Sphincter of oddi laxity: a considerable issue in hepatolithiasis / 中华消化外科杂志

Hepatolithiasis is still a common biliary disease in China with unknown pathogenesis and poor long-term outcomes.Surgery is probably the only curative treatment to hepatolithiasis.However,surgeons and patients cannot keep trouble from high recurrence and reoperation rates after surgery.Hepatolithiasis is a serious disease,which can cause cholangitis,liver abscess,liver cirrhosis,and even cholangiocarcinoma.Sphincter of Oddi,which controls the unidirectional outflow of bile and separates the bile duct from the bacteria-filled intestinal tract,is thought to be a gatekeeper of the almost-sterile biliary tract.Dysfunction of sphincter of Oddi,including stenosis,spasm and laxity,is closely associated with biliary disease,A lax sphincter of Oddi will aggravate bilioenteric reflux,leading to biliary infection and calculi development eventually.This issue has gradually gained enough attention.How to evaluate sphincter of Oddi function reliably and restore or replace its function,which is key to treat hepatolithiasis and prevent its recurrence,remain unclear.

Reoperation for cholangioenterostomy anastomostic stenosis / 中华肝胆外科杂志

Objective To study the surgical treatment and the related risk factors of cholangioenterostomy anastomotic stenosis.Methods We retrospectively analysed the clinical data of 41 patients who underwent surgical treatment for cholangioenterostomy anastomotic stenosis in the PLA General Hospital from January 1,2008 to November 30,2014.Results All patients' clinical symptoms were alleviated and they were discharged home.No one died perioperatively.Anastomotic restenosis happened in 5 patients.Conclusions Reoperation for cholangioenterostomy anastomotic stenosis was difficult.The surgeon should make the anastomosis as large as possible to decrease the risk of restenosis.A T tube should be used when necessary.

Recent Treatment Modalities for Hepatolithiasis and Long-term Outcomes

PURPOSE: Treatment of hepatolithiasis is difficult because of the high recurrence rate, and the long-term outcome is not satisfactory. We reviewed clinical outcomes to determine the optimal treatment modalities for hepatolithiasis. METHODS: Between 1981 and 2005, 648 patients with hepatolithiasis were treated at our institute. Changing patterns of treatment modalities and outcomes were analyzed for the periods: 1st (1981~1985; n=159), 2nd (1986~1990; n=100), 3rd (1991~1995; n=111), 4th (1996~2000; n=141), and 5th (2001~2005; n=137). Clearance and recurrence rates according to the treatment modalities and associated malignancies were analyzed in patients for the most recent 10 years. RESULTS: During the past 25 years, hepatectomy as a treatment for hepatholithiasis has increased in frequency and become the major treatment modality in the recent 10 years, while choledocholithotomy and drainage procedures have decreased in frequency. With improvement in operative clearance and post-operative lithotripsy, the final clearance rate improved from 79.0% to 91.3%. In the most recent 10 years, the final clearance rate of hepatectomy, choledocholithotomy, cholangioenterostomy, and PTCS was 97.1%, 82.0%, 78.8%, and 100%, respectively, and the recurrence rate was 34.7%, 15.4%, 17.0%, and 42.9%, respectively. Twenty-six patients (47.2%) had recurrences within 2 years, and 12 patients (21.8%) had recurrences after 5 years. Cholangiocarcinomas occurred in 10 patients (3.6%). The diagnosis of cholangiocarcinoma was established pre-operatively in 2 patients, post-operatively in 4 patients, and during the follow-up period in 4 patients. CONCLUSION: In the treatment of hepatolithiasis, hepatectomy has a high clearance rate and a low recurrence rate. To reduce the recurrence rate, complete stone clearance without residual stones seems to be of utmost importance. Suspicion of malignancy and long-term follow-up are needed in the management of patients with hepatolithiasis.

Experience with Surgical Treatments for Hepatolithiasis

Hepatolithiasis is characterized by its intractablity and frequent recurrence that requires multiple operative and non-operative interventions. To clarify the optimal treatment modalities and their effectiveness, a total of 648 patients with hepatolithiasis and who had treated at Seoul National University Hospital between January 1981 and December 2005 were analyzed according to the different time periods. Hepatectomy as a primary treatment of hepatolithiasis has gradually increased and become the major treatment modality in the recent 10 years, while choledocholithotomy and drainage procedures have decreased. New treatment modalities such as percutaneous choledochoscopic stone removal (PTCS) and laparoscopic liver resection were instituted during the past decades. Over the last 25 years, both advances in the operative stone clearance rate and the success rate of postoperative lithotripsy have resulted in an improved final stone clearance rate, and this has been progressive from 79.0% in the first period to 91.3% in the fifth period. In the last 10 years, the final clearance rate of hepatectomy, choledocholithotomy, drainage procedures and PTCS was 97.1%, 82.0%, 78.8% and 85.7%, respectively, and the rate of performing repeated hepatectomy, choledocholithotomy, drainage procedures and PTCS was 11.2%, 26.2%, 9.1% and 28.6% respectively. Hepatolithiasisassociated cholangiocarcinomas were found in 24 (4.7%) patients (1991-2005, n=512), and 5 of them were diagnosed after 5 years of follow-up. Histopathologic examinations of the resected livers showed various degrees of pathologies from proliferative cholangitis and hyperplasia through dysplasia and cholangiocarcinoma. Therefore, a suspicion of malignancy and long term follow-up are needed for managing the patients who suffer with hepatolithiasis.

Clinical research on cholangioenterostomy without stent tube drainage / 中国普通外科杂志

Objective To investigate the feasibility of cholangioenterostomy without stent tube drainage. (Methods) In this study 52 cases anastomosed without stent tube drainage (group A) and 56 cases with stent tube drainage (control,group B) were included. The patients′course of therapy and recovery, postoperative follow-up and reoperation were compared between group A and B. Results The rate of bile leakage was (5.8)% (3/52) in group A and 3.6%(2/56) in group B, respectively ,which was not significant(P

Treatment of hepatolithiasis by combination of stricture repairment and partial hepatectomy preserving a subcutaneous blind bowel loop / 中国普通外科杂志

Objective To enhance therapeutic effects of hepatolithiasis by improving surgical procedures. Methods Forty eight patients suffering from hepatolithiasis with bile duct stricture were treated in this study, in whom 27% (13/48) of the stone was located in the left lobe, 19% (9/48) in the right, and 54% (26/48) in bilateral lobe. Stone coexisted with stricture in 71% (34/48). Hepatic duct and stricture were opened, making a basin at the porta, and repaired by one end of a segment of jejunum. The other end was set subcutaneously. At the same time, a portion of the liver habouring stone was resected. Results Forty four out of 48 patients were followed up (92%) with an average of 5 years. The rate of recurrent stone was 20% (9/44), the rate of cholangitis was 16% (7/44), and 84% of cases fared very well. Postoperatively, 7 cases underwent lithotomy by choledochoscope through the subcutaneous blind loop. Conclusion This procedure decreases the relapsing cholangitis effectively.