The surgical treatment of isolated left-sided hepatolithiasis: A 22-year experience

The surgical treatment of isolated left-sided hepatolithiasis: A 22-year experience Wen-Bing Sun, MD, Ben-Li Han, MD, and Jing-Xiu Cai, MD, Chongqing, China

Background. Various therapeutic methods are used in isolated left hepatolithiasis (ILH), and long-term results are not as satisfactory as they should be. Methods. A retrospective analysis of 128 patients with ILH who were treated in our center over the last 22 years was undertaken to address patient age, gender, preoperative evaluation, operative findings, treatment modalities, and postoperative courses. Results. Sixty of the 128 patients were male and 68 were female, with a mean age of 42 years (range, 16-72 years). Among these patients, most (81%) had stones in both left external hepatic duct (LEHD) and left medial hepatic duct; in contrast 13 patients (10%) had stones only in the LEHD, and 7 patients (6%) had stones only in the left hepatic duct. Concomitant strictures were present in the left hepatic duct, left medial hepatic duct, and LEHD in 60%, 76%, and 82%, respectively, most of which were severe. When compared with left lateral segmentectomy, left hepatic lobectomy had a lower rate of residual stones (4% vs 22%; P < .01). Residual/recurrent stones and ductal strictures were the 2 most common causes that affected the long-term results. Before June 1996, left lateral segmentectomy was performed more frequently than left hepatic lobectomy (59% vs 12%; P < .01); after June 1996, left hepatic lobectomy was performed more frequently (77% vs 13%; P < .01). Although there were no differences in length of operation, intraoperative bleeding, and postoperative complications, residual stones were more common after left lateral segmentectomy. Conclusions. Left hepatic lobectomy appears to be the most effective treatment for selected patients with ILH, if other operative procedures cannot remove all the related lesions, which include stones, dilation, stricture, or potential cholangiocarcinoma. (Surgery 2000;127:493-7.) From the Hepatobiliary Surgery Center of the People’s Liberation Army, Southwest Hospital, Third Military Medical University, Chongqing, China

HEPATOLITHIASIS IS A COMMON DISEASE in China, especially in southwest China.1,2 In our hepatobiliary center, hepatolithiasis represents 1 of the most common diseases we manage. Before the availability of ultrasonography, treatment was often neglected or postponed until the entire liver was involved or biliary cirrhosis had occurred. Isolated left-sided or right-sided hepatolithiasis, an early stage of hepatolithiasis, was rarely diagnosed. In the recent 2 decades, more cases of isolated left hepatolithiasis (ILH) have been diagnosed and treated in our Accepted for publication November 20, 1999. Current address (W-B. S.): Department of Surgery, No 302 Hospital of the People’s Liberation Army, Beijing 100039, China. Reprint requests: Ben-Li Han, MD, Hepatobiliary Surgery Center, Southwest Hospital, the Third Military Medical University, Chongqing 400038, China. Copyright © 2000 by Mosby, Inc. 0039-6060/2000/$12.00 + 0 doi:10.1067/msy.2000.104663

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center. We reviewed our experience in the management of ILH, attempting to identify factors that are responsible for poor outcomes to select an appropriate approach to the treatment of this disorder. PATIENTS AND METHODS Between June 1976 and June 1998, 1118 patients with primary intrahepatic lithiasis were treated in our center; 151 patients (14%) had ILH. Evaluation of the hepatobiliary system included endoscopic retrograde cholangiography (ERC), percutaneous transhepatic cholangiography (PTC), ultrasonography, and computed tomography (CT). These imaging examinations were able to delineate the presence of stones, strictures, biliary dilations, and associated liver atrophy before elective operation was planned. Operations were tailored to the individual patients according to the preoperative evaluations. Of the 151 patients with ILH, 128 patients (60 male and 68 female) underwent operative SURGERY 493

494 Sun, Han, and Cai

Surgery May 2000

Table I. Location of biliary stones Patients Location LEHD only LMHD only LHD only LEHD + EHD LEHD + LMHD LEHD + LMHD + EHD TOTAL

n

%

13 0 7 5 55 48 128

10 0 5 4 43 38 100

Table II. The rates (%) of successful imaging of bile ducts by various preoperative imaging modalities Location

ERC (n = 90)

PTC (n = 22)

Ultrasonography (n = 104)

CT (n = 56)

Combination (n = 116)

LEHD LMHD LHD EHD

87 21 90 100

95 36 86 86

88 49 94 91

73 39 68 91

84 53 94 96

treatment with no deaths. The mean age was 41.5 years (range, 16-72 years). A retrospective review of these 128 patients was performed. Preoperative evaluation, operative findings, treatment, and postoperative course were quantitated. The mean (± SD) follow-up time from treatment until death or to date was 9.8 ± 3.1 years. During the follow-up, ERC, PTC, ultrasonography, and CT were applied to detect stone recurrence, restricture, and other hepatobiliary diseases. Forty patients (31%) underwent reoperation for repeated cholangitis or obstructive jaundice as the result of residual stones and strictures in the left medial lobe and the left hepatic duct (LHD). All the data are expressed as mean ± standard error. Statistical analyses were performed with the chi-squared test and the Student t tests. Probability differences of .05 or less were considered significant. RESULTS Distribution of calculi. The location of calculi in patients with ILH is shown in Table I. Preoperative evaluation. Table II shows the rates of successful imaging of the left external hepatic duct (LEHD), left medial hepatic duct (LMHD), LHD, and extrahepatic duct (EHD) by ERC, PTC, ultrasonography, and CT and by a combination of 2 or more of these imaging tests. Left intrahepatic biliary ductal strictures. Strictures in the LHD were detected before the operation in 60% of patients with ILH. The LMHD and the LEHD were not routinely explored during the operative procedures that do not involve a left

hepatic lobectomy because of the difficulty of the operation. However, as seen in Table III, strictures of the LMHD and LEHD were even more common (76% and 82%, respectively) than those in the LHD. Operative treatment. Over the study period, left lateral segmentectomy was the most commonly performed treatment for ILH (53%); left hepatic lobectomy was used less frequently (21%). Bile duct exploration and either external drainage (T tube) or internal drainage (hepatico-choledochojejunostomy) was often indicated in patients with acute cholangitis of the severe type,3 in patients who could not financially afford a definitive operation (hepatic resection), or in the early stage of hepatolithiasis such as isolated LHD stone. Before June 1996, left lateral segmentectomy was more frequently used to treat ILH than left hepatic lobectomy (59% vs 12%); in the recent 2 years, the latter was much more commonly used than the former (77% vs 13%). Management of nonresected biliary strictures. When a left hepatic lobectomy was not performed, severe strictures in the LHD were managed either by dilatation, stricturoplasty or bilioenteric anastomosis (Table IV). The lowest restricture rates occurred after a combination of stricturoplasty and internal biliary drainage; dilatation or stricturoplasty alone were complicated by restricture rates of 50% or more. Operative deaths and morbidity. There were no operative deaths in the 128 patients (Table V). The duration of the operations was similar, and blood loss was kept to a minimum. The incidence of serious complications was quite low.

Sun, Han, and Cai 495

Surgery Volume 127, Number 5 Table III. Occurrence of strictures of the LHD system Location LHD LMHD LEHD

Patients (n)

Mild stricture* (%)

Severe stricture† (%)

Total (%)

30 (23) 14 (29) 34 (37)

47 (37) 23 (47) 41 (45)

77 (60) 37 (76) 75 (82)

128 49 91

*A

stricture with a diameter more than one half of the greatest diameter of the dilated ducts.

†A

stricture with a diameter of one half or less of the greatest diameter of the dilated ducts.

Table IV. Management of the LHD stricture of the severe degree and restricture rates Operation

Patients (n)

Stricturoplasty and biliary-enteric anastamosis (%) Stricturoplasty only (%) Dilatation only (%) TOTAL (%)

22 (47) 4 (9) 9 (19) 47 (100)

Mean follow-up (y) 10.1 ± 2.4 8.2 ± 3.5 10.7 ± 2.7 9.3 ± 2.8

Restricture rate (n) 4 (18)* 2 (50) 9 (100) 15 (32)

*Chi-squared test, P < .05 vs dilatation only.

Table V. Perioperative comparison of left hepatic lobectomy and left lateral segmentectomy Left lateral segmentectomy*

Intraoperative Operative duration (h) Bleeding (mL) Postoperative (n) Death Hepatic failure Renal failure Pneumonia Bile leakage Subphrenic abscess

Left hepatic lobectomy*

T tube BDED (n = 40)

Cholangiojejunostomy (n = 28)

T tube BDED (n = 19)

Cholangiojejunostomy (n = 8)

2.6 ± 0.8 358 ± 135

3.2 ± 0.9 657 ± 151

3.1 ± 0.9 579 ± 161

3.6 ± 1.1 675 ± 132

0 0 0 2 3 2

0 0 0 2 4 2

0 0 2 1 2 0

0 0 1 1 1 0

BDED, Bile duct external drainage. *No statistically significant differences between groups.

Residual stones. The rate of residual stones after left hepatic lobectomy (4%) was lower than after left lateral segmentectomy (22%) or bile duct exploration (56%; Table VI). In addition, the residual stones after left hepatic lobectomy occurred in the extrahepatic biliary tree and could be treated more easily than stones after left lateral segmentectomy, which were usually in LMHD. Long-term results. Definitions of outcome were as follows: good, no further episodes of cholangitis or obstructive jaundice after the operation; poor, recurrent cholangitis or obstructive jaundice. Table VI outlines the follow-up data. Formal hepatic resections had superior results compared with bile duct drainage alone. The reader should remember, however, that most left hepatic lobectomies had been performed since 1996 and that the follow-up time is short (≤2 years). Nevertheless, the incidence of residual biliary stones is less after left hepatic lobectomy (4%) than after left lateral seg-

mentectomy (22%), whether or not an extrahepatic bile duct exploration with external or internal drainage is carried out concomitantly. DISCUSSION The left hepatobiliary system is the most commonly involved site in hepatolithiasis.4 ILH is thus usually regarded as an early stage of intrahepatic hepatolithiasis. Although the calculi are localized in the left hepatobiliary system, ILH that is associated with repeated cholangitis and endotoxemia is believed to lead to biliary tract stones and strictures of the right hepatic lobe, hepatic abscesses, postobstructive atrophy, eventual biliary cirrhosis, and even portal hypertension.5 In addition, there is a strong association between intrahepatic cholangiocarcinoma and long-standing hepatolithiasis. Thus early treatment of ILH should be instituted promptly and properly.6 In theory, isolated left-sided or right-sided hepa-

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Table VI. Operative procedures, residual stone, and the long-term results Outcome (%) Procedure Left lateral segmentectomy Left hepatic lobectomy Bile duct external drainage Choledocho-hepaticojejunostomy TOTAL

Patients (n) 68 27 18 15 128

Residual stones (%)

Good

Poor

Unknown

22* 4*‡ 56 47

53† 96*‡ 6 47

34* 4‡ 78 53

13 0 17 0

26

54

36

9

*Chi-squared test, P < .05 vs bile duct external drainage and choledocho-hepaticojejunostomy. †Chi-squared test, P < .05 vs bile duct external drainage. ‡Chi-squared test, P < .05 vs left lateral segmentectomy, bile duct external drainage, and choledocho-hepaticojejunostomy.

tolithiasis can be cured by means of hepatic resection by complete removal of the stones, biliary strictures, and areas of postobstructive biliary dilation to prevent progressive liver damage and potential malignancy.7,8 Left hepatic resection (more commonly left lateral segmentectomy or left hepatic lobectomy) is indicated for patients with isolated left-sided hepatolithiasis. Despite this approach, some patients with ILH had poor results and even required reoperation.9,10 It has taken a long time for hepatobiliary surgeons in China to more fully understand the treatment principles of ILH. When ultrasonography and CT were not available and ERC or PTC often failed to delineate LMHD, it was believed that the LMHD was rarely involved in hepatolithiasis; and even if it was, a hepatojejunostomy would adequately lead to drainage of the residual stones in LMHD; the emphasis was directed at treatment of the LEHD system in the management of ILH. Inadequate surgical technique, inexperience, and the poor general condition of some patients also limited the widespread use of left hepatic lobectomy. Our current data show that ILH usually involves both LEHD and LMHD simultaneously and is commonly complicated by various degrees of biliary strictures in these ducts and the LHD. Left lateral segmentectomy resulted in high rates of residual stones (22%), LHD restricture (43%), and unsatisfactory results (64%). Many patients who were treated before 1996 required reoperation (mainly left medial lobe resection) for repeated cholangitis or obstructive jaundice because of the residual stones, strictures, and cholangiocarcinoma in the left medial lobe and the LHD. From the 27 patients who underwent left hepatic lobectomy, the longterm results of left hepatic lobectomy were better than those of left lateral segmentectomy, with a higher complete stone clearance, and lower rates of recurrent stones and/or strictures in long-term follow-up. Furthermore, the residual stones after

left lobectomy were in the extrahepatic biliary duct and were much easier to treat than stones after lateral segmentectomy, which were usually in LMHD. We acknowledge that our results with one half of the patients after left hepatic lobectomy are limited by a relatively short follow-up time because 13 of the 27 patients underwent operation after June 1996; nevertheless, the trends in recurrence rates of stones and strictures are reassuringly low. In the recent 2 years, a better understanding of the prognostic significance of stones, strictures,11,12 and dilation11 and the potential for cholangiocarcinoma in the LMHD in association with improvements in surgical technique and perioperative management have led surgeons to prefer left hepatic lobectomy to left lateral segmentectomy in the management of ILH with complicated lesions. Our study data showed that, before June 1996, left lateral segmentectomy was performed more frequently than left hepatic lobectomy (59% vs 13%), although after June 1996 the opposite occurred (12% vs 77%). Interestingly, duration of operation, intraoperative blood loss, and postoperative complications were similar in patients who underwent either left hepatic lobectomy or left lateral segmentectomy. The results suggest that, if the patient’s medical condition permits, left hepatic lobectomy remains a safe and applicable procedure and should be strongly indicated in the treatment of ILH with complicated lesions. With better understanding of the pathophysiologic changes of ILH and widespread use of ultrasonography and CT, it will be easier to diagnose and treat patients with ILH in its early stages. When only the LHD is involved with stones but the LEHD and LMHD are not involved and the left liver is morphologically normal, the impacted stones can be removed by bile duct exploration and biliary reconstruction without formal hepatectomy, provided all biliary strictures can be adequately treated. In contrast, hepatic segmentectomy or lobecto-

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Surgery Volume 127, Number 5

my is indicated in patients whose stones could not be completely removed by other procedures, whose related dilation and stricture could not be successfully managed, or in whom cholangiocarcinoma could not be reliably excluded. REFERENCES 1. Nakayama F, Soloway RD, Nakama T, Miyazaki K, Ichimiya H, Sheen PC, et al. Hepatolithiasis in East Asia: retrospective study. Dig Dis Sci 1986;31:21-6. 2. Huang ZQ. Progress of surgical treatment of intrahepatic lithiasis in China. Chin Med J 1996;109:506-8. 3. Sun WB, Han BL, He ZP. An approach to timing selection of emergency operation for acute cholangitis of severe type. Journal of Medical Colleges of the People’s Liberation Army 1992;7:251-5. 4. Koga A, Miyazaki K, Ichimiya H, Nakayama F. Choice of treatment for hepatolithiasis based on pathological findings. World J Surg 1984;8:36-40. 5. Fan ST, Wong J. Review article: complications of hepatolithiasis. J Gastroenterol Hepatol 1992;7:324-7.

O

6. Chen MF, Jan YY, Wang CS, Hwang TL, Jeng LB, Chen SC, et al. A reappraisal of cholangiocarcinoma in patient with hepatolithiasis. Cancer 1993;71:2461-5. 7. Fan ST, Lai ECS, Wong J. Hepatic resection for hepatolithiasis. Arch Surg 1993;128:1070-4. 8. Hung CJ, Lin PW. Role of right hepatic lobectomy in the treatment of isolated right-sided hepatolithiasis. Surgery 1997;121:130-4. 9. Chijiiwa K, Yamashita H, Yoshida J, Kuroki S, Tanaka M. Current management and long-term prognosis of hepatolithiasis. Arch Surg 1995;130:194-7. 10. Sun WB, Han BL, Cai JX, He ZP, Huang ZQ. Surgical treatment and long-term prognosis of localized left hepatolithiasis. Chin Med J 1998;111:82-3. 11. Mueller PR, van Sonnenberg E, Ferrucci JT, Weyman PJ, Butch RJ, Malt RA, et al. Biliary stricture dilation: multicenter review of clinical management in 73 patients. Radiology 1986;160:17-22. 12. Sun WB, Han BL, Cai JX, He ZP. Surgical treatment of the biliary ductal strictures complicating localized left hepatolithiasis. China Natl J New Gastroenterol 1997;3:24-6.

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