Hepaticojejunostomy for hepatolithiasis: A critical appraisal

AIM： To evaluate the long-term outcome and surgical indications of hepaticojejunostomy （H J） for the treatment of hepatolithiasis. METHODS- Three hundred and fourteen elective cases with hepatolithiasis but without biliary stricture or cystic dilatation treated in the past 10 years were reviewed retrospectively. The patients were divided into HJ group and T tube drainage group according to biliary drainage procedure. Furthermore, four subgroups were subdivided by hepatectomy as a balance factor, group A1： hepatectomy＋HJ; group A2： choledochoctomy＋HJ; group B1： hepatectomy ＋ choledochoctomy T tube drainage; group B2： choledochoctomy ＋ T tube drainage. The stone residual rate, surgical efficacy and long-term outcome were compared among different procedures. RESULTS： There was no surgical mortality among all patients. The total hospital mortality was 1.6%. The overall stone residual rate after surgical clearance was 25.9%. There was no statistical difference between HJ group and T tube drainage group in terms of stone residual rate after surgical clearance, however, after postoperative choledochoscopic lithotripsy, the total stone residual rate of T tube drainage group was significantly lower than that of HJ group （0.5% vs 16.7%, P 〈 0.01）. Hepatectomy ＋ choledochoctomy tube drainage achieved the optimal therapeutic effect, only 8.2% patients suffered from an attack of cholangitis postoperatively, which was significantly lower than that of hepatectomy ＋ HJ （8.2% vs 22.0%, P = 0.034）. The major reason for postoperative cholangitis was stone residual in the HJ group （16/23, 70.0%）, and stone recurrence in the T tube drainage group （34/35, 97.1%）. The operative times were significantly prolonged in those undergoing HJ, and the operative morbidity of HJ was higher than those of T tube drainage. CONCLUSION： The treatment result of HJ for hepatolithiasis is not satisfactory in this retrospective study due to high rate of stone residual and postoperative cholangi- tis. HJ could not drain residual stone effectively. HJ may hinder post-operative choledochoscopic lithotripsy, which is the optimal management for postoperative residual stone. The indications of HJ for hepatolithiasis should be strictly selected.

Gallbladder bile composition in patients with Crohn's disease

AIM： To further elucidate the pathogenesis and mechanisms of the high risk of gallstone formation in Crohn＇s disease. METHODS： Gallbladder bile was obtained from patients with Crohn＇s disease who were admitted for elective surgery （27 with ileal/ileocolonic disease and 7 with Crohn＇s colitis）. Fourteen gallstone patients served as controls. Duodenal bile was obtained from ten healthy subjects before and after the treatment with ursodeoxycholic acid. Bile was analyzed for biliary lipids, bile acids, bilirubin, crystals, and crystal detection time （CDT）. Cholesterol saturation index was calculated. RESULTS： The biliary concentration of bilirubin was about 50% higher in patients with Crohn＇s disease than in patients with cholesterol gallstones. Ten of the patients with Crohn＇s disease involving ileum and three of those with Crohn＇s colitis had cholesterol saturated bile. Four patients with ileal disease and one of those with colonic disease displayed cholesterol crystals in their bile. About 1/3 of the patients with Crohn＇s disease had a short CDT. Treatment of healthy subjects with ursodeoxycholic acid did not increase the concentration of bilirubin in duodenal bile. Several patients with Crohn＇s disease, with or without ileal resection/disease had gallbladder bile supersaturated with cholesterol and short CDT and contained cholesterol crystals. The biliary concentration of bilirubin was also increased in patients with Crohn＇s colitis probably not due to bile acid malabsorption. CONCLUSION： Several factors may be of importance for the high risk of developing gallstones of both cholesterol and pigment types in patients with Crohn＇s disease.The skillful technical assistance of Ms Lisbet Benthin and Ms Ingela Arvidsson is acknowledged.

Another new variant of Bouveret's syndrome

Although Bouveret's syndrome,i.e.gastric outlet obstruction by a large gallstone impacted in the proximal duodenum secondary to a cholecystoduodenal fistula,is rare,its pathogenesis and clinical features are well characterized.However,existence of variant forms of the syndrome are not well known,and as far as we know,only two cases of variant Bouveret's syndrome have been described in the English-language literature.We present a case of another new variant of Bouveret's syndrome in a 54-year-old Korean woman.

胆囊十二指肠瘘26例诊断与治疗

胆囊十二指肠瘘是胆囊与十二指肠之间形成的病理性通道,临床上少见,在胆囊结石症患者中发病率为0.3%~5.0%[1,2],其临床表现复杂,常缺乏特异性,术前常难以明确诊断,多在术中发现,临床上误诊率、漏诊率较高。现回顾性分析南京医科大学附属江宁医院收治的26例胆囊十二指肠瘘患者的临床资料,旨在加深对本病认识,提高诊断和治疗水平。资料与方法1.一般资料2013年2月—2015年8月确诊的胆囊十二指肠瘘患者26例,男8例,女18例,年龄61~81（68±10）岁。