1.What is gallstone disease? What is hepatobiliary stone? Cholelithiasis is a disease in which stones occur in any part of the biliary system (including gallbladder and bile duct). In Eastern countries, because of less consumption of animal fat and less absorption of vegetable fat, the concentration of cholesterol in blood is generally lower than that of Westerners, so cholesterol stones are less common, while bile pigment stones are more common than in Western countries, and most gallstone diseases in China are related to infection. As a common condition of the biliary system, the incidence of cholelithiasis has been gradually increasing in recent years. According to survey statistics, the incidence is second only to acute appendicitis. Depending on where the stones are located gallstone disease can be divided into gallbladder stones, extrahepatic bile duct stones, and intrahepatic bile duct stones. Intrahepatic bile ducts, also known as hepatobiliary stone disease, are more common in China, accounting for 20%-30% of all gallstones, and are particularly common in the vast regions of South China, Southwest China, Yangtze River basin and Southeast coast. Because of its complex lesions, high recurrence rate and often serious complications, this disease has become an important cause of death from benign biliary diseases in China. 2.What are the causes of hepatobiliary stones? What are the adverse consequences? The etiology of hepatobiliary stone disease is not fully understood. The formation of intrahepatic stones is related to chronic inflammation of the biliary tract, bacterial infection, biliary ascariasis, biliary stasis, malnutrition and other factors. Chronic inflammation in the bile ducts is an important factor in stone formation, and bile stasis is a necessary condition for stone formation. Stagnant bile flow and chronic inflammation of the biliary tract are most likely to form intrahepatic bile duct stones. The course of hepatobiliary stone disease is long and complex, and many serious complications can occur, so its clinical manifestations are complex and varied, basically, it can be divided into 3 types. (1) Quiet type: Patients have no obvious symptoms or mild symptoms, only vague pain and discomfort in the epigastrium, which is often detected during physical examination. (2) Obstructive type: manifests as intermittent jaundice, persistent pain and discomfort in the liver area and chest and abdomen, decreased digestive function and other biliary obstruction symptoms. Bilateral hepatobiliary stones with hepatobiliary stenosis may present with persistent jaundice. (3) Cholangitis type: manifesting as recurrent epigastric paroxysmal colic or persistent distension, chills, fever, jaundice; right upper abdominal pressure pain, percussion pain in the liver area, hepatomegaly with tenderness, etc., severe cases may be accompanied by sepsis; peripheral blood leukocytes and neutrophils are significantly elevated, serum transaminase is sharply elevated, serum bilirubin, alkaline phosphatase, glutamyl transpeptidase is elevated. In cases of acute hepatic cholangitis combined with left or right hepatic duct stone obstruction, jaundice may be absent or mild, serum bilirubin may be normal or mildly elevated, and the interictal period may be asymptomatic or obstructive. The following serious complications can occur with hepatic bile duct stones Severe acute cholangitis: i.e. acute obstructive purulent cholangitis or biliary sepsis, which is a common complication of hepatobiliary stones and a major cause of death. Biliary-derived liver abscess: a late manifestation of acute suppurative cholangitis secondary to intrahepatic bile duct stones, where the abscess occurs within the drainage area of the diseased hepatic duct. Biliary hemorrhage: due to stone obstruction secondary to purulent biliary infection, multiple ulcerations of the bile duct mucosa in the affected area erode the accompanying hepatic artery or portal vein branches and can lead to biliary hemorrhage; biliary hepatic abscess can also collapse into the bile duct and adjacent intrahepatic vascular branches and biliary hemorrhage occurs. The typical clinical manifestation of biliary hemorrhage is sudden onset of biliary colic, followed by vomiting blood or blood in stool, jaundice or deepening of jaundice, with periodic episodes and an interval of 5 to 14 days. Hepatobiliary duct cancer: Intrahepatic bile duct stones combined with hepatobiliary duct cancer occurs on the basis of migratory cholangitis. The heterogeneous hyperplasia of the epithelium of the diseased bile duct and the glands of the duct wall is the precancerous lesion of bile duct cancer. Patients often have a long history of recurrent intrahepatic bile duct stones and multiple biliary surgeries, and the hepatic bile duct obstruction is rapidly aggravated in the near future, which may manifest as frequent episodes of severe cholangitis or biliary fistula. Biliary cirrhosis and portal hypertension: long-term obstruction and infection of the bile ducts due to bile duct stones cause diffuse damage and fibrosis of the liver parenchyma, leading to secondary biliary cirrhosis and portal hypertension. It manifests as persistent obstructive jaundice or frequent episodes of cholangitis, hepatosplenomegaly, esophagogastric fundic varices, liver function impairment, hypoproteinemia, and anemia. 3.What tests are needed to diagnose hepatobiliary stones? The imaging techniques that have practical value for the diagnosis of hepatobiliary stones are mainly ultrasound, CT, MR I, ERCP, PTC, postoperative bile duct angiography, cholangioscopy and so on. A single examination is often unable to obtain a comprehensive diagnosis, and more than one imaging examination is often required to corroborate each other to achieve a correct diagnosis. Because of the complexity of hepatobiliary stones, it is difficult to make a comprehensive and accurate diagnosis before surgery, especially to determine the secondary lesions caused by the stones. The preoperative diagnosis of hepatobiliary stones should be based on a combination of ultrasound, CT and/or MRI, with ultrasound being the first choice. It can provide clues for clinical diagnosis, but cannot be used as a complete basis for surgical procedures. CT can show the distribution of intrahepatic bile duct stones, the dilatation of the bile duct system and the lesions of the liver parenchyma, which is an important diagnostic value for hepatic bile duct stones. Magnetic resonance examination can show the intrahepatic bile duct tree in multiple directions, which can accurately determine the distribution of intrahepatic stones, the location and extent of stenosis and dilatation of the bile duct system and the lesions of the liver parenchyma. 4.How to treat hepatobiliary stones? Hepatic bile duct stones with obvious clinical symptoms need to be treated. There is no unanimous opinion as to whether treatment is needed for quiescent stones that do not have obvious symptoms. In view of the fact that with the progression of the disease and the development of the lesion, most cases will have obvious symptoms and the possibility of malignant transformation of the involved hepatic ducts, most experts advocate active surgical treatment or percutaneous transhepatic biliary choledochoscopy for the treatment of static stones. The treatment of hepatic bile duct stones mainly relies on surgery, and the principles are to remove the lesion, remove the stone, correct the stricture, unblock the drainage, and prevent recurrence. With the continuous improvement of laparoscopic surgery technology and the gradual improvement of surgical instruments, bile duct lithotomy and partial hepatic lobectomy can be done through laparoscopic surgery, which can be completed by inserting surgical instruments into the abdominal cavity through 3-5 small 0.5-1.0 cm holes in the abdominal wall. Because the “big incision” is avoided, the damage to the abdominal wall is minimal, which has the advantages of small trauma and fast recovery. In addition, the application of intraoperative ultrasound, cholangiography and cholangioscopy plays a very important role in the adoption of the correct surgical approach. Intraoperative ultrasound: it can clearly determine the distribution of stones in the liver, guide the extraction of stones, and significantly reduce the rate of residual stones. It can also show the relationship between the important blood vessels entering and leaving the liver and the lesion, determine the extent of the lesion, and thus guide the liver resection. Intraoperative cholangiography: It is important to understand whether there is any variation in the biliary system, to avoid the occurrence of bile duct injury and to prevent and control the residual stones in the bile duct. Intraoperative cholangioscopy: It is one of the most important methods in the treatment of hepatic bile duct stones. The lithotripsy basket, lithotripsy instruments and balloon catheter can overcome the blind area of conventional instruments, which can improve the efficiency of lithotripsy and reduce the residual rate of stones. In cases of intraoperative stone residues, the residual stones in the hepatobiliary duct can be removed after surgery by entering the bile duct through the T-tube sinus tract, biliary fistula tract or subcutaneous buried blind loop of bile duct jejunostomy. For recurrent stones, choledochoscopic stone extraction can be performed through subcutaneous blind loops. Percutaneous hepatic puncture for endoscopic stone extraction is also an effective method for treating recurrent stones.