Progress on biliary flora and primary intrahepatic stone formation / 公共卫生与预防医学

Primary intrahepatic stone （PIS）is one of the intractable diseases in hepatobiliary surgery and an important cause of death from benign biliary tract diseases, and it has a high prevalence in the Yangtze River basin and southeastern coastal areas of China. At present, the mechanism of PIS occurrence has not been fully elucidated, but the role of biliary flora in the formation of PIS has been recognized by more and more studies. This article reviews the research progress of biliary flora in the formation of PIS with a view to strengthening the clinical understanding of mechanism of PIS, increasing the attention to the detection of biliary flora, and providing a reference for the prevention and treatment of PIS and the improvement of prognosis.

Research advances in the formation mechanism of primary intrahepatic stones caused by biliary flora / 临床肝胆病杂志

Primary intrahepatic stones (PIS) is a refractory disease with a high incidence rate in southwest China, and some patients still require surgery again or even more times after initial treatment. Many studies in recent years have shown that some specific flora can colonize in the intrahepatic bile duct, leading to chronic infection and inflammation of the biliary system, and these specific types of flora, called "stone-causing flora", can produce metabolites such as β-glucuronidase and play an important role in the formation of pigmented stones. This article analyzes the role of stone-causing flora in the pathogenesis of PIS, so as to provide more treatment options for PIS patients.

The Study on the Treatment of Ursodeoxycholic Acid Plus Xiaoyao San in Patients with Primary Intrahepatic Stones / 医学研究杂志

Objective To study the clinical therapeutic effectiveness on primary intrahepatic stones(PIS) treated by Ursodeoxycholic Acid(UDCA) combined with Xiaoyao San.Methods 90 cases of patients with PIS were randomly divided into two groups:the therapeutic group(n=60) and control group(n=30).The therapeutic group treated by UDCA combined with Xiaoyao San for 45 days.And the control group treated by UDCA alone.Then we observed the changes of symptoms as well as B-ultrasonic examine.Results The total effective rate was 86.7% in therapeutic group,higher than that in the control group,60%(P

Clinical Significance of Intrahepatic Biliary Stricture: The Impact on Efficacy of Hepatic Resection in Intrahepatic Stones

BACKGROUND: In the Far East, it is well known that hepatic resection is a best form of treatment for complicated intrahepatic stones (IHS). However, many investigators have reported that the associated intrahepatic biliary stricture is the main cause of treatment failure, requiring additional management because of recurrent cholangitis. PURPOSE: A retrospective comparative study was undertaken to clarify the long term efficacy of hepatic resection in IHS and to investigate the clinical significance of intrahepatic biliary stricture affected on treatment failure after hepatic resection. Patient and METHOD: The clinical records of 44 among 51 consecutive patients with symptomatic IHS who underwent hepatic segmentectomy or lobectomy between July 1986 and October 1996 were reviewed. We excluded 7 patients from study group because of postoperative death or incomplete follow- up. Patients were divided into two study groups: group A with intrahepatic biliary stricture (n=28) and group B without stricture (n=16). Residual or recurrent stones, recurrence of intrahepatic biliary stricture, late cholangitis, and final outcomes were analyzed and compared statistically between group A and B. Patients were followed up for a median duration of 65 months after hepatectomy. RESULTS: The overall incidence of residual or recurrent stones were 36% and 11%, respectively. The initial treatment failure rate was 50% in group A and 31% in group B. Intrahepatic biliary stricture was recurred in 46% of group A, but in none of group B (P=0.001). More than two thirds of restrictures were identified on the primary site. The incidence of late cholangitis was higher in group A (54%) than in group B (6%)(p=0.002). The late cholangitis was severe, recurrent and related to stones and strictures in 11 of the 15patients in group A. Twelve patients (ten in group A and two in group B) needed additional secondary multiple procedures at a median of 12 months after hepatectomy. These consisted of percutaneous fluoroscopic stone retrieval (n=6), postoperative cholangioscopy (POC) or percutaneous transhepatic cholangioscopy (PTCS) with electrohydraulic lithotripsy (EHL)(n=3), balloon dilatation (n=7)choledochotomy (n=3), S4 segmentectomy (n=1), Sphincteroplasty (n=1), drainage of the delayed subphrenic or liver abscess (n=2), and repair of prolonged biliary fistula (n=1). The final outcomes after hepatectomy with or without secondary management were good in 80%, fair in 16%, and poor in 4% of the cases. CONCLUSION: The majority of the recurrent cholangitis after hepatectomy in IHS were related to recurrent intrahepatic ductal strictures. Therefore, hepatic resection should be included the strictured duct. However, with hepatectomy alone, it is difficult to clean the IHS and relieve the ductal strictures completely, particularly in cases of bilateral IHS, so a perioperative team approaches, including both radiologic and cholangioscopic interventions, should be used for effective management of IHS.

Bile Duct Stenosis & Intrahepatic Stones after a Transcather Hepatic Arterial Embolization: A case report

Transcatheter hepatic arterial embolization (THAE) is one of the treatment modalities that can be applied to hepatocellular carcinomas (HCC) and metastatic tumors of the liver. Complications such as cholecystitis and gallbladder necrosis, are common with THAE, but liver and peripheral bile duct necrosis are rare, and intrahepatic stones with main bile duct necrosis have never been reported. To prevent intrahepatic spread during operative manupulation and to decrease the vascularity and size of the tumor, we performed a THAE on a huge-sized HCC five times before performing the hepatectomy. We succesfully undertook a right lobectomy after the THAE with lipiodol, gelform, and adriamycin. However, severe bile duct stricture and intrahepatic stones were confirmed during the operation.

Multimodal Treatment of Intrahepatic Stones

The management of intrahepatic stones is very difficult and troublesome because of the high incidence of residual stones and complications. A retrospective study was undertaken to evaluate the results of multimodal treatment for 50 patients with intrahepatic stones who had been treated at the Department of Surgery, Pusan National University Hospital from March 1992 to February 1996. The results obtained are as follows: 1) The incidence of the intrahepatic-stones in the 413 gallstone patients was 12.1% (50 cases). The mean age of intrahepatic stone patients was 50.8 years old, and the ratio of males to females was 1.17:1. Of these 50 cases of intrahepatic stones, 23 cases involved the left hepatic duct, 7 cases the right hepatic duct, and 20 cases both ducts. 2) The most frequent drainage procedure was an end to side hepaticocutaneous jejunostomy (28 cases, 56.0%). This include 8 cases involving a combination of surgeries with hepatic resections. The other major treatment modality was a hepatic resection (16 cases, 32.0%). After the initial operations, the overall incidence of residual stones was 28.0%. The treatment by hepatic resection had the lowest incidence of residual stones, 2 cases (12.5%) of 16 patients. In the 20 cases involving a hepaticocutaneous jejunostomy, 5 (25.0%) had residual stones. Among the 5 choledocoduodenostomies, 2 patients (40.0%) had residual stones. Among the 5 transduodenal sphincteroplasties 2 patients (40.0%) had residual stones. For the 4 cases of other operations, 3 had residual stones (75.0%). 3) Of the 14 cases with residual stones, 11 cases underwent an additional lithotomy: 7 cases of a percutaneoustranshepatic cholangiographic lithotomy (PTC-L), and 4 cases of a choledochoscopic lithotomy through an anchored subcutaneous jejunal limb (Endo-L). All the PTC-Ls were successful. However, two Endo-Ls failed, and these patients were later successfully treated with a PTC-L. In conclusion, the data showed a high incidence of intrahepatic stones in gallstone patients. For the treatment of intrahepatic stones, hepatic resections seemed to be the best choice, showing the lowest incidence of residual stones. For the drainage procedure, the hepaticocutaneous jejunostomy seemed to be the best choice for the following reasons: the ease of performing the frequently required lithotomy using a choledochoscope after the initial operation, and the ease of intervening in case of complications during a PTC-L.

Hepatic Resection for Intrahepatic Stones

The main objectives of the surgical treatment of intrahepatic stones are complete removal of the stones and correction of biliary stasis and strictures. Hepatic resection is expected to yield a most satisfactory treatment result by eradicating the stones and the strictured bile duct as well. To evaluate the effectiveness and the risk of hepatic resection, we reviewed 149 patients who underwent hepatic resection due to intrahepatic stones over a fourteen-year period and who were followed up. There were 48 males and 101 females, and ages ranged from 20 to 70 years. The stones were located in the left lobe in 96 patients, the right lobe in 13 patients, and both lobes in 40 patients. The operative procedures executed in the patients were 96 lateral segmentectomies, 33 left lobectomies, 14 right lobectomies, one extended right lobectomy, and five partial resections. Biliary drainage procedures were added in 40 patients. Postoperatively, retained stones were found in 24.2% of the patients which was lowered to 10.7% at the time of discharge with assistance of radiologic interventions. During follow-up over a mean period of 63 months, 93.2% of the patients showed good rehabilitation, and recurrent stones had developed in 5 patients (3.5%). Operative complications were biliay fistula in 10 patients, intra-abdominal abscess in seven patients, hepatic failure in two patients, and postoperative bleeding in one patient, and the overall operative mortality rate was 2.0%. We conclude that hepatic resection is a safe and satisfactory treatment option for patients with intrahepatic stones.

Surgical Management of Intrahepatic Stone

Intrahepatic stones are found predominantly in southeast Asia and causes serious problems including obstructive jaundice, cholangitis, and liver abscesses. The operative principles for resolving these problems are complete removal of the stones within intrahepatic and extrahepatic ducts and establishment of adequate drainage. The clinical features and follow-up results of 90 patients with intrahepatic stones who were treated surgically at the Department of Surgery of St. Benedict Hospital during the period of 10 years from January 1987 to December 1996 are presented. This study includes all the gallstones located in the intrahepatic ducts above the confluence of the main hepatic ducts. Biliary bypass operations were performed in 30 cases (33%) with 29 biliojejunostomies and one choledochoduodenostomy. Five of the 29 hepaticojejunostomies had subcutaneous jejunal limb. Partial hepatectomies were performed in 20 cases (22%) with 16 left lateral segmentectomy and 4 of left hepatic lobectomies. The overall postoperative complication rate was 40%: 70% in the hepatic resection group and 31% in the non-hepatic resection group. The relative incidence of good results was higher in the hepatic resection group (68%) than in the non-hepatic resection group (41%) and in the biliary bypass operation group (54%) than in the non-biliary bypass operation group (41%). In conclusion, an aggressive hepatic resection with biliary bypass operation should be performed, if permitted, in patients with intrahepatic stones.

Hepatic Resection for Intrahepatic Stones

The intrahepatic stones and associated cholangitis result in progressive biliary stricture, hepatic atrophy, hepatic abscess and ultimately in irreversible liver cirrhosis and biliary malignancy of the liver. Although removal of intrahepatic stones using stone fragmentation and cholangioscope has been a general treatment modality, hepatic resection with removal of the affected ducts should be required for a permanent cure. We experienced hepatic resection of 100cases with intrahepatic duct calculi from November 1978 to May 1996 in the Department of Surgery, Hanyang University Hospital. The results were as follows: 1) The peak incidence of age was noted in the 4th decade (35 cases, 35.0%),5th decade (26 cases, 26.0%). 2) The male to female ratio was 46(46.0%):54(54.0%) in 100 cases. 3) Previous biliary operation(cholecystectomy with T-tube choledochostomy) was done in 30(30.0%) cases. 4) The most common clinical symptom and sign were RUQ pain(75 cases, 75.0%) and RUQ tenderness(75 cases, 75.0%). 5) In the lab findings, Alk P(55 cases, 55.0%) and ALT(52 cases, 52.0%) were especially increased. 6) 80 cases(80.0%) of intrahepatic stones were found in the left intrahepatic duct and 60 cases(60.0%) of Intrahepatic duct stones were associated cholelithiasis and/or choledocholithiasis. 7) 79 out of 100 cases had left lateral segmentectomy,15 out of 100 cases had left lobectomy, 3 cases had right lobectomy, 1 case pleurisegmentectomy, 1 case bisegmentectomy and 1 case atypical resection of the liver. 8) The incidence of residual stones was 10.0% and the incidence of recurrent cholangitis was 9.0%(9 cases). 9) The postoperative complications were wound complications(16 cases, 16.0%), chest complications(13 cases, 13.0%), bile leakage(4 cases, 4.0%), subhepatic abscess(3 cases, 3.0%). 10) The intrahepatic stones were combined with 3 cholangiocarcinoma,2 hepatocellular carcinoma and 1 GB cancer.

The treatment of intrahepatic stones by Roux-En-Y choledochojunostomy with subcutaneous jejunal conduit.

The major problem in the management of intrahepatic stones is recurrent cholangitis due to residual stones in the liver dislodging and obstructing the main path of biliary system. In order to avoid the re-operation, the Roux-Y choloedochojejunostomy with subcutaneous jejunal conduit is intervened. The procedure provides a permanent route from the exterior into the biliary system through which appropriate instruments can be passed for stones removal and biliary drainage. Recurrent cholangitis from residual stones in these patients were thus treated successfully. This may reduce the morbidity and mortality in the management of intrahepatic stones.