Intrahepatic bile duct exploration lithotomy is a useful adjunctive hepatectomy method for bilateral primary hepatolithiasis: an eight-year experience at a single centre

Evolution of surgical treatment for hepatolithiasis

Hepatolithiasis is a common disease where stones are located in the intrahepatic bile duct. Hepatolithiasis is a disease with regional characteristics. The complication and postoperative recurrence rates of the disease are high. The intrahepatic cholangiocarcinoma and the incidence of liver cirrhosisare the main causes of death in patients with hepatolithiasis. Thus, it is difficult to treat. The majority of biliary stones are readily removed endoscopically, however complex intrahepatic or large refractory extrahepatic stones often require surgical or percutaneous interventions when standard endoscopic methods fail. At present, the main clinical treatment for hepatolithiasis is surgery, of which there are different methods depending on the patient's condition. With the continuous updates and development of medical technology, the treatment of hepatolithiasis has improved. In this paper, several mainstream surgical methods including partial hepatectomy, choledochojejunostomy, biliary tract exploration and lithotomy, percutaneous transhepatic chledochoscopic lithotripsy and liver transplantation used in the clinic are reviewed for clinicians' reference. Depending on the characteristics of each case, a suitable surgical method is chosen to obtain the best treatment effect.

Intrahepatic Duct Incision and Closure for the Treatment of Multiple Cholelithiasis in a Dog

This report describes the successful intrahepatic duct incision and closure for the treatment of multiple cholelithiasis in a dog with untreated hypothyroidism. A 12-year-old spayed female Spitz dog weighing 11.3 kg was diagnosed with multiple cholelithiasis, and a quadrate liver lobectomy and cholecystectomy were performed. Large gallstones were located in the left liver lobe's intrahepatic duct distal to the anastomosis of the intrahepatic ducts of the left medial and lateral lobes. The dilated intrahepatic duct was packed off with wet gauze, and incision and closure were performed on the most dilated section, which was proximal to the largest gallstone. After surgery, the patient showed normal liver function and was discharged with normal total bilirubin and C-reactive protein levels. On postoperative day 83, no stones were observed in the dilated common bile duct (CBD), and the degree of dilatation of the CBD had decreased from 9 mm to 4 mm, with no obstructions. Right intrahepatic gallstones were confirmed without dilatation. Hypothyroidism was managed medically. Hepatic duct incision and closure can be performed in dogs with multiple cholelithiasis. Although not the first option, intrahepatic bile duct incision proves to be a new alternative for the successful treatment of cholelithiasis in dogs.

PERCUTANEOUS CHOLANGIOSCOPY AND LASER BILIARY LITHOTRIPSY FOR BILIARY INTRAHEPATIC STONES MANAGEMENT: CASE REPORT

Intrahepatic biliary stone disease is a difficult condition to treat, due to anatomical complexity of biliary tract, association with colestasis, and high recurrence rates, with potential short- and long-term complications, such as cholangitis and secondary biliary cirrhosis. Removal of biliary stones via intraductal access can be achieved endoscopically or percutaneously, with preference for cholangioscopy-guided laser lithotripsy in complex cases. The surgical approach, despite its prolonged results, is a more invasive and risky procedure. The authors present a case of cholangioscopy with percutaneous laser biliary lithotripsy as an option for the treatment of intrahepatic biliary stone disease associated with biliary stricture following biliodigestive anastomosis due to bile duct injury following cholecystectomy, a safe and effective alternative with low morbidity and satisfactory outcomes in follow-up.

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.

Intrahepatic cholelithiasis with gallbladder-like metaplasia of intrahepatic bile ducts associated with gallbladder agenesis in a wild boar

An unknown-aged adult female wild boar (Sus scrofa) was brought to Kyungpook National University for postmortem examination. Gross examination revealed gallbladder agenesis. Histologically, the liver was cirrhotic and had intrahepatic cholelithiasis, the choleliths were yellow, brown, gray, and black, and had coffin-lid and pyramidal appearances. Fourier-transform infrared spectroscopy analysis revealed that the components were 80% struvite and 20% calcium oxalate monohydrate. Chronic inflammatory cell infiltration was observed, with hyperplastic hepatocellular nodules characterized by large nuclei, prominent nucleoli, and scant cytoplasm with frequent binucleation, surrounded by thick fibrous septa. The epithelium of intrahepatic bile ducts that contained choleliths had undergone gallbladder-like metaplasia, which might have been induced by chronic irritation from the stones or by the accompanying chronic bacterial infection that was observed in Gram stains.

Clinical characteristics and prognosis of primary hepatolithiasis in hospitalized children

The purpose of this study is to evaluate the clinical characteristics and prognosis of primary hepatolithiasis in hospitalized children. This retrospective cohort study included 106 hospitalized patients with primary hepatolithiasis at Beijing Children's Hospital. Clinical data were derived from electronic inpatient (2010-2021) and outpatient (2016-2021) medical records. The prognosis was evaluated by outpatient ultrasounds after discharge and telephone interviews performed in December 2022. Intrahepatic bile duct stones in patients enrolled in the study were all found incidentally by abdominal ultrasound during hospitalization, with an incidence of 1.7 per 10,000 hospitalized children. The mean age at diagnosis was 9.3 ± 3.6 years, with male predominance (69/106, 65.1%). The right lobe of the liver (80/106, 75.5%) was preferentially affected. All patients underwent conservative observation. Seventy-eight patients (78/106, 73.6%) were followed up with a mean follow-up age of 17.1 ± 5.0 years, and 4 (4/78, 5.1%) had intermittent abdominal pain. From 2016 to 2021, 32 patients were diagnosed with primary hepatolithiasis, and follow-up abdominal ultrasounds were performed in 20 of them (20/32, 60.0%) with a median time of 2.1 (0.1, 3.5) years. The stones were present in 17 patients (17/20, 85.0%).

CONCLUSION

Primary hepatolithiasis in hospitalized children is rare, almost found accidentally; mostly affects the right lobe of the liver; and can be conservatively observed without surgical treatment in childhood.

WHAT IS KNOWN

• Primary hepatolithiasis in adults often presents with severe clinical symptoms and requires hepatectomy.. • There are few studies on primary hepatolithiasis in children.

WHAT IS NEW

• Primary hepatolithiasis in children is mostly found accidentally by abdominal ultrasound without associated symptoms during hospitalization. • Children with accidental primary hepatolithiasis can be conservatively observed without surgical treatment in childhood.

The postoperative choledochoscopy in the management of the residual hepatolithiasis involving the caudate lobe: A retrospective study

To reveal the role of the postoperative choledochoscopy in treating the residual calculi in the caudate lobe (CL) of the liver.We recruited 66 patients with T-tube/percutaneous transhepatic cholangioscopy tract who still had residual gallstones in the CL at least 6 weeks after the operation. Imaging examinations determined the gallstones' locations in the patients, and all of them underwent the postoperative choledochoscopic examination through the T-tube/percutaneous transhepatic cholangioscopy tract for therapeutic intervention.Among the 66 patients, the residual gallstones were mostly located in the Spiegel lobe (48/66, 72.7%), and the residual gallstones that located in the origin of the CL bile branches were successfully determined in the 57 patients (57/66, 86.4%), the remaining 9 patients were unclear because the proximal ducts were severely narrow or even atresia. The mean frequency of the postoperative choledochoscopy was 3.6 (range, 1-10) times. There were 9 patients with complications, and no mortality occurred. In the origin-proved 57 patients, 6 patients failed to remove the gallstones altogether, and the final residual gallstone clearance rate was 77.3% (51/66). There was no significant difference between the Spiegel lobe and the other parts of the CL in determining the bile duct's origins, gallstone clearance rate, and complications. However, the frequency of choledochoscopy in the other parts of the CL was more than in the Spiegel lobe.The postoperative choledochoscopy, an essential method for treating the residual gallstones in the CL, commands high efficiency for calculi extraction and fewer complications. The main reasons for failing to remove the residual gallstones are that the bile duct's origins could not be determined, and the distal bile ducts are atretic in the CL.

New clinical pathological classification and treatment system for hepatolithiasis

Hepatolithiasis is a complex disease with extensive lesions. There are currently many clinical classifications available. However, these classifications cannot accurately reflect the pathological changes and degree of hepatolithiasis, and are not conducive to communication. Various methods are used for treatment of hepatolithiasis, but they are often misused. We tried to establish a new HLDO classification based on the clinicopathological characteristics of hepatolithiasis and a treatment system based on this classification, so as to comprehensively and accurately describe the pathological changes and degree, scientifically and reasonably treat it, and reduce its residual stone rate and recurrence rate.

The circRNA_102911/miR-129-5p/SOX6 axis is involved with T lymphocyte immune function in elderly patients with laparoscopic left hepatectomy for hepatolithiasis

The aim of the present study was to investigate the impact of laparoscopic left hepatectomy (LLH) for hepatolithiasis on the T lymphocyte immune changes of elderly patients and to analyze underlying mechanisms of action behind these changes. A total of 164 patients who underwent LLH due to left-sided hepatolithiasis were recruited. In terms of T lymphocyte immune changes, it was found that firstly, the basic quantity of peripheral lymphocytes in the elderly group was significantly lower than that in a younger preoperative group. Secondly, after surgical trauma, the immune function of T lymphocytes had a significant decline and lasted longer when compared with younger patients, which was reflected by the perioperative changes in the T lymphocyte proliferative ability, levels of IL-2 secreted by T lymphocytes and the percentage of CD3⁺/CD4⁺ T lymphocytes in the peripheral blood. Circular RNA (circRNA) 102911 (102911) was upregulated and microRNA (miR)-129-5p was downregulated in CD3⁺/CD4⁺ T lymphocytes from elderly patients with LLH for hepatolithiasis. Furthermore, the overexpression of 102911 inhibited the proliferation of CD3⁺/CD4⁺ T lymphocytes as well as promoting cell apoptosis, with the opposite effects being observed on knockdown of 102911. miR-129-5p is involved in the proliferation and apoptosis of CD3⁺/CD4⁺ T lymphocytes and may be a promising target of 102911. Moreover, SOX6 is a downstream molecule of miR-129-5p. Immune function and number of T lymphocytes decreased significantly after surgical trauma compared to younger patients, and this decline lasted longer in older patients treated with LLH for hepatolithiasis. The 102911/miR-129-5p/SOX6 axis was found to be involved in T lymphocytes immune function, which provided a novel insight for the treatment of elderly patients with hepatolithiasis.

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

BACKGROUND

Intrahepatic lithiasis (IHL) is a rare disease in the western world. Complications associated with IHL include acute cholangitis, liver atrophy, secondary biliary cirrhosis, and risk for intrahepatic cholangiocarcinoma. Liver resection is considered the treatment of choice for IHL. The objective of this study was to analyze patients who underwent liver resection for non-Asian hepatolithiasis.

METHODS

127 patients with symptomatic non-Asian hepatolithiasis underwent resection in six institutions. Demographic data, clinical presentation, diagnosis, classification according to stone location, presence of atrophy, bile duct stricture, biliary cirrhosis, incidence of cholangiocarcinoma, treatment and postoperative course were evaluated.

RESULTS

52 patients (40.9%) were male and the mean age was 46.1 years. Sixty-six patients (51.9%) presented with history of cholangitis. Stones were located in the left lobe in 63 (49.6%), and right lobe in 28 patients (22.0%). Atrophy was observed in 31 patients (24.4%) and biliary stenosis in 18 patients (14.1%). The most common procedure performed was left lateral sectionectomy in 63 (49.6%) patients, followed by left hepatectomy in 36 (28.3%), right hepatectomy in 19 (15.0%), and associated hepaticojejunostomy in 28 (22.0%). Forty-two patients (33.0%) presented postoperative complications and the most common were biliary fistula (13.3%) and surgical site infection (7.0%). Postoperative mortality was 0.7%. Intrahepatic cholangiocarcinoma was observed in 2 patients (1.5%). Recurrence was identified in 10 patients (7.8%), mostly with bilateral stones and/or hepaticojejunostomy.

CONCLUSION

Liver resection is the standard treatment for symptomatic unilateral or complicated IHL with good operative results. Risk of cholangiocarcinoma was low in non-Asian patients.

Application of Laparoscopic Technique in the Treatment of Hepatolithiasis

Hepatolithiasis is commonly encountered in Southeastern and East Asian countries, and its incidence is increasing in Western countries. For symptomatic hepatolithiasis or asymptomatic hepatolithiasis with signs of liver atrophy or malignancy, surgical intervention is needed, especially when peroral cholangioscopy and percutaneous transhepatic cholangioscopic lithotomy are not suitable or fail to be performed. Currently, laparoscopic surgery is gradually replacing traditional open surgery and becoming a better option. Various types of laparoscopic surgeries, including laparoscopic hepatectomy, laparoscopic biliary exploration through the common bile duct or the hepatic duct stump, and robotic-assisted laparoscopic surgery, have been developed for the treatment of simple hepatolithiasis, hepatolithiasis concomitant with choledocholithiasis, recurrent hepatolithiasis, and complicated hepatolithiasis. The related clinical experience is gradually accumulating. In this review, the laparoscopic applications and their advantages will be summarized. In most cases, the laparoscopic technique could provide the advantages of less trauma, reduced blood loss, and faster postoperative recovery.

T-tube drainage versus choledochojejunostomy in hepatolithiasis patients with sphincter of Oddi laxity: study protocol for a randomized controlled trial

Background

Residual and recurrent stones remain one of the most important challenges of hepatolithiasis and are reported in 20 to 50% of patients treated for this condition. To date, the two most common surgical procedures performed for hepatolithiasis are choledochojejunostomy and T-tube drainage for biliary drainage. The goal of the present study was to evaluate the therapeutic safety and perioperative and long-term outcomes of choledochojejunostomy versus T-tube drainage for hepatolithiasis patients with sphincter of Oddi laxity (SOL).

Methods/design

In total, 210 patients who met the following eligibility criteria were included and were randomized to the choledochojejunostomy arm or T-tube drainage arm in a 1:1 ratio: (1) diagnosed with hepatolithiasis with SOL during surgery; (2) underwent foci removal, stone extraction and stricture correction during the operation; (3) provided written informed consent; (4) was willing to complete a 3-year follow-up; and (5) aged between 18 and 70 years. The primary efficacy endpoint of the trial will be the incidence of biliary complications (stone recurrence, biliary stricture, cholangitis) during the 3 years after surgery. The secondary outcomes will be the surgical, perioperative and long-term follow-up outcomes.

Discussion

This is a prospective, single-centre and randomized controlled two-group parallel trial designed to demonstrate which drainage method (Roux-en-Y hepaticojejunostomy or T-tube drainage) can better reduce biliary complications (stone recurrence, biliary stricture, cholangitis) in hepatolithiasis patients with SOL.

Trial registration

Clinical Trials.gov: NCT04218669. Registered on 6 January 2020.

Management of Hepatolithiasis: Review of the Literature

PURPOSE OF REVIEW

Hepatolithiasis is a disease characterized by intrahepatic stone formation. In this article, we review the features of this disease and explore the established and emerging treatment modalities.

RECENT FINDINGS

Recent reports show an increasing prevalence of hepatolithiasis, likely owed to increased immigration and shifts in the Western diet. New pharmacotherapy options are limited and are often only supportive. Endoscopic intervention still cruxes on removal of impacted stones, though new techniques such as bile duct exploratory lithotomy and lithotripsy continue to advance management. Although hepatectomy of the effected portion of the liver offers definitive therapy, alternative less invasive modalities such as combined endoscopic/interventional radiology modalities have been utilized in select patients. Additionally, liver transplant serves as an option for otherwise incurable hepatolithiasis with coexisting liver dysfunction. Multiple emerging pharmacologic and procedural interventions may provide novel treatment for hepatolithiasis. While definitive therapy remains resection of affected liver segments, these modalities offer hope for less invasive approaches in the future.