Management of Intrahepatic Duct Stone / 대한소화기학회지

Intrahepatic duct (IHD) stone is the presence of calculi within the intrahepatic bile duct specifically located proximal to the confluence of the left and right hepatic ducts. This stone is characterized by its intractable nature and frequent recurrence, requiring multiple therapeutic interventions. Without proper treatment, biliary strictures and retained stones can lead to repeated episodes of cholangitis, liver abscesses, secondary biliary cirrhosis, portal hypertension, and death from sepsis or hepatic failure. The ultimate treatment goals for IHD stones are complete removal of the stone, the correction of the associated strictures, and the prevention of recurrent cholangitis. A surgical resection can satisfy the goal of treatment for hepatolithiasis, i.e., complete removal of the IHD stones, stricture, and the risk of cholangiocarcinogenesis. On the other hand, in some cases, such as bilateral IHD stones, surgery alone cannot achieve these goals. Therefore, the optimal treatments require a multidisciplinary approach, including endoscopic and radiologic interventional procedures before and/or after surgery. Percutaneous transhepatic cholangioscopic lithotomy (PTCS-L) is particularly suited for patients at poor surgical risk or who refuse surgery and those with previous biliary surgery or stones distributed in multiple segments. PTCS-L is relatively safe and effective for the treatment of IHD stones, and complete stone clearance is mandatory to reduce the sequelae of IHD stones. An IHD stricture is the main factor contributing to incomplete clearance and stone recurrence. Long-term follow-up is required because of the overall high recurrence rate of IHD stones and the association with cholangiocarcinoma.

The Diagnosis of Intrahepatic Bile Duct Stones with Early Intrahepatic Cholangiocarcinoma by Combining CA199, CEA, CA50 and ALP and Magnetic Resonance Imaging / 昆明医科大学学报

Objective To explore the use of CA199,CEA,CA50 and ALP combined with magnetic resonance imaging (MRI) in diagnosis of intrahepatic bile duct stones with early bile duct carcinoma.Methods The clinical diagnosis of 36 cases of patients with hepatolithasis-associated intrahepatic cholangiocarcinoma (HICC) and 118 cases with intrahepatic duct stone (IHDS) were analyzed retrospectively.Serum CA199,CEA,CA50,ALP and magnetic resonance (MRI,MRCP) were performed and the results were analyzed.Results Abdominal pain discomfort in Hepatolithasis-associated intrahepatic cholangiocarcinoma showed multiple symptoms.Three typical Charcot syndromes were rare.On the gender distribution,intrahepatic bile duct stones was frequently found in women,on the contrary,Hepatolithasis-associated intrahepatic cholangiocarcinoma was frequently more found in men (P ＜0.05) Abdominal pain and fever in patients of Hepatolithasis-associated intrahepatic cholangiocarcinoma was more than that of patients with Intrahepatic bile duct stone (P＜0.05) When alkaline phosphatase (ALP) was more than 169 U/L,significant difference was seen between two groups (P＜ 0.05) According to the diagnosis of HICC,the accuracy of CA199,CEA,CA50 combined with ALP was 88.6％,the accuracy of magnetic resonance examination alone was 90.2％,and the accuracy of multiple serological markers and magnetic resonance was 95.5％.Conclusion MRI combined with serum CA199,CEA,CA50 and ALP can effectively improve the HICC preoperative diagnosis rate.

Changes in the types of liver diseases requiring hepatic resection: a single-institution experience of 9016 cases over a 10-year period

BACKGROUNDS/AIMS: To understand the changing demands for hepatic resection (HR), we collected data regarding HR performed in a tertiary centre over a period of 10 years. METHODS: We carried out extensive search of institutional databases to identify HR cases performed between January 2005 and December 2014. A study cohort of 9,016 patients were divided into 5 disease categories, namely hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (ICC), intrahepatic duct stone disease (IHDS), colorectal cancer liver metastasis (CRLM), and uncommon/rare diseases (URD). RESULTS: There were 5,661 (62.8%) HCC cases, followed by 1441 (16.0%) CRLM, 942 (10.5%) ICC, 638 (7.1%) IHDS and 334 (3.7%) URD. The number of annual HR cases gradually increased from 443 in 2005 to 1,260 in 2015. Annual HCC cases also gradually increased, but the annual proportion of HCC cases fluctuated narrowly between 58.3% and 70.2%. Annual CRLM cases increased rapidly, and their proportion increased progressively from 4.7% to 20.5%. Annual ICC cases increased slowly, and their annual proportion fluctuated between 7.2% and 15.6%. Annual IHDS cases decreased slowly, and their annual proportion decreased progressively from 17.2% to 3.4%, while annual URD cases fluctuated, with annual proportions varying between 2.3% and 5.6%. CONCLUSIONS: Annual cases of HR increased over the last 10 years in a tertiary center probably due to a center-specific centralization effect. The number of CRLM cases increased rapidly; those of HCC and ICC increased gradually, and those of IHDS declined gradually. We believe that these results reflect real changes in the types of liver disease requiring HR.

Laparoscopic left hepatectomy in patients with intrahepatic duct stones and recurrent pyogenic cholangitis

BACKGROUNDS/AIMS: Recently many studies have been reported the early results of a hepatectomy for various intrahepatic lesions. Also various types of laparoscopic hepatectomies are being performed in many centers. Some reports about the safety of laparoscopic parenchymal dissection of the liver have been published. In this study, we reported our experiences of laparoscopic left hepatectomies in patients with an intrahepatic duct (IHD) stone with recurrent pyogenic cholangitis (RPC), and investigated whether the total laparoscopic parenchymal dissection is as safe as open surgery. METHODS: From April 2008 to December 2010, 25 patients had been admitted for left IHD stones with RPC. Preoperatively, the type of surgery was decided with the intention of treating each patient. Initially 10 patients underwent a laparoscopy-assisted left hepatectomy and the next 15 patients underwent total laparoscopic left hepatectomy as our experience grew. Demographics, peri- and postoperative results were collected and analyzed comparatively. RESULTS: The mean age, gender ratio, preoperative American Society of Anesthesiologists (ASA) score, accompanied acute cholangitis and biliary pancreatitis, and the number of preoperative percutaneous transhepatic biliary drainage (PTBD) inserted cases were not different between the two groups who had undergone laparoscopy-assisted and totally laparoscopic left hepatectomy. The operation time, intraoperative transfusions and postoperative complications also showed no difference between them. The postoperative hospital stay did not show a significant difference statistically. CONCLUSIONS: In this study, we concluded that a laparoscopic left hepatectomy can be adapted to the patients with a left IHD stone with RPC. Also laparoscopic parenchymal dissection is safe and equivalent to an open procedure.

Therapeutic effects of hepatectomy plus Roux-en-Y choledochojejunostomy in combination with reflux prevention on intrahepatic bile duct stone / 中华肝胆外科杂志

Objective To investigate the therapeutic effects of hepatic resection plus Roux-en-Y choledochojejunostomy in combination with reflux prevention on intrahepatie bile duct stone. Methods The clinical data of 230 patients with intrahepaticbile duet stone surgically treated in our hospital in the past 18 years were retrospectively analyzed. Of the 230 patiets, 110 underwent hepatectomy plus Roux-en-Y choledochojejunostgmy in combination with reflux prevention and the others received other surgeries. The complications of pleural effusions, infection of incisional wound, leakage of bile and retained calculus after operation were studied. Meanwhile, the recurrent rate of stone and long-term effects were determined. Results The occurrinjg rate of pleural effusion, infection of incision wound,leakage of bile was not significantly different among different groups. However, the retained calculus and recurrent rate of stone in the group of patients underwent hepateetomy plus Roux-en-Y choledochojejunostomy in combination with reflux prevention were significantly decreased as compared with other group (P<0.05). So was the effect in long-term (P<0.05). Conclusion Hepatectomy plus Roux-en-Y choledochojejunostomy in combination with reflux prevention could have better effect on patients with intrahepatic bile duct stone.

Two Cases of Percutaneous Transhepatic Choledochoscopy Treatment of Intrahepatic Duct Stones that Occurred after Living Donor Liver Transplantation / 대한소화기내시경학회지

Percutaneous transhepatic cholangioscopy (PTCS) is the primary treatment option for general cases of intrahepatic duct stones. However, there are no reports on the use of PTCS for intrahepatic duct stones in patients who had undergone living donor liver transplantation (LDLT). We experienced two cases of successful intrahepatic stone removal by the use of PTCS in LDLT patients. With these cases, we have confirmed that PTCS management can be safely performed not only for a general bile duct stone, but also for a bile duct stone that develops in a patient that had previously undergone liver transplantation.

The Analysis of the Cholesterol Contents of Intrahepatic Duct Stones in the West Gyeongnam Region

PURPOSE: Hepatolithiasis is a recurrent disease and common in Far East Asia. In Korea, almost all intrahepatic duct (IHD) stones were pigment stones 30~40 years ago. The nationwide cooperative study showed a higher cholesterol content of IHD stones compared to the previous data. Some reports have shown a close relationship between urbanization and the cholesterol content of stones. The purpose of this study was to evaluate the cholesterol content of IHD stones in the West Gyeongnam region and evaluate the associated clinical and demographic variables. METHODS: The IHD stones were removed surgically from twenty patients who had hepatolithiasis between July 2005 and April 2007. The stones were grouped by their gross findings. The cholesterol contents were measured quantitatively by infrared spectrophotometry and compared with the clinical variables. RESULTS: Among twenty patients, 19 had pigment stones and only one had gross evidence of a cholesterol stone. The cholesterol content of the stones were 30%~50% in 13 patients, 50~70% in 6 patients and over 70% in one patient. In urban patients, the cholesterol contents of the IHD stones were higher (567.029 mg/g) than in rural patients (421.822 mg/g)(p<0.05). All stones in rural patients were pigment stones; the stones of urban patients consisted of 5 pigment, 6 mixed and 1 cholesterol stone (p<0.05). CONCLUSION: The mean cholesterol content of the IHD stones was 508.946 mg/g; the content of the stone was significantly related to the residence of the patients. These results suggest that the cholesterol content of IHD stones are likely to increase in West Gyeongnam as urbanization increases.

Comparison of Clinical and Surgical Outcomes between Unilateral and Bilateral Intrahepatic Duct Stone Disease

PURPOSE: Intrahepatic duct stone (IHD) disease, especially bilateral lesion, is difficult to management for complete cure. The purpose of this study is to analyze the clinical manifestations and treatment outcomes and is to consider adequate strategy of treatment between unilateral and bilateral IHD stones. METHODS: From October 1993 to July 2004, 218 patients with IHD stone were performed by surgical management at Ewha Womans University Mokdong Hospital. The medical records of these patients were reviewed retrospectively. We classified into two groups, such as unilateral group (U group) and bilateral group (B group), and compared two groups for clinical manifestations and outcomes. RESULTS: Of the 218 IHD stone patients, 188 cases underwent conventional open surgery, 20 cases underwent laparoscopic surgery, and 10 cases underwent laparoscopic assisted surgery. U group and B group was composed 162 and 56 cases, respectively. IHD stones were more common in left lobe of liver than right lobe in U group (P<0.001). IHD stricture were more common in U group (P=0.048). On the other hand, remnant stones were more common in B group (P<0.001). There was no statistical significance for postoperative complication and method of operation include liver resection between two groups. CONCLUSION: We presume that the pathogenesis may be different between unilateral and bilateral IHD stone. To cure or reduce the remnant stone rate, more aggressive treatment such as liver resection should be also considered in the patients with bilateral as well as unilateral IHD stone because of no difference of complication rate of two groups.

The Role of Intraoperative Choledochoscopy for Diagnosis and Treatment in Biliary Surgery

PURPOSE: A choledochoscopy is useful for treating stone disease in the biliary tract. In the era of laparoscopic surgery, this method is expected to be used more widely. Its use during surgery may not only aid disease treatment, but may also help in making a differential diagnosis and a decision on the appropriate operative method. The aim of this study was to determine the role of intraoperative choledochoscopy in biliary surgery. METHODS: This study was a prospective analysis for 119 cases of biliary surgery where a choledochoscopy was used at the Ewha Womans University Mokdong Hospital from June, 1999 to February, 2001. An attempt was made to determine if the use of choledochoscopy altered the preoperative diagnosis, added another diagnosis and influenced the surgical treatment. In addition, the frequency of the remnant stones in biliary stone disease, and the complications related with this procedure were evaluated. RESULTS: The male to female ratio was 1:1.53, and the mean age was 61.1 (+/-14.53) years. A choledochoscopy was used in 82 cases (69%) in open surgery, and 37 cases (31%) in laparoscopic surgery. In 31 cases (26.1%), the diagnosis was changed by the choledochoscopic findings. In 9 cases (7.5%), new finding that was not recognized in the preoperative state was added with the use of choledochoscopy. The surgical method was influenced by the use of a choledochoscopy in 39 cases (32.8%). The remnant stones in patients with an intrahepatic duct stone and common bile duct stone were detected in 8 cases and 3 cases, respectively. The respective clearance rate of the stones were 79.5% (31/39) and 94.5% (52/55). There was no complications and side effects associated with the use of choledochoscopy. The mean time for diagnostic use was 14.6 (+/-10.0) minutes and for therapeutic use was 47 (+/-60.4) minutes. CONCLUSION: Intraoperative choledochoscopy provided useful information for a precise diagnosis and assisted in determining the appropriate treatment for biliary disease. Furthermore, it is very important for making a differential diagnosis in patients with an undetermined malignancy.

Classification of Intrahepatic Duct Stones and Analysis of Operation Methods

PURPOSE: Intrahepatic duct stones have been known to be a benign disease but because of the associated serious complications and the high recurrence rate, the management of the hepatolithiasis is very difficult. This purpose of this study was to classify the patterns of intrahepatic duct stones, and to evaluate the effect of surgical treatment according to their type and the residual stones that were present. METHODS: The clinical records of 212 patients who underwent a hepatic resection or drainage procedures between January 1988 and December 2000 were reviewed. RESULTS: We classified the intrahepatic duct stones as being either a localized simple type, a localized complicated type, a diffuse simple type, or a diffuse complicated type. Hepatic resections were performed in 177 (83.5%) cases. Among these we performed a hepatic resection along with drainage procedures in 41 cases (19.3%). In 35 (16.5%) cases, only drainage procedures were performed. Of a total of 25 cases of postoperative residual stones (25 cases), 13 (52%) cases were removed completely or partially by choledochoscopic procedures in 13 (52%) cases and in 15 (60.0%) cases they were removed completely or partially by spontaneous drainages. CONCLUSION: Our conclusions were that the, localized type of the IHD stones were treated successfully by a hepatic resection and the localized complicated type and the diffuse type IHD stones were treated effectively by hepatic resection and drainage procedures which reduced the opportunity for residual stones to develop following an accurate preoperative diagnosis of the location of the stones. Therefore, treatment methods should be individualized for each type of stone and by surgical treatments that combine endoscopic and resolution methods.

The Surgical Investigation of Hepatic Resection for Intrahepatic Duct Stone / 한국간담췌외과학회지

BACKGROUND/AIMS: Intrahepatic duct stone (IHDS) present serious health problem in East Asian countries including Korea because of recurrent or residual stones and stones induced hepatic damage. Hepatic resection is known as most definitive procedure especially in patients with ductal stricture, but postoperative morbidity and residual or recurrent stones are still high. METHODS: We analyzed early and late complication according to type of hepatic resection in IHDs (38 cases) and also determined the predisposing factors related to complication. RESULTS: Location of IHDs was left in 30 cases (78.9%), right in 1 case (2.7%), both in 7 cases (18.4%), and 28 cases (73.7%) had concomitant extrahepatic duct stone. The type of hepatic resection was left lateral segmentectomy in 24 cases (63.2%), left lobectomy in 11 cases (28.9%) and right lobectomy in 3 cases (7.9%). Overall complication rate was 44.7% and it was increased by extension of resection (p<0.05). Overall incidence of residual or recurrent stone was 36.8% and it was higher in patients with left lateral segmentectomy and without biliary drainage procedure although statistically not significant. The postoperative mortality was 11.8% (2 cases). CONCLUSIONS: Hepatic resection can be a curative therapy in IHDS and routine use of intraoperative choledochoscopy and additional drainage procedures are recommended to minimize the incidence of residual or recurrent stones.

Intrahepatic Duct Stones in Young Patients

PURPOSE: The etiology of intrahepatic duct stone has not yet been elucidated. This disease is more prevalent in older patients, but it can occur in young patient, too. The study of intrahepatic duct stones in young patients may provide clues to the pathogenesis of this disease. METHODS: We analyzed the anatomic distribution of stones and the presence of ductal strictures, as well as the operative methods and the results of treatment. We treated 125 patients with intrahepatic duct stones, of which 15 patients were under 40 years of age and 110 patients were over 40. RESULTS: The average age was 32.9 in young patients and 58.4 in older patients. The anatomic distributions of stones in young patients were even between the right and the left lobes, 4 in the right lobe, 8 in both lobes and 3 in the left lobe. However, the distributions in older patients showed predominance in the left lobe, 61 in the left lobe, 31 in both lobes and 18 in the right lobe. Strictures of duct were present in 7 (46.7%) patients in the young group and 35 (31.8%) in the older group. Hepatic resections were done in 7 (46.7%) and 35 (52.7%) in young and older patients, respectively. The incidence of remnant stones was similar between the two group, 40% in young patients and 31.8% in older ones. The complication rate was less in young patients (6.7%) than in older patients (24.5%). CONCLUSION: Intrahepatic duct stones in young patients had a tendency to develop in the right lobe and to have strictures in the duct. More aggressive treatment is recommended for this group of patients.

Preduodenal Portal Vein and Left Sided Gallbladder in Hepatolithiasis Patient: A case report

A preduodenal portal vein is a rare anomaly. A left-sided gallbladder is also a rare anatomical variant that may be occasionally combined with a preduodenal portal vein. We report here a patient with multiple biliary stones whose preduodenal portal vein was discovered at operation. The anomaly was a preduodenal portal vein associated with a left-sided gallbladder, which is very rare. This is the first case reported in Korea. An abnormal location of the round ligament to the right side can make the gallbladder appear to be a left-sided gallbladder. Our case belongs to this category. This patient had multiple biliary stones in the intrahepatic duct, the common bile duct, and the gallbladder. We treated him with a cholecystec tomy, choledochotomy, and choledochoscopic stone extraction using a basket, and electrohydraulic lithotripter. All procedures were done using a laparoscopic method. The patient was treated well with no complication.

The Result of Operative Treatment and Clinical Characteristics of the Intrahepatic Duct Stone Patients / 한국간담췌외과학회지

The intrahepatic duct (IHD) stone shows diverse spectrum of clinical features such as recurrent cholangitis, obstructive jaundice, liver abscess, biliary cirrhosis and association with cholangiocarcinoma. The result of operative treatment is still not satisfied in spite of many kinds of surgical treatment modalities. The purpose of this study is to elucidate the clinical characteristics and the operative principle of IHD stone by the reviewing the medical records, retrospectively. The 61 patients who received operation at the Department of Surgery, Chungbuk National University Hospital were included in this study. The mean age of the patients is 56 and the age of predilection is sixth and seventh decade. The incidence of IHD stone is higher in females, with a female-to-male ratio of 2.6:1. All of the patients experienced cholangitis more than one episode before operation. The location of IHD stone was 31 patients in left, 8 patients in right, and 21 patients in both IHD. Liver resection was preferred to drainage procedure when the stones were limited to one lobe or segment. 46(75%) cases of liver resection, 11(18%) drainage procedure, 2(3%) T-tube choledocholithomy and 2(3%) open biopsy were performed. Residual stones were found 8 patients(17%) on the liver resection group, 8(61%) on the drainage procedure or T-tube choledocholithotomy group. The patients who had stones in one lobe or limited in the localized part of the liver showed residual stones in one (3%) patients after liver resection. Seven patients(44%) of both IHD stone group who received liver resection, however, had residual stones. There was no postoperative mortality in the liver resection group. IHD stone-associated cholangiocarcinoma was found in 6 patients(10% of studied patients). Three of them were diagnosed during IHD stone operation. The rest was detected after operation(1 - 5 years). Liver resection is the treatment of choice of IHD stone considering residual stones and association with cholangiocarcinoma, especially. These data also suggest that longterm follow-up of the IHD stone patients is needed because of cholangiocarcinoma.

Application of Electrohydraulic Lithotripsy for Bile Duct Stones Difficult to Remove

BACKGROUND: The use of choledochoscopy has been increasing lately in open and laparoscopic surgery for bile duct stones. Intraoperative choledochoscopy is useful for assessing the biliary trees and stones and for assisting in the removal of bile duct stones. However, large or impacted bile duct stones are difficult to remove using choledochoscopy alone. Application of electrohydraulic lithotripsy (EHL) seems to be suited for these difficult cases. METHODS: Twenty-six (26) patients with bile duct stones were treated with intraoperative cho ledochoscopic EHL to remove stones which could not be retrieved using stone forceps, a basket, saline flushing, or a Fogarty catheter. We divided the 26 cases into two groups: 12 cases of laparoscopic surgery and 14 cases of open surgery. These cases were further divided into two groups: common bile duct stones and intrahepatic duct stones RESULTS: The indications of EHL in laparoscopic surgery for common bile duct stones were large stones in 2 cases and impacted stones in 4 cases. Eighteen (18) patients with intrahepatic duct stones were treated with EHL for impacted stones. Stone clearence rate was 88.5%, and complications occurred in 3 cases (11.5%). One case of a biliary fistula was managed conservatively, and two cases of mucosal bleeding of the bile duct were spontaneously controlled. CONCLUSION: Intraoperative choledochoscopic electrohydraulic lithotripsy is a safe and effective method for removing large or impacted bile duct stones.

The Role of Operative Choledochoscopy in the Treatment of Intrahepatic Duct Stone

BACKGROUND: Choledochoscopy has been widely used to remove residual intrahepatic duct stones postoperatively. Intraoperative use of choledochoscopy may be useful in the assessment of the intrahepatic biliary tree and the removal of stones. The aim of this study was to clarify the role of intraoperative choledochoscopy and its effectiveness in reducing the rate of residual stones. METHODS: We divided the 73 patients with intrahepatic duct stone into two groups by two periods. In the first period, operative choledochoscopy was not used, 43 patients, during the operation, and in latter period, operative choledochoscopy was used, 30 patients. RESULTS: The rate of residual stones was 51.2% for the group in which operative choledochoscopy was not used, but in the group in which choledochoscopy was used, the rate was 33.3%. CONCLUSION: Choledochoscopy is useful in reducing the rate of residual stones by providing direct visualization of the biliary tree and the stones during operation.

Results of Surgical Treatment for Intrahepatic Duct Stones

BACKGROUND: The treatment of intrahepatic stones is difficult because of frequent recurrence and residual stones. There are several suggested methods of treatment which include surgical bile-uct exploration with or without biliary drainage, an endoscopic procedure, transhepatic cholangiolithotomy, and hepatic resection. METHODS: We reviewed the therapeutic results in 96 patients who had hepatolithiasis and received surgery at Soon Chun Hyang University Chunan Hospital during the 10 years from June 1987 to June 1997. We divided them into 2 groups: one was the group of patients receiving a hepatic resection with or without a drainage procedure (resection group), and the other was the group of patients receiving only a T-ube choledochostomy or drainage procedure (nonresection group). RESULTS: The male-to-female ratio was 1:1.74, and the most prevalent age group was the 5th decade (31.3%). The most common symptoms were epigastric pain (61%) and RUQ pain (60%), and the locations of stones were the right intrahepatic duct in 10 cases (10.4%), the left intrahepatic duct in 47 cases (49%), and both intrahepatic duct in 39 cases (40.6%). Operative methods were a resection in 29 cases and a nonresection in 67 cases. The incidence of residual stones were 31.0% in the hepatic resection group and 68.6% in the nonresection group. The postoperative complication rate was 20.6% in hepatic resection group and 38.8% in the nonresection group, and the follow-p study showed the good results (Good & Fair) for 92.5% of the hepatic resection group and 66.7% of the nonresection group. CONCLUSION: The hepatic resection with or without drainage is an adequate treatment for hepatolithiasis. It can eradicate localized intrahepatic calculi, irreversible biliary stricture, an atrophied segment, and, possibly, an associated cholangiocarcinoma, with good results in clinical evaluation.