Surgical treatment and evaluation of intrahepatic bile duct stones

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.

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.