Hepatobiliary stones are common and intractable biliary diseases in China, with an incidence rate of more than 80% among stone biliary diseases, characterized by extensive lesions, complex disease, high incidence of complications, and high rate of residual stones or recurrence after surgery. The traditional treatment of hepatobiliary stones mainly uses open surgery. With the maturity of endoscopic and laparoscopic technologies, minimally invasive surgery has changed the pattern of traditional biliary surgery in China, and minimally invasive treatment is not only used for gallbladder stones and extrahepatic bile duct stones, but also for the treatment of hepatobiliary duct stones. So far, the minimally invasive surgical treatment of hepatobiliary stones mainly includes lumpectomy surgery and endoscopic surgery, etc.
1.Duodenoscopic application
For hepatobiliary stones, preoperative retrograde cholangiopancreatography (ERCP), sphincter of Oddi dissection (EST) and endoscopic nasobiliary drainage (ENBD) can be performed by duodenoscopy to accurately understand the biliary lesions and remove the stones.
1.1 EST or papillary sphincter balloon dilation
The success rate of stone extraction is reported in the literature to be 80-90%. The key to visiting the therapy is to reasonably grasp the position and length of the incision to smoothly remove or expel the stones in the bile duct and reduce the occurrence of complications.There are three types of incisions for EST: large, medium and small. The sphincter is cut to widen its opening and the stone is expelled naturally, or the stone is removed by various methods.
The larger the EST incision, the easier the removal of the common bile duct stones, the better the bile drainage, and the lower the recurrence rate of common bile duct stones. In case of large stones or stone impaction, mechanical lithotripsy can be performed first if the stone cannot be forcibly retracted. This method is more effective for stones <1.0cm in diameter, especially for stones <0.5cm, with an efficiency rate of 80%~91%. The cure rate is 36%~83%.
It is less effective in patients with stones >1.0cm in diameter, and it is easy to cause stone impaction and complication of purulent cholangitis or biliary pancreatitis, but under the condition of mechanical lithotripsy mesh basket, 2~3cm large stones can still be crushed and successfully removed. est combined with biliary lithotripsy herbal medicine for hepatobiliary stones can improve the efficacy.
1.2 Lithotripsy by transnasal bile duct placement and perfusion
The effective lithotriptic agent is injected into the biliary system through the catheter, which directly contacts the gallstones to obtain the effect of lithotripsy, and the lithotriptic efficiency reaches 95.3%, with the advantages of less trauma, less complications and lower physical requirements for patients.
2.Laparoscopic treatment of hepatobiliary stones
2.1 Laparoscopic hepatic lobectomy
In 1996, Azagra et al. reported the first successful laparoscopic lobectomy of the left outer lobe of the liver, creating a new era of laparoscopic lobectomy. With the advancement of laparoscopic techniques and improvement of equipment, laparoscopic lobectomy has also been used for the treatment of hepatobiliary stones, mainly for left hepatic and right anterior lobectomy Indications: intrahepatic bile duct stones; fibrotic atrophy of intrahepatic lesions; although there is no obvious fibrotic atrophy of the liver surface, but combined with bile duct stenosis, the stones cannot be removed and are relatively limited, the lesions are located in the left or right lower lobe, especially the left lobe is the most suitable; no Those who need bile duct reconstruction.
2.2 Laparoscopic choledochotomy and T-tube drainage
For intrahepatic bile duct stones without bile duct stenosis, laparoscopic choledochotomy and T-tube drainage can be used. Under laparoscopy, stones in the main trunk of the left and right hepatic ducts can be easily removed, but stones in its branches are more difficult to be removed, and the residual stones can be left for postoperative extraction via T-duct sinusoidal fiberoptic choledochoscopy.
2.3 Laparoscopic choledochoduodenal anastomosis
It is suitable for the patients with lower choledochal duct incompetence and relatively old bile duct stones, the number of reported cases is relatively small, and there are controversial disadvantages of reflux cholangitis, but it marks a further broadening of the indications for laparoscopic treatment.
3.Application of fiberoptic cholangioscope
The incidence of postoperative residual stones can be as high as 30% to 90% with traditional methods of treating hepatobiliary stones, and it has great blindness and limitations that can cause complications such as bile duct manipulation, biliary bleeding, and damage to the sphincter of Oddi and duodenum.
The application of intraoperative and postoperative fiberoptic choledochoscopy is of great value to improve the surgical outcome of hepatobiliary stones and can reduce the residual stone rate of bile duct stones to 0~2.8%. Some studies have concluded that: intraoperative fiberoptic choledochoscopy is superior to postoperative fiberoptic choledochoscopy via the T-tube sinusoid; it has a guiding role in the selection of the surgical procedure for intrahepatic bile duct stones; postoperative fiberoptic choledochoscopy via the T-tube sinusoid is the main means of treating residual intrahepatic bile duct stones.
3.1 Intraoperative application of fiberoptic choledochoscope
Surgical removal of stones is the core of surgical treatment of hepatobiliary stones. A significant difference in the rate of residual stones between intraoperative use and non-use of cholangioscope has been reported. Cholangioscopy combined with hepatectomy is more complete in removing stones and can significantly improve the outcome. The value of intraoperative application of fiberoptic cholangioscopy is that it can observe the whole picture of the intra- and extrahepatic bile ducts and understand the presence of residual stones or ascaris, relative stenosis of the intrahepatic bile ducts and the presence of neoplastic organisms in the bile ducts.
For intrahepatic grade I and II bile duct stones, the stones can be removed under direct vision of the cholangioscope. For grade III bile duct or larger embedded stones, the stones can be removed after lithotripsy or flushing to the larger hepatic duct. For larger hepatic bile duct stones that are difficult to remove, lithotripsy is often required before removal.
3.2 Intraoperative application of fiberoptic choledochoscope
Postoperative lithotripsy and lithotripsy via fiberoptic cholangioscopy is a remedial measure for the treatment of residual and/or recurrent stones in the hepatobiliary duct, with a stone removal rate of 97.0% to 99.2%. Therefore, it is advocated that fiberoptic choledochoscopy should be routinely performed after biliary surgery to prevent missed stones and untreated biliary strictures. Fiberoptic choledochoscopy is usually started 4-6 weeks after surgery, and stone extraction is performed through the sinus tract formed by the T-tube, the blind collaterals of the jejunum left subcutaneously by the choledochal anastomosis and the dilated PTCD sinus tract. The fiberoptic cholangioscope can directly view the whole intrahepatic grade I-IV bile ducts, and can peep at the degree and location of bile duct strictures and mucosal lesions, identify blood clots, roundworms, swellings, air bubbles, stones and clarify the size, shape and location of stones in the bile ducts, and can perform stone extraction and bile duct dilation treatment under direct vision, overcoming the blind spots of conventional instrumentation for stone extraction and effectively reducing stone residues. The lithotripsy can improve the efficiency of stone extraction and play a role that surgery cannot play.
4.Interventional treatment
With the progress of interventional instruments and the improvement of interventional techniques, some scholars have explored the treatment of hepatobiliary stones through interventional techniques. Percutaneous transhepatic choledochoscopy (PTCS) is a simple, effective, safe and repeatable treatment for hepatobiliary stones based on percutaneous percutaneous percutaneous choledochal drainage (PTCD) with fistula dilation and the use of choledochoscopy combined with modern high-tech lithotripsy and stone extraction equipment and drainage stents. It is a very promising treatment for hepatobiliary diseases, especially for old and frail patients, those who are not suitable for or unwilling to undergo traditional surgery, and those who have a history of multiple surgeries and poor results of other endoscopic treatments.
This method combined with EST or mechanical lithotripsy can achieve a 98.5% stone retrieval rate. However, this method requires 1 week of indwelling drainage tube via PTCD, and then sinus exploration strip dilatation to gradually dilate the sinus tract to F16~22, which usually takes 2~3 weeks before PTCS treatment may be performed, which is more time-consuming and can lead to complications such as intra-abdominal bleeding, biliary bleeding, bile leak, biliary tract infection, biliary peritonitis, sinus tract perforation, etc. Moreover, patients need to receive X-ray radiation for a longer period of time.
5.Multiple minimally invasive techniques combined application
Due to the complex condition of hepatobiliary stones and large differences in pathology, a combination of multiple minimally invasive means is often required to improve the efficacy.
5.1 Combined application of laparoscopy and cholangioscopy
The combined application of laparoscopy and choledochoscopy not only provides operational access for stone extraction, but also allows direct visualization of the internal situation of the bile duct and observation of the presence or absence of residual stones, but the procedure is difficult and requires high technical requirements for choledochotomy and suturing, which help require that the operator should have a solid foundation in bile duct anatomy, bile duct surgery experience and more skilled laparoscopic operation techniques and choledochoscopic stone extraction techniques. Laparoscopic choledocholithotomy is not a complete substitute for open choledocholithotomy and is suitable for those with few intrahepatic stones.
Currently, most laparoscopic cholecystectomies are followed by stone extraction via the cystic duct or incision of the common bile duct bile duct. The former is done by placing a choledochoscope or ultra-fine choledochoscope through the dilated cholecystic duct to remove the stones in the bile duct, or by using laser or liquid electrolysis methods to crush the stones and then flush them out.
5.2 Combined application of laparoscopy, duodenoscopy and choledochoscopy
If the bile duct stones are combined with acute cholangitis, ERCP should be done first to determine the bile duct stones, then EST or ENBD should be performed to decompress and drain the common bile duct to facilitate the control of biliary infection. After passing the risk period, laparoscopic surgery should be considered, and intrahepatic bile duct stones should be removed intraoperatively by choledochoscopy.