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Management of intrahepatic stones: The role of subcutaneous hepaticojejunal access loop. A prospective cohort study
International Journal of Surgery 12 (2014) 886e892
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Original research
Management of intrahepatic stones: The role of subcutaneous hepaticojejunal access loop. A prospective cohort study Mohamed I. Kassem, Magdy A. Sorour*, Abdel-Hamid A. Ghazal, Hany M. El-Haddad, Mohamed T. El-Riwini, Hassan A. El-Bahrawy Department of Surgery, Faculty of Medicine, University of Alexandria, Egypt
h i g h l i g h t s Recurrence of stones occurs frequently after surgical removal of intrahepatic stones. BLong-term access routes involving the subparietal hepaticojejunal access loop for stone retrieval have been developed. The closed subcutaneous access loop offers the advantage of permanent access for removal of intrahepatic stones. The subcutaneous access loop permitted easy access to intrahepatic ducts without the needs for cutaneous stomas.
a r t i c l e i n f o
a b s t r a c t
Article history: Received 25 April 2014 Received in revised form 6 July 2014 Accepted 16 July 2014 Available online 28 July 2014
Background: Patients with intrahepatic stones usually present with recurrent cholangitis, biliary sepsis and intrahepatic abscesses, may develop liver atrophy and may progress to cholangiocarcinoma. Treatment of intrahepatic stones is difficult and the disease progresses in most patients even after adequate treatment. Surgical removal of stones has been the standard management but residual stones and stone recurrence occur frequently whatever the technique. Because of the need for repeated biliary instrumentation, long-term access routes involving percutaneous transhepatic cholangioscopic lithotripsy (PTCSL), hepaticocutaneousjejunostomy (HCJ) and subparietal hepaticojejunal access loop to permit stone retrieval or stricture dilatation have been developed. Purpose: The aim of this work was to evaluate the outcome of subcutaneous hepaticojejunal access loop in the management of intrahepatic stones. Patients and methods: Between January 2009 and January 2013, 42 patients with intrahepatic stones underwent surgical treatment at the Gastrointestinal Surgery Unit, Main Alexandria University Hospital. Demographic data, details of operative findings, follow up details, and treatment of recurrent stones were analyzed. After approval of local ethics committee, all patients included in the study were informed well about the procedure and an informed written consent was obtained from every patient before carrying the procedure. Results: Forty-two patients (17 males and 25 females) with intrahepatic stones underwent surgery with construction of a subcutaneous hepaticojejunal access loop. Stones were confined to the left lobe in 25 patients, the right lobe in 3 patients and bilobar in 14 patients. Associated extrahepatic stones were found in 33 patients. Twenty-two patients had associated intrahepatic duct strictures. Five patients with atrophy of segments II and III underwent hepatic resection at the time of access loop formation. The mean operation time was 4.9 h and mean blood loss was 440 mL. Mean postoperative hospital stay was 10 days. Wound infection was the commonest complication, occurring in 5 (12%) patients. There were no specific complications attributable to the construction of the access loop. The subcutaneous access loop was used to gain access to the biliary tree in 28 patients with residual or recurrent stones. A total of 55 procedures (range 1e5) were attempted with successful access achieved in all cases and successful stone clearance in 21 of the 28 patients, and all of them were symptom free for at least 12 months after the last procedure. Partial stone clearance was achieved in the remaining seven patients. These seven patients had different degrees of biliary strictures. Conclusion: The subcutaneous access loop offers the advantage of permanent access for the successful management of retained or reformed intrahepatic stones with minimal morbidity since it permitted easy access to intrahepatic ducts
Keywords: Intrahepatic stones Hepaticojejunostomy Subcutaneous jejunal access loop
* Corresponding author. E-mail address: [email protected] (M.A. Sorour). http://dx.doi.org/10.1016/j.ijsu.2014.07.264 1743-9191/© 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
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using the conventional forward-viewing endoscope or the choledochoscope, without the additional morbidity of a biliary-cutaneous fistula or transhepatic access. © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
1. Introduction Intrahepatic stones are defined as calculi located proximal to the confluence of the right and left hepatic ducts, irrespective of the coexistence of gallstones in the common bile duct and/or gallbladder [1e3]. This disease is prevalent in East and Southeast Asian countries and infrequent in Western population. [1,4e8]. In most cases, intrahepatic stones consist of calcium bilirubinate (brown pigment stones), but contain more cholesterol than those in either the common bile duct or the gallbladder. Almost pure cholesterol stones are sporadically reported [9,10]. The aetiology of intrahepatic stones is not exactly known, although recurrent bacterial infection (mixed infections:- Escherichia coli, Klebsiella, Streptococcus fecalis, Clostridia, and Bacteroides), parasitic infestation (Clonorchis sinensis or Ascaris lumbricoides), ethnic background, and stasis due to congenital abnormalities of the biliary tract have been implicated in the pathogenesis [2,11,12]. Rarely, intrahepatic stones can form as a result of iatrogenic bile duct stricture, and choledochal cysts [11]. Primary intrahepatic stones are associated with strictures in up to 85 per cent of cases and the natural history is characterized by progression with recurrent attacks of biliary sepsis [13]. Patients with intrahepatic stones usually present with recurrent cholangitis, intrahepatic abscesses, and may develop liver atrophy and secondary biliary cirrhosis [4,5]. The triad of symptoms e fever, jaundice, and right upper quadrant pain e is present in 60% of cases [11]. The symptoms can be mild with minimal abdominal tenderness and jaundice or severe with shock and mental confusion. The disease may progress to epithelial dysplasia and cholangiocarcinoma in 3%e8% of cases. [5,14]. Treatment of intrahepatic stones is complex and the disease progresses in most patients even after adequate treatment [5,14]. Patients having stones and strictures confined to a liver segment/ section/hemiliver with subsequent atrophy are best treated by hepatic resection [15,16]. Surgical removal of stones has been the standard management but residual stones and stone recurrence occur frequently whatever the technique [11,17e20]. Because of the need for repeated biliary instrumentation, long-term access routes involving percutaneous transhepatic access tubes [21], or hepaticocutaneousjejunostomy (HCJ) to permit stone retrieval or stricture dilatation have been developed [22e24]. These provide good access to the biliary system but patients are left with the unpleasant side effects of a biliary stoma [19,23]. Our experience with a subparietal hepaticojejunal access loop, without a stoma, in the management of intrahepatic stones is reported. [18]. 2. Aim of the work The aim of this work was to evaluate the outcome of subcutaneous hepaticojejunal access loop in the management of intrahepatic stones. 3. Patients Between January 2009 and January 2013, 42 patients with radiologically confirmed intrahepatic stones were admitted and treated at the Gastrointestinal Surgery Unit, Main Alexandria
University Hospital. Demographic data, details of operative findings, follow-up details, and treatment of recurrent stones were analyzed. Patients with predominant intrahepatic calculi were included; those with associated extensive extrahepatic bile duct calculi or secondary biliary cirrhosis were excluded.
4. Methods A post-intervention prospective cohort study was designed to include all patients with intrahepatic stones who underwent surgery for stone retrieval with construction of a subcutaneous hepaticojejunal access loop. After approval of the local ethics committees of both the General Surgery Department and the Alexandria Faculty of Medicine, all patients included in the study were well informed about the operative procedure and the possible complications and an informed written consent was obtained from each patient before surgery. All patients were subjected to complete history taking, thorough clinical examination, routine laboratory studies, liver enzymes, serum bilirubin level, and CA19.9 measurements. Abdominal ultrasonography, multi-slice CT (MSCT) abdomen, and MRI with magnetic resonance cholangiopancreatography (MRCP) were routinely performed. All patients received prophylactic antibiotic (3rd generation cephalosporin 1 g, intravenously) at the time of induction of anaesthesia and then every 4 h during the operation and twice daily thereafter for 5 days. A right subcostal incision with extension to the left, as appropriate, was used to provide exposure of the porta hepatis. The first step was cholecystectomy, unless the gallbladder had already been removed, followed by bile duct exploration. Choledochotomy was sited close to the biliary confluence to allow easy extension to one or both hepatic ducts, depending on the predominant location of stones for better clearance and wider anastomosis. Intrahepatic stones were removed using Desjardine's forceps, saline flushing, and balloon extraction. Intraoperative flexible choledochoscopy (Karl Storz, Germany) with operating channels and end vision was used to identify and remove intrahepatic calculi using a choledochoscope-guided biliary balloon catheter and metallic wire basket retriever. A mechanical basket lithotripter passed via the working channel of a choledochoscope was used for fragmentation of big stones located beyond strictures. Occasionally stricture dilatation using an angioplasty balloon under fluoroscopic control was used to remove all stones. Stone clearance was confirmed using intraoperative cholangiogram. When liver atrophy was present hepatic resection was performed. A biliary-enteric anastomosis was performed using a side-to-side anastomosis between the hepatic duct confluence and a jejunal Roux-en-Y loop. If the left or right duct was narrowed, the hepatic duct incision was extended beyond the stricture to provide a wide anastomosis. A site 12-cm proximal to the closed end of the jejunal loop was selected for anastomosis using a single layer of interrupted 3/0 polyglactin (Vicryl; Ethicon, Johnson and Johnson) suture to the hepatic duct confluence. Two ligaclips were used to mark the anastomosis for later radiological identification. The length between the hepaticojejunostomy and the jejunojejunostomy was 50 cm. The closed proximal limb was
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passed through the anterior abdominal wall and was then fixed to the wall in a subcutaneous position using 3/0 polyglactin sutures (Fig. 1). The limb between the hepaticojejunal anastomosis and the subcutaneous fixation should be short and straight. Ligaclips were used to mark the jejunal loop by clipping the sutures holding the access loop in place. An umbilical feeding tube was passed through the skin and into the access loop to permit postoperative cholangiography. If obstructive jaundice, biliary pain or cholangitis subsequently developed, recurrent or residual stones were suspected. Abdominal ultrasonography followed by MRCP were then carried out. Once residual or recurrent intrahepatic stones were identified, cholangiography was carried out without sedation or local anaesthesia. Contrast was first injected percutaneously into the subcutaneous loop of jejunum (identified by the scar). After confirming that the contrast was intraluminal by fluoroscopy, the patient was placed in a Trendelenberg position and more contrast was injected, which
flowed into the liver outlining the anastomosis and the intrahepatic ducts. Antibiotic prophylaxis was given and biliary access was then gained under direct vision. The skin over the access loop was incised to visualize the jejunal loop which was entered under vision using a conventional esophagogastroscope (end view) or a choledochoscope. The endoscope was passed through the subcutaneous access limb and negotiated towards the liver until the hepaticojejunostomy was identified. After the anastomosis was entered, the hepatic duct was reached under fluoroscopic guidance. A cholangiogram was then performed by the use of a three-way balloon catheter. Then a combination of Dormia basket and extraction balloons was used to extract calculi. In case of a duct stricture, a guidewire was inserted via the working channel of the scope and then through the strictured segment of the biliary tree. A balloon catheter was inserted over the guidewire and inflated to a maximum size (i.e. 5 mm) for 10 min to dilate the stricture. On completion, the ducts were flushed with saline. The skin and
Fig. 1. Side-to-side hepaticojejunostomy (HJ) between the hepatic duct confluence and a jejunal Roux-en-Y loop with construction of a subcutaneous access loop. Conventional endoscope (end viewer) passed through the subcutaneous jejunal access loop for stone retrieval.
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jejunal loop were closed after the procedure. Patients were admitted overnight for observation and two further doses of antibiotics were administered following the procedure. Patients were reviewed 6 weeks after surgery, at 3-month intervals thereafter for the first year, and at 6-month intervals thereafter, unless they became symptomatic again. Complete liver function tests and abdominal ultrasonography were done during the follow-up visits to detect residual stones. If there was a suspicion of stone recurrence or evidence of cholangitis, the patient was re-admitted for further evaluation and treatment. All patients were followed up for a median of 30 (range 12e60) months. A minimum of 12 months follow-up without evidence of residual or recurrent stones was considered satisfactory. Recurrent cholangitis was defined as occurrence of two separate episodes of clinical and biochemical features of cholangitis during the postoperative period. Patients with recurrent cholangitis were managed with antibiotics, ursodeoxycholic acid and endoscopic stone extraction through the access loop. Data were presented with numbers, percentage, arithmetic mean (X) and standard deviation (SD) and were analyzed using the SPSS (version 16) statistical software. P values less than 0.05 were considered to be statistically significant. 5. Results Forty-two patients with intrahepatic stones underwent surgery with construction of a subcutaneous hepaticojejunal access loop. Ten patients had previously undergone a total of 12 biliary tract operations prior to the definitive procedure. These included open cholecystectomy in seven patients; laparoscopic cholecystectomy in three; common bile duct exploration and T-tube drainage in one; and common bile duct exploration and choledochoduodenostomy in the remaining patient. The patients' demographic data and preoperative parameters are shown in Table 1. Stones were mostly found in the left hemiliver. In patients with right hemiliver involvement, stones were seen predominantly in liver segments VI and VII. Associated extrahepatic stones were found in 33 patients. Twenty-two patients had associated intrahepatic duct strictures. Atrophy of segments II and III was identified before operation by computed tomography in five patients, all of Table 1 Patients' demographic data and preoperative parameters. Characteristics
Patients (n ¼ 42)
Age Male:female Serum bilirubin (mg/dL) Serum ALT Serum AST Serum alkaline phosphatase Presenting features Abdominal pain Recurrent fever Obstructive jaundice Cholangitis Hepatomegaly Morphological features Bilobar disease Unilobar disease Left lobe Right lobe Extrahepatic and intrahepatic calculi Intrahepatic calculi alone Associated atrophy of liver Associated intrahepatic stricture Mild stricture Severe stricture
41 ± 8.4 (32e64) 17:25 5.5 ± 3.7 (1.1e17.3) 79 ± 47 (32e237) 87 ± 62 (23e326) 276 ± 172 (137e1047) 39 (93%) 34 (81%) 29 (69%) 25 (60%) 5 (12%) 14 (33%) 28 (67%) 25 (60%) 3 (7%) 33 (79%) 9 (21%) 5 (12%) 22 (52%) 18 (43%) 4 (10%)
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whom underwent hepatic resection (left lateral sectionectomy in 4 and left hepatectomy in 1) at the time of the access loop construction. A mild stricture happened when choledochoscopic access to the stones was impossible without dilatation. A severe stricture happened when a guide-wire could not pass through the stricture. A positive bile culture was obtained in 39 (93%) patients. The cultured organisms were E. coli in 15 patients (38%), Klebsiella in 11 (28%), and multiple organisms in 13 (33%) patients. The mean operation time, including that for choledochoscopy, and cholangiography was 4.9 h and the mean blood loss was 440 mL. The mean postoperative hospital stay was 10 days. Minor complications were encountered in 8 (19%) patients. Four patients presented with more than one complication. Wound infection was the commonest complication, occurring in 5 (12%) patients. Pulmonary complications occurred in 3 (7%) patients, and intraabdominal collections in 2 (4.8%) patients. Two (4.8%) patients had biliary leak after left lateral sectionectomy. All responded to conservative treatment with full recovery. There were no specific complications attributable to the construction of the access loop. None of the patients developed postoperative cholangitis prior to stone recurrence and none presented with strictures at the site of the bilioenteric anastomosis. Recurrent cholangitis occurred in 22 (52%) patients. Recurrence of cholangitis occurred at a mean period of 10 months after the initial surgical procedure, was always associated with recurrent stones, and required 2 hospital admissions per patient. The presence of intrahepatic strictures was associated with recurrent cholangitis. Fourteen patients (33%) had no residual or recurrent stones after the initial surgical procedure and did not require the access loop, the ‘no need group’. Retained or re-formed stones were found in 28 (67%) patients. The subcutaneous access loop was used to gain access to the biliary tree in all these patients. A total of 55 procedures (range 1e5) were attempted with successful access achieved in all cases and successful stone clearance in 21 of the 28 patients, and all of them were symptom free for at least 12 months after the last procedure, the ‘successful use group’. There was no significant complication of these procedures. Partial stone clearance was achieved in the remaining seven patients, the ‘failed use group’. These seven patients had different degrees of biliary strictures. The flowchart in Fig. 2 summarizes the outcomes of stone retrieval through the subcutaneous access loop. Severe bile-duct stricture was the major cause for the failure to remove stones. Table 2 shows the parameters associated with the final outcomes of the procedure. Of the 42 patients treated, 20 patients had no bile duct stricture, 18 had a mild stricture, and 4 had a severe stricture (Table 3). In the no stricture group, the stone of one patient was large and impacted and could not be removed completely. Of the 18 patients in the mild-stricture group, after endoscopic dilatation, stones could be removed from 16 patients (89%) and were partially removed in the remaining two patients. In the severe-stricture patients, the guidewire could not be passed through some strictures and the stones in all the 4 patients (100%) were not removed completely. These 4 patients underwent hepatic resection at the time of the access loop construction. 6. Discussion Intrahepatic stones are frequently associated with intrahepatic strictures which may cause bile stasis, cholangitis and recurrent stone formation [25]. The principal approaches to intrahepatic stones are surgical exploration of bile duct and intrahepatic ducts for stone removal with biliary drainage or hepatico-jejunostomy
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Patients with intrahepatic stones (n = 42) Hepaticojejunostomy with subcutaneous access loop
Residual or recurrent stones
'No need' group
(n = 28) (67%)
Patients who did not need the access loop No residual or recurrent stones symptom free for a minimum of 12 months (n = 14) (33%)
Stone retrieval via the subcutaneous access loop (1 – 5 procedures)
'Successful use' group
'Failed use' group
Patients who did benefit from the access loop Successful clearance (n = 21) (50%)
Patients who failed to benefit from the access loop Partial clearance (n = 7) (17%)
Symptom free for at least one year after the last procedure
No stricture big stone
Mild stricture (n = 2)
Severe stricture (n = 4)
(n = 1) Hepatic resection Fig. 2. Flowchart summarizes the outcome of subcutaneous hepaticojejunal access loop in the management of intrahepatic stones.
(with or without access loop construction), hepatic resection [26], and percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) [27,28]. The success rates with these procedures range from 72% to 92%. [29e31]. The incidence of retained stones after operation is about 55 per cent and a number of strategies have been developed to enable removal of both retained and recurrent intrahepatic stones [5,15,25,32,33]. After removal of as many of the intrahepatic stones as possible, reconstruction of the biliary tree by choledochoduodenostomy has not proved to be a reliable method for management of subsequent intrahepatic stones [34,35]. Although direct endoscopic access is still possible, the presence of strictures, peripheral stone impaction and ductal angulation make endoscopic extraction difficult [36,37]. Cunha et al. [38] reported a biliary access technique for the long-term endoscopic management of intrahepatic stones that involved a side-to-side duodenojejunostomy between the isolated Roux-en-Y jejunal limb 20 cm distal to the biliary anastomosis and the lateral duodenal wall 15 cm from the pylorus. To access the anastomosis, the endoscope must be negotiated through this duodenojejunostomy and then travels upward for about 20 cm. The Roux-en-Y hepaticocutaneousjejunostomy (HCJ) has been used to permit endoscopic access for removal of intrahepatic stones
[4,5,17,39,40]. This technique provides good access to the biliary tree [41]. However, the necessity of a stoma is unsatisfactory because of the unpleasant side-effects of mucus and bile leakage with associated cutaneous irritation and excoriation [17,21]. Routine early closure of the stoma has been recommended to avoid these side-effects after removal of retained stones following surgery [42]. Stoma closure is associated with significant complications of wound infection, fistula formation and parastomal hernia [43]. Furthermore, many patients required reopening of the stoma for removal of recurrent stones after only 2 years of followup. [43]. An alternative access to the biliary tree for intervention is the percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) approach. It is being increasingly used with the advent of the fourangled choledochoscope [14]. The transhepatic route requires the development of a working tract which necessitates sequential dilatation over a period of up to 3 weeks, following which choledochoscopy can be performed for stone removal or stricture dilatation [44]. The procedure is not without complications, with severe pain and bleeding resulting in treatment failure in many cases [45]. Stone clearance rates of 80 per cent have been achieved with repeated procedures [46,47]. The transhepatic catheter has
M.I. Kassem et al. / International Journal of Surgery 12 (2014) 886e892 Table 2 Parameters associated with final outcomes of the procedure. Parameter
‘No need’ group (n ¼ 14)
‘Successful use ’ group (n ¼ 21)
‘Failed use ’ group (n ¼ 7)
Common bile duct calculi Bilobar disease Unilobar disease Associated intrahepatic stricture Postoperative cholangitis Atrophy of liver Hepatic resection
12
16
5
5 9 e
6 15 16
3 4 6
e e e
15 1 e
7 4 4
been a major source of complaint and access is only temporary as the fistula closes after removal of the catheter. [7,17]. In the present study, hepatic resection with subcutaneous hepaticojejunal access loop was performed only for patients with hemihepatic disease associated with atrophy. Twenty-eight (67%) patients had hemihepatic disease and 5 of these patients underwent hepatic resection. The present study has no experience with hepatic resection for bilateral liver disease. Our policy for such patients was to perform surgical exploration and dilatation of strictures followed by stone clearance and construction of a subcutaneous hepaticojejunal access loop for biliary interventions in the future should patients develop recurrent stones or cholangitis. The subparietal access loop can be used for stone retrieval under local anaesthesia [48]. The afferent loop can be identified fluoroscopically by determining the position of the ‘ligaclip runway lights’. The loop can be entered percutaneously between the ‘runway’ clips using a 21-gauge fine-bore needle with intermittent contrast injections and a guidewire. A converting dilator allowed percutaneous introduction of larger guidewire catheters directed by fluoroscopy into the jejunal lumen where a combination of Dormia baskets, angioplasty balloons and snare wires can be used to fragment and extract calculi. Krige and Beningfield [49] described a new double-entry access loop (DEAL) technique as a modification of the subparietal single-entry access loop to enhance percutaneous radiological entry and facilitate intrahepatic biliary intervention. The subcutaneous access loop used in this study is a good alternative to the subparietal access loop that allowed reliable access to the biliary tree in all cases. The median number of procedures performed per patient was 2 with one patient requiring 5 procedures over a 4-year period, thus emphasizing the need for a permanent access route. There was no complication attributable to the formation of the access loop and bacterial overgrowth of the Roux-en-Y loop has not been observed. Although cholangiocarcinoma is reported in 6 per cent of patients with oriental intrahepatic stone disease (IHSD) [37,50,51], none occurred in the present series. In the present study, there was significant association between intrahepatic strictures and recurrent stones. Jan and Chen [46] reported residual or recurrent stones in 21% of patients with
Table 3 Bile-duct strictures and choledochoscopic removal of stones. Bile duct stricture
No. of patients
Choledochoscopic removal Complete
Incomplete
No stricture Mild stricture Severe stricture Total
20 18 4 42
19 (95%) 16 (89%) 0 35 (83%)
1 2 4 7
(5%) (11%) (100%) (17%)
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strictures as compared to no stones in those without stricture. Various techniques have been used for postoperative access of biliary system in the treatment of recurrent stone with cholangitis [43,48,52e54]. Postoperative choledochoscopic removal of stones through a T-tube tract was once popular; however Cheung et al. [52] reported poor overall success rate (50%) and technical difficulties like inaccessibility of the ducts, failed manipulation due to strictures, losing the tract during dilatation, and difficulties in extracting large stones. The closed subcutaneous access loop offers the advantage of a permanent and re-usable access for stone removal with minimal morbidity since it permitted easy access to intrahepatic ducts using a conventional forward-viewing endoscope or a choledochoscope, without the need for transhepatic tubes or cutaneous stomas. Factors associated with ‘failed use’ “i.e. severe stricture” should be added to the exclusion criteria in patient selection. However, expert opinion is of paramount importance in selecting patients for this procedure. Moreover, those who did not need the access loop ‘i.e. no need group’ and were symptom free for at least 12 months after stone retrieval and construction of the access loop may benefit from the loop later in their life should they develop recurrent stones. Ethical approval Ethical approval was given by Ethical Committee of Alexandria Faculty of Medicine. Funding No sources of funding as all cases were done in the Main University Hospital with no added costs. Author contribution All authors share the study design, collection and analysis of data, performing operations and writing the paper. Conflicts of interest There are no specific conflicts of interest. References [1] T.K. Choi, Intrahepatic stones, Br. J. Surg. 76 (1989) 213e214. [2] M.H. Kim, J. Sekijama, S.P. Lee, Primary intrahepatic stones, Am. J. Gastroenterol. 90 (1995) 540e548. [3] F. Nakayama, Intrahepatic calculi: a special problem in East Asia, World J. Surg. 6 (1982) 802e804. [4] S.T. Fan, T.K. Choi, C.M. Lo, F.P. Mok, E.C.S. Lai, J. Wong, Treatment of hepatolithiasis: improvement of result by a systematic approach, Surgery 109 (1991) 474e480. [5] K. Chijiiwa, H. Yamashita, J. Yoshida, S. Kuroki, M. Tanaka, Current management and long-term prognosis of hepatolithiasis, Arch. Surg. 130 (1995) 194e197. [6] K.S. Jeng, I. Ohta, F.S. Yang, Reappraisal of the systematic management of complicated hepatolithiasis with bilateral intrahepatic strictures, Arch. Surg. 131 (1996) 141e147. [7] H.A. Pitt, A.C. Venbrux, J. Coleman, C.A. Prescott, M.S. Johnson, F.A. Osterman, et al., Intrahepatic stones: the transhepatic team approach, Ann. Surg. 219 (1994) 527e537. [8] I. di Carlo, A. Sauvanet, J. Belghiti, Intrahepatic lithiasis: a Western experience, Surg. Today 30 (2000) 319e322. [9] S.D. Strichartz, M.Z. Abedin, A.F. Ippoliti, et al., Intrahepatic cholesterol stones: a rationale for dissolution therapy, Gastroenterology 100 (1991) 228e232. [10] T. Ohta, T. Nagakawa, T. Takeda, et al., Histological evaluation of the intrahepatic biliary tree in intrahepatic cholesterol stones, including immunohistochemical staining against apolipoprotein AeI, Hepatology 17 (1993) 531e537. [11] T. Choi, J. Wong, Current management of intrahepatic stones, World J. Surg. 14 (1990) 487e491.
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[34] F. Nakayama, T. Furusawa, T. Nakama, Hepatolithiasis in Japan: present status, Am. J. Surg. 139 (1980) 216e219. [35] R.H. Carmona, R.A. Crass, R.C. Lim Jr., D.D. Trunkey, Oriental cholangitis, Am. J. Surg. 148 (1984) 117e124. [36] D.H. Bonnel, C.E. Liguory, F.E. Cornud, J.F. Lefebvre, Common bile duct and intrahepatic stones: results of transhepatic electrohydraulic lithotripsy in 50 patients, Radiology 180 (1991) 345e348. [37] K. Yasuda, M. Nakajama, E. Cho, H. Mukai, K. Kawai, Comparison of peroral and percutaneous cholangioscopy, Endoscopy 21 (Suppl. 1) (1989) 347e350. [38] J.E.M. Cunha, P. Herman, M.C.C. Machado, et al., A new biliary access technique for long-term endoscopic management of intrahepatic stones, J. Hepatobiliary Pancreat. Surg. 9 (2002) 261e264. [39] P.E. Gott, M.H. Tieva, P.J. Barcia, J.M. Laberge, Biliary access procedure in the management of cholangiohepatitis, Am. Surg. 62 (1996) 930e934. [40] C.L. Liu, S.T. Fan, J. Won, Primary biliary stones: diagnosis and management, World J. Surg. 22 (1998) 1162e1166. [41] T.K. Choi, M. Fok, M.J. Lee, R. Lui, M. Fok, J. Wong, Postoperative flexible choledochoscopy for residual primary intrahepatic stones, Ann. Surg. 203 (1986) 260e265. [42] S.T. Fan, T.K. Choi, J. Wong, Recurrent pyogenic cholangitis: current management, World J. Surg. 15 (1991) 248e253. [43] S.T. Fan, F. Mok, S.S. Zheng, E.C. Lai, C.M. Lo, J. Wong, Appraisal of hepaticocutaneous jejunostomy in the management of hepatolithiasis, Am. J. Surg. 165 (1993) 332e335. [44] M.E. Clouse, K.R. Falchuk, Percutaneous transhepatic removal of common bile duct stones: report of ten patients, Gastroenterology 85 (1983) 815e819. [45] K.-S. Jeng, H.J. Chiang, S.C. Shih, Limitations of percutaneous transhepatic cholangioscopy in the removal of complicated biliary calculi, World J. Surg. 13 (1989) 603e610. [46] Y.Y. Jan, M.F. Chen, Percutaneous transhepatic cholangioscopic lithotomy for hepatolithiasis: long-term results, Gastrointest. Endosc. 42 (1995) 1e5. [47] Y.H. Yeh, M.H. Huang, J.C. Yang, L.R. Mo, J. Lin, S.K. Yueh, Percutaneous transhepatic cholangioscopy and lithotripsy in the treatment of intrahepatic stones: a study with 5 year follow-up, Gastrointest. Endosc. 42 (1995) 13e18. [48] I.J. Beckingham, J.E.J. Krige, S.J. Beningfield, P.C. Bornman, Subparietal hepaticojejunal access loop for the long-term management of intrahepatic stones, Br. J. Surg. 85 (1998) 1360e1363. [49] J.E.J. Krige, S.J. Beningfield, The new DEAL e a novel technique using a doubleentry access loop to facilitate bilateral intrahepatic biliary access for complex intrahepatic stones, SAJS 44 (2006) 56e58. [50] K.T. Lee, C. Sheen, C.C. Tsai, J.S. Chen, C.G. Ker, Longterm results of one hundred and seven hepatic resections for intrahepatic stones, Dig. Surg. 9 (1992) 298e302. [51] S.M. Sheen-Chen, F.F. Chou, H.L. Eng, Intrahepatic cholangiocarcinoma in hepatolithiasis. A frequently overlooked disease, J. Surg. Oncol. 47 (1991) 131e135. [52] M.T. Cheung, Postoperative choledochoscopic removal of intrahepatic stones via a T-tube tract, Br. J. Surg. 84 (1997) 1224e1228. [53] G.V. Stiegmann, M.A. Mansour, J.S. Goff, N.W. Pearlman, Roux en-Y jejunoduodenostomy for endoscopic access to hepaticojejunostomy, Surg. Gynecol. Obstet. 173 (1991) 153e154. [54] V. Sitaram, B. Perakath, A. Chacko, B.S. Ramakrishna, G. Kurian, P. Khanduri, Gastric access loop in hepaticojejunostomy, Br. J. Surg. 85 (1998) 110e113.
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Original research
Management of intrahepatic stones: The role of subcutaneous hepaticojejunal access loop. A prospective cohort study Mohamed I. Kassem, Magdy A. Sorour*, Abdel-Hamid A. Ghazal, Hany M. El-Haddad, Mohamed T. El-Riwini, Hassan A. El-Bahrawy Department of Surgery, Faculty of Medicine, University of Alexandria, Egypt
h i g h l i g h t s Recurrence of stones occurs frequently after surgical removal of intrahepatic stones. BLong-term access routes involving the subparietal hepaticojejunal access loop for stone retrieval have been developed. The closed subcutaneous access loop offers the advantage of permanent access for removal of intrahepatic stones. The subcutaneous access loop permitted easy access to intrahepatic ducts without the needs for cutaneous stomas.
a r t i c l e i n f o
a b s t r a c t
Article history: Received 25 April 2014 Received in revised form 6 July 2014 Accepted 16 July 2014 Available online 28 July 2014
Background: Patients with intrahepatic stones usually present with recurrent cholangitis, biliary sepsis and intrahepatic abscesses, may develop liver atrophy and may progress to cholangiocarcinoma. Treatment of intrahepatic stones is difficult and the disease progresses in most patients even after adequate treatment. Surgical removal of stones has been the standard management but residual stones and stone recurrence occur frequently whatever the technique. Because of the need for repeated biliary instrumentation, long-term access routes involving percutaneous transhepatic cholangioscopic lithotripsy (PTCSL), hepaticocutaneousjejunostomy (HCJ) and subparietal hepaticojejunal access loop to permit stone retrieval or stricture dilatation have been developed. Purpose: The aim of this work was to evaluate the outcome of subcutaneous hepaticojejunal access loop in the management of intrahepatic stones. Patients and methods: Between January 2009 and January 2013, 42 patients with intrahepatic stones underwent surgical treatment at the Gastrointestinal Surgery Unit, Main Alexandria University Hospital. Demographic data, details of operative findings, follow up details, and treatment of recurrent stones were analyzed. After approval of local ethics committee, all patients included in the study were informed well about the procedure and an informed written consent was obtained from every patient before carrying the procedure. Results: Forty-two patients (17 males and 25 females) with intrahepatic stones underwent surgery with construction of a subcutaneous hepaticojejunal access loop. Stones were confined to the left lobe in 25 patients, the right lobe in 3 patients and bilobar in 14 patients. Associated extrahepatic stones were found in 33 patients. Twenty-two patients had associated intrahepatic duct strictures. Five patients with atrophy of segments II and III underwent hepatic resection at the time of access loop formation. The mean operation time was 4.9 h and mean blood loss was 440 mL. Mean postoperative hospital stay was 10 days. Wound infection was the commonest complication, occurring in 5 (12%) patients. There were no specific complications attributable to the construction of the access loop. The subcutaneous access loop was used to gain access to the biliary tree in 28 patients with residual or recurrent stones. A total of 55 procedures (range 1e5) were attempted with successful access achieved in all cases and successful stone clearance in 21 of the 28 patients, and all of them were symptom free for at least 12 months after the last procedure. Partial stone clearance was achieved in the remaining seven patients. These seven patients had different degrees of biliary strictures. Conclusion: The subcutaneous access loop offers the advantage of permanent access for the successful management of retained or reformed intrahepatic stones with minimal morbidity since it permitted easy access to intrahepatic ducts
Keywords: Intrahepatic stones Hepaticojejunostomy Subcutaneous jejunal access loop
* Corresponding author. E-mail address: [email protected] (M.A. Sorour). http://dx.doi.org/10.1016/j.ijsu.2014.07.264 1743-9191/© 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
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using the conventional forward-viewing endoscope or the choledochoscope, without the additional morbidity of a biliary-cutaneous fistula or transhepatic access. © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
1. Introduction Intrahepatic stones are defined as calculi located proximal to the confluence of the right and left hepatic ducts, irrespective of the coexistence of gallstones in the common bile duct and/or gallbladder [1e3]. This disease is prevalent in East and Southeast Asian countries and infrequent in Western population. [1,4e8]. In most cases, intrahepatic stones consist of calcium bilirubinate (brown pigment stones), but contain more cholesterol than those in either the common bile duct or the gallbladder. Almost pure cholesterol stones are sporadically reported [9,10]. The aetiology of intrahepatic stones is not exactly known, although recurrent bacterial infection (mixed infections:- Escherichia coli, Klebsiella, Streptococcus fecalis, Clostridia, and Bacteroides), parasitic infestation (Clonorchis sinensis or Ascaris lumbricoides), ethnic background, and stasis due to congenital abnormalities of the biliary tract have been implicated in the pathogenesis [2,11,12]. Rarely, intrahepatic stones can form as a result of iatrogenic bile duct stricture, and choledochal cysts [11]. Primary intrahepatic stones are associated with strictures in up to 85 per cent of cases and the natural history is characterized by progression with recurrent attacks of biliary sepsis [13]. Patients with intrahepatic stones usually present with recurrent cholangitis, intrahepatic abscesses, and may develop liver atrophy and secondary biliary cirrhosis [4,5]. The triad of symptoms e fever, jaundice, and right upper quadrant pain e is present in 60% of cases [11]. The symptoms can be mild with minimal abdominal tenderness and jaundice or severe with shock and mental confusion. The disease may progress to epithelial dysplasia and cholangiocarcinoma in 3%e8% of cases. [5,14]. Treatment of intrahepatic stones is complex and the disease progresses in most patients even after adequate treatment [5,14]. Patients having stones and strictures confined to a liver segment/ section/hemiliver with subsequent atrophy are best treated by hepatic resection [15,16]. Surgical removal of stones has been the standard management but residual stones and stone recurrence occur frequently whatever the technique [11,17e20]. Because of the need for repeated biliary instrumentation, long-term access routes involving percutaneous transhepatic access tubes [21], or hepaticocutaneousjejunostomy (HCJ) to permit stone retrieval or stricture dilatation have been developed [22e24]. These provide good access to the biliary system but patients are left with the unpleasant side effects of a biliary stoma [19,23]. Our experience with a subparietal hepaticojejunal access loop, without a stoma, in the management of intrahepatic stones is reported. [18]. 2. Aim of the work The aim of this work was to evaluate the outcome of subcutaneous hepaticojejunal access loop in the management of intrahepatic stones. 3. Patients Between January 2009 and January 2013, 42 patients with radiologically confirmed intrahepatic stones were admitted and treated at the Gastrointestinal Surgery Unit, Main Alexandria
University Hospital. Demographic data, details of operative findings, follow-up details, and treatment of recurrent stones were analyzed. Patients with predominant intrahepatic calculi were included; those with associated extensive extrahepatic bile duct calculi or secondary biliary cirrhosis were excluded.
4. Methods A post-intervention prospective cohort study was designed to include all patients with intrahepatic stones who underwent surgery for stone retrieval with construction of a subcutaneous hepaticojejunal access loop. After approval of the local ethics committees of both the General Surgery Department and the Alexandria Faculty of Medicine, all patients included in the study were well informed about the operative procedure and the possible complications and an informed written consent was obtained from each patient before surgery. All patients were subjected to complete history taking, thorough clinical examination, routine laboratory studies, liver enzymes, serum bilirubin level, and CA19.9 measurements. Abdominal ultrasonography, multi-slice CT (MSCT) abdomen, and MRI with magnetic resonance cholangiopancreatography (MRCP) were routinely performed. All patients received prophylactic antibiotic (3rd generation cephalosporin 1 g, intravenously) at the time of induction of anaesthesia and then every 4 h during the operation and twice daily thereafter for 5 days. A right subcostal incision with extension to the left, as appropriate, was used to provide exposure of the porta hepatis. The first step was cholecystectomy, unless the gallbladder had already been removed, followed by bile duct exploration. Choledochotomy was sited close to the biliary confluence to allow easy extension to one or both hepatic ducts, depending on the predominant location of stones for better clearance and wider anastomosis. Intrahepatic stones were removed using Desjardine's forceps, saline flushing, and balloon extraction. Intraoperative flexible choledochoscopy (Karl Storz, Germany) with operating channels and end vision was used to identify and remove intrahepatic calculi using a choledochoscope-guided biliary balloon catheter and metallic wire basket retriever. A mechanical basket lithotripter passed via the working channel of a choledochoscope was used for fragmentation of big stones located beyond strictures. Occasionally stricture dilatation using an angioplasty balloon under fluoroscopic control was used to remove all stones. Stone clearance was confirmed using intraoperative cholangiogram. When liver atrophy was present hepatic resection was performed. A biliary-enteric anastomosis was performed using a side-to-side anastomosis between the hepatic duct confluence and a jejunal Roux-en-Y loop. If the left or right duct was narrowed, the hepatic duct incision was extended beyond the stricture to provide a wide anastomosis. A site 12-cm proximal to the closed end of the jejunal loop was selected for anastomosis using a single layer of interrupted 3/0 polyglactin (Vicryl; Ethicon, Johnson and Johnson) suture to the hepatic duct confluence. Two ligaclips were used to mark the anastomosis for later radiological identification. The length between the hepaticojejunostomy and the jejunojejunostomy was 50 cm. The closed proximal limb was
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passed through the anterior abdominal wall and was then fixed to the wall in a subcutaneous position using 3/0 polyglactin sutures (Fig. 1). The limb between the hepaticojejunal anastomosis and the subcutaneous fixation should be short and straight. Ligaclips were used to mark the jejunal loop by clipping the sutures holding the access loop in place. An umbilical feeding tube was passed through the skin and into the access loop to permit postoperative cholangiography. If obstructive jaundice, biliary pain or cholangitis subsequently developed, recurrent or residual stones were suspected. Abdominal ultrasonography followed by MRCP were then carried out. Once residual or recurrent intrahepatic stones were identified, cholangiography was carried out without sedation or local anaesthesia. Contrast was first injected percutaneously into the subcutaneous loop of jejunum (identified by the scar). After confirming that the contrast was intraluminal by fluoroscopy, the patient was placed in a Trendelenberg position and more contrast was injected, which
flowed into the liver outlining the anastomosis and the intrahepatic ducts. Antibiotic prophylaxis was given and biliary access was then gained under direct vision. The skin over the access loop was incised to visualize the jejunal loop which was entered under vision using a conventional esophagogastroscope (end view) or a choledochoscope. The endoscope was passed through the subcutaneous access limb and negotiated towards the liver until the hepaticojejunostomy was identified. After the anastomosis was entered, the hepatic duct was reached under fluoroscopic guidance. A cholangiogram was then performed by the use of a three-way balloon catheter. Then a combination of Dormia basket and extraction balloons was used to extract calculi. In case of a duct stricture, a guidewire was inserted via the working channel of the scope and then through the strictured segment of the biliary tree. A balloon catheter was inserted over the guidewire and inflated to a maximum size (i.e. 5 mm) for 10 min to dilate the stricture. On completion, the ducts were flushed with saline. The skin and
Fig. 1. Side-to-side hepaticojejunostomy (HJ) between the hepatic duct confluence and a jejunal Roux-en-Y loop with construction of a subcutaneous access loop. Conventional endoscope (end viewer) passed through the subcutaneous jejunal access loop for stone retrieval.
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jejunal loop were closed after the procedure. Patients were admitted overnight for observation and two further doses of antibiotics were administered following the procedure. Patients were reviewed 6 weeks after surgery, at 3-month intervals thereafter for the first year, and at 6-month intervals thereafter, unless they became symptomatic again. Complete liver function tests and abdominal ultrasonography were done during the follow-up visits to detect residual stones. If there was a suspicion of stone recurrence or evidence of cholangitis, the patient was re-admitted for further evaluation and treatment. All patients were followed up for a median of 30 (range 12e60) months. A minimum of 12 months follow-up without evidence of residual or recurrent stones was considered satisfactory. Recurrent cholangitis was defined as occurrence of two separate episodes of clinical and biochemical features of cholangitis during the postoperative period. Patients with recurrent cholangitis were managed with antibiotics, ursodeoxycholic acid and endoscopic stone extraction through the access loop. Data were presented with numbers, percentage, arithmetic mean (X) and standard deviation (SD) and were analyzed using the SPSS (version 16) statistical software. P values less than 0.05 were considered to be statistically significant. 5. Results Forty-two patients with intrahepatic stones underwent surgery with construction of a subcutaneous hepaticojejunal access loop. Ten patients had previously undergone a total of 12 biliary tract operations prior to the definitive procedure. These included open cholecystectomy in seven patients; laparoscopic cholecystectomy in three; common bile duct exploration and T-tube drainage in one; and common bile duct exploration and choledochoduodenostomy in the remaining patient. The patients' demographic data and preoperative parameters are shown in Table 1. Stones were mostly found in the left hemiliver. In patients with right hemiliver involvement, stones were seen predominantly in liver segments VI and VII. Associated extrahepatic stones were found in 33 patients. Twenty-two patients had associated intrahepatic duct strictures. Atrophy of segments II and III was identified before operation by computed tomography in five patients, all of Table 1 Patients' demographic data and preoperative parameters. Characteristics
Patients (n ¼ 42)
Age Male:female Serum bilirubin (mg/dL) Serum ALT Serum AST Serum alkaline phosphatase Presenting features Abdominal pain Recurrent fever Obstructive jaundice Cholangitis Hepatomegaly Morphological features Bilobar disease Unilobar disease Left lobe Right lobe Extrahepatic and intrahepatic calculi Intrahepatic calculi alone Associated atrophy of liver Associated intrahepatic stricture Mild stricture Severe stricture
41 ± 8.4 (32e64) 17:25 5.5 ± 3.7 (1.1e17.3) 79 ± 47 (32e237) 87 ± 62 (23e326) 276 ± 172 (137e1047) 39 (93%) 34 (81%) 29 (69%) 25 (60%) 5 (12%) 14 (33%) 28 (67%) 25 (60%) 3 (7%) 33 (79%) 9 (21%) 5 (12%) 22 (52%) 18 (43%) 4 (10%)
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whom underwent hepatic resection (left lateral sectionectomy in 4 and left hepatectomy in 1) at the time of the access loop construction. A mild stricture happened when choledochoscopic access to the stones was impossible without dilatation. A severe stricture happened when a guide-wire could not pass through the stricture. A positive bile culture was obtained in 39 (93%) patients. The cultured organisms were E. coli in 15 patients (38%), Klebsiella in 11 (28%), and multiple organisms in 13 (33%) patients. The mean operation time, including that for choledochoscopy, and cholangiography was 4.9 h and the mean blood loss was 440 mL. The mean postoperative hospital stay was 10 days. Minor complications were encountered in 8 (19%) patients. Four patients presented with more than one complication. Wound infection was the commonest complication, occurring in 5 (12%) patients. Pulmonary complications occurred in 3 (7%) patients, and intraabdominal collections in 2 (4.8%) patients. Two (4.8%) patients had biliary leak after left lateral sectionectomy. All responded to conservative treatment with full recovery. There were no specific complications attributable to the construction of the access loop. None of the patients developed postoperative cholangitis prior to stone recurrence and none presented with strictures at the site of the bilioenteric anastomosis. Recurrent cholangitis occurred in 22 (52%) patients. Recurrence of cholangitis occurred at a mean period of 10 months after the initial surgical procedure, was always associated with recurrent stones, and required 2 hospital admissions per patient. The presence of intrahepatic strictures was associated with recurrent cholangitis. Fourteen patients (33%) had no residual or recurrent stones after the initial surgical procedure and did not require the access loop, the ‘no need group’. Retained or re-formed stones were found in 28 (67%) patients. The subcutaneous access loop was used to gain access to the biliary tree in all these patients. A total of 55 procedures (range 1e5) were attempted with successful access achieved in all cases and successful stone clearance in 21 of the 28 patients, and all of them were symptom free for at least 12 months after the last procedure, the ‘successful use group’. There was no significant complication of these procedures. Partial stone clearance was achieved in the remaining seven patients, the ‘failed use group’. These seven patients had different degrees of biliary strictures. The flowchart in Fig. 2 summarizes the outcomes of stone retrieval through the subcutaneous access loop. Severe bile-duct stricture was the major cause for the failure to remove stones. Table 2 shows the parameters associated with the final outcomes of the procedure. Of the 42 patients treated, 20 patients had no bile duct stricture, 18 had a mild stricture, and 4 had a severe stricture (Table 3). In the no stricture group, the stone of one patient was large and impacted and could not be removed completely. Of the 18 patients in the mild-stricture group, after endoscopic dilatation, stones could be removed from 16 patients (89%) and were partially removed in the remaining two patients. In the severe-stricture patients, the guidewire could not be passed through some strictures and the stones in all the 4 patients (100%) were not removed completely. These 4 patients underwent hepatic resection at the time of the access loop construction. 6. Discussion Intrahepatic stones are frequently associated with intrahepatic strictures which may cause bile stasis, cholangitis and recurrent stone formation [25]. The principal approaches to intrahepatic stones are surgical exploration of bile duct and intrahepatic ducts for stone removal with biliary drainage or hepatico-jejunostomy
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Patients with intrahepatic stones (n = 42) Hepaticojejunostomy with subcutaneous access loop
Residual or recurrent stones
'No need' group
(n = 28) (67%)
Patients who did not need the access loop No residual or recurrent stones symptom free for a minimum of 12 months (n = 14) (33%)
Stone retrieval via the subcutaneous access loop (1 – 5 procedures)
'Successful use' group
'Failed use' group
Patients who did benefit from the access loop Successful clearance (n = 21) (50%)
Patients who failed to benefit from the access loop Partial clearance (n = 7) (17%)
Symptom free for at least one year after the last procedure
No stricture big stone
Mild stricture (n = 2)
Severe stricture (n = 4)
(n = 1) Hepatic resection Fig. 2. Flowchart summarizes the outcome of subcutaneous hepaticojejunal access loop in the management of intrahepatic stones.
(with or without access loop construction), hepatic resection [26], and percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) [27,28]. The success rates with these procedures range from 72% to 92%. [29e31]. The incidence of retained stones after operation is about 55 per cent and a number of strategies have been developed to enable removal of both retained and recurrent intrahepatic stones [5,15,25,32,33]. After removal of as many of the intrahepatic stones as possible, reconstruction of the biliary tree by choledochoduodenostomy has not proved to be a reliable method for management of subsequent intrahepatic stones [34,35]. Although direct endoscopic access is still possible, the presence of strictures, peripheral stone impaction and ductal angulation make endoscopic extraction difficult [36,37]. Cunha et al. [38] reported a biliary access technique for the long-term endoscopic management of intrahepatic stones that involved a side-to-side duodenojejunostomy between the isolated Roux-en-Y jejunal limb 20 cm distal to the biliary anastomosis and the lateral duodenal wall 15 cm from the pylorus. To access the anastomosis, the endoscope must be negotiated through this duodenojejunostomy and then travels upward for about 20 cm. The Roux-en-Y hepaticocutaneousjejunostomy (HCJ) has been used to permit endoscopic access for removal of intrahepatic stones
[4,5,17,39,40]. This technique provides good access to the biliary tree [41]. However, the necessity of a stoma is unsatisfactory because of the unpleasant side-effects of mucus and bile leakage with associated cutaneous irritation and excoriation [17,21]. Routine early closure of the stoma has been recommended to avoid these side-effects after removal of retained stones following surgery [42]. Stoma closure is associated with significant complications of wound infection, fistula formation and parastomal hernia [43]. Furthermore, many patients required reopening of the stoma for removal of recurrent stones after only 2 years of followup. [43]. An alternative access to the biliary tree for intervention is the percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) approach. It is being increasingly used with the advent of the fourangled choledochoscope [14]. The transhepatic route requires the development of a working tract which necessitates sequential dilatation over a period of up to 3 weeks, following which choledochoscopy can be performed for stone removal or stricture dilatation [44]. The procedure is not without complications, with severe pain and bleeding resulting in treatment failure in many cases [45]. Stone clearance rates of 80 per cent have been achieved with repeated procedures [46,47]. The transhepatic catheter has
M.I. Kassem et al. / International Journal of Surgery 12 (2014) 886e892 Table 2 Parameters associated with final outcomes of the procedure. Parameter
‘No need’ group (n ¼ 14)
‘Successful use ’ group (n ¼ 21)
‘Failed use ’ group (n ¼ 7)
Common bile duct calculi Bilobar disease Unilobar disease Associated intrahepatic stricture Postoperative cholangitis Atrophy of liver Hepatic resection
12
16
5
5 9 e
6 15 16
3 4 6
e e e
15 1 e
7 4 4
been a major source of complaint and access is only temporary as the fistula closes after removal of the catheter. [7,17]. In the present study, hepatic resection with subcutaneous hepaticojejunal access loop was performed only for patients with hemihepatic disease associated with atrophy. Twenty-eight (67%) patients had hemihepatic disease and 5 of these patients underwent hepatic resection. The present study has no experience with hepatic resection for bilateral liver disease. Our policy for such patients was to perform surgical exploration and dilatation of strictures followed by stone clearance and construction of a subcutaneous hepaticojejunal access loop for biliary interventions in the future should patients develop recurrent stones or cholangitis. The subparietal access loop can be used for stone retrieval under local anaesthesia [48]. The afferent loop can be identified fluoroscopically by determining the position of the ‘ligaclip runway lights’. The loop can be entered percutaneously between the ‘runway’ clips using a 21-gauge fine-bore needle with intermittent contrast injections and a guidewire. A converting dilator allowed percutaneous introduction of larger guidewire catheters directed by fluoroscopy into the jejunal lumen where a combination of Dormia baskets, angioplasty balloons and snare wires can be used to fragment and extract calculi. Krige and Beningfield [49] described a new double-entry access loop (DEAL) technique as a modification of the subparietal single-entry access loop to enhance percutaneous radiological entry and facilitate intrahepatic biliary intervention. The subcutaneous access loop used in this study is a good alternative to the subparietal access loop that allowed reliable access to the biliary tree in all cases. The median number of procedures performed per patient was 2 with one patient requiring 5 procedures over a 4-year period, thus emphasizing the need for a permanent access route. There was no complication attributable to the formation of the access loop and bacterial overgrowth of the Roux-en-Y loop has not been observed. Although cholangiocarcinoma is reported in 6 per cent of patients with oriental intrahepatic stone disease (IHSD) [37,50,51], none occurred in the present series. In the present study, there was significant association between intrahepatic strictures and recurrent stones. Jan and Chen [46] reported residual or recurrent stones in 21% of patients with
Table 3 Bile-duct strictures and choledochoscopic removal of stones. Bile duct stricture
No. of patients
Choledochoscopic removal Complete
Incomplete
No stricture Mild stricture Severe stricture Total
20 18 4 42
19 (95%) 16 (89%) 0 35 (83%)
1 2 4 7
(5%) (11%) (100%) (17%)
891
strictures as compared to no stones in those without stricture. Various techniques have been used for postoperative access of biliary system in the treatment of recurrent stone with cholangitis [43,48,52e54]. Postoperative choledochoscopic removal of stones through a T-tube tract was once popular; however Cheung et al. [52] reported poor overall success rate (50%) and technical difficulties like inaccessibility of the ducts, failed manipulation due to strictures, losing the tract during dilatation, and difficulties in extracting large stones. The closed subcutaneous access loop offers the advantage of a permanent and re-usable access for stone removal with minimal morbidity since it permitted easy access to intrahepatic ducts using a conventional forward-viewing endoscope or a choledochoscope, without the need for transhepatic tubes or cutaneous stomas. Factors associated with ‘failed use’ “i.e. severe stricture” should be added to the exclusion criteria in patient selection. However, expert opinion is of paramount importance in selecting patients for this procedure. Moreover, those who did not need the access loop ‘i.e. no need group’ and were symptom free for at least 12 months after stone retrieval and construction of the access loop may benefit from the loop later in their life should they develop recurrent stones. Ethical approval Ethical approval was given by Ethical Committee of Alexandria Faculty of Medicine. Funding No sources of funding as all cases were done in the Main University Hospital with no added costs. Author contribution All authors share the study design, collection and analysis of data, performing operations and writing the paper. Conflicts of interest There are no specific conflicts of interest. References [1] T.K. Choi, Intrahepatic stones, Br. J. Surg. 76 (1989) 213e214. [2] M.H. Kim, J. Sekijama, S.P. Lee, Primary intrahepatic stones, Am. J. Gastroenterol. 90 (1995) 540e548. [3] F. Nakayama, Intrahepatic calculi: a special problem in East Asia, World J. Surg. 6 (1982) 802e804. [4] S.T. Fan, T.K. Choi, C.M. Lo, F.P. Mok, E.C.S. Lai, J. Wong, Treatment of hepatolithiasis: improvement of result by a systematic approach, Surgery 109 (1991) 474e480. [5] K. Chijiiwa, H. Yamashita, J. Yoshida, S. Kuroki, M. Tanaka, Current management and long-term prognosis of hepatolithiasis, Arch. Surg. 130 (1995) 194e197. [6] K.S. Jeng, I. Ohta, F.S. Yang, Reappraisal of the systematic management of complicated hepatolithiasis with bilateral intrahepatic strictures, Arch. Surg. 131 (1996) 141e147. [7] H.A. Pitt, A.C. Venbrux, J. Coleman, C.A. Prescott, M.S. Johnson, F.A. Osterman, et al., Intrahepatic stones: the transhepatic team approach, Ann. Surg. 219 (1994) 527e537. [8] I. di Carlo, A. Sauvanet, J. Belghiti, Intrahepatic lithiasis: a Western experience, Surg. Today 30 (2000) 319e322. [9] S.D. Strichartz, M.Z. Abedin, A.F. Ippoliti, et al., Intrahepatic cholesterol stones: a rationale for dissolution therapy, Gastroenterology 100 (1991) 228e232. [10] T. Ohta, T. Nagakawa, T. Takeda, et al., Histological evaluation of the intrahepatic biliary tree in intrahepatic cholesterol stones, including immunohistochemical staining against apolipoprotein AeI, Hepatology 17 (1993) 531e537. [11] T. Choi, J. Wong, Current management of intrahepatic stones, World J. Surg. 14 (1990) 487e491.
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