In order to standardize the diagnosis and treatment of hepatobiliary stone disease in China, the Biliary Surgery Group of the Chinese Society of Medical Surgery summarized the experience of diagnosis and treatment of hepatobiliary stone disease in China and drew on the latest clinical research results at home and abroad to formulate the first “Guidelines for the Diagnosis and Treatment of Hepatobiliary Stone Disease”. The essence of the guideline includes.
I. Principles of surgery for intrahepatic bile duct stones
The treatment of intrahepatic bile duct stones mainly relies on surgery. The principles of surgery are to remove the lesion, remove the stone, correct the stricture, unblock the drainage and prevent recurrence. According to the number and distribution of intrahepatic bile duct stones, the location and degree of hepatic stenosis, the pathological changes of the liver, the functional status of the liver and the patient’s general condition, an individualized treatment plan for each case is formulated and an appropriate surgical method is selected.
Surgical methods
There are four main surgical methods for hepatobiliary stones: (1) bile duct excision and extraction; (2) partial hepatectomy; (3) repair and reconstruction of hilar bile duct stenosis; (4) liver transplantation.
Biliary ductotomy is the basic procedure in the systemic treatment of hepatobiliary stones. Simple bile duct lithotomy and drainage procedures are mostly used in acute and severe cases, aiming to temporarily clear the biliary flow, control biliary infection, improve liver function to save the patient’s life or prepare for stage II definitive surgery. Only in a few cases where the number of stones is small and the involved hepatic ducts and liver lesions are mild, and where there are no residual lesions inside or outside the liver after stone extraction and no bile duct stenosis, hepatobiliary duct extraction alone may be used as a definitive procedure, but active measures are needed to prevent stone recurrence after surgery. Through combined incision of the hilar bile duct and hepatobiliary duct and transhepatic parenchymal incision of the intrahepatic bile duct, direct visual exploration combined with intraoperative cholangiography, intraoperative ultrasound, and intraoperative cholangioscopy can provide a comprehensive understanding of the location and number of biliary stones, biliary stricture obstruction and patency of the lower biliary duct. Blind instrumentation via the extrahepatic bile duct route is an important reason for the high rate of residual stones after hepatobiliary stone surgery. Adequate incision of the hilar bile duct stenosis and, if necessary, secondary hepatic ducts can be removed from the major hepatic ducts under direct vision, which, combined with cholangioscopic lithotripsy, can effectively remove stones from the hepatic ducts and significantly reduce the residual stone rate.
Partial hepatectomy is the most effective treatment for intrahepatic bile duct stones by removing the diseased hepatic segment to maximize the removal of lesions containing stones, strictures and dilated bile ducts. For regional stones, the segment or lobe containing the stone is removed; for diffuse stones, a regional disfiguring lesion confined to the segment or lobe is removed. The main regional destructive lesions to be resected include: atrophy of the liver lobe or segment; multiple stones that are difficult to remove; stenosis or cystic dilatation of the liver duct that is difficult to correct; combined chronic liver abscess; and combined intrahepatic bile duct cancer. The extent of hepatic resection for hepatobiliary stones depends on the distribution of stones and the extent of destructive lesions. The extent of hepatic bile duct stones is segmentally distributed along the diseased bile duct tree, therefore, hepatic lobectomy requires regular resection of liver segments and lobes in order to completely remove the diseased bile duct tree and the drained liver area. This is the basic condition and key to achieve excellent results. Whether for regional intrahepatic choledocholithiasis in the case of diseased liver segments or for diffuse intrahepatic choledocholithiasis in the case of destructive lesions, inadequate resection of the liver and the remaining lesions are often the source of postoperative complications and recurrence of symptoms.
For extensive stones in the left hepatic duct system, regular left hemicolectomy should be chosen, and resection of only the left outer lobe of the liver in combination with a bile duct jejunostomy should not be the preferred procedure. If only the left outer lobe of the liver is resected, left inner lobe hepatic duct stones, diseased liver tissue and left hepatic duct stenosis will be left behind, and it is almost impossible to remove all the stones dispersed in the second and third level of the left inner lobe through the extrahepatic bile duct and the left hepatic duct stump in the liver section. For stones confined to the left outer lobe and combined with stones in the left hepatic duct trunk, effective treatment can be achieved by resection of the diseased liver segment and removal of the stones in the downstream hepatic duct, without the need for left hepatectomy.
Regular right hepatectomy for right intrahepatic bile duct stones is often more technically difficult. In the case of right hepatic lobe stones, the right liver atrophies while the left liver compensates for the enlargement, causing the first hepatic hilar and hepatic segment or interlobular fissure to rotate to the right posteriorly and superiorly on the central axis of the inferior vena cava. It is necessary to accurately determine the area of hepatobiliary duct and liver lesions and the extent of resection of the diseased liver with the help of diagnostic imaging methods. In cases of regional stones with atrophy of the draining liver segments distributed in bilateral lobes, regular bilateral resection of the diseased liver segments can be performed at the same time, provided that the functional volume of the residual liver is adequate.
There are three main types of surgical methods for repair and reconstruction of hilar bile duct stenosis. Due to the complexity of the lesion type of hilar bile duct stenosis, a combination of surgical methods is often required.
(1) Bile duct stenoplasty and jejunal Roux-en-Y anastomosis: Applicable to cases of hilar bile duct stenosis in which intrahepatic lesions and upstream hepatic stenosis have been removed. Based on adequate incision of the stenosed bile duct in the hilar region and in situ plasticization, the bile duct defect is repaired with a Roux-en-Y jejunal loop with lateral anastomosis to the bile duct incision. In cases with residual stones or the possibility of recurrence, the stump of the jejunal loop can be buried subcutaneously as a postoperative access for stone extraction. However, bile-intestinal anastomosis abolishes the control of the biliary system by the sphincter of Oddi, and inappropriate bile-intestinal drainage in the absence of upstream hepatic stenosis correction and intrahepatic stone extraction may cause or aggravate serious complications such as biliary infection. There is no solid evidence that various additional anti-reflux measures on the bile duct jejunostomy or jejunal loop can effectively prevent the reflux of intestinal fluid into the bile duct, so such additional procedures are not recommended.
(2) Bile duct stenoplasty and free jejunal segment anastomosis: It is suitable for cases where intrahepatic lesions and upstream hepatic duct stenosis have been removed and stones remain or there is a possibility of stone recurrence while the lower bile duct is patent. The bile duct stenosis in the hilar region is fully incised and shaped in situ, and a free jejunal segment of appropriate length is intercepted and the output end is used to make an end-lateral anastomosis with the bile duct incision to repair the defect in the bile duct wall, and the input end is closed and buried subcutaneously as an access point for removing residual or recurrent stones by choledochoscopy. The procedure can also be accomplished by replacing the jejunal segment with the gallbladder.
(3) Bile duct stenosis shaping and tissue patch repair: For cases where the intrahepatic lesion and upstream hepatic duct stenosis have been removed, stones have been removed and there is no possibility of recurrence, and only mild stenosis of the bile duct in the hilar region exists. The stenotic segment and the bile ducts at both ends are fully incised, the scarred bile duct tissue is excised, the posterior wall of the bile duct is formed by suturing the hepatobiliary flap, and the defect of the anterior wall of the bile duct is repaired with a hemorrhagic hepatic round ligament flap, gallbladder flap, gastric flap, jejunal flap or other autologous tissue patch.
Liver transplantation is suitable for hepatobiliary stones in which diffuse irreversible damage and functional failure of both the liver and biliary system have occurred.
Treatment of combined extrahepatic stones
(1) Extrahepatic bile duct stones: the stones should be removed at the same time during surgery, and attention should be paid to the removal of stones that easily remain in the lower bile duct. The removal of stones after transduodenoscopic Oddi sphincterotomy is only applicable to simple extrahepatic bile duct stones; for hepatobiliary stones and strictures, reflux cholangitis is likely to occur after Oddi sphincterotomy and should be regarded as contraindicated.
(2) Relaxation of the sphincter of Oddi: Combined extrahepatic bile duct stones and dilatation are mostly accompanied by relaxation of the sphincter of Oddi at the lower end of the bile duct. If the sphincter of Oddi is severely relaxed, or if a previous sphincter of Oddi or bile duct duodenal anastomosis has caused reflux cholangitis, common bile duct transection and bile duct jejunostomy can be considered, thereby reducing reflux cholangitis via the lower bile duct route.
(3) Stenosis of the sphincter of Oddi: This is rare and choledochoscopy should be used to exclude stone obstruction of the lower bile duct. Bile duct jejunostomy Roux-en-Y anastomosis is feasible for confirmed lower bile duct stenosis.
The value of intraoperative modern hepatobiliary surgical equipment
The application of intraoperative ultrasound, intraoperative cholangiography, intraoperative cholangioscopy and various physical lithotripsy can play an important role in improving the surgical results of hepatobiliary stones. (1) 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 liver resection. (2) 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. (3) Intraoperative cholangioscopy: It is one of the most important methods for the treatment of hepatic bile duct stones. The lithotripsy basket, lithotripsy instruments and balloon catheter are used under the microscope to overcome the blind spot of conventional instruments, which can improve the efficiency of lithotripsy and reduce the residual rate of stones. (4) Physical lithotripsy: For large stones or embedded stones that are difficult to be removed directly, liquid electric or laser lithotripsy can be used to break them up and remove them.
V. Treatment and prevention of postoperative residual stones
For recurrence of stones, the residual stones in the hepatobiliary duct can be removed after surgery through the T-tube sinus tract, biliary fistula or subcutaneous 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. Regular postoperative review, administration of cholestatic drugs, and early detection and management of recurrent stones can significantly improve the long-term outcome. Postoperative residual lesions or recurrent lesions including hepatic duct stones and major hepatic duct strictures with significant symptoms that are difficult to treat with non-surgical methods require reoperation. Reoperation after biliary tract surgery often involves many complex issues, regardless of its technical difficulty, scope of surgery, postoperative complication rate and the patient’s general condition, which are all complex and high-risk procedures. Therefore, the timing and indications for reoperation must be mastered, and the surgical plan should be aggressive and prudent.