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Surgical treatment of hepatolithiasis: Long-term results
Surgical treatment of hepatolithiasis: Long-term results Yi-Yin Jan, MD, Miin-Fu Chen, MD, FACS, Chia-Siu Wang, MD, Long-Bin Jeng, MD, Tsann-Long Hwang, MD, and Shin-Cheh Chen, MD, Taipei, Taiwan
Background. Hepatolithiasis is a common disease in East Asia and is prevalent in Taiwan. Surgical and nonsurgical procedures for management of hepatolithiasis have been discussed, but long-term follow-up results of surgical treatment of hepatolithiasis are rarely reported. Methods. We conducted a retrospective study of case records of patients with hepatolithiasis who underwent surgical or nonsurgical percutaneous transhepatic cholangioscopy treatment. Of 614 patients with hepatolithiasis seen betweenJanuary 1984 and December 1988, 427 underwent follow-up after surgical (380) or percutaneous transhepatic cholangioscopy (47) treatment for 4 to i0 years and constituted the basis of this study. Results. Long-term results of 427 patients with hepatolithiasis after surgical and nonsurgical treatment within 4 to 10 years of follow-up were recurrent stone rate 29.6% (105 of 355), repeated operation 18.7% (80 of 427), secondary biliary cirrhosis 6.8% (29 of 427), late development of cholangiocarcinoma 2.8 % (12 of 42 7), and mortality rate 10.3 % (44 of 42 7). The patients with hepatectomy had a better quality of life (symptom-free) with a lower recurrent stone rate (9.5 %), lower mortality rate (2.1%), and lower incidence of secondary biliary cirrhosis (2.1%) and cholangiocarcinoma (0 %) than did the nonhepatectomy group (p < O.01). The patients without residual stones after choledochoscopy had a better quality of life than did the residual stone group (p < O.01). Conclusions. Long-term follow-up study of hepatolithiasis after surgical treatment revealed a high recurrent stone rate (29.6%) that required repeated surgery and a high mortality rate (10.3%) resulting from repeated cholangitis, secondary biliary cirrhosis, and late development of cholangiocarcinoma. Patients who received h~atectomy or without residual stones after choledochoscopy had a good prognosis and quality of life. (Surgery 1996;120:509-14.) From the Department of Surgery, Chang C.ung Memorial Hospital, Linkou Medical Center, Chang Gung Medical College, Taipei, Taiwan
in Southeast Asia and are especially prevalent in Taiwan. TM S u e t al. 5 reported that the relative incidence of hepatolithiasis was 20% of all gallstone diseases. The primary procedures for surgical removal of intrahepatic calculi include lithotomy by extended choledochotomy, transhepatic cholangiolithotomy, and hepatic resection. Additional procedures r e c o m m e n d e d for biliary obstruction are transduodenal sphincteroplasty, choledochoduodenostomy, and hepaticojejunostomy Roux-en-Y. a' 2, 5 Retained and recurrent intrahepatic stones are the two main problems in the surgical treatment of hepatolithiasis. The incidence of retained stones after operation has been markedly reduced to 10% to 30.2% with intraoperative INTRAHEPATIC STONES ARE COMMON
Accepted for publication Feb. 8, 1996. Reprint requests:~fi-~SnJan,MD, Department of Surgery,Chang Gung Memorial Hospital, 199, Tun Hwa North Rd., Taipei. Taiwan. Copyright 9 1996 by Mosby-YearBook, Inc. 0039-6060/96/$5.00 + 0 11/56/72580
and postoperative choledochofiberscopy. 69 Percutaneous transhepatic cholangioscopy (PTCS) was introduced for the diagnosis and treatment of biliary tract diseases in 1981.1~ 11 Long-term follow-up of surgical results of hepatolithiasis has rarely been reported. 12-14 This article presents our experience and evaluation of the long-term results of surgical treatment for hepatolithiasis.
PATIENTS AND METHODS During the period from January 1984 through December 1988, 614 (250 men and 364 women) consecutive patients (24.1%) with hepatolithiasis were noted in 2510 patients with biliary lithiasis in the surgical department of the Chang Gung Memorial Hospital, Taipei, Taiwan. Their ages ranged from 17 to 85 years with a mean age of 45 years. Two hundred twenty-six (37%) patients had undergone one or more biliary operations in the past. Operative treatment of intrahepatic stones was essential except in selective patients who could
SURGERY 509
510 J a n et al.
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Table I. Location of stones and bile duct strictures in 614 patients with hepatolithiasis n
Location of stones Bilateral IHD 237 Left IHD 270 Right IHD 107 Common bile duct 411 Location of bile duct strictures Left IHD 241 Right IHD 101 Bilateral IHD 81 Hilum 35 Distal CBD 61
Table II. Surgical procedures for patients with hepatolithiasis Procedures
n
Percent
Common bile duct exploration Cholecystectomy Hepaticotomy Left lateral segmentectomy Left lobectomy Right partial hepatectomy Hepaticojejunstomy Roux-en-Y Choledochoduodenostomy Ductoplasty Liver abscess drainage PTCS
566 290 21 128 15 11 11 10 5 21 48
92.2 47.2 3.4 20.9 2.4 1.8 1.8 1.6 0.8 3.4 7.8
Percent
38.6 44.0 17.4 66.9 39.3 16.5 13.2 5.7 9.9
1HD, Intrahepatic duct; CBD, common bile duct.
be treated by PTCS. The choice of operation was based on the location of stones and biliary strictures (Table I). The procedures performed for patients with hepatolithiasis are indicated in Table II. Intraoperative choledochoscopy was routinely used instead of intraoperafive cholangiography for visualizing the residual stones, ductal strictures, and tumors. Postoperative cholangiography and postoperative choledochoscopy (POC) were performed routinely to detect residual stones. An improved fiberoptic choledochoscope (CHF 4B or P10; Olympus, Tokyo, Japan) was inserted through the T tube or percutaneous transhepatic biliary drainage fistula orifice, where grasping forceps could be inserted through the choledochoscope to remove any stones. Giant or impacted stones were fragmented by introducing an electrohydraulic shock wave litho-triptor probe or a laser catheter through the same channel. 15' 16 The intrahepatic and biliary-enteric anastomotic strictures were dilated with a balloon catheter (Cook Co., Bloomington, Ind.) 4 to 10 m m in diameter. 17 Complete stone clearance was documented by cholangiographic, choledochoscopic, and sonographic examinations. When recurrence of symptoms was noted at follow-up, sonographic and cholangiographic investigations were undertaken to detect any recurrent stones or strictures. Twenty-seven operative deaths and 30 patients with cholangiocarcinoma were excluded from the study. Postoperative follow-up in 557 patients included chart review and telephone and letter communication during a 4- to 10-year period. One h u n d r e d thirty patients were lost to follow-up. Four h u n d r e d twenty-seven patients who were monitored after surgical (380) or PTCS (47) treatment constituted the basis of this study. Assessment of long-term results included recurrent symptoms (abdominal pain, fever, chills, jaundice), recurrent stones, repeated operation, secondary biliary cirrhosis (liver failure, varies bleeding), cholangiocarcinoma, and mortality.
RESULTS Immediate results. Immediate surgical and PTCS results of hepatolithiasis are summarized in the Figure. Five h u n d r e d sixty-six patients underwent operation. Operative death occured in 26 patients, resulting in a 4.6% mortality rate. Causes of death were acute suppurative cholangitis with septic shock in 14 patients, liver cirrhosis with liver failure or with bleeding varices in five patients, cholangiocarcinoma with acute cholangitis in three patients, liver cirrhosis with liver abscess in one patient, pneumonia with respiratory failure in one patient, myocardial infarction in one patient, and intraabdominal abscess with septic shock in one patient. Seventy-seven patients had residual intrahepatic stones after POC. Intrahepatic strictures (48 patients), dislodged drain tube or tortuous fistula tract (7 patients), and duodenal fistula (7 patients) were the main causes of failed treatment by postoperative choledochoscopic removal of stones. Forty-eight patients with hepatolithiasis selected treatment by PTCS. Complete clearance of intrahepatic stones was achieved in 40 patients, with an overall success rate of 83.3%. Failed treatment with PTCS in eight patients with intrahepatic strictures included bilateral intrahepatic stones with multiple right intrahepatic strictures in three patients, intrahepatic stones after hepaticojejunostomy in two, right superior posterior hepatic stone with stricture in one, right intrahepatic stone with liver abscess formation in one, and left recurrent intrahepatic stones with bile duct strictures associated with biliary cirrhosis complicated with hemobilia and septic shock after percutaneous transhepatic biliary drainage resulting in death in the final patient, resulting in a 2.1% mortality rate. Long-term results. Four hundred twenty-seven patients with hepatolithiasis (355 with complete stone clearance and 72 with retained stones) with effective
Surgery Volume 120, Number 3
Jan et al.
r -
complete stone clearance 437
postoperative choledochofiberscopy 510 - - ~ 1 _ residual stones
-Surgery (566) - - combined cholangiocarcinoma Hepatolithiasis-
511
. operative mortality
77
30 26
(614 patients) ~ 9PTCS (48)
complete stone clearance
40
-~-residual stones
7
/ t-mortality
1
Figure. Immediate surgical and PTCS results of hepatolithiasis T a b l e I I I . Long-term results of 315 POC and 40 PTCS complete stone clearance for hepatolithiasis during 4- to 10-year follow-up period
Postoperative choledochoscopy (315) Long-term result
Hepatectomy Nonhepatectomy PTCS (95) (%) (220)(%) (40) (%)
Free of symptoms 76 (80) Recurrent stones 9 (9.5) Symptoms without 10 (10.5) stones Repeated operation 2 (2.1) Biliary cirrhosis 2 (2.1) Cholangiocarcinoma 0 (0) Died 2 (2.1)
120 (54.5) 80 (36.4) 20 (9.1) 34 9 5 22
(15.5) (4.1) (2.3) (10)
22 (55) 16 (40) 2 (5) 9 (22.5) 1 (2.5) I (2.5) 3 (7.5)
follow-up of 4 to 10 years were studied. The long-term outcomes of the 355 patients with complete stone clearance via POC and PTCS during a 4- to 10-year follow-up period are summarized in Table III. The long-term results of 72 patients with hepatolithiasis who did not have all stones removed via POC and PTCS are summarized in Table W. In all, 80 patients with retained or recurrent intrahepatic stones received subsequent surgical treatment. The surgical procedures performed during the 4- to 10year follow-up period are extended choledochotomy in 48 patients, left hepatectomy in 13 patients, repeated PTCS in 7 patients, laparotomy for t u m o r biopsy or drainage of abscess cavity in 7 patients, and percutaneous drainage for liver abscess in 5 patients. In all, 44 patients with hepatolithiasis died during the
T a b l e IV. Long-term results of 355 nonretained versus 72 retained hepatolithiasis cases after choledochoscopic lithotomy with 4 to 10-year follow-up period
Long-term result Symptom free Repeated operation Biliary cirrhosis Liver failure Esophageal varices Cholangiocarcinoma Died
No. nonretained No. retained (355) (%) (72) (%) p Value 218 45 12 4 7 6 27
(61.4) (12.7) (3.4) (1.1) (2.0) (1.7) (7.6)
3 (4.2) 35 (48.6) 17 (23.6) 3 (4.2) 8 (11.1) 6 (8.3) 17 (23.6)
<0.001 <0.001 <0.001 0.09 0.001 0.007 <0.001
Chi-squared test,
4- to 10-year follow-up period. Patients with residual stones after choledochoscopic lithotomy had a higher mortality rate than did the nonresidual stone group (23.6% versus 7.6%, p < 0 . 0 1 ) . The causes of death were retained or recurrent stones with sepsis in 12 (27.3%) patients, cholangiocarcinoma in 9 (20.4%) patients, biliary cirrhosis with liver failure or bleeding varies in 10 (22.7%) patients, proven malignancy other than cholangiocarcinoma in 6 (13.6%) patients, medical disease in 4 (9.1%) patients, and suspected liver malignancy not proven by biopsy in another 6 (13.6%). Six patients died of other malignancies including hepatocellular carcinoma in one patient, gastric adenocarcin o m a in one patient, pancreatic adenocarcinoma in one patient, ovarian cancer in one patient, renal carcin o m a in one patient, and carcinomatosis of unknown origin in one patient.
512 Jan et al.
Surgery september 1996
DISCUSSION
Biliary strictures are defined by Matsumoto et al. 23 as a localized diminution in bile duct caliber proximal to the c o m m o n hepatic duct. Three quarters of patients with hepatolithiasis in Asia have associated biliary strictures. 4 In this series the incidence of associated biliary strictures was as high as 84.5%. Intrahepatic stones associated with biliary strictures are a great challenge to surgeons, with strictures being the main cause of treatment failure in conventional surgery, choledochoscopic lithotomy through the T tube, and PTBD track for hepatolithiasis) 4' 6-11,23, 24 Hepatic resection is the treatment of choice for hepatolithiasis with intrahepatic strictures limited to the left lobe or lateral segments. 12'13'25'26 To eliminate the intrahepafic strictures and to pass the sharp angulafion of the intrahepatic duct, through T-tube tract or percutaneous transhepatic dilatation of the biliary strictures with a Grfintzig or a big PTCS catheter and repeated dilatation are required. 17'27' 28 Intrahepatic strictures are the main cause of retained or recurrent stones in hepatolithiasis surgery. 23' 24,27,28 Percutaneous transhepatic balloon dilatation has been used for benign biliary strictures, achieving a patency rate of 42% to 76% after a mean follow-up of 36 months. 29' 3o In a previous study by the authors the restenosis rate for successfully dilated intrahepatic and anastomotic strictures was f o u n d to be 45% during a follow-up period of 5 to 7~ years. 17 Secondary biliary cirrhosis that develops after a long period of biliary strictures, calculous obstruction, and repeated cholangitis may be due to hepatic insufficiency and portal hypertension. Resultant complications include bleeding, esophageal varices, hypersplenism with pancytopenia, ascites, and encephalopathy. 31-34 Scheuer 33 reported that secondary biliary cirrhosis develops 7 years after the onset of obstruction from a stricture, 4~ years after a calculous obstruction, and 10 months after the onset of malignant strictures. Jeng et al.34 reported 10.1% of hepatolithiasis cases are associated with secondary biliary cirrhosis. Twenty-nine (6.8%) patients had secondary biliary cirrhosis after hepatolithiasis surgery; this cirrhosis was detected by ultrasonographic examination with a 4- to 10-year period follow-up in our series. Ten of the 29 patients died of secondary biliary cirrhosis with bleeding varices or liver failure within the 4- to 10-year follow-up period. After secondary biliary cirrhosis the patient is not a good candidate for repeated surgery; however, PTCS and other percutaneous procedures also carry significant risks of bleeding and sepsis. The association between cholangiocarcinoma and hepatolithiasis is well recognized, and the incidence of cholangiocarcinoma in patients with hepatolithiasis ranges from 2.36% to 10%. 35-37Prolonged initiation of
Biliary tract obstruction with acute cholangitis is a severe complication of hepatolithiasis that may result from fetal conditions with suppurative, portal thrombophlebifis or microabscesses of the portal tracts without adequate drainage. 18-2~In the emergency operation for acute cholangitis with intrahepatic stones, the intrahepatic stricture should be dilated until the purulent bile is obtained, and then the T tube should be passed through the stricture site. Intraoperative choledochoscopy is helpful in detecting the intrahepafic strictures. Surgical mortality in acute cholangitis caused by hepatolithiasis is high, up to 12%. 19 In this series operative mortality in hepatolithiasis was 4.6%, and acute cholangifts with septic shock was the main cause of death. Nonoperative procedures such as endoscopic nasobiliary and percutaneous transhepatic biliary drainage are attractive approaches in the emergency treatment of acute cholangitis from hepatolithiasis. 2~ 21 PTCS for removal of the intrahepatic stones through the dilated percutaneous tract is feasible, z' 11,12,16, 22 In this series 61 patients with acute cholangitis from hepatolithiasis were well controlled through percutaneous transhepatic biliary drainage, and 28 of 61 patients had successful removal of intrahepatic stones by means of PTCS. Residual and recurrent stones are the most troublesome problem after surgery for hepatolithiasis. 1-4 The incidence of residual stones has been markedly reduced from 21.1% N 62.3% without choledochofiberscopy to 10% N 30.2% with intraoperative and postoperative choledochofiberscopy.14, 6-9 In this series the residual stone rates after POC and PTCS for hepatolithiasis are 15.1% and 16.6%, respectively. Recurrent stone rates after complete stone clearance of POC and PTCS for hepatolithiasis during a 4- to 10-year follow-up period are 28.2% and 40%, respectively. The recurrent stone rates after complete stone clearance of POC for hepatolithiasis in the hepatectomy versus nonhepatectomy group were 9.5% and 36.4%, respectively. Lee et al.12 reported a 4.2% recurrent stone rate after hepatic resection for hepatolithiasis with a mean follow-up period of 38 months. A 15% recurrent stone rate after hepatic resection for hepatolithiasis during a mean follow-up period of 4 years was reported by Chijiiwa et a1.13 In our study there was an increased chance of repeated operation for recurrent cholangitis or liver abscess (48.6% versus 12.7%, p < 0.01), development of secondary biliary cirrhosis (23.6% versus 3.4%, p < 0.001), late development ofcholangiocarcin oma ( 8.3 % versus 1.7 %, p = 0.007), and death (23.6% versus 7.6%, p < 0.001) in the retained stone group than in the nonretained stone group with a 4- to 10-year follow-up after postcholedochoscopic lithotomy.
Surgery Volume 120, Number 3 biliary e p i t h e l i u m by r e t a i n e d stones, l o n g - t e r m e x p o s u r e to b i l e a n d its p r o d u c t s , r e p e a t e d i n f e c t i o n s a n d m e t a b o l i c activity o f b a c t e r i a i n t h e biliary tree, a n d dyn a m i c i r r i t a t i o n by t h e u n s t a b l e bile flow i n c l u d i n g bile stasis, reflux, a n d t u r b u l e n c e h a v e all b e e n p r o p o s e d as p a t h o g e n i c m e c h a n i s m s o f c h o l a n g i o c a r c i n o m a . 38 T h e i n c i d e n c e o f c h o l a n g i o c a r c i n o m a d e v e l o p i n g a f t e r treatm e n t o f h e p a t o l i t h i a s i s was 2.8% in this series, a n d t h e incidences of cholangiocarcinoma in patients with postoperative retained and nonretained stones were 8.3% a n d 1.7%, respectively (p < 0.05). N o p a t i e n t h a d cholangiocarcinoma after hepatolithiasis that occurred a f t e r h e p a t e c t o m y in o u r study; L e e e t al. lz r e p o r t e d t h e s a m e f i n d i n g s in t h e l o n g - t e r m o u t c o m e s o f 107 h e p a t i c r e s e c t i o n s f o r i n t r a h e p a t i c stones. Chijiiwa e t a l ) 3 reported three patients who had cholangiocarcinoma after hepatic resection for hepatolithiasis within 3 m o n t h s to 20 years. I n t h e Chijiiwa series 15 o f 43 patients with hepatic resection had bilateral intraheparle stones. T h e r e s i d u a l c h o l a n g i t i s d u c t m a y h a v e been the focus for development of cholangiocarcin o m a . Chijiiwa e t al. 30 r e p o r t e d e i g h t cases o f c h o l a n g i o c a r c i n o m a i n J a p a n i n 109 p a t i e n t s with i n t r a h e p a t i e s t o n e s w i t h i n t h e follow-up p e r i o d . T h e m e a n i n t e r v a l f r o m t r e a t m e n t o f s t o n e s to t h e d e v e l o p m e n t o f c h o l a n g i o c a r c i n o m a was 8 years. F r o m o u r e x p e r i e n c e t h e interval r a n g e d f r o m 1 to 8 years with a m e a n o f 3 years a n d 4 m o n t h s . 4~ I n c o n c l u s i o n , l o n g - t e r m results o f h e p a t o l i t h i a s i s aft e r surgical a n d n o n s u r g i c a l t r e a t m e n t w i t h i n t h e 4- to 10-year follow-up p e r i o d r e v e a l e d a h i g h r e c u r r e n t s t o n e s r a t e (29.6%) t h a t r e q u i r e d r e p e a t e d s u r g e r y a n d a h i g h m o r t a l i t y rate (10.3%) t h a t was d u e to r e p e a t e d c h o l a n g i t i s w i t h sepsis, s e c o n d a r y biliary c i r r h o s i s w i t h b l e e d i n g varices a n d liver failure, a n d late d e v e l o p m e n t of cholangiocarcinoma. Patients with hepatolithiasis w h o u n d e r w e n t h e p a t e c t o m y o r p a t i e n t s w i t h o u t residual s t o n e s a f t e r c h o l e d o c h o s c o p y h a d a g o o d p r o g n o s i s a n d quality o f life. REFERENCES
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7. Birkette DH, Williams LF. Choledochoscopic removal of retained stones via a T-tube tract. ArnJ Surg 1980;139:531-4. 8. Chen MF, Chou FF, Wang CS, Jan YY. Post-operative choledochofiberscopic removal of intrahepatic stones. J Formosan Med Assoc 1980;79:700-5. 9. Sheen PC, Ker CG. Postoperative choledochofiberscopy. In: Okuda K, editor, lntrahepatic calculi. New York: Liss, 1984:30319. 10. Nimura Y. Percutaneous transhepatic cholangioscopy (PTCS). Stomach and Intestine 1981;16:681-9. 11. Chen MF,Jan YY.Percutaneous transhepatic removal of common bile duct and intrahepatic stones with fiberoptic choledochoscope. Gastrointest Endoscopy 1986;32:347-9. 12. Lee KT, Sheen PC, Tsai CC, ChenJS, Ker CG. Long-term results of one hundred and seven hepatic resections for intrahepatic stones. Dig Surg 1992;19:298-302. 13. Chijiiwa K, Kameoka N, Komura M, Yamasaki T, Noshiro H, Nakano K. Hepatic resection for hepatolithiasis and long-term resuits. J Am Coil Surg 1995;180:43-8. 14.Jan YY, Chen MF. Percutaneous transhepatic cholangioscopic lithotomy for hepatolithiasis: long term results: Gastrointest Endoscopy 1995;42:1-5. 15. Ker CG, Sheen PC. Choledochoscopic electrohydraulic shock wave for treatment of residual intrahepatic stones. Kaohsiung J Med Sci 1985;1:425-32. 16. Chen MF, Jan YY. Percutaneous transhepatic cholangioscopic lithotripsy. BrJ Surg 1990;77:530-2. 17. Jan YY, Chen MF, Ho CF. Balloon dilatation of intrahepatic duct and biliary-enteric anastomosis strictures-long term result. Int Surg 1994;79:103-5. 18. Fan ST, Wong J. Complications of hepatolithiasis. J Gastroent Hepat 1992;7:324-7. 19. Fan ST, Lai ELS, Mok FPT, et al. Acute cholangitis secondary to hepatolithiasis. Arch Surg 1991;126:1027-31. 20. Chen MF, Jan YY, Lee TY. Percutaneous transhepatic biliary drainage for acute cholangitis. Int Surg 1987;72:131-3. 21. Huang MH & Ker CG. Ultrasonic guided percutaneous transhepatic bile drainage for cholangitis due to intrahepatic stones. Arch Surg 1988;123:106-9. 22. Pitt HA, Venbrttx AC, Coleman J, et al. Intrahepatic stones, the transhepatic team approach. Ann Surg 1994;219:527-37. 23. Matsumoto Y, Fuji HJ, Yoshioka M, et al. Biliary strictures as a cause of primary intrahepadc bile duct stones. World J Surg 1986;10:867-75. 24. Mercadier M, Fingerhut A. Stricture of the intrahepatic bile duct. World J Surg 1984;8:15-21. 25. Choi TK, Wong J. Partial hepatectomy for intrahepatic stones. World J Surg 1986;10:281-6. 26. Chen MF, Jan YY, Chou FF, et al. Hepatic resection for intrahepatic stones. Chang Gung MedJ 1984;8:36-40. 27. Jeng KS, Yang FS, Chiang HJ, Ohta I. Bile duct stents in the management of hepatolithiasiswith long-segment intrahepatic biliary strictures. BrJ Surg 1992;79:663-6. 28. Jeng KS, Yang FS, Ohm I, Chiang HJ. Dilatation of intrahepatic strictures in patients with hepatolithiasis. World J Surg 1990; 14:587-93. 29. Mueller PR, Vansonneuberg E, FerrucciJT, et al. Biliary stricture dilatation: nmlticenter review of clinical management in 73 patients. Radiology 1986;160:17-22. 30. Moore AV, Illescas FF, Mills SR, et al. Percutaneous dilatation of benign biliary strictures. Radiology 1987;163:625-8. 31. MacSween RNM. Secondary biliary cirrhosis: mechanical ductal obstruction. In: Peters RL, CraigJR, editors. Liver pathology. New York: Churchill Lavingstone, 1986:172-5. 32. Scobie BA, Summerskill WHS. Hepatic cirrhosis secondary
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Surgery september 1996 37. Chen MF, Jan YY,Wang CS, et al. A reappraisal of cholangiocarcinoma in patient with hepatolithiasis. Cancer 1993;71:2461-5. 38. Nakanuma Y, Terada T, Tanaka Y, Ohta G. Are hepatolithiasis and cholangiocarcinoma aetiologically related? A morphological study of 12 cases of hepatolithiasis associated with cholangiocarcinoma. Virchows Arch [A] 1985;406:45-58. 39. Chijiiwa K, Ichimiya H, Kuroki S, et al. Late development of cholangiocarcinoma after the treatment of hepatolithiasis. Surg Gynecol Obstet 1993;177:279-82. 40. Jan YY, Chen MF, Chen TJ. Cholangiocarcinoma occurring in postoperative follow-up study of hepatolithiasis. J Surg Assoc 1994;27:2500-7.
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Background. Hepatolithiasis is a common disease in East Asia and is prevalent in Taiwan. Surgical and nonsurgical procedures for management of hepatolithiasis have been discussed, but long-term follow-up results of surgical treatment of hepatolithiasis are rarely reported. Methods. We conducted a retrospective study of case records of patients with hepatolithiasis who underwent surgical or nonsurgical percutaneous transhepatic cholangioscopy treatment. Of 614 patients with hepatolithiasis seen betweenJanuary 1984 and December 1988, 427 underwent follow-up after surgical (380) or percutaneous transhepatic cholangioscopy (47) treatment for 4 to i0 years and constituted the basis of this study. Results. Long-term results of 427 patients with hepatolithiasis after surgical and nonsurgical treatment within 4 to 10 years of follow-up were recurrent stone rate 29.6% (105 of 355), repeated operation 18.7% (80 of 427), secondary biliary cirrhosis 6.8% (29 of 427), late development of cholangiocarcinoma 2.8 % (12 of 42 7), and mortality rate 10.3 % (44 of 42 7). The patients with hepatectomy had a better quality of life (symptom-free) with a lower recurrent stone rate (9.5 %), lower mortality rate (2.1%), and lower incidence of secondary biliary cirrhosis (2.1%) and cholangiocarcinoma (0 %) than did the nonhepatectomy group (p < O.01). The patients without residual stones after choledochoscopy had a better quality of life than did the residual stone group (p < O.01). Conclusions. Long-term follow-up study of hepatolithiasis after surgical treatment revealed a high recurrent stone rate (29.6%) that required repeated surgery and a high mortality rate (10.3%) resulting from repeated cholangitis, secondary biliary cirrhosis, and late development of cholangiocarcinoma. Patients who received h~atectomy or without residual stones after choledochoscopy had a good prognosis and quality of life. (Surgery 1996;120:509-14.) From the Department of Surgery, Chang C.ung Memorial Hospital, Linkou Medical Center, Chang Gung Medical College, Taipei, Taiwan
in Southeast Asia and are especially prevalent in Taiwan. TM S u e t al. 5 reported that the relative incidence of hepatolithiasis was 20% of all gallstone diseases. The primary procedures for surgical removal of intrahepatic calculi include lithotomy by extended choledochotomy, transhepatic cholangiolithotomy, and hepatic resection. Additional procedures r e c o m m e n d e d for biliary obstruction are transduodenal sphincteroplasty, choledochoduodenostomy, and hepaticojejunostomy Roux-en-Y. a' 2, 5 Retained and recurrent intrahepatic stones are the two main problems in the surgical treatment of hepatolithiasis. The incidence of retained stones after operation has been markedly reduced to 10% to 30.2% with intraoperative INTRAHEPATIC STONES ARE COMMON
Accepted for publication Feb. 8, 1996. Reprint requests:~fi-~SnJan,MD, Department of Surgery,Chang Gung Memorial Hospital, 199, Tun Hwa North Rd., Taipei. Taiwan. Copyright 9 1996 by Mosby-YearBook, Inc. 0039-6060/96/$5.00 + 0 11/56/72580
and postoperative choledochofiberscopy. 69 Percutaneous transhepatic cholangioscopy (PTCS) was introduced for the diagnosis and treatment of biliary tract diseases in 1981.1~ 11 Long-term follow-up of surgical results of hepatolithiasis has rarely been reported. 12-14 This article presents our experience and evaluation of the long-term results of surgical treatment for hepatolithiasis.
PATIENTS AND METHODS During the period from January 1984 through December 1988, 614 (250 men and 364 women) consecutive patients (24.1%) with hepatolithiasis were noted in 2510 patients with biliary lithiasis in the surgical department of the Chang Gung Memorial Hospital, Taipei, Taiwan. Their ages ranged from 17 to 85 years with a mean age of 45 years. Two hundred twenty-six (37%) patients had undergone one or more biliary operations in the past. Operative treatment of intrahepatic stones was essential except in selective patients who could
SURGERY 509
510 J a n et al.
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Table I. Location of stones and bile duct strictures in 614 patients with hepatolithiasis n
Location of stones Bilateral IHD 237 Left IHD 270 Right IHD 107 Common bile duct 411 Location of bile duct strictures Left IHD 241 Right IHD 101 Bilateral IHD 81 Hilum 35 Distal CBD 61
Table II. Surgical procedures for patients with hepatolithiasis Procedures
n
Percent
Common bile duct exploration Cholecystectomy Hepaticotomy Left lateral segmentectomy Left lobectomy Right partial hepatectomy Hepaticojejunstomy Roux-en-Y Choledochoduodenostomy Ductoplasty Liver abscess drainage PTCS
566 290 21 128 15 11 11 10 5 21 48
92.2 47.2 3.4 20.9 2.4 1.8 1.8 1.6 0.8 3.4 7.8
Percent
38.6 44.0 17.4 66.9 39.3 16.5 13.2 5.7 9.9
1HD, Intrahepatic duct; CBD, common bile duct.
be treated by PTCS. The choice of operation was based on the location of stones and biliary strictures (Table I). The procedures performed for patients with hepatolithiasis are indicated in Table II. Intraoperative choledochoscopy was routinely used instead of intraoperafive cholangiography for visualizing the residual stones, ductal strictures, and tumors. Postoperative cholangiography and postoperative choledochoscopy (POC) were performed routinely to detect residual stones. An improved fiberoptic choledochoscope (CHF 4B or P10; Olympus, Tokyo, Japan) was inserted through the T tube or percutaneous transhepatic biliary drainage fistula orifice, where grasping forceps could be inserted through the choledochoscope to remove any stones. Giant or impacted stones were fragmented by introducing an electrohydraulic shock wave litho-triptor probe or a laser catheter through the same channel. 15' 16 The intrahepatic and biliary-enteric anastomotic strictures were dilated with a balloon catheter (Cook Co., Bloomington, Ind.) 4 to 10 m m in diameter. 17 Complete stone clearance was documented by cholangiographic, choledochoscopic, and sonographic examinations. When recurrence of symptoms was noted at follow-up, sonographic and cholangiographic investigations were undertaken to detect any recurrent stones or strictures. Twenty-seven operative deaths and 30 patients with cholangiocarcinoma were excluded from the study. Postoperative follow-up in 557 patients included chart review and telephone and letter communication during a 4- to 10-year period. One h u n d r e d thirty patients were lost to follow-up. Four h u n d r e d twenty-seven patients who were monitored after surgical (380) or PTCS (47) treatment constituted the basis of this study. Assessment of long-term results included recurrent symptoms (abdominal pain, fever, chills, jaundice), recurrent stones, repeated operation, secondary biliary cirrhosis (liver failure, varies bleeding), cholangiocarcinoma, and mortality.
RESULTS Immediate results. Immediate surgical and PTCS results of hepatolithiasis are summarized in the Figure. Five h u n d r e d sixty-six patients underwent operation. Operative death occured in 26 patients, resulting in a 4.6% mortality rate. Causes of death were acute suppurative cholangitis with septic shock in 14 patients, liver cirrhosis with liver failure or with bleeding varices in five patients, cholangiocarcinoma with acute cholangitis in three patients, liver cirrhosis with liver abscess in one patient, pneumonia with respiratory failure in one patient, myocardial infarction in one patient, and intraabdominal abscess with septic shock in one patient. Seventy-seven patients had residual intrahepatic stones after POC. Intrahepatic strictures (48 patients), dislodged drain tube or tortuous fistula tract (7 patients), and duodenal fistula (7 patients) were the main causes of failed treatment by postoperative choledochoscopic removal of stones. Forty-eight patients with hepatolithiasis selected treatment by PTCS. Complete clearance of intrahepatic stones was achieved in 40 patients, with an overall success rate of 83.3%. Failed treatment with PTCS in eight patients with intrahepatic strictures included bilateral intrahepatic stones with multiple right intrahepatic strictures in three patients, intrahepatic stones after hepaticojejunostomy in two, right superior posterior hepatic stone with stricture in one, right intrahepatic stone with liver abscess formation in one, and left recurrent intrahepatic stones with bile duct strictures associated with biliary cirrhosis complicated with hemobilia and septic shock after percutaneous transhepatic biliary drainage resulting in death in the final patient, resulting in a 2.1% mortality rate. Long-term results. Four hundred twenty-seven patients with hepatolithiasis (355 with complete stone clearance and 72 with retained stones) with effective
Surgery Volume 120, Number 3
Jan et al.
r -
complete stone clearance 437
postoperative choledochofiberscopy 510 - - ~ 1 _ residual stones
-Surgery (566) - - combined cholangiocarcinoma Hepatolithiasis-
511
. operative mortality
77
30 26
(614 patients) ~ 9PTCS (48)
complete stone clearance
40
-~-residual stones
7
/ t-mortality
1
Figure. Immediate surgical and PTCS results of hepatolithiasis T a b l e I I I . Long-term results of 315 POC and 40 PTCS complete stone clearance for hepatolithiasis during 4- to 10-year follow-up period
Postoperative choledochoscopy (315) Long-term result
Hepatectomy Nonhepatectomy PTCS (95) (%) (220)(%) (40) (%)
Free of symptoms 76 (80) Recurrent stones 9 (9.5) Symptoms without 10 (10.5) stones Repeated operation 2 (2.1) Biliary cirrhosis 2 (2.1) Cholangiocarcinoma 0 (0) Died 2 (2.1)
120 (54.5) 80 (36.4) 20 (9.1) 34 9 5 22
(15.5) (4.1) (2.3) (10)
22 (55) 16 (40) 2 (5) 9 (22.5) 1 (2.5) I (2.5) 3 (7.5)
follow-up of 4 to 10 years were studied. The long-term outcomes of the 355 patients with complete stone clearance via POC and PTCS during a 4- to 10-year follow-up period are summarized in Table III. The long-term results of 72 patients with hepatolithiasis who did not have all stones removed via POC and PTCS are summarized in Table W. In all, 80 patients with retained or recurrent intrahepatic stones received subsequent surgical treatment. The surgical procedures performed during the 4- to 10year follow-up period are extended choledochotomy in 48 patients, left hepatectomy in 13 patients, repeated PTCS in 7 patients, laparotomy for t u m o r biopsy or drainage of abscess cavity in 7 patients, and percutaneous drainage for liver abscess in 5 patients. In all, 44 patients with hepatolithiasis died during the
T a b l e IV. Long-term results of 355 nonretained versus 72 retained hepatolithiasis cases after choledochoscopic lithotomy with 4 to 10-year follow-up period
Long-term result Symptom free Repeated operation Biliary cirrhosis Liver failure Esophageal varices Cholangiocarcinoma Died
No. nonretained No. retained (355) (%) (72) (%) p Value 218 45 12 4 7 6 27
(61.4) (12.7) (3.4) (1.1) (2.0) (1.7) (7.6)
3 (4.2) 35 (48.6) 17 (23.6) 3 (4.2) 8 (11.1) 6 (8.3) 17 (23.6)
<0.001 <0.001 <0.001 0.09 0.001 0.007 <0.001
Chi-squared test,
4- to 10-year follow-up period. Patients with residual stones after choledochoscopic lithotomy had a higher mortality rate than did the nonresidual stone group (23.6% versus 7.6%, p < 0 . 0 1 ) . The causes of death were retained or recurrent stones with sepsis in 12 (27.3%) patients, cholangiocarcinoma in 9 (20.4%) patients, biliary cirrhosis with liver failure or bleeding varies in 10 (22.7%) patients, proven malignancy other than cholangiocarcinoma in 6 (13.6%) patients, medical disease in 4 (9.1%) patients, and suspected liver malignancy not proven by biopsy in another 6 (13.6%). Six patients died of other malignancies including hepatocellular carcinoma in one patient, gastric adenocarcin o m a in one patient, pancreatic adenocarcinoma in one patient, ovarian cancer in one patient, renal carcin o m a in one patient, and carcinomatosis of unknown origin in one patient.
512 Jan et al.
Surgery september 1996
DISCUSSION
Biliary strictures are defined by Matsumoto et al. 23 as a localized diminution in bile duct caliber proximal to the c o m m o n hepatic duct. Three quarters of patients with hepatolithiasis in Asia have associated biliary strictures. 4 In this series the incidence of associated biliary strictures was as high as 84.5%. Intrahepatic stones associated with biliary strictures are a great challenge to surgeons, with strictures being the main cause of treatment failure in conventional surgery, choledochoscopic lithotomy through the T tube, and PTBD track for hepatolithiasis) 4' 6-11,23, 24 Hepatic resection is the treatment of choice for hepatolithiasis with intrahepatic strictures limited to the left lobe or lateral segments. 12'13'25'26 To eliminate the intrahepafic strictures and to pass the sharp angulafion of the intrahepatic duct, through T-tube tract or percutaneous transhepatic dilatation of the biliary strictures with a Grfintzig or a big PTCS catheter and repeated dilatation are required. 17'27' 28 Intrahepatic strictures are the main cause of retained or recurrent stones in hepatolithiasis surgery. 23' 24,27,28 Percutaneous transhepatic balloon dilatation has been used for benign biliary strictures, achieving a patency rate of 42% to 76% after a mean follow-up of 36 months. 29' 3o In a previous study by the authors the restenosis rate for successfully dilated intrahepatic and anastomotic strictures was f o u n d to be 45% during a follow-up period of 5 to 7~ years. 17 Secondary biliary cirrhosis that develops after a long period of biliary strictures, calculous obstruction, and repeated cholangitis may be due to hepatic insufficiency and portal hypertension. Resultant complications include bleeding, esophageal varices, hypersplenism with pancytopenia, ascites, and encephalopathy. 31-34 Scheuer 33 reported that secondary biliary cirrhosis develops 7 years after the onset of obstruction from a stricture, 4~ years after a calculous obstruction, and 10 months after the onset of malignant strictures. Jeng et al.34 reported 10.1% of hepatolithiasis cases are associated with secondary biliary cirrhosis. Twenty-nine (6.8%) patients had secondary biliary cirrhosis after hepatolithiasis surgery; this cirrhosis was detected by ultrasonographic examination with a 4- to 10-year period follow-up in our series. Ten of the 29 patients died of secondary biliary cirrhosis with bleeding varices or liver failure within the 4- to 10-year follow-up period. After secondary biliary cirrhosis the patient is not a good candidate for repeated surgery; however, PTCS and other percutaneous procedures also carry significant risks of bleeding and sepsis. The association between cholangiocarcinoma and hepatolithiasis is well recognized, and the incidence of cholangiocarcinoma in patients with hepatolithiasis ranges from 2.36% to 10%. 35-37Prolonged initiation of
Biliary tract obstruction with acute cholangitis is a severe complication of hepatolithiasis that may result from fetal conditions with suppurative, portal thrombophlebifis or microabscesses of the portal tracts without adequate drainage. 18-2~In the emergency operation for acute cholangitis with intrahepatic stones, the intrahepatic stricture should be dilated until the purulent bile is obtained, and then the T tube should be passed through the stricture site. Intraoperative choledochoscopy is helpful in detecting the intrahepafic strictures. Surgical mortality in acute cholangitis caused by hepatolithiasis is high, up to 12%. 19 In this series operative mortality in hepatolithiasis was 4.6%, and acute cholangifts with septic shock was the main cause of death. Nonoperative procedures such as endoscopic nasobiliary and percutaneous transhepatic biliary drainage are attractive approaches in the emergency treatment of acute cholangitis from hepatolithiasis. 2~ 21 PTCS for removal of the intrahepatic stones through the dilated percutaneous tract is feasible, z' 11,12,16, 22 In this series 61 patients with acute cholangitis from hepatolithiasis were well controlled through percutaneous transhepatic biliary drainage, and 28 of 61 patients had successful removal of intrahepatic stones by means of PTCS. Residual and recurrent stones are the most troublesome problem after surgery for hepatolithiasis. 1-4 The incidence of residual stones has been markedly reduced from 21.1% N 62.3% without choledochofiberscopy to 10% N 30.2% with intraoperative and postoperative choledochofiberscopy.14, 6-9 In this series the residual stone rates after POC and PTCS for hepatolithiasis are 15.1% and 16.6%, respectively. Recurrent stone rates after complete stone clearance of POC and PTCS for hepatolithiasis during a 4- to 10-year follow-up period are 28.2% and 40%, respectively. The recurrent stone rates after complete stone clearance of POC for hepatolithiasis in the hepatectomy versus nonhepatectomy group were 9.5% and 36.4%, respectively. Lee et al.12 reported a 4.2% recurrent stone rate after hepatic resection for hepatolithiasis with a mean follow-up period of 38 months. A 15% recurrent stone rate after hepatic resection for hepatolithiasis during a mean follow-up period of 4 years was reported by Chijiiwa et a1.13 In our study there was an increased chance of repeated operation for recurrent cholangitis or liver abscess (48.6% versus 12.7%, p < 0.01), development of secondary biliary cirrhosis (23.6% versus 3.4%, p < 0.001), late development ofcholangiocarcin oma ( 8.3 % versus 1.7 %, p = 0.007), and death (23.6% versus 7.6%, p < 0.001) in the retained stone group than in the nonretained stone group with a 4- to 10-year follow-up after postcholedochoscopic lithotomy.
Surgery Volume 120, Number 3 biliary e p i t h e l i u m by r e t a i n e d stones, l o n g - t e r m e x p o s u r e to b i l e a n d its p r o d u c t s , r e p e a t e d i n f e c t i o n s a n d m e t a b o l i c activity o f b a c t e r i a i n t h e biliary tree, a n d dyn a m i c i r r i t a t i o n by t h e u n s t a b l e bile flow i n c l u d i n g bile stasis, reflux, a n d t u r b u l e n c e h a v e all b e e n p r o p o s e d as p a t h o g e n i c m e c h a n i s m s o f c h o l a n g i o c a r c i n o m a . 38 T h e i n c i d e n c e o f c h o l a n g i o c a r c i n o m a d e v e l o p i n g a f t e r treatm e n t o f h e p a t o l i t h i a s i s was 2.8% in this series, a n d t h e incidences of cholangiocarcinoma in patients with postoperative retained and nonretained stones were 8.3% a n d 1.7%, respectively (p < 0.05). N o p a t i e n t h a d cholangiocarcinoma after hepatolithiasis that occurred a f t e r h e p a t e c t o m y in o u r study; L e e e t al. lz r e p o r t e d t h e s a m e f i n d i n g s in t h e l o n g - t e r m o u t c o m e s o f 107 h e p a t i c r e s e c t i o n s f o r i n t r a h e p a t i c stones. Chijiiwa e t a l ) 3 reported three patients who had cholangiocarcinoma after hepatic resection for hepatolithiasis within 3 m o n t h s to 20 years. I n t h e Chijiiwa series 15 o f 43 patients with hepatic resection had bilateral intraheparle stones. T h e r e s i d u a l c h o l a n g i t i s d u c t m a y h a v e been the focus for development of cholangiocarcin o m a . Chijiiwa e t al. 30 r e p o r t e d e i g h t cases o f c h o l a n g i o c a r c i n o m a i n J a p a n i n 109 p a t i e n t s with i n t r a h e p a t i e s t o n e s w i t h i n t h e follow-up p e r i o d . T h e m e a n i n t e r v a l f r o m t r e a t m e n t o f s t o n e s to t h e d e v e l o p m e n t o f c h o l a n g i o c a r c i n o m a was 8 years. F r o m o u r e x p e r i e n c e t h e interval r a n g e d f r o m 1 to 8 years with a m e a n o f 3 years a n d 4 m o n t h s . 4~ I n c o n c l u s i o n , l o n g - t e r m results o f h e p a t o l i t h i a s i s aft e r surgical a n d n o n s u r g i c a l t r e a t m e n t w i t h i n t h e 4- to 10-year follow-up p e r i o d r e v e a l e d a h i g h r e c u r r e n t s t o n e s r a t e (29.6%) t h a t r e q u i r e d r e p e a t e d s u r g e r y a n d a h i g h m o r t a l i t y rate (10.3%) t h a t was d u e to r e p e a t e d c h o l a n g i t i s w i t h sepsis, s e c o n d a r y biliary c i r r h o s i s w i t h b l e e d i n g varices a n d liver failure, a n d late d e v e l o p m e n t of cholangiocarcinoma. Patients with hepatolithiasis w h o u n d e r w e n t h e p a t e c t o m y o r p a t i e n t s w i t h o u t residual s t o n e s a f t e r c h o l e d o c h o s c o p y h a d a g o o d p r o g n o s i s a n d quality o f life. REFERENCES
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Surgery september 1996 37. Chen MF, Jan YY,Wang CS, et al. A reappraisal of cholangiocarcinoma in patient with hepatolithiasis. Cancer 1993;71:2461-5. 38. Nakanuma Y, Terada T, Tanaka Y, Ohta G. Are hepatolithiasis and cholangiocarcinoma aetiologically related? A morphological study of 12 cases of hepatolithiasis associated with cholangiocarcinoma. Virchows Arch [A] 1985;406:45-58. 39. Chijiiwa K, Ichimiya H, Kuroki S, et al. Late development of cholangiocarcinoma after the treatment of hepatolithiasis. Surg Gynecol Obstet 1993;177:279-82. 40. Jan YY, Chen MF, Chen TJ. Cholangiocarcinoma occurring in postoperative follow-up study of hepatolithiasis. J Surg Assoc 1994;27:2500-7.
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