Hepatolithiasis Research Articles

Retrospective analysis of surgical management options of hepatolithiasis in a tertiary care centre in Bangladesh

Background: Hepatolithiasis (HL) is the presence of stones in the bile ducts proximal to the confluence of the hepatic ducts. It is endemic in the Asia-Pacific region. The etiology of hepatolithiasis is not fully understood but genetic, dietary and environmental factors are thought to be contributory. Malnutrition and low socioeconomic conditions are associated with a high incidence of intrahepatic stones. This study aimed to analyze the demographic and clinicopathological factors, appraise the role of surgical management and analyse the postoperative outcomes of HL in a tertiary care centre in Bangladesh. Methods: This study was conducted in the Department of Hepato-Biliary-Pancreatic Surgery and Liver Transplant (HBPS & LT), BIRDEM General Hospital, Dhaka, Bangladesh. Retrospective data of all patients operated for HL from January 2011 to December 2022 were analyzed with regard to clinical parameters, biochemical parameters and different types of surgical management. Results: A total of 52 patients underwent surgical treatment for HL. Of the patients, 65.4% were female and 34.6% were male. Of the patients, 94.2% had abdominal pain, 57.7% had fever and 28.8% presented with jaundice. A total of 30.8% of patients had a history of previous biliary surgery. Liver atrophy was present in 38.5% of cases. Hepaticojejunostomy (HJ) alone was done in 36 (69.2%) patients, hepatic resection with bilioenteric anastomosis was done in 10 (19.2%) patients and hepatic resection with T-tube placement in common bile duct (CBD) done in 6 (11.5%) patients. Endoluminal access loop was done in 2 (3.8%) patients. On followup visits, 60% of patients were asymptomatic. There was no postoperative mortality. Conclusion: Results from present study revealed encouraging results with minimal post operative complications and no mortality. BIRDEM Med J 2024; 14(3): 137-142

Comparing triple scope-combined bile duct exploration lithotripsy with laparoscopic hepatectomy for hepatolithiasis (with video)

BackgroundTo compare the efficacy of Three-scope combined (laparoscopic, rigid choledochoscopy and electronic choledochoscopy, TS) with laparoscopic hepatectomy (LH) for patients with hepatolithiasis (HL). MethodsBetween January 2019 and January 2020, 118 consecutive patients with HL treated with TS (TS group, n = 57) or LH (LH group, n = 61) were analyzed in this study. Perioperative and long-term outcomes, including operative time, intraoperative blood loss, blood transfusion, postoperative bowel function recovery time, postoperative hospital stay, complication rate, stone removal rate, and stone recurrence rate, were compared and analyzed between the two groups. ResultsCompared with the LH group, the TS group had significantly lower intraoperative blood loss and transfusions, significantly shorter operative time and hospital stay, and fewer complications (P < 0.05 for all). There was no significant difference in the final stone removal rate, stone recurrence rate and postoperative bowel function recovery time (P > 0.05 for all). ConclusionTS is a safe and effective treatment for HL and is superior to LH in terms of overall treatment outcome and complications.

Clinical, histopathological, and immunohistochemical spectrum of hepatolithiasis: a tertiary care center-based study from north India.

Hepatolithiasis (HL), an uncommon disease among Indians, occurs due to a complex interplay of various structural and functional factors. We retrospectively evaluated the clinical and histopathological spectrum of HL (N = 19) with immunohistochemical evaluation for biliary apomucins and canalicular transporter proteins, both crucial for lithogenesis. Nineteen surgically resected cases were included. Histopathology was systematically evaluated. Immunohistochemistry for apomucins (MUC1, MUC2, MUC4, MUC5AC, and MUC6) and canalicular transporter proteins (BSEP and MDR3) was applied to all cases. The median age was 51years with female preponderance (F:M = 1.4:1). The stone was cholesterol-rich in 71.4% and pigmented in 28.6% (n = 14). Histopathology showed variable large bile-duct thickening due to fibrosis and inflammation with peribiliary gland hyperplasia. Structural causes (Caroli disease, choledochal cyst, and post-surgical complication) were noted in 15.8% of cases (secondary HL). Expression of gel-forming apomucin MUC1, MUC2, and MUC5AC was seen in either bile duct epithelia or peribiliary glands in 84.2%, 10.5%, and 84.2% cases respectively. Loss of canalicular expression of MDR3 was noted in 42.1% of cases while BSEP was retained in all. Primary HL in the north Indian population can be associated with the loss of MDR3 expression (with retained BSEP) and/ or a shift in the phenotype of biliary apomucins to gel-forming apomucins. The former factor alters the bile acid/ phospholipid ratio while the latter parameter promulgates crystallization. In conjunction, these factors are responsible for the dominantly cholesterol-rich stones in the index population.

Evaluating prognostic value of biliary stone in intrahepatic cholangiocarcinoma by propensity score matching analysis.

Background: To explore biliary tract stone (BTS) as prognostic factors of intrahepatic cholangiocarcinoma (ICC). Methods: Clinical data of 985 ICC patients were classified into no BTS group and BTS group-subgrouped into hepatolithiasis (HL) and non-hepatolithiasis (NHL) group. Propensity score matching was utilized to mitigate baseline characteristics. Preoperative peripheral inflammation parameters (PPIP) were further investigated. Immunostaining of CD3, CD4, CD8, CD68, PD1 and PD-L1 were conducted. Results: Overall survival (OS) of patients without BTS surpassed BTS group (P = 0.040) while no difference of time to recurrence (TTR) was observed (P = 0.146). HL group had shorter OS and TTR than HL-matched group (P < 0.001 and P = 0.017, respectively) and survival time of NHL group differed not with NHL-matched group (P > 0.05). PPIP like neutrophils to lymphocytes ratio (NLR), platelet to lymphocyte ratio (PLR) and systemic immune inflammation (SII) of HL group exceeded no BTS group or NHL group (all P < 0.05). Associations of PPIP and tumorous immunocytes differed vastly among HL group, NHL group and no BTS group. Tumorous CD4+/CD3+ ratio and PD1+/CD3+ ratio of HL group surpassed those in no BTS group (P = 0.036 and P < 0.001, respectively) and NHL group (P = 0.015 and 0.002, respectively). Para-tumorous CD68+ macrophages exceeded that in tumor samples of HL group (P < 0.001). No difference of CD8+/CD3+ lymphocyte ratio and PD-L1 rank were detected. Conclusions: Hepatolithiasis, rather than extra-hepatic biliary stone, is a poor prognostic indicator of ICC. Immunotherapy is promising in treating HL-related ICC.

Hepatolithiasis: A Retrospective Analysis of Surgical Management Options in a Tertiary Care Centre in Southern India.

Introduction: Hepatolithiasis (HL) is the presence of stones in the bile ducts proximal to the confluence of the hepatic ducts. This study aims to analyse the case presentations of HL in a tertiary care centre in South India and define the role of hepatic resection in these cases and their outcomes.Methods: Retrospective data of all patients operated on for HL from 2012 to 2021 were analysed with regard to clinical parameters, biochemical parameters, and different types of surgical management. Descriptive data analyses were done.Results: A total of 42 patients underwent surgical treatment for HL between 2012 and 2021 in our institution. Of the patients, 64% were females. A total of 50% of patients were affected by bilateral HL. Of the patients, 95% had abdominal pain, 57% had a fever, and 29% presented with jaundice. A total of 38% of patients had a history of previous biliary surgery. Atrophy was present in 38% of cases. Choledochoduodenostomy was performed in 26%, and hepatic resection with bilio-enteric anastomosis was done in 36% of patients. Endoluminal access loop was done in 21%. Hepaticojejunostomy alone was done in 14%. On follow-up visits (mean: 61.5 months), 60% of patients were asymptomatic with no recurrence. There was nil 30-day postoperative mortality.Conclusion: The treatment options for HL were based on the extent of liver involvement. The bilio-enteric anastomosis was done after the clearance of stones for uncomplicated HL. Complicated HL may need liver resection with hepaticojejunostomy, with an endoluminal access loop for a good outcome.

Hepatolithiasis followed by recurrent cholangitis as a consequence of inadequate hepaticojejunostomy for common bile duct injury

Introduction. Hepatolithiasis (HL) is defined as gallstones present in bile ducts above the common bile duct confluence, regardless of the coexistence of gallstones in other parts of the biliary tract. HL is common among patients with recurrent pyogenic cholangitis. Chronic infection can lead to the development of malignancy. Case outline. A 65-year-old woman presented with intermittent fever, jaundice, abdominal pain, and nausea. Eighteen years previously, the patient had an open cholecystectomy due to acute cholecystitis. During the early post-operative days, the patient developed icterus. Intrahepatic biliary ductal dilatation was confirmed by abdominal ultrasound. Due to suspicion of iatrogenic common bile duct injury, the patient underwent a second operation, during which the said injury was confirmed. ?Non-Roux-en-Y? hepaticojejunostomy (HJ) was performed as a problem-resolving procedure. Despite the performed biliary bypass, the patient continued to have episodes of recurrent cholangitis over the 18 years. Given the patient?s recurrent symptoms and results of MRI consistent with HL, surgical treatment was indicated. A left hepatectomy was performed, with Roux-en-Y HJ biliary reconstruction. The post-operative course was uneventful, after which the patient has been symptom-free. Conclusion. The main purpose of treating HL is to eliminate infection which leads to recurrent cholangitis and subsequent hepatic fibrosis. Adequate solution of HL decreases the need for repeated interventions and prevents progression of the disease to cholangiocarcinoma.

Laparoscopic middle-hepatic-vein-guided anatomical hemihepatectomy in the treatment of hepatolithiasis: a 10-year case study.

This retrospective 10-year case study evaluated the perioperative results and long-term efficacy of laparoscopic middle-hepatic-vein-guided hemihepatectomy (L-MHV-H) and traditional anatomical hemihepatectomy (TAH) in the treatment of hepatolithiasis (HL). From January 2010 to December 2019, 99 patients with regional HL underwent laparoscopic anatomical hemihepatectomy (LAH) at our centre, including 43 patients in the L-MHV-H group and 56 patients in the TAH group. All patients in both groups were Child-Pugh grade A before operation. No significant between-group differences in general information, stone distribution, comorbidities, history of previous abdominal surgery or co-occurrence of gallstones and common bile duct stones were observed. The L-MHV-H group exhibited a higher intraoperative stone clearance rate (95.3% vs. 75.0%, p = 0.014) and a lower postoperative complication rate (10.1% vs. 48.2%, p = 0.005) compared with the TAH group. In the median follow-up time of 60months (range 6-125months), the L-MHV-H group had lower stone recurrence (2.3% vs. 19.6%, p = 0.013) and cholangitis recurrence (2.3% vs. 17.9%, p = 0.034) rates. No significant between-group differences in the other results were observed. L-MHV-H is safe and feasible for HL with certain advantages over TAH in improving the intraoperative stone clearance rate, reducing postoperative complication incidence and reducing stone and cholangitis recurrence rates.

Hepatolithiasis: clinical series, review and current management strategy.

Hepatolithiasis (HL) continues to be a problem due to its local and systemic complications, insufficiency in treatment modalities and high risk of recurrence. There are various surgical options available, ranging from endoscopic interventions to a small segment resection and ultimately to transplantation. In this article, patients with the diagnosis of HL and our treatment strategies were evaluated in the light of literature. The patients diagnosed with HL in our clinic between 2014-2019 were evaluated retrospectively by examining the patient files. Demographic characteristics of the patients, causes of the disease, complications and treatment options were evaluated. 17 patients were included into the study. Mean age of the patients was 64.3 years (range 32-89 years). Seven patients had previous cholecystectomies. Stenosis was found to be developed in hepaticojejunostomy (HJ) site in three patients (two had HJ due to bile duct injury and one had HJ following the Whipple procedure), and in hepaticoduodenostomy site in one patient who had the history of biliary tract injury during cholecystectomy. Two patients with HL without previous cholecystectomies had no gallbladder stones. Nine patients underwent surgery. Left hepatectomy was performed in two patients and lateral sector resection was performed in 2 patients. Two patients with anastomotic stenosis underwent HJ revision and two patients with anastomotic stenosis and one patient with stent ingrowth underwent bifurcation resection and neo-hepaticojejunostomy. Eight patients were followed-up nonoperatively with medical and endoscopic approaches. Hepatolithiasis is a serious condition that needs to be treated with a multimodal approach. Stenting and anastomotic stenosis facilitate the development of hepatolithiasis and increase the risk of its occurrence. In particular, by performing functional hepaticojejunostomy, the development of this complication will be decreased.

S1392 A Souvenir to Remember: A Rare Case of Primary Hepatolithiasis in a White Active Duty Sailor

INTRODUCTION: Primary Hepatolithiasis (HL), is a condition defined by de novo formation of pigmented calcium bilirubinate stones in the intrahepatic bile ducts. The exact mechanism is unknown, but it is likely multifactorial due to ethnic predisposition and environmental exposures such as diet and bacterial/parasitical infections. The most common clinical manifestation is recurrent bouts of cholangitis resulting in sclerosing cholangitis and parenchymal fibrosis. HL is endemic to South East Asia (SEA), and when recorded in the west it is nearly exclusive to Asian immigrants. Here we present a case of HL in a Caucasian Sailor with limited exposure to SEA. CASE DESCRIPTION/METHODS: A 28 year old white Navy male with no previous medical history, presented with 1 day history of acute onset epigastric pain, fevers, chills, anorexia and nausea. The pain was described as being sharp and localized in his right upper quadrant. He reported a previous similar self-limited episode 1 month prior. Also noted to have dark-colored urine with pale appearing stools. History notable for very rare EtOH and no tobacco use. He had been stationed in Japan for 2 years but departed in 2016; 3 years prior to presentation. His ROS was otherwise negative. His vitals were unremarkable except for a HR in the 90’s. His labs were notable for a WBC of 12.7 cells/microliter, total bilirubin 4.2 mg/dL, direct bilirubin 2.5 mg/dL, ALT 260 U/L, AST 108 U/L and ALP 343 U/L. Lipase was normal. RUQUS revealed distension of the gallbladder with no cholelithiasis or choledocholithiasis. MRCP revealed innumerable small stones within the intrahepatic biliary ducts resulting in biliary ductal dilatation and ductal hyperenhancement. He was treated supportively with IV fluids, pain control with fentanyl and ondansetron with complete resolution of symptoms within 48 hours. Based on the patient’s clinical presentation, travel history, and MRCP findings, we believe this to be a case of HL. DISCUSSION: HL is a very rare disease process outside SEA. Western cases of hepatolithiasis are more often secondary and attributable to bile duct malformations (Caroli disease or choledochal cysts), primary sclerosing cholangitis, or postoperative/posttraumatic strictures. The risk of progressive disease and late complications such as cholangiocarcinoma remain unclear in this patient. This case is unique as it suggests that HL can occur through limited endemic exposure.Figure 1.: Innumerable stones within the left intrahepatic bile duct.

Identification of Cholangiocarcinoma Associated with Hepatolithiasis via the Combination of miRNA and Ultrasound.

BackgroundIdentification of cholangiocarcinoma (CCA) associated with hepatolithiasis (HL) is difficult. There is no effective method to discriminate CCA associated with HL (HL-CCA) from HL currently.ObjectiveTo explore the value of clinical data, ultrasonic characteristics and miRNA expression level in the identification of HL-CCA.MethodsThirty-one patients with HL-CCA in Huazhong University of Science and Technology Union Shenzhen Hospital were enrolled in the observation group, while 40 patients with HL alone were included in the control group. The clinical data, ultrasonic characteristics, and miRNA expression level of the two groups were recorded and analyzed to explore the potential indicators for the identification of HL-CCA.ResultsThe accuracy of ultrasound in the diagnosis of HL-CCA was low (54.84%). Multivariate logistic regression analysis showed that liver abscess (P=0.021), indistinct border demarcation (P=0.015), non-homogenous echotexture (P=0.019), missed portal vein around lesion (P=0.032), miRNA-21 (P=0.018) and miRNA-221 (P=0.009) were the potential indicators for the identification of HL-CCA. The combined diagnosis based on logistic regression contained liver abscess, border demarcation, echotexture, portal vein around lesion, miRNA-21 and miRNA-221. The results showed that the accuracy of combined diagnosis identifying HL-CCA was the most accurate (AUC=0.911), which was significantly greater than the AUC of miRNA-21 or miRNA-221 individually (P<0.05), with a sensitivity and specificity of 77.42% and 97.50%, respectively.ConclusionPatients with HL-CCA show high incidence of hepatic abscess and elevated miRNA-21 and miRNA-221 expression level. The ultrasonic features are more likely to show indistinct border demarcation, non-homogenous echotexture, and missed portal vein around lesion. The combined diagnosis is more accurate in the identification of HL-CCA.

The ultrasonic navigation technique in percutaneous transhepatic one-step biliary fistulation with rigid cholangioscopic lithotripsy for complicated hepatolithiasis

Objective To study the efficacy and safety of percutaneous transhepatic one-step biliary fistulation (PTOBF) with rigid cholangioscopic lithotripsy for treatment of complicated hepatolithiasis under the ultrasonic navigation technique. Methods In this retrospective study, PTOBF lithotripsy surgery was performed in 94 patients with hepatolithiasis under general anesthesia with tracheal intubation, and with percutaneous transhepatic puncture of targeted bile duct under ultrasonic navigation in The First Affiliated Hospital of Guangzhou Medical University. Biliary expanders were used along a guidewire to expand the sinus gradually until 14Fr to establish a fistulous channel. Lithotripsy was then performed through the channel by rigid cholangioscopy. The operation-related data were collected and analyzed, including puncture and fistula establishment success ratio, complication rate, intraoperative blood loss, residual and recurrence hepatolithiasis rates. Results 94 patients (total 122 patient-times) underwent PTOBF lithotripsy. There was no perioperative mortality. The overall puncture success rate was 100%, and the fistula/puncture rate was 97.5% (119/122). In 118 patients success was achieved in 2 time (96.7%). The complication rate was 9.6% (9/94). The average intraoperation blood loss were (24.9±21.3)ml. The residual calculus rate after therapy was 13.8%(13/94). All patients were followed-up for a period that ranged between 18 and 30 months. The recurrence rate was 14.9%(14/94). Conclusions Ultrasonic navigation technique plays an important role in bile duct puncture, sinus expansion and rigid cholangioscopic lithotripsy for treatment of complicated hepatolithiasis. PTOBF lithotripsy is a safe and effective procedure, which provides a new way in mini-invasive treatment for hepatolithiasis. It is worth generalizing. Key words: Ultrasound; Navigation; Percutaneous transhepatic puncture; Hepatolithiasis; Rigid cholangioscope

New management of hepatolithiasis: Can surgery be avoided? (with video)

BackgroundThe presence of hepatolithiasis (HL) is prevalent in eastern countries. It is a clinical entity which is rarely reported in non-surgical series because the standard treatment is the surgical option. Currently, treatment has evolved, with the use of endoscopic techniques being increased and the number of hepatectomies being decreased.SpyGlass™ is a small-calibre endoscopic direct cholangiopancreatoscopy developed to explore and perform procedures in the bile and pancreatic ducts. Single-operator peroral cholangioscopy (POC) is an endoscopic technique useful for treating difficult bile duct stones. AimsTo assess the usefulness, efficacy, and safety of POC with the SpyGlass™ system in patients with HL. Primary objectives: to achieve technical success of the procedure and clinical success of patients with HL. Study design and patientsRetrospective, single-centre cohort study of patients with HL from April 2012 to August 2018. SpyGlass™ was chosen in symptomatic patients referred from the surgery unit as the first-line procedure. To perform electrohydraulic lithotripsy (EHL), we used a Northgate Autolith IEHL generator with a 0.66-mm biliary probe. ResultsWe performed a total of 13 procedures in 7 patients with HL. The mean age was 46 years (range 35–65) and 3/7 of patients were female. We achieved technical success in 5/7 cases (71.4%) and clinical success in 4/7 cases (57%). DiscussionSpyGlass™ is safe and effective in the treatment of HL. With these results, we confirm the need for management of patients with HL in a multidisciplinary team. When the endoscopic approach is the option, this procedure must be performed by experts in advanced endoscopy.

Analysis of prognostic factors of patients with intrahepatic cholangiocarcinoma and establishment of a nomogram for survival prediction

Objective To explore the prognostic factors of patients with intrahepatic cholangiocarcinoma (ICC) after surgical resection and establish a nomogram for survival prediction. Methods A total of 160 patients with ICC who underwent surgical resection in the First Affiliated Hospital of Xi′an Jiaotong University from January 2010 to December 2018 were retrospectively analyzed. Among them, 89 patients were males and 71 were females, aged from 29 to 81 years with a age of (57.41±10.35) years. Observation indicators included: (1) The result of follow-up: postoperative survival. (2) The univariate analysis and multivariate analysis affecting postoperative patients′ prognosis. (3) The establishment and validation of nomogram model. The follow-up using outpatient and telephone was performed once every 3 months within 1 year postoperatively and once every 3-6 months after 1 year postoperatively up to August 1, 2019. The follow-up included liver function, CA19-9, upper abdominal ultrasound, CT or MRI. The overall postoperative survival time, end point of observation, was the date from the operation date to the follow-up date, or the date of death due to tumor recurrence and metastasis. The patients′ clinicopathological data was included in the prognostic factor analysis, the Kaplan-meier method and Log-rank test were conducted for the univariate analysis, the Cox proportional risk regression model was used for the multivariate analysis. The independent risk factors based on Cox regression model were screened to establish a nomogram for postoperative survival prediction. The patients were divided into the model group (n=112) for the establishment of survival nomogram and the validation group (n=48) for the assessment of predictive ability at a ratio of 7∶3, and the accuracy of nomogram in postoperative survival prediction was assessed by c-index. Measurement data with normal distribution were expressed with (Mean±SD). Measurement data with skewed distribution were described as M (range). Count data were expressed as cases and percentage. Results During the follow-up period, all patients with ICC after surgical resection were followed up for a survival time of 20 months (2-111 months). 100 patients died of multiple organ failure caused by tumor recurrence and metastasis and 60 patients survived. The 1-, 3- and 5-year overall survival rates of patients were 63.3%, 30.0% and 19.6%, respectively. Univariate analysis showed that CA19-9, hepatolithiasis, number of tumor, range of liver resection, tumor differentiation, pathology type, tumor diameter, vascular invasion, TNM stage, lymphatic metastasis, satellite foci and surgical margin were the prognostic factors of ICC patients after surgical resection (HR=1.78, 1.97, 2.91, 1.89, 3.06, 2.86, 2.07, 1.94, 2.24, 1.95, 2.68, 2.00, 95%CI: 1.12-2.85, 1.22-3.16, 1.85-4.56, 1.26-2.85, 1.38-6.82, 1.31-6.25, 1.37-3.14, 1.07-3.51, 1.24-4.06, 1.26-3.01, 1.28-5.60, 1.11-3.59, P<0.05). Multivariate analysis showed that hepatolithiasis, number of tumor, range of liver resection, tumor differentiation (low differentiation) and pathology type were independent risk factors of ICC patients after surgical resection (HR=2.47, 2.37, 2.06, 5.52, 5.72, 95%CI: 1.39-4.38, 1.44-3.91, 1.25-3.40, 1.24-24.49, 2.31-14.17, P<0.05). The nomogram was established based on above five independent risk factors, the c-index value for postoperative survival of the model group and validation group were 0.71 (95%CI: 0.64-0.79) and 0.71(95%CI: 0.61-0.81), respectively. Conclusion A nomogram based on hepatolithiasis, number of tumor, range of liver resection, tumor differentiation and pathology type has better accuracy in postoperative survival prediction for patients with ICC. Key words: Bile duct neoplasms; Prognosis; Nomograms; Intrahepatic cholangiocarcinoma; Survival prediction

Hepatolithiasis; case series, review and current management strategy

Background: Intrahepatic biliary tract stone formation is referred to as hepatolithiasis (HL). Hepatolithiasis causes local and systemic complications and insufficient treatment Methods with increased risk of reoccurrence makes it an important health problem. Surgical interventions ranges from endoscopic attempts to small segment resection and finally to liver transplant. Here in, we evaluated the patients who are diagnosed with HL and the treatment strategies in light of the current literature. Materials and Methods: Patients who are diagnosed with HL between the years of 2014 to 2018 and the applied treatment strategies were retrospectively examined. Patient demographics, causes of disease, complications and the treatment options of the patients were evaluated. Results: Totaly 16 patients were admitted to the study. Mean age of the patients was 64.3. We determined that 7 patients had been received cholecystectomy before. Out of these 7 patients, three patients, because they had been operated for main bile duct trauma during laparoscopic cholecystectomy, had been suffered from anastomotic stenosis in which has 2 hepaticojejunostomy (HJ) stenosis and 1 hepaticoduodenostomy stenosis with metal stent. Also, HJ stenosis and then HL developed in one patient after Whipple procedure. Ultrasonography, EUS, MRCP, CT, ERCP, PTC Methods are applied for diagnostic purposes. Eight patients were operated for HL; left hepatectomy for 2 patients and lateral sector resection in one patient. HJ revised in two patients. Stenotic region including stent ingrowth and fibrotic stricture resected and neo-hepaticojejunostomy performed in 2 patients. Anastomotic resection and portojejunostomy (Kasai) performed in one patient. All of HJ were done in Roux-en-Y style. The remaining 8 patients were observed with medical and endoscopic approaches. Discussion and Conclusions: Hepatolithiasis is a serious condition that requires multimodal treatment approaches. Anastomosis stenosis and stent implementation promote hepatolithiasis formation and increase recurrence. Functional HJ procedures will especially decrease the formation of this complication.

Treatment strategies of complicated extrahepatic bileduct stones

Complicated extrahepatic bile duct stone is defined as not easy to achieve the treatment standard of total stone clearance, stricture removal, unobstructed drainage and recurrence preventing in a single operation or combined with other liver diseases, which include hepatic hilar bile duct stones incarceration, distal bile duct stone incarceration, Mirizzi syndrome, residual cystic duct stones, recurrent extrahepatic bile duct stones, and combined with portal hypertension or intrahepatic bile duct stones. Through comprehensive and meticulous preoperative evaluation, we can clarify the cause of extrahepatic bile duct stones, the location of stones and bile duct stenosis, the variability of bile duct, the anatomy of the hepatoduodenal ligament, the condition of liver function and biliary tract infection, and make the proper surgery plan. During the surgery, we apply the perihilar surgical techniques, pancreatic hilar plate reduction techniques, Oddi sphincter incision and shaping, and choledochoscopic lithotripsy and lithotomy comprehensively to achieve the goal of reducing residual stone rate and recurrence rate. It is important that reasonably select endoscopic retrograde cholangiopancreatography indications, correctly hold indications of bilioenteric anastomosis, and prevent iatrogenic injury of extrahepatic bile ducts on the premise of clearing stones. Key words: Hepatolithiasis; Extrahepatic bileduct stone; Perihilar surgical techniques; Pancreatic hilar plate reduction techniques; Choledochoscope; Lithotripsy

Research progress of hepatolithiasis

Hepatolithiasis is a disease which stone firstly occurs in intrahepatic bile duct system.This disease has complex pathogenetic condition, extensive lesion.It also has high recurrence rate, residual stone rate and complication occurrence rate.And at the same time, it has possibility to be canceration.At present, hepatectomy is considered to be the best approach to treat hepatolithiasis.What's more, there are also some other therapies, such as transhepatic cholangiolithotomy, bile duct stricture repair revascularization, liver transplatation and non-operation treatment, and so on.In recent years, the symptom of hepatolithiasis in our country becomes lighter, the range becomes more limited, and the course becomes more early.However, this disease is still a big challenge for hepatobiliary surgeon.In this article, we review the epidemiology, pathogenesis and treatment progress of hepatolithiasis. Key words: Calculus of intrahepatic duct; Epidemiology; Reviev

Anatomical hepatectomy combined with intraoperative choledochoscopy in treatment of complicated hepatolithiasis

Objective To study the clinical outcomes of anatomical hepatectomy combined with intraoperative choledochoscopy in treatment of complicated hepatolithiasis. Methods The clinical data of 176 patients with complicated hepatolithiasis who underwent operation at the Department of General Surgery of No.960 Hospital of PLA from May 2005 to July 2015 were analyzed retrospectively. The data included general data, clinical manifestations, types of stones, operative methods, postoperative complications and follow-up. Results There was no perioperative death. The postoperative complications which occurred in 31 patients (17.6%) included lung infection, intra-abdominal infection, bile leakage, and liver failure. Eighteen patients (10.2%) were found to have residual stones. After a follow-up which ranged from 1 to 3 years, 152 patients (94.4%) had good clinical outcomes. Recurrent stones were found in 12 patients (7.5%). Conclusion Anatomical hepatectomy combined with intraoperative choledochoscopy improved operative outcomes in patients with complicated hepatolithiasis and decreased residual stone and recurrence rates. Key words: Hepatolithiasis; Anatomical hepatectomy; Choledochoscope

Efficacy and safety of laparoscopy and open choledochal exploration in the treatment of complicated hepatolithiasis

Objective To study the efficacy and safety of laparoscopy and open choledochal exploration in the treatment of complicated hepatolithiasis. Methods From March 2014 to March 2017, 150 cases of complicated hepatolithiasis who were treated in Heji Hospital Affiliated to Changzhi Medical College were selected.The patients were divided into observation group and control group according to random number table, with 75 cases in each group.The control group was treated with conventional open abdominal common bile duct exploration, and the observation group was treated by laparoscopic choledochal exploration.The levels of surgical indicators, the incidence of complications, the recurrence rate, the bilirubin level before operation and 1 month after operation, and the quality of life before operation and 6 months after operation were compared between the two groups. Results The operative time, intraoperative blood loss, gastrointestinal recovery time and hospitalization time in the observation group were (154.23±20.47)min, (59.12±8.92)mL, (19.65±3.48)h, (11.48±2.48)d, respectively, which were significantly lower than those in the control group [(217.59±30.59)min, (87.24±10.17)mL, (27.87±6.12)h, (16.51±4.28)d] (t=14.908, 18.002, 10.112, 8.806, all P<0.05). The levels of total bilirubin, direct bilirubin and indirect bilirubin in the observation group at 1 month after operation were (14.38±3.69)μmol/L, (3.39±1.17)μmol/L, (11.45±3.02)μmol/L, which were significantly lower than those in the control group [(28.43±4.31)μmol/L, (6.31±2.08)μmol/L, (21.05±4.87)μmol/L] (t=21.445, 10.596, 14.508, all P<0.05). The incidence rate of complications and recurrence rate of the observation group at 6 months after operation were 2.67% and 0.00%, respectively, which were lower than 14.67% and 10.67% of the control group (χ2=6.822, 8.451, all P<0.05). The scores of social activities, energy, physical activity and sleep mood in the observation group at 6 months after operation were (4.72±0.85)points, (13.25±1.21)points, (3.81±0.51)points, (6.52±2.44)points, respectively, which were higher than those in the control group [(2.65±0.61)points, (8.09±0.68)points, (1.95±0.52)points, (3.98±2.38)points] (t=10.513, 11.605, 12.604, 6.454, all P<0.05). Conclusion Laparoscopic choledochal exploration is effective in the treatment of complicated hepatolithiasis, and it can improve the level of bilirubin and improve the quality of life, the safety is good. Key words: Cholecystolithiasis; Laparoscopy; Bilirubin; Comparative Effectiveness Research

Changes of local microenvironment in the evolution of intrahepatic cholelithiasis to intrahepatic cholangiocarcinoma

Hepatolithiasis is a very common hepatobiliary disease in Asia. Recurrent hepatolithiasis frequently lead to incidence of intrahepatic cholangiocarcinoma. The associated intrahepatic cholangiocarcinoma is generally hidden and often covered up by the related clinical symptoms caused by stones, which can easily lead to missed the best time of diagnosisand treatment. This paper mainly showed the diseases of intrahepatic cholangiocarcinoma associated with intrahepatic cholelithiasis, and expounded the changes of local microenvironment of bile duct tissue from intrahepatic cholelithiasis to intrahepatic cholangiocarcinoma. The purpose of this study is to look for the risk factors related to the development of intrahepatic cholelithiasis to intrahepatic cholangiocarcinoma and to provide a new research direction for the clinical treatment of intrahepatic cholangiocarcinoma. Key words: Biliary duct neoplasms; Tumor microenvironment; Intrahepatic cholelithiasis; Intrahepatic cholangiocarcinoma

Relationship between Pst-I polymorphism of mucin 4 gene and primary hepatolithiasis

Objective To investigate the relationship between Pst-I polymorphism of mucin 4 gene and primary hepatolithiasis in the Chinese population. Methods Venous blood of 96 healthy controls and 56 patients with hepatolithiasis were collected, and DNA was extracted. Polymerase chain reaction combined with restriction enzyme (PCR-RFLP) digestion was used to detect Pst-I polymorphism of mucin 4 gene in the two groups. The genotype and gene frequency between the two groups were then compared. Results The genotype frequencies of GC, GT, TT in the control and the hepatolithiasis groups were 21.3%, 12.7%, 55.6% and 53.2%, 41.2%, 19.8%, respectively. The alleles C and T gene frequencies in the control and the hepatolithiasis groups were 21.5%, 72.7% and 66.3%, 30.2%, respectively. There were significant differences in Pst-I polymorphism of mucin 4 genotype frequency and gene frequency between the two groups. Conclusion The data showed Pst-I polymorphism of mucin 4 gene was associated with primary hepatolithiasis in Chinese patients. Key words: Mucin 4; Pst-I polymorphism; Hepatolithiasis