Abstract Hepatolithiasis is a common and refractory disease, for which the effective treatment method is surgery for removing the lesion, depleting stones, correcting stenosis, unobstructive drainage, and preventing recurrence. There are many surgical treatments available for hepatolithiasis, including bile duct exploration, bile duct drainage, bile duct reconstruction, hepatectomy, and liver transplantation. In clinical practice, combination therapies are often performed in a large number of patients. Here we discuss the choice of surgical treatments for hepatolithiasis and evaluate their respective therapeutic effects.
0 Introduction
Intrahepatic bile duct stones refer to stones that originate in the bile duct above the confluence of the hepatic ducts. They are one of the most common and difficult to treat diseases in biliary surgery. The treatment of intrahepatic bile duct stones mainly relies on surgical operations. The principle is to “remove the lesion, remove all stones, correct strictures, ensure smooth drainage, and prevent recurrence”.
Currently, there are many surgical methods for the treatment of intrahepatic bile duct stones, but they can be summarized into four main types: bile duct incision and drainage surgery, bile duct stricture repair and reconstruction surgery, liver resection, and liver transplantation. In clinical practice, these four types of surgical methods are often used sequentially and in combination.
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1. Choledocholithotomy
The bile duct lithotomy for intrahepatic bile duct stones is performed through a common hepatic duct incision up to the porta hepatis. Under direct vision, each main hepatic duct, the caudate lobe hepatic duct, and the openings of the secondary hepatic duct are explored one by one to clarify factors such as stones, stenosis, and hepatic duct lesions. It also includes intrahepatic bile duct lithotomy through the liver parenchyma. This surgical method is the most basic surgical procedure for intrahepatic bile duct stone system. It is mostly used in emergency and severe cases, aiming to temporarily patency bile flow, control bile duct infection, improve liver function to save the patient’s life or prepare for subsequent secondary definitive surgery. When combined with acute cholangitis, liver resection should not be performed during the acute inflammatory period. Studies have shown that if the liver is resected within 1 month of cholangitis control, the incidence of residual stones during surgery, postoperative infectious complications, and bile leakage in patients is significantly increased. Therefore, during an acute cholangitis attack, it is advisable to wait for 1 month after the bile duct inflammation is relieved after biliary drainage and decompression, and preferably 3 months before a planned liver resection is performed.
This procedure can be used as a definitive surgical method for a small number of cases with a small number of stones, mild hepatic duct and liver lesions, no residual lesions inside or outside the liver after all the stones are removed, and no stenosis of the bile duct. With the widespread use of intraoperative cholangiography, intraoperative ultrasound, and intraoperative choledochoscopy, direct exploration combined with the above methods can more comprehensively understand the location, number, stenosis and obstruction of bile duct stones, and the patency of the lower end of the bile duct, providing strong evidence for the formulation of the final surgical plan. During the operation, the use of instruments to remove intrahepatic bile duct stones should be gentle, and violence should be avoided to avoid bile duct injury and bleeding. Blindly using instruments to remove stones during surgery often makes it difficult to remove all intrahepatic bile duct stones, and it is easy to cause residual stones after surgery. When inserting a catheter (urinary) tube into the intrahepatic bile duct for flushing, it is necessary to master the correct method and avoid high-pressure water injection to flush the bile duct, otherwise it is easy to cause excessive pressure in the hepatic duct, and the infected bile will flow back into the sinusoids, causing the spread of infection, and developing into sepsis and shock. Even death.
2. Hepatectomy
Resection of the diseased liver segment to maximally remove liver lesions containing stones, strictures and dilated bile ducts is the most effective means of treating intrahepatic bile duct stones. This method has been widely adopted and has achieved excellent results.
Intrahepatic bile duct stones are more common in the left lateral lobe and right posterior lobe of the liver. Liver resection is the best way to treat intrahepatic bile duct stones. The postoperative residual stone rate is low and the long-term effect is good.
2.1 Left lateral hepatectomy
Intrahepatic bile duct stones are more common in the left lateral lobe of the liver, and left lateral lobe resection is a relatively simple procedure in liver resection. It can be performed in many primary hospitals and is the most commonly used procedure in liver resection for the treatment of intrahepatic bile duct stones. However, this procedure is mainly used for simple left lateral lobe stones without concomitant stenosis of the left hepatic duct and transverse part and thickening of the bile duct wall. For stones that are not confined to the left lateral lobe of the liver, resection of the left lateral lobe is often not enough. Although stones can be removed from the left inner lobe through the bile duct of the liver section, it is difficult to remove S4a stones, and the stones are often not completely removed, resulting in residual stones after surgery.
2.2 Left hepatectomy
Left hepatectomy is mainly used to treat fibrosis and atrophy of the left liver caused by long-term hepatic duct obstruction such as stenosis of the left hepatic duct or stone incarceration. When the left hepatic duct has stones or stenosis but has not yet caused changes in the liver parenchyma, there are currently two methods: one is to remove the left lateral lobe and explore the bile duct through the liver section to remove stones in the left hepatic duct and the left internal lobe branches; the other advocates left hepatectomy. Dong Jiahong et al. proposed that for regional stones in the left hepatic duct, regular left hepatectomy should be the first choice, rather than only left lateral lobe resection combined with bile duct jejunostomy. Some scholars have also confirmed that for intrahepatic bile duct stones limited to the left internal lobe, left hepatectomy should also be performed if liver function tolerates it, and left lateral lobe resection should be avoided, because the recurrence rate of stones after left hepatectomy is low, and the long-term effect is significantly better than left lateral lobe resection. The author believes that as long as there are clear pathological changes such as stenosis of the left hepatic duct opening and dilatation of the distal bile duct, Regardless of whether the left liver parenchyma is damaged or not, the left hemiliver should be removed actively. If the lesion is indeed limited to the bile duct of the left inner lobe (S4), especially if the left outer lobe is hypertrophic, anatomical left inner lobe resection (S4 segment resection) should be considered. There is no need to sacrifice the normal liver tissue of the left outer lobe unnecessarily.
2.3 Right hepatectomy
The incidence of bile duct stones in the right lobe of the liver is lower than that in the left lobe, so the chances of right hemihepatectomy are also reduced accordingly. When performing right hemihepatectomy for intrahepatic bile duct stones, the selection of surgical indications needs to be strictly controlled, and multiple aspects need to be considered and weighed to ensure safe and smooth surgery and good short- and long-term results. Usually, obstruction of the right hepatic duct or its main branches and recurrent infection lead to extensive damage to the right liver, fibrosis in the portal area, and atrophy of the right liver. At the same time, the left lobe of the liver is compensatory, which makes the proportion of the left and right lobes unbalanced, and gradually rotates clockwise around the inferior vena cava, so that the diseased right lobe of the liver is pushed to the right rear, making surgical exposure and operation more difficult. When removing the right liver lesion of hepatobiliary stones, it is necessary to take a right lateral approach to expose the displaced portal and right hemiliver, fully free the adhesions between the right hemiliver and the posterior abdominal wall and the inferior vena cava, and completely free the entire right hemiliver to facilitate complete resection of the lesion. Intraoperative ultrasound is used to accurately determine the direction of the middle hepatic vein and select the appropriate liver cutting plane for regular resection of the right hemiliver. If the right part of the caudate lobe (caudate process) is involved, it needs to be removed together. However, if the caudate lobe bile duct is not involved and has compensatory hyperplasia, it should be retained in principle.
2.4 Regular segmentectomy for intrahepatic bile duct stones
Regular segmental resection refers to the removal of liver tissue strictly according to the anatomical range of the hepatic duct, starting from the anatomy of the liver hilum. The distribution of intrahepatic bile duct stones is generally based on the liver lobe and/or liver segment, especially in the early stage, it is mostly a localized lesion limited to a certain sub-segment or segment of the liver. Its pathological changes are strictly segmented according to the diseased bile tree. Segmental resection according to the anatomical boundary can completely remove the diseased bile tree and the liver area it drains. For right-sided intrahepatic bile duct stones, regular right anterior and right posterior segment (segment) resection or even selective regular segment, sub-segment or local bile duct tree resection has been more frequently performed in recent years. This further reduces the scope of liver resection, is more conducive to the recovery of the physiological state of the liver and bile duct, and has better results. When performing regular segmental resection, the normal bile duct and liver tissue should be preserved to the maximum extent, and the patient’s bile duct and lesions should be completely removed to achieve the purpose of radical resection. If the liver is not removed enough, residual lesions will often lead to symptom recurrence. Affects the outcome of surgery.
2.5 Laparoscopic liver resection
With the expansion of the application scope of laparoscopic liver resection, it has shown good development prospects and trends for regular liver resection and hemi-liver resection. Studies have shown that laparoscopic surgery is safe and feasible for the treatment of regional hepatobiliary stones, can achieve the same therapeutic effect as open surgery, and can largely reflect the characteristics and advantages of minimally invasive surgery. However, there are also relative contraindications:
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(1) diffuse hepatobiliary stones, especially combined with biliary cirrhosis and biliary portal hypertension, severe porta transposition, and difficulty in exposure;
(2) severe stenosis of the hilar bile duct;
(3) a history of multiple biliary surgeries. It should be emphasized that laparoscopic liver resection requires good professional training and rich experience in open liver resection surgery as a foundation, otherwise it may be counterproductive and the effect may be poor.
3 Repair and reconstruction of hilar bile duct stricture
Hepatobiliary stenosis is an obstacle to the surgical treatment of intrahepatic bile duct stones, and 80% of surgical treatment failures are caused by it. About 30%-40% of patients with intrahepatic bile duct stones have hepatobiliary stenosis, and the proportion is even higher among those who undergo reoperation [ 10 ]. Therefore, relieving hepatobiliary stenosis during intrahepatic bile duct stone surgery is an important part of surgical treatment. For high-level intrahepatic bile duct stenosis, especially hepatobiliary stenosis above the third-order branches, the purpose of eliminating the stenosis can be achieved by liver lobe or liver segment resection. For first- and second-order bile duct stenosis at the hilar region, stricture incision and plastic anastomosis have become the typical surgical procedures in hepatobiliary stone surgery. Because the lesion types of hilar bile duct stenosis are relatively complex, it is often necessary to combine multiple surgical methods for treatment:
(1) Biliary stricture shaping and tissue patch repair. It is suitable for cases where the intrahepatic lesion and upstream hepatic duct stenosis have been removed, the stones have been removed and there is no possibility of recurrence, and only mild hilar bile duct stenosis exists. Fully incise the stricture segment and the bile duct at both ends. The scarred bile duct tissue is removed, and the hepatobiliary flap is sutured to form the posterior wall of the bile duct. The defect of the anterior wall of the bile duct is repaired with a vascularized hepatic round ligament flap, gallbladder flap, stomach flap, jejunal flap or other autologous tissue patch;
(2) Bile duct stricture shaping and Roux-en-Y jejunal anastomosis. The stricture of the bile duct at the porta hepatis is fully incised and reshaped in situ. The bile duct incision and the jejunal loop are anastomosed side-to-side or end-to-side with Roux-en-Y. Since reflux cholangitis and extrahepatic bile duct stones may occur after side-to-side bile duct anastomosis, the extrahepatic bile duct is transected as much as possible and anastomosed end-to-side with bile duct, especially for patients with extrahepatic bile duct dilatation, Oddi sphincter relaxation, and those who have undergone Oddi sphincteroplasty. For cases with residual stones or the possibility of recurrence, the stump of the jejunal loop can be buried in the subcutaneous part of the abdominal wall as a passage for postoperative stone removal. It is worth noting that if the upstream hepatic duct stenosis is not corrected and the intrahepatic stones are not completely removed, choledochojejunostomy may cause or aggravate serious complications such as biliary infection. Therefore, this procedure is suitable for cases of hilar bile duct stenosis in which the intrahepatic lesions and upstream hepatic duct stenosis have been removed.
4. Choice of surgical plan for patients with intrahepatic bile duct stones combined with portal hypertension
Patients with intrahepatic bile duct stones develop secondary biliary cirrhosis and even biliary portal hypertension due to long-term and recurrent bile duct inflammation and mechanical obstruction. At this time, the choice of surgical treatment is often very difficult. On the one hand, patients have extremely poor tolerance for major surgery, and the incidence and mortality of surgical complications are high; on the other hand, there are many dilated collateral circulation vessels in the portal area during portal hypertension, and surgery is often more difficult due to heavy bleeding. It is sometimes difficult to decide whether to solve portal hypertension first or to deal with bile duct obstruction first, whether to deal with both at the same time in one operation or in stages, which tests the comprehensive judgment and handling ability of hepatobiliary surgeons for complex cases. It is generally believed that if the bile duct stenosis and intrahepatic lesions are relatively simple, portal hypertension is obvious, and the liver compensatory function is still good, the problems of bile duct and portal hypertension can be dealt with simultaneously in one stage of surgery. If the lesions of the bile duct and liver are complex, portal hypertension is obvious, and liver function is severely impaired, staged surgery is appropriate. Patients with severe bile duct obstruction and liver function impairment, especially those with concurrent infection, The bile duct should be drained first, and definitive biliary surgery should be performed at a later date after liver function improves. If portal hypertension is significant and varicose vessels of the hepatoduodenal ligament hinder biliary surgery, a portalocaval shunt should be performed first, and definitive biliary surgery should be performed at a later date after portal hypertension is relieved. However, it is undeniable that when facing such specific patients in the clinic, we often fall into a dilemma. At this time, individualized analysis and treatment must be carried out. If necessary, a comprehensive consultation should be organized with interventional departments, gastroenterology departments, endoscopy centers, etc., to develop a practical treatment plan and then decide on the specific surgical method.
5 Liver transplantation
When extensive intrahepatic stones are accompanied by end-stage liver cirrhosis and liver function falls into a decompensated state, liver transplantation is a good choice, but its clinical application is limited by problems such as donor shortage, rejection reaction, and high treatment costs.
6 Conclusion
The surgical treatment of intrahepatic bile duct stones should be to remove the lesions in the early stage, restore the physiological function of the bile duct in a timely and effective manner, and cure the disease, rather than waiting for the disease to become chronic biliary system infection and more extensive intrahepatic stones before treatment. The selection of specific surgical treatment plans should be based on the number and distribution of intrahepatic bile duct stones, the location and degree of hepatic duct stenosis, liver pathological changes, liver function status and the patient’s general condition, and an individualized surgical treatment plan should be formulated for specific cases. In recent years, with the rapid development of related disciplines and technologies such as imaging, digital medicine, and medical devices, as well as the further establishment and expansion of the concept of minimally invasive surgery, especially the establishment of a theoretical system of precise liver surgery, they have profoundly affected the transformation and progress of the concept of intrahepatic bile duct stone treatment. However, it is undeniable that the comprehensive treatment of intrahepatic bile duct stones, which is currently dominated by surgery, still needs to solve many problems, such as the thoroughness of the operation, the prevention and treatment of stone recurrence, etc., which need to be further studied and discussed. The further deepening of related basic research on etiology, molecular biology, pathology, etc., Perhaps this may provide important inspiration for the final solution to the clinical problem of intrahepatic bile duct stones.
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