Effect and Course of Percutaneous Transhepatic Cholangioscopy in Intrahepatic Stone Related Complication after Liver Resection / 대한췌담도학회지

BACKGROUND/AIMS: Percutaneous transhepatic cholangioscopy (PTCS) is an effective treatment used for intrahepatic stone in patients who have undergone hepatectomy. There are few reports on natural course in these patients. Thus, we report the long-term results. METHODS: We conducted a retrospective study of 19 patients who underwent PTCS after hepatectomy at Samsung Medical Center between January 1998 and December 2014. We investigated patient characteristics and recurrence of biliary complications during follow up period. Then, we analyzed the factors related to recurrence. RESULTS: Indications for PTCS were cholangitis, symptomatic stone, liver abscess and biliary dilatation. Complete stone removal was achieved in 12 patients (63.2%). After receiving PTCS, the recurrence of intrahepatic stone related complication occurred in 52.6% (10/19) of patients during a median follow-up of 4.9 years (range, 1.8–7.8). Complications were cholangitis (5/10, 50%), cholangitis with liver abscess (3/10, 30%), liver abscess (1/10, 10%) and symptomatic stone (1/10, 10%). On univariate analysis, factors including multiple stone involvement, complete stone removal and bile duct stricture were not significantly associated with recurrent biliary complications. CONCLUSIONS: PTCS is an effective treatment for complications of recurrent intrahepatic stones in patients who have undergone hepatectomy. However, long term follow-up is necessary because of the recurrence of biliary complications.

Correlation of variations of ABCB11 gene and primary intrahepatic stone / 中华消化外科杂志

Objective To investigate the correlation of variations of ABCB11 gene and primary intrahepatic stone (PIS).Methods The retrospective case-control study was conducted.The clinical data of 319 patients with PIS and 344 healthy controls who were admitted to the Southwest Hospital of the Third Military Medical University between December 2012 and December 2015 were collected.Three hundred and ninteen patients with PIS and 344 healthy controls were respectively allocated into the PIS and control groups.Twenty-seven exons in ABCB11 gene were detected via polymerase chain reaction (PCR) and DNA sanger sequencing.Observation indicators included:(1) variations and genotype frequency distribution of ABCB11 gene in the 2 groups;(2) correlation analysis between variations of ABCB11 gene and clinical data of patients with PIS:preoperative indicators of liver function test,recurrent episodes of cholangitis,preoperative obstructive jaundice,type and recurrence of stones.Comparison between groups in variations and genotype frequency distribution of ABCB11 gene was analyzed by the Logistic regression.The Kruskal-Wallis H test was performed to explore the correlation between genotype of ABCB11 gene and clinical test results of patients with PIS.Correlation between genotype of ABCB11 gene and clinicopathological data of patients with PIS was analyzed by the chi-square test.Results (1) Variations and genotype frequency distribution of ABCB11 gene in the 2 groups:whole-exome sequencing results showed that synonymous mutations of rs3815675,rs2287616 and rs497692 and missense mutations of rs2287617,rs2287622 and rs118109635 in the PIS group were respectively detected in exon 4,9,24 and 9,13,21.CT genotype frequency of rs118109635 was 4.70％(15/319) in the PIS group and 1.45％ (5/344) in the control group,respectively,with a statistically significant difference [OR=3.49,95％ confidence interval (CI):1.17-10.40,P＜0.05].GG and AG+GG genotype frequency of rs497692 were 46.08％ (147/319),87.46％ (279/319) in the PIS group and 37.79％ (130/344),79.36％ (273/344) in the control group,respectively,with a statistically significant difference (OR=1.73,1.65,95％ CI:1.05-2.83,1.04-2.61,P＜0.05).(2) Correlation analysis between variations of ABCB11 gene and clinical data of patients with PIS:levels of glutamyl-transpeptidase (GGT),alkaline phosphatase (ALP) and direct bilirubin (DBil) in the PIS group were 167 U/L (range,7-1 968 U/L),166 U/L (range,36-1 527 U/L),4 μmol/L(range,1-272 μmol/L) in the CC genotype of rs118109635 and 433 U/L(range,17-864 U/L),232 U/L (range,85-613 U/L),6 μmol/L(range,2-173 μmol/L) in the CT genotype of rs118109635,respectively,with a statistically significant difference (H=6.025,5.879,8.056,P＜0.05).Globulin level of PIS group was respectively 32 g/L (range,20-40 g/L),34 g/L(range,17-50 g/L) and 33 g/L(range,14-49 g/L) in the AA,AG and GG genotype of rs497692,respectively,with a statistically significant difference (H=12.119,P＜0.05).Of 81 patients with recurrence of PIS,GG and GA genotypes of rs2287617 were detected in 78 and 3 patients,respectively,with a statistically significant difference (x2=5.367,P＜0.05);TT,TC and CC genotypes of rs2287622 were detected in 12,39 and 30 patients,respectively,with a statistically significant difference (x2=6.153,P＜0.05).Of 127 patients with obstructive jaundice,116 and 11 patients had CC and CT genotypes of rs118109635,respectively,with a statistically significant difference (x2=7.381,P＜0.05);11,43 and 73 patients had AA,AG and GG genotypes of rs497692,respectively,with a statistically significant difference (x2 =11.364,P＜0.05).Conclusion There is a correlation between rs118109635 and rs497692 of ABCB11 gene and PIS,meanwhile,the above variation loci are associated with obstruction of biliary tract and cholestasis.

Laparoscopic Dissection of Liver Resection for Intrahepatic Stone / 实用医学杂志

Objective To observe the laparoscopic dissection of liver resection for intrahepatic stone. Method 112 patients with intrahepatic stone in our hospital were selected and randomly divided into two groups, 56 cases each group. The control group adopted open surgery and treatment group adopted laparoscopic surgery. The hospitalization condition and complications of two groups were compared. Result The activity time of leaving bed , operation time , bleeding amount and time of passing gas of treatment group were significantly shorter than those of control group (P 0.05). Conclusions The laparoscopic dissection of liver resection has an obvious curative effect for intrahepatic stone , has fewer bleeding amount , shorter hospitalization time , earlier time of leaving bed and fast recovery and lower complications , improves the patients’ life quality after surgery and treatment compliance. It shall be applied in clinical practices.

Advances in the pathogenesis of primary intrahepatic cholelithiasis / 中华肝胆外科杂志

Primary intrahepatic stone is a common disease in China. It is difficult to treat this benign biliary tract disease because it has many complications and the surgery is difficult. Understanding the cause of this disease has important implications in prevention and treatment. This article reviewed the cause of primary intrahepatic stone from four aspects: imbalance of bile components, infection, bile protein, and macromolecular and metabolism of the cells.

The Feasibility of Laparoscopic Hepatectomy for the Patients with Left Intrahepatic Stones

PURPOSE: Recently, there have been several studies on the early results of hepatectomy for various intrahepatic lesions. We report the early experience of our hospital after total laparoscopic left hepatectomy in patients with intrahepatic stones in the left hemi-liver. METHODS: We retrospectively analyzed the medical records of patients who were diagnosed with left intrahepatic stones and underwent hepatectomy between January 2007 and June 2009. The patients were grouped according to operative procedure into open hepatectomy, laparoscopy-assisted hepatectomy, and total laparoscopic hepatectomy. RESULTS: There were 31 patients who underwent Lt hemihepatectomy and Lt lateral sectionectomy during this period. Hepatectomy with open method, laparoscopy-assisted method, and total laparoscopy method were performed in 10, 14, and 7 cases. There were no significant differences between the three methods for operating time and postoperative complications. But the number of fasting times and hospital days was shorter with total laparoscopic hepatectomy than with others. CONCLUSION: Total laparoscopic liver resection is a safe and useful method for treating patients with intrahepatic stones and offers the advantage of quick patient recovery. Careful selection of appropriate patients and further development in the laparoscopic surgical technique resulting from accumulated experiences will help enable the laparoscopic hepatectomy to be performed more easily and safely in patients with intrahepatic stones.

Evaluation of our clinical pathologic stage for 1259 intrahepatic stones / 第三军医大学学报

Objective To analyze whether there is statistic significance among sex,age and outcome of patients suffering from intrahepatic stones,who were grouped according to our clinical pathologic staging proposed recently by professor Dong Jia-hong.Methods Totally 1 259 cases of intrahepatic stones were included.Statistic difference of different typing in sex,age,therapeutic methods and outcome was analyzed by SPSS 11.0 software.Results All types and subtypes by our clinical pathologic stage for intrahepatic stones have statistic difference in therapeutic methods and outcome.Conclusion Our clinical pathologic staging is a reasonable typing method for intrahepatic stones.

Clinical Review and Surgical Treatment of Intrahepatic Stones / 한국간담췌외과학회지

BACKGROUND: Intrahepatic stones are common in East Asia and pose serious complications such as biliary stricture, liver atrophy, liver abscess, sepsis and sometimes cholangiocarcinoma. The management of primary intrahepatic stones is difficult and it is also difficult to remove all stones during operation. METHODS: Eighty seven patients with hepatolithiasis were admitted to the department of surgery, Keimyung University Dongsan Medical Center during 4 year period between 1994 and 1997. We reviewed medical records retrospectively for these patients. RESULTS: The peak incidence of age was 50's and the male to female ratio was 1:1.2. Intrahepatic stones were located in the left lobe in 62.1%, right lobe 17.2% and both lobe 20.7%. Stones were found only within the liver (I type) in 34.5% and both inside and outside the liver (IE type) in 65.5%. Analysis of the composition of intrahepatic stones revealed calcium bilirubinate as the most common compound (over 75%) and E. coli was the most common organism in bile culture. We classified intrahepatic stones as four types. Type I (45.9%) is cases with liver atrophy on abdominal CT, type II (20.6%) is cases without liver atrophy as IE type, type III (16.0%) is cases with dilatation of extrahepatic bile duct as I type, and type IV (17.2%) is cases without liver atrophy nor extrahepatic bile duct dilatation. Of the 72 operated patients, liver resection was done in 43 (59.7%) and 9 patients (20.0%) had residual stones. Cholangiocarcinoma was found in 3 (7.0%) of the total 43 patients who underwent liver resection. CONCLUSION: Hepatic resection should be performed in selected patients with intrahepatic stones because of lowest presence of residual stones and no difference of postoprative complications compared with drainage procedure.

The Efficacy of Percutaneous Transhepatic Choledochoscopic Removal of Intrahepatic Stones / 대한내과학회지

OBJECTIVE: Intrahepatic stones provide a quite different spectrum of problems faced by surgeons in the Eastern hemisphere. Although unilateral left intrahepatic stones have been treated by left hepatic lobectomy, bilateral or right intrahepatic stones can be even more troublesome because they frequently cannot be completely removed by conventional surgical stone extraction procedure. Recently, the use of a flexible fiberoptic choledochoscope, electrohydraulic lithotriptor(EHL) and dilators make it possible to completely remove intrahepatic stones by nonsurgical procedures in the majority of cases. METHODS: During the last 5 years, we treated intrahepatic stones in 114 patients with a fiberoptic choledochoscope, EHL and dilators via percutaneous transhepatic route. For construction of percutaneous transhepatic routes, we punctured intrahepatic ducts by ultrasonographic guidance and then dilated the tracts by PTBD set(Nipro Co., Japan) under fluoroscopic guidance. Choledochoscopy were performed at 4-6 weeks later, and Dormina basket, EHL, balloon or bougie dilators were used for removal of stones. RESULTS: Success rates according to the locations of stones were 87.5%(14/16) in unilateral right intrahepatic stones, 92.9%(39/42) in unilateral left intrahepatic stones, and 89.3%(50/56) bilateral intrahepatic stones. Overall success rate was 90.4%(103/114). Causes of incomplete removal of the stones in our patients included the failure of construction or maintenance of percutaneous transhepatic routes in 4 cases, intrahepatic bile duct stricture proximal to impacted stones in 3, acute ductal angulation in 2, and stones located at the very distal branches of intrahepatic ducts in 2 cases. Complications associated with the procedure were transient fever in 8 cases, severe hemobila in 2 cases and biliary perforation in 3 cases. CONCLUSON: These results suggest that percutaneous transhepatic choledochoscopic approach is a relatively safe and effective method for treatment of intrahepatic stones.

Peripheral Cholangicoarcinoma

Peripheral cholangiocarcinoma (PCC) is defined as a malignancy of intrahepatic bile duct presenting as a focal liver mass, specifically, those located peripheral to the 2nd-order branchings of the bile duct. During the study period of 11 years from Jan. 1985 through Dec. 1995, a total of 12 patients underwent liver resection for PCC at the Department of Surgery, Inje University Paik Hospital, Seoul. This figure accounts for 8.3% of primary liver cancer. There were 9 men and 3 women with a ratio of 3:1, the mean age was 53.3 years with a range of 39 to 67 years. Twenty-five per cent of the patients had concomitant intrahepatic stone (IHS). HBsAg was positive in one case (8.3%) who had chronic hepatitis. No patient had liver cirrhosis. The accurate preoperative diagnosis of PCC in 3 cases was difficult because of the association with IHS. These 3 patients underwent surgery under the diagnosis of chronic cholangitis rather than PCC. CEA and CA 19-9 were elevated in 70% and 50% of the patients, respectively. In most cases concomitant measurement of CEA and AFP facilitated the differentiation between PCC and hepatocellular carcinoma. As to the tumor characteristics, 83% of the patients had tumors greater than 5 cm in diameter, indicating the advanced stage of the tumor at the time of resection. The site of origin of tumor mass was distributed more or less evenly between the hepatic lobes. The patients with mass-forming, expanding type of tumors made up 58% of the cases, infiltrating type 25%, and the remainder being the combination of both. A significant number of patients, 27%, had nodal metastasis. Two thirds of the patients underwent major hepatic resections. Segmentectomies here include the resection of lateral segment done as a treatment for IHS, which later proved to be cancer on histologic examination. There was no operative death among the 12 patients. The overall median survival time was 12 months. The overall survival rates at 1, 3, and 5 years were 42.4%, 42.4%, and 42.4%, respectively. Only the radicality of the resection was the statistically significant risk factor for survival by univariate analysis. The 5-year survival rate was 100% in 6 patients who had curative resection (no lymph node invasion, no peritoneal seeding, clear resection margin). The prognosis of patients with advanced PCC is unfavorable unless the tumor is entirely removed. In view of the association of IHS in a significant portion of the cases, the possible coexistence of the carcinoma should always be borne in mind when dealing with patients with IHS.

Fibrocalcific Nodule in the Liver Capsule Caused by Ascaris Eggs: A case report

Ascariasis is probably the most common helminthic infestation of man, but it seldom causes severe illness. Pathologic conditions of Ascaris may be caused by adult worms, eggs or larvae. We describe a case of Ascaris egg granulomas that were found incidentally on the surface of the liver in a 75-year-old woman who had undergone a segmentectomy for an intrahepatic stone. Grossly, there were several yellowish calcific nodules of 0.4 cm in diameter on the lateral surface of the left lobe of the liver. Microscopically, the lesions were located in the hepatic capsule and consisted of fibrocalific nodules with many eggs. The eggs were round to oval, thick-shelled and measured 50~75x30~50 um. Most of the morphologically preserved eggs were fertilized eggs, but they had smooth shells without external protein coats. This case is of interest for the unusual location of the lesion, the presence of eggs without mammillation, and the association with the intrahepatic stone.