatectomy 11.4% developed a bile leak. Eight per cent of patients who underwent a left lateral sectionectomy had infective complications. During a median follow-up period of 63 (range 3-134) months, 2 (2.1%) patients were discovered to have residual stones and five (5.2%) others possessed recurrent stones.

CONCLUSIONS

This study highlights the impact of the presence or absence of bile duct stricture on the clinical and histological profile of patients as well as their operative and the post-operative behaviour. It is concluded that hepatic resection is an appropriate treatment modality in localized left-sided hepatolithiasis.

A rare grade III symptomatic Tsunoda class III left lobe hepatolithiasis in a North American woman

A 44-year-old Caucasian woman without any identified predisposing factors, presented to her local emergency room with multiple episodes of recurrent ascending cholangitis. She underwent a laparoscopic cholecystectomy several years prior to her admission to the hospital for parenteral antibiotic therapy and she had no personal or family history of hypercholesterolaemia. Transferred to a tertiary hospital for surgical therapy, she underwent a left hepatic resection for a chronically infected left lobe hepatolithiasis (HL) conditioning atrophy of the parenchyma due to obstruction of the biliary tree by multiple large cholesterol stones. HL is a very rare condition in Western countries and its aetiology and predisposing factors are still unclear. We present her symptomatology, diagnostic and therapeutic management and discuss the epidemiology and risk factors of HL, that is, a common condition in South East Asia while exceptional in Caucasian patients who have not travelled in high-prevalence regions.

Anatomic hepatectomy as a definitive treatment for hepatolithiasis: a cohort study

BACKGROUND

Treatment requirements in hepatolithiasis may vary and may involve a multidisciplinary approach. Surgical resection has been proposed as a definitive treatment.

OBJECTIVES

This study aimed to evaluate the clinical results of anatomic liver resection among Chilean patients with hepatolithiasis.

METHODS

An historical cohort study was conducted. Patients who underwent hepatectomy as a definitive treatment for hepatolithiasis from January 1990 to December 2010 were included. Patients with a preoperative diagnosis of cholangiocarcinoma were excluded. Preoperative, operative and postoperative variables were evaluated.

RESULTS

A total of 52 patients underwent hepatectomy for hepatolithiasis. The mean ± standard deviation patient age was 49.8 ± 11.8 years (range: 24-78 years); 65.4% of study subjects were female. A total of 75.0% of subjects had a history of previous cholecystectomy. The main presenting symptom was abdominal pain (82.7%). Hepatic involvement was noted in the left lobe in 57.7%, the right lobe in 34.6% and bilaterally in 7.7% of subjects. The rate of postoperative clearance of the biliary tree was 90.4%. Postoperative morbidity was 30.8% and there were no postoperative deaths. Three patients had recurrence of hepatolithiasis, which was associated with Caroli's disease in two of them. Overall 5-year survival was 94.5%.

CONCLUSIONS

Anatomic liver resection is an effective treatment in selected patients with hepatolithiasis and is associated with low morbidity and no mortality. At longterm follow-up, anatomic hepatectomy in these patients was associated with a lower rate of recurrence.

Predictive factors for cholangiocarcinoma associated with hepatolithiasis determined on the basis of Japanese Multicenter study

AIM

  The aim of this study was to delineate predictive factors for cholangiocarcinoma in patients with hepatolithiasis, and to establish optimal management for hepatolithiasis from the viewpoint of carcinogenesis on the basis of a Japanese nationwide survey for hepatolithiasis.

METHODS

  The Hepatolithiasis Research Group was organized in 2006 by the Ministry of Health, Labour and Welfare of Japan, and conducted a nationwide survey. The research group collected data on 336 cases of hepatolithiasis in 2006, in a cross-sectional survey involving 2592 institutions in Japan. Predictive factors for cholangiocarcinoma associated with hepatolithiasis were analyzed by univariate and multivariate analyses of clinicopathological and therapeutic factors.

RESULTS

  Twenty-three patients had cholangiocarcinoma. Histories of choledocoenterostomy and liver atrophy were found to be significantly predictive factors by multivariate analysis. In 87.5% of cases of cholangiocarcinoma with liver atrophy, cholangiocarcinoma was located in the atrophic lobes. The method of reconstruction did not affect the incidence of cholangiocarcinoma (choledochojejunostomy vs. choledochoduodenostomy; side-to-end vs. side-to-side anastomosis).

CONCLUSIONS

  Choledocoenterostomy and liver atrophy may increase the risk of developing cholangiocarcinoma. Choledocoenterostomy is thus contraindicated in patients with hepatolithiasis. An aggressive resection strategy is recommended for an atrophic segment.

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.

Epithelial-mesenchymal transitions of bile duct epithelial cells in primary hepatolithiasis

The purpose of this study was to explore the role of epithelial-mesenchymal transition in the pathogenesis of hepatolithiasis. Thirty-one patients with primary hepatolithiasis were enrolled in this study. Expressions of E-cadherin, alpha-catenin, alpha-SMA, vimentin, S100A4, TGF-beta1 and P-smad2/3 in hepatolithiasis bile duct epithelial cells were examined by immunohistochemistry staining. The results showed that the expressions of the epithelial markers E-cadherin and alpha-catenin were frequently lost in hepatolithiasis (32.3% and 25.9% of cases, respectively), while the mesenchymal markers vimentin, alpha-SMA and S100A4 were found to be present in hepatolithiasis (35.5%, 29.0%, and 32.3% of cases, respectively). The increased mesenchymal marker expression was correlated with decreased epithelial marker expression. The expressions of TGF-beta1 and P-smad2/3 in hepatolithiasis were correlated with the expression of S100A4. These data indicate that TGF-beta1-mediated epithelial-mesenchymal transition might be involved in the formation of hepatolithiasis.

Anti-proliferation activity of celecoxib in cholangitis

AIM: To investigate the application value of celecoxib in treating chronic proliferative cholangitis (CPC).

METHODS: Thirty healthy male Sprague-Dawley rats were randomly divided into three groups: sham-operation group (n = 10), CPC model group (n = 10), and celecoxib therapy group (n = 10). CPC was induced in rats by inserting a 5-0 nylon suture into the common bile duct up to the porta hepatis retrogradely through the vater papilla. Rats in the sham-operation group only underwent abdominal wall incision and suturing. Celecoxib [50 mg/(kg·d)] was injected into the abdominal cavity of each rat in the therapy group from day 1 after operation. All rats were executed 1 wk after operation. The anti-proliferation activity of celecoxib was evaluated by hematoxylin and eosin (HE) staining, periodic acid-Schiff (PAS) staining, Masson staining and immunohistochemistry staining of the biliary epithelial mucosa, submucosal gland and collagen fiber in the bile duct wall of CPC rats.

RESULTS: The proliferative degree of the biliary epithelial mucosa and submucosal gland as well as the fibrotic degree of the biliary wall in the celecoxib therapy group were obviously lower than those in the CPC group, but still higher than those in the sham-operation group. Immunohistochemistry analysis showed that the expression intensity of cyclooxygenase 2 (COX-2) in the celecoxib therapy group was obviously inferior to that in the CPC model group (IA: 8.62 ± 0.19 vs 35.27 ± 0.43, P < 0.05), but close to that in the sham-operation group (IA: 8.62 ± 0.19 vs 8.41 ± 0.13, P > 0.05).

CONCLUSION: By down-regulating COX-2 expression, celecoxib can effectively inhibit the hyperplasia of the biliary epithelial mucosa, submucosal gland, and collagen fiber and reduce the amount of mucous glycoprotein secreted by the submucosal gland, thus holding the promise for controlling CPC and reducing the recurrence of intrahepatic bile duct stones.

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.

Efficacy of antisense gene therapy for proliferative cholangitis

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

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

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

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