Imaging Modalities for Diagnosing Hepatolithiasis: A Case Report of Multiple Hepatolithiasis

Hepatolithiasis or intrahepatic duct stones is uncommon in western setting, but it has quite a high prevalence in far eastern countries. The natural history of the disease may not be well understood in a western society, however due to increasing immigration, there are increasing numbers of cases that have occurred and will only continue occurring. The case report is regarding an elderly lady with previous complicated cholecystectomy presented with worsening recurrent right upper quadrant pain. Computed tomography (CT) and magnetic resonance imaging (MRI) interestingly revealed multiple intraductal hepatolithiasis. The aim of imaging should be to accurately identify the biliary tree and liver anatomy, stones, stricture, liver segment involved and excluding complication such as abscesses or cholangiocarcinoma.

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(HLCCA). 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 biliaryenteric 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.

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 twogroups. No perioperative death occurred in either group. Fifty-seven patients (93.4%) were followed up for 2-40 mo (mean 17 mo), including 27 in LLH group and 30 in OLH group. Stone recurrence occurred in 1 patient of each group. CONCLUSION: LLH for hepatolithiasis is feasible and safe in selected patients with an equal therapeutic effect to that of traditional open hepatectomy.

Laparoscopic VS open hepatectomy for hepatolithiasis: An updated systematic review and meta-analysis

AIM To perform a meta-analysis on laparoscopic hepatectomy VS conventional liver resection for treating hepatolithiasis.METHODS We conducted a systematic literature search on Pub Med,Embase,Web of Science and Cochrane Library,and undertook a meta-analysis to compare the efficacy and safety of laparoscopic hepatectomy V S conventional open liver resection for local hepatolithiasis in the left or right lobe. Intraoperative and postoperative outcomes(time,estimated blood loss,blood transfusion rate,postoperative intestinal function recovery time,length of hospital stay,postoperative complication rate,initial residual stone,final residual stone and stone recurrence) were analyzed systematically.RESULTS A comprehensive literature search retrieved 16 publications with a total of 1329 cases. Meta-analysis of these studies showed that the laparoscopic approach for hepatolithiasis was associated with significantly less intraoperative estimated blood loss [weighted mean difference(WMD): 61.56,95% confidence interval(CI): 14.91-108.20,P = 0.01],lower blood transfusion rate [odds ratio(OR): 0.41,95%CI: 0.22-0.79,P = 0.008],shorter intestinal function recovery time(WMD: 0.98,95%CI: 0.47-1.48,P = 0.01),lower total postoperative complication rate(OR: 0.52,95%CI: 0.39-0.70,P < 0.0001) and shorter stay in hospital(WMD: 3.32,95%CI: 2.32-4.32,P < 0.00001). In addition,our results showed no significant differences between the two groups in operative time(WMD: 21.49,95%CI: 0.27-43.24,P = 0.05),residual stones(OR: 0.79,95%CI: 0.50-1.25,P = 0.31) and stone recurrence(OR: 0.34,95%CI: 0.11-1.08,P = 0.07). Furthermore,with subgroups analysis,our results proved that the laparoscopic approach for hepatolithiasis in the left lateral lobe and left side could achieve satisfactory therapeutic effects. CONCLUSION The laparoscopic approach is safe and effective,with less intraoperative estimated blood loss,fewer postoperative complications,reduced length of hospital stay and shorter intestinal function recovery time than with conventional approaches.

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 incidenceof 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.

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

AIM:To compare the outcomes of concomitant cholangiocarcinoma(C-CCA)and subsequent cholangiocar-cinoma(S-CCA)associated with hepatolithiasis. METHODS:From December 1987 to December 2007, 276 patients underwent hepatic resection for hepa-tolithiasis in Changhua Christian Hospital.Sixty-five patients were excluded due to incomplete medical records and the remaining 211 patients constituted our study population base.Ten patients were diag-nosed with C-CCA based on the preoperative biopsy or postoperative pathology.During the follow-up period, 12 patients developed S-CCA.The diagnosis of S-CCA was made by image-guided biopsy or by pathology if surgical intervention was carried out.Patient charts were reviewed to collect clinical information.Parameters such as CCA incidence,interval from operation to CCA diagnosis,interval from CCA diagnosis to disease-related death,follow-up time,and mortality rate were calculated for both the C-CCA and S-CCA groups.The outcomes of the C-CCA and S-CCA groups were math-ematically compared and analysed. RESULTS:Our study demonstrates the clinical implications and the survival outcomes of C-CCA and S-CCA. Among the patients with unilateral hepatolithiasis,the incidence rates of C-CCA and S-CCA were fairly similar (4.8%vs 4.5%,respectively,P=0.906).However,for the patients with bilateral hepatolithiasis,the incidence rate of S-CCA(12.2%)was higher than that of C-CCA (4.7%),although the sample size was limited and the difference between two groups was not statistically sig-nificant(P=0.211).The average follow-up time was 56 mo for the C-CCA group and 71 mo for the S-CCA group.Regard to the average time intervals from operation to CCA diagnosis,S-CCA was diagnosed after 67 mo from the initial hepatectomy.The average time intervals from the diagnoses of CCA to disease-related death was 41 mo for the C-CCA group and 4 mo for the S-CCA group,this difference approached statistical sig-nificance(P=0.075).Regarding the rates of overall and disease-related mortality,the C-CCA group had signifi-cantly lower overall mortality(70%vs 100%,P=0.041) and disease-related mortality(60%vs 100%,P=0.015) than the S-CCA group.For the survival outcomes of two groups,the Kaplan-Meier curves corresponding to each group also demonstrated better survival outcomes for the C-CCA group(log rank P=0.005).In the C-CCA group,three patients were still alive at the time of data analysis,all of them had free surgical margins and did not have pathologically proven lymph node metastasis at the time of the initial hepatectomy.In the S-CCA group,only one patient had chance to undergo a second hepatectomy,and all 12 S-CCA patients had died at the time of data analysis. CONCLUSION:C-CCA has better outcomes than S-CCA.The first hepatectomy is crucial because most patients with recurrent CCA or S-CCA are not eligible for repeated surgical intervention.

Sphincter of Oddi laxity:An important factor in hepatolithiasis

AIM:To evaluate the importance of sphincter of Oddi laxity (SOL) in hepatolithiasis (HL).METHODS:Subjects included 98 patients diagnosed with HL between 2002 and 2007. Detailed histories were taken and the subjects were monitored until July 2008. HL patients were divided into two groups:Group included 45 patients with SOL,and Group included 53 patients without. Recurrence and reoperation indices of both groups were calculated and compared.RESULTS:The recurrence index was 0.135 in Group and 0.018 in Group fldex was 0.070 in Group and 0.010 in Group (P <0.001). The mean frequency of biliary operation was 2.07in Group (P = 0.001). Differences between the two groups are significant.CONCLUSION:HL patients with SOL tend to have a higher risk of recurrence and a larger demand for re-operation than those without this condition.

Risk factors of intrahepatic cholangiocarcinoma in patients with hepatolithiasis:a case-control study

BACKGROUND:Why 3.3% to 10% of all patients with hepatolithiasis develop intrahepatic cholangiocarcinoma (ICC) remains unknown.We carried out a hospital-based case-control study to identify risk factors for the development of ICC in patients with hepatolithiasis in China.METHODS:Eighty-seven patients with pathologically diagnosed hepatolithiasis associated with ICC and 228 with hepatolithiasis alone matched by sex,age (±2 years),hospital admittance and place of residence were interviewed during the period of 2000-2008.Odds ratios (OR) and 95% confidence intervals (CI) were calculated for each risk factor.RESULTS:Among the patients with hepatolithiasis associated with ICC,the mean age was 57.7 years and 61.0% were female Univariate analysis showed that the significant risk factors for ICC development in hepatolithiasis were smoking,family history of cancer,appendectomy during childhood (under age 20),and duration of symptoms >10 years.In multivariate stepwise logistic regression analysis,smoking (OR=1.931,95% CI:1.000-3.731),family history of cancer (OR=5.175,95% CI:1.216-22.022),and duration of symptoms >10 years (OR=2.348 95% CI:1.394-3.952) were independent factors.CONCLUSION:Smoking,family history of cancer and duration of symptoms >10 years may be risk factors for ICC in patients with hepatolithiasis.

Comparatively lower postoperative hepatolithiasis risk with hepaticocholedochostomy versus hepaticojejunostomy

BACKGROUND: Optimal surgical technique plays a key role in preventing the postoperative recurrence of hepatolithiasis. Tian et al developed the subcutaneous tunnel and hepatocholangioplasty using the gallbladder (STHG) technique and applied it in hepatolithiasis patients who had an approximately normal gallbladder and sphincter of Oddi. However, the technique is controversial. In the present study, a canine model was established for hepatocholangioplasty (HC) and hepaticojejunostomy (HJ) to simulate STHG and Roux-en-Y cholangiojejunostomy in the clinic, respectively. Then, the alterations of bile components in the vicinity of the anastomosis were compared. This may provide an experimental guide for choosing an optimal technique for the treatment of hepatolithiasis in the clinic. METHODS: The animals were randomly separated into a control group (5 dogs) and a model group (stenosis of the common bile duct; 24 dogs). The 24 dogs in the model group were randomly divided into an HC group and an HJ group (12/group). Bile was collected from the bile duct at I and 5 months after the operation, and the bile components were determined. RESULTS: The levels of total bile acid, cholesterol, total bilirubin, and phospholipid in the HC group were higher than those in the HJ group (P<0.05). However, no statistical difference was seen in unconjugated bilirubin and calcium ions. The mucin level in bile in the HC group was lower than that in the HJ group at 5 months after the operation (P<0.05). The postoperative lipid peroxidation level was remarkably lower than that in the HJ group (P<0.05). However, the superoxide dismutase level was remarkably higher than that in the HJ group (P<0.05). Finally, a significant difference was found in the positive bacterial culture rate in bile between the groups. CONCLUSION: Changes of bile components near the anastomosis after HC might be more preferable for preventing hepatolithiasis formation than HJ.

Laparoscopic hepaticoplasty using gallbladder as a subcutaneous tunnel for hepatolithiasis

AIM:To investigate the feasibility,efficacy and safety of laparoscopic hepaticoplasty using gallbladder as subcutaneous tunnel and sphincter-of-Oddi preservation for hepatolithiasis.METHODS:From January 2010 to July 2013,six patients with hepatolithiasis were treated at our institution.All the patients underwent laparoscopic surgery.The procedures included common hepatic duct exploration,stone clearance by fiberoptic choledochoscopy,hilar bile duct hepaticoplasty with preservation of the sphincter of Oddi,anastomosis between the hilar bile duct and neck of the gallbladder,and establishment of a subcutaneous tunnel with the gallbladder.Two patients underwent left lateral hepatectomy simultaneously.Clinical data including operation time,intraoperative blood loss,operative morbidity,hospital mortality,stone clearance,and recurrence rate were analyzed.RESULTS:All patients successfully completed laparoscopic surgery.The mean length of hospital stay was4.5±0.9 d(range:3-6 d).The mean blood loss of the hepatectomy was 450 mL(range:200-700 mL),and the blood loss of the other four was 137±151 mL (range:50-400 mL).The mean operative time was 318±68 min(range:236-450 min).The operative morbidity and hospital mortality were zero.The immediate stone clearance rate was 100%.All patients were followed up for an average of 17 mo(range:7-36 mo).One of the six patients had abdominal mass with pain,and subcutaneous tunnel cholangiography showed severe gallbladder-biliary anastomotic stricture at 4 mo postoperatively.There was no stone recurrence and no cholangitis during follow-up.CONCLUSION:Laparoscopic hepaticoplasty using gallbladder with a subcutaneous tunnel and preserving the sphincter of Oddi is feasible,safe and effective for hepatholithiasis.

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 clinicalclassification.METHODS:Sixty-eight HL patients were hospitalized and treated surgically from August 2011 to December2012 and they were classified into four HL types according to pathological evolution of the disease.These four HL types included typeⅠprimary type(defined as no previous biliary tract surgery),typeⅡinflammatory type(with previous biliary tract surgery and cholangitis),typeⅢmass-forming type(HL complicated by hepatic mass-forming lesion),and typeⅣterminal 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 typeⅠ-Ⅳwas 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 typeⅠ(88.2%),fever was predominant in typeⅡ(52.0%),the malignancy rate in typeⅢwas high(71.4%),and portal hypertension and spleen enlargement were common in typeⅣ(2/2,100.0%).Liver resection rate for typesⅠ-Ⅲwas 79.4%,72.0%and 71.4%,respectively.The overall incidence of postoperative complications was23.5%(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 of68 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 optimizingtreatment strategy,and patients can benefit from thisclassification when it is used properly.

Liver transplantation for patients with hepatolithiasis

Because of its complicated pathological features such as repeated cholangitis and multiple operations, hepatolithiasis is difficult to treat and often lead to portal hypertension, and liver failure. The aim of this study was to investigate the indications of orthotopic liver transplantation ( OLT) for patients with hepatolithiasis and the improvement of operative techniques and the treatment of postoperative complications. METHODS:The data of 4 patients with hepatolithiasis who had undergone OLT at our department in recent years were reviewed retrospectively. RESULTS:The 4 patients with hepatolithiasis complicated with secondary biliary cirrhosis in end-stage liver disease included 1 woman and 3 men. One patient underwent OLT using veno-venous bypass prior to the mobilization of the liver. Two patients were subjected to liver transplantation with improved piggyback technique without bypass. One patient received OLT without bypass. All patients were operated on successfully and recovered uneventfully. Patient 1 had bleeding from the digestive tract on the postoperative day 6. Patient 2 had hemorrhage from the digestive tract and a leakage of end-to-side intestinal anastomosis on the postoperative day 44. Patient 4 was reoperated on because of hemorrhage from the anastomotic stoma of the hepatic artery on the postoperative days 8 and 10. In the 4 patients the mean operative time was 7.9 hours and blood loss was 910 ml. Postoperative pathological analysis revealed biliary liver cirrhosis. Follow-up of all patients showed good conditions. CONCLUSIONS:Hepatolithiasis with secondary biliary liver cirrhosis in patients with end-stage liver disease is indicated for liver transplantation. Veno-venous bypass prior to the mobilization of the liver and improved piggyback tech- nique can lower the incidence of intraoperative bleeding, the duration of surgery and postoperative complications.

Management hepatolithiasis with operative choledochoscopic FREDDY laser lithotripsy combined with or without hepatectomy

BACKGROUND: Hepatolithiasis is very common in East Asia. It is benign in nature, but has a high recurrence rate. It is likely to lead to biliary cirrhosis and increase the risk of cholangiocarcinoma. Hence, the treatment of hepatolithiasis is difficult but vital. In this report, we present a novel approach to manage hepatolithiasis using the choledochoscopic Frequency-Doubled Double pulse Nd:YAG (FREDDY) laser lithotripsy combined with or without hepatectomy. METHODS: Between July 2009 and October 2012, 45 patients underwent choledochoscopic FREDDY laser lithotripsy combined with or without hepatectomy (laser lithotripsy group). Fortyeight patients underwent a traditional operation (traditional method group) from January 2009 to June 2009. Comparative analysis was made of demographic and clinical characteristics of the two groups. RESULTS: The final stone clearance rate of the laser lithotripsy group was 93.3%, whereas that of the traditional method group was 85.4% (P=0.22). In the laser lithotripsy group, 2 patients experienced hemobilia and 3 patients had acute cholangitis. In the traditional method group, 3 patients had intraoperative hemorrhage, 1 patient had bile leakage, 6 patients had acute cholangitis, and 1 patient died of liver failure. Moreover, the operative time in the traditional method group was significantly longer than that in the laser lithotripsy group (P=0.01). The mean hospital stay of the patients in the traditional method group was longer than that in the laser lithotripsy group (9.8 vs8.2 days, P=0.17). Recurrent intrahepatic bile duct stones were not found during the follow-up period in the two groups. CONCLUSION: Operative choledochoscopic FREDDY laser lithotripsy combined with or without hepatectomy may be an effective and safe treatment for hepatolithiasis.

Oddi sphincter preserved cholangioplasty with hepaticosubcutaneous stoma for hepatolithiasis

AIM: To evaluate the long-term outcomes of Oddi sphincter preserved cholangioplasty with hepaticosubcutaneous 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.

Levels of serum leptin,cholecystokinin,plasma lipid and lipoprotein differ between patients with gallstone or/and those with hepatolithiasis

BACKGROUND: A significant relationship exists among food intake and nutritional status and cholelithiasis, including gallstone and hepatolithiasis. Leptin is associated with obesity. This study was to investigate the differences in serum leptin levels in patients with gallstone and hepatolithiasis and to evaluate the relationships among leptin, cholecystokinin (CCK), lipid and lipoprotein concentrations. METHODS: Body mass index (BMI), serum leptin, CCK, insulin, lipid and lipoprotein concentrations, and liver function were measured in 382 patients with gallstone (GS group), 83 patients with hepatolithiasis (HS group) and 30 healthy controls (control group). The values of these indices were compared among the groups. In each group, Pearson's product-moment correlation coefficient among these indices were evaluated. RESULTS: There were notable differences in serum leptin, CCK, total cholesterol, total triglycerides, apolipoprotein-a (APO-a), globulin, direct reacting bilirubin, and BMI between the GS and HS groups (P<0.05). Positive correlations between serum leptin and BMI, CCK, total cholesterol, gamma-glutamyl transpeptidase (GGT), aminotransferase, and insulin were found in the GS group (P<0.05). Positive correlations were observed between serum leptin and CCK, bilirubin, aminotransferase, GGT, in the HS group (P<0.05), but negative correlations between serum leptin and albumin or APO-a (P<0.05). CONCLUSIONS: Leptin participates in modulating lipid metabolism. There are notable differences in leptin, serum lipid, and CCK between patients with gallstone and those with hepatolithiasis. The role of leptin in the pathophysiological course of cholelithiasis needs further investigation.

Middle and long-term clinical outcomes of patients with regional hepatolithiasis after subcutaneous tunnel and hepatocholangioplasty with utilization of the gallbladder

BACKGROUND: Roux-en-Y choledochojejunostomy is routinely performed in patients with regional hepatolithia-sis. However, some of these patients, who have a normal gallbladder and normal Oddi 's sphincter, are unnecessarily undergoing bilio-intestinal drainage. Alternatively, reconstruction can be achieved by subcutaneous tunnel and hepa-tocholangioplasty with the utilization of the gallbladder (STHG). This method is effective to potential endoscopic tunnel and intervention during follow-up, and prevention of reflux cholangitis as well as the disorders of the GI tract. METHODS: The middle and long-term complications of 46 patients who underwent STHG were analyzed. With B-ul-trasonography and biochemical assay, the contraction and concentration function of the gallbladder were also studied. RESULTS: Follow-up showed that all patients survived with a relatively normal life. One patient experienced right epigastric pain, chills and fever because of a stone which impacted in the left hepatic bile duct. Another patient had cholangitis because of biliary ascariasis. The two patients were treated by endoscopic therapy within the subcutaneous gallbladder under local anesthesia. CONCLUSIONS: This operation not only keeps the normal physical functional of the gallbladder, Oddi s sphincter and gastrointestinal tract, but also prevents reflux cholangitis and the disorder of the digestive tract. Hence STHG is a novel operation dealing with regional hepatolithiasis.

Subacute liver and respiratory failure after segmental hepatectomy for complicated hepatolithiasis with secondary biliary cirrhosis: A case report

BACKGROUND Despite being a benign disease, hepatolithiasis has a poor prognosis because of its intractable nature and frequent recurrence. Nonsurgical treatment is associated with high incidences of residual and recurrent stones. Consequently, surgery via hepatic lobectomy or segmental hepatectomy has become the main treatment modality. Clinical management and resolution of complicated hepatolithiasis with bilateral or diffuse intrahepatic stones remain very difficult and challenging. Repeated cholangitis and calculous obstruction may result in secondary biliary cirrhosis, a limiting factor in the treatment of hepatolithiasis.CASE SUMMARY A 53-year-old woman with a 5-year history of intermittent abdominal pain and fever was admitted to the hepatopancreatobiliary surgery department following worsening symptoms over a 3-d period. Blood tests revealed elevated transaminases, alkaline phosphatase, γ-glutamyl transpeptidase, and total bilirubin, as well as anemia. Magnetic resonance cholangiopancreatography showed dilatation of the intrahepatic, left and right hepatic, common hepatic, and common bile ducts, and multiple short T2 signals in the intrahepatic and common bile ducts. Abdominal computed tomography showed splenomegaly and splenic varices. The diagnosis was bilateral hepatolithiasis and choledocholithiasis with cholangitis. Surgical treatment included hepatectomy of segments Ⅱ and Ⅲ, cholangioplasty, left hepaticolithotomy, second biliary duct exploration, choledocholithotomy, T-tube drainage, and accretion lysis. Surgical and pathological findings confirmed secondary biliary cirrhosis. Liver-protective therapy and anti-infectives were administered. The patient developed liver and respiratory failure, severe abdominal infection, and septicemia. Eventually, her family elected to discontinue treatment.CONCLUSION Liver transplantation, rather than hepatectomy, might be a treatment option for complicated bilateral hepatolithiasis with secondary liver cirrhosis.

Negative short-term impact of intraoperative biliary lavage in patients with hepatolithiasis

AIM: To evaluate short-term outcomes following intraoperative biliary lavage for hepatolithiasis.METHODS: A total of 932 patients who were admitted to the West China Medical Center of Sichuan University between January 2010 and January 2014 and underwent bile duct exploration and lithotomy were retrospectively included in our study. The patients were divided into the lavage group and the control group. Related pre-, intra-, and postoperative factors were recorded, analyzed, and compared between the two groups in order to verify the effects of biliary lavage on the short-term outcome of patients with hepatolithiasis. RESULTS: Amongst the patients who were included, 678 patients with hepatolithiasis were included in the lavage group, and the other 254 patients were enrolled in the control group. Data analyses revealed that preoperative baseline and related intraoperative variables were not significantly different. However, patients who underwent intraoperative biliary lavage had prolonged postoperative hospital stays(6.67 d vs 7.82 d, P = 0.024), higher hospitalization fees(RMB 28437.1 vs RMB 32264.2, P = 0.043), higher positive rates of bacterial cultures from blood(13.3% vs 25.8%, P = 0.001) and bile(23.6% vs 40.7%, P= 0.001) samples, and increased usage of advanced antibiotics(26.3% vs 38.2%, P = 0.001). In addition, in the lavage group, more patients had fever(> 37.5℃, 81.4% vs 91.1%, P = 0.001) and hyperthermia(> 38.5℃,39.7% vs 54.9%, P = 0.001), and higher white blood cell counts within 7 d after the operation compared to the control group.CONCLUSION: Intraoperative biliary lavage might increase the risk of postoperative infection, while not significantly increasing gallstone removal rate.

Platelet activation and the protective effect of aprotinin in hepatolithiasis patients

OBJECTIVE: To explore platelet activation and the protective effect of aprotinin in patients with hepatolithiasis. METHODS: The count of plaletets and levels of CD_(62P) and CD_(63) were measured by flow cytometry in 38 patients with hepatolithiasis. Several measurements were carried out after treatment with aprotinin. RESULTS: The levels of CD_(62P), CD_(63) in patients with hepalolithiasis were higher than those in patients with cholecystolithiasis (P<0.05), but the count of platelets was lower (P<0.05). After operation, the levels of CD_(62P), CD_(63) were significantly increased in patients with hepatolithiasis, but the count of platelets was lower (P<0.05). Postoperative levels of CD_(62P), CD_(63) were significantly lower in patients treated with aprotinin than in normal controls (P<0.05); but there was no significant change in the count of platelets in the two groups. CONCLUSION: Platelet activation occurs in patients with hepatolithiasis, and may be inhibited by aprotinin.

Effects of epidermal growth factor receptor inhibitor on proliferative cholangitis in hepatolithiasis

BACKGROUND： There is currently no effective medication to prevent stone recurrence after choledochoscopic lithotomy or to treat proliferative cholangitis（PC）, which is the pathologic basis of hepatolithiasis. This study aimed to investigate whether gefitinib, an epidermal growth factor receptor（EGFR） inhibitor, inhibited cholangio hyperplasia and lithogenesis in PC.METHODS： After cholangioscopic lithotomy, indwelling catheters were placed in the diseased bile duct lumens in 94 patients with hepatolithiasis. Subsequently, 49 of the 94 patients were treated with 250 mg gefitinib solution via a catheter twice a week, and they were subjected to choledochoscopic biopsy at 6 and 12 weeks. The rest 45 hepatolithiasis patients without gefitinib treatment served as controls.RESULTS： The expressions of EGFR, PCNA and procollagen I were significantly reduced in the patients treated with gefitinib in 12 weeks compared with those in the control group. Patients in the gefitinib group had a much lower degree of hyperplasia of the biliary epithelium, submucosal glands and collagen fibers compared with those in the control group. Gefitinib treatment significantly decreased mucin 3 expression and β-glucuronidase activity.CONCLUSION： Postoperative gefitinib treatment could significantly inhibit PC-mediated hyperplasia and lithogenesis, which might provide a novel strategy for the prevention of biliary restenosis and stone recurrence in patients with hepatolithiasis.