Primary hepatobiliary stones – stones originating in the intrahepatic bile ducts – are common in our country, with complex lesions, high residual stone rate and easy recurrence. It is a difficult problem in biliary surgery and an important cause of death from benign biliary lesions.
Etiology
1.Unclear.
2, related to chronic inflammation, bacterial infection, biliary ascariasis, biliary stasis, malnutrition.
Pathology
1.The deposition of material in the bile is the basis of stone formation.
2. Inflammation in the bile duct is an important factor in stone formation.
3, Bile stagnation is an important condition for stone formation.
4.The lesions are segmentally or regionally distributed along the bile duct tree.
5. Different degrees of hepatobiliary stenosis often coexist.
6.Stones and bile duct stenosis lead to atrophy of diseased liver, hypertrophy of normal liver, and hepatic atrophy-hyperplasia complex.
7.Biliary obstruction, infection, purulent cholangitis, chronic liver abscess.
8, late stage often occurs biliary cirrhosis and portal hypertension.
9.Secondary intrahepatic bile duct cancer.
Clinical manifestations
1.Incognito type (resting type): only distension and discomfort in liver area or chest and back.
2.Obstructive type.
Unilateral hepatic bile duct stones with pain in the liver area and chest and abdomen, intermittent jaundice.
unilateral hepatic duct stones with bile duct stenosis and asymmetric enlargement of the liver.
Bilateral hepatic duct stones and advanced hepatobiliary stenosis with persistent jaundice.
Cholangitis type: stone obstruction secondary to infection with intrahepatic obstructive purulent cholangitis, biliary-derived liver abscess, subphrenic abscess, bile duct bronchial fistula.
Complex type: combined extrahepatic bile duct stones + Charcot’s triad (abdominal pain, chills and fever, jaundice).
Diagnosis
1.Detailed medical history.
2.Imaging examination.
(1) Single examination is often difficult to obtain comprehensive information, and two or more imaging examinations corroborate each other. It is an important step in surgical decision making.
(2) Including ultrasound, CT, MRCP, PTC, ERCP, bile duct angiography, cholangioscopy and other examinations.
(3) Bus: preferred, providing an important diagnostic basis but not a comprehensive one, guiding intraoperative stone extraction and determining residual stones.
(4) CT: shows stone distribution, bile duct dilatation, liver parenchymal lesions, comprehensive reading of pictures; 3D stereoscopic imaging shows intrahepatic bile duct stones, stenosis and occupancy.
MRI and MRCP.
Advantages: non-invasive display of intrahepatic biliary tree, bile duct stones, stenosis, site and extent of dilatation, liver parenchymal lesions.
Disadvantages: not as clear as CT and Bus for stone image display
Diagnostic value is better than CT and direct cholangiography.
PTC clearly shows intra- and extra-hepatic bile duct stones, strictures, dilatations and variants, mainly in the obstructed segment of the bile duct, invasive, with the risk of complications such as bleeding, biliary tract infection and biliary fistula.
ERCP diagnoses distal bile ducts and papillary lesions, and hepatic bile ducts above the second level are easily missed, invasive, and can cause biliary tract infection and pancreatitis
Intraoperative postoperative cholangiography reduces the occurrence of residual stones.
3.Laboratory examination
Liver and kidney function, blood biochemistry, serum enzymatic examination to assess the general condition, liver function and Child classification in cirrhotic liver
CEA and γ-GT elevation for bile duct cancer
Typing
1.Type I: confined type, the stone is confined to a certain liver segment or sub-segment of bile duct, mostly of insidious clinical type.
2.Type II: regional type, the stones are confined to one or several liver segments along the intrahepatic bile duct tree, often combined with stenosis of the hepatic ducts and atrophy of the affected liver segments, clinical cholangitis type.
Type III: Diffuse type, with stones distributed throughout both hepatic bile ducts, divided into 3 subtypes.
Type III a: without significant liver parenchymal fibrosis and atrophy.
Type III b: with regional parenchymal fibrosis and atrophy, often combined with stenosis of the hepatic ducts in the atrophic hepatic segment.
Type III c: with extensive parenchymal fibrosis secondary to biliary cirrhosis and portal hypertension.
It is often associated with severe stenosis of the right and left hepatic ducts or bile ducts below the confluence.
Type E: additional type, combined with extrahepatic bile duct stones, divided into 3 subtypes according to the function of the sphincter of Oddi
Ea: normal function of the lower bile duct
Eb: relaxation of the lower end of the bile duct
Ec: stenosis of the lower bile duct
Treatment
1.Treatment principle: “remove the lesion, remove the stone, correct the stricture, clear the drainage, and prevent recurrence”.
2.Treatment method: Surgery is the main treatment.
Systemic treatment
(1) Control the infection: Gˉ bacteria and anaerobic bacteria effective antibiotics.
(2) regulation of systemic conditions: nutritional support, control of ascites.
(3) Improve liver function: vitamin supplementation, improve coagulation.
(4) Reducing yellowing: mixed opinions, PTCD or END.
(5) Prevention of renal failure: jaundice, endotoxemia hepatorenal syndrome.
Surgical treatment
(1) High biliary duct dissection for lithotripsy is the basis.
(2) Incision of the common hepatic duct up to the confluence until the right and left hepatic ducts and the opening of the caudate lobe bile duct are shown. The caudate lobe bile duct should be inspected and its opening should be enlarged or incised for stone extraction if necessary.
(3) Intraoperative choledochoscopy is performed to check the bile duct for residual stones and bile duct strictures.
(4) Intraoperative ultrasound to improve the detection rate of residual stones; assist in determining the extent of hepatic resection.
(5) Cholangioscopy and intraoperative ultrasound are the right hand of biliary surgeons.
Individual surgeons do not deal with intrahepatic stones and narrow bile ducts in the first operation, but only perform laparoscopic or open cholecystectomy plus choledochotomy to retrieve stones, and then repeatedly retrieve stones via T-tube sinusoidal choledochoscopy after the operation, which is undesirable in the pursuit of “minimally invasive”.
(6) Partial lobectomy of the liver: for complex intrahepatic bile duct stones, partial resection of the affected liver is performed at the same time.
(7) Multi-directional and multi-sectional partial hepatectomy for extensive intrahepatic bile duct stones.
Indications for hepatectomy
1.Limited lesions in one section, one lobe or one side of the liver, long-term obstruction of intrahepatic bile ducts, obvious atrophy and fibrosis of liver tissue.
2, bile duct stones and bile duct stenosis, other methods are difficult to remove the stones to correct the stenosis.
3.One side of bile duct stone and intrahepatic bile duct cystic dilatation.
4.Regional intrahepatic bile duct stones and liver abscess, intrahepatic or extrahepatic bile duct fistula.
5.Intrahepatic bile duct stone and hepatic bile duct bleeding, other methods can not stop the bleeding.
6.Intrahepatic bile duct stone and intrahepatic bile duct cancer on one side.
7.For bile duct stones and/or stenosis in the hilar region of the liver, in order to reveal the anatomical structure, it is necessary to remove the enlarged part of the liver lobe with multi-directional and multi-sectional partial hepatectomy.
Treatment of biliary strictures
For benign biliary strictures above grade II, resection of the diseased liver lobe (segment) is the way to completely deal with stones and strictures. When lobectomy is performed, care must be taken to remove the narrowed bile duct.
For biliary stenosis located in the hilar region, the stenosis ring can be cut longitudinally to reach the proximal end of the dilated bile duct and sutured transversely for shaping, or the adjacent tissue can be used for patching.
3.After complete correction of bile duct stricture, internal drainage or external drainage can be performed as appropriate.
4.If the extrahepatic bile duct is not obstructed by stenosis, internal drainage of the bile intestine is not necessary.
5.Regardless of internal drainage, it is best to leave an external drainage tube in place for postoperative imaging and choledochoscopic stone extraction.
Bile duct drainage
1. External drainage should be placed in all biliary tract exploration and lithotripsy procedures.
2. Internal drainage is mainly used for extrahepatic bile duct strictures.
3.Biliary-intestinal anastomosis and re-evaluation of the function of the sphincter of Oddi
A. Bile drainage slows down after bile-intestinal anastomosis, and the chance of retrograde bile duct infection increases, making it difficult for various anti-reflux measures to play a practical role.
B, reflux cholangitis can develop into chronic proliferative cholangitis, and eventually cancer can occur.
4, biliary intestinal anastomosis eliminates the regulation of the biliary system by the sphincter of Oddi, so it can only remove the lesion, lift the obstruction, and correct the stricture after unobstructed drainage as appropriate
5. Do not perform anastomosis without correcting the hepatobiliary stenosis and removing intrahepatic stones, and strictly control the indications
Management of cholestatic portal hypertension
1, PBCH is a manifestation of the late course of bile duct stones. Bleeding from esophagogastric fundic varices in portal hypertension is a serious threat to life.
2, Liver function impairment, coagulation dysfunction, and hepatic portal varices make biliary surgery difficult.
3.And to solve biliary obstruction first? Deal with portal hypertension first?
4.One surgery? Staged surgery?
5.For those with better liver function, ChildA/B grade, no esophagogastric fundic varices, or varices, but no history of bleeding or signs of bleeding. Strive for surgical management of biliary tract disease first.
6, attention must be paid to the removal of narrow bile ducts when performing lobectomy of the liver.
7.The liver should be cut without blocking the hepatic hilum as much as possible or strictly control the time of hepatic hilum blocking.
8.The volume of the cut liver should be controlled appropriately.
9, Those with good liver function, history of ruptured esophagogastric fundic varices and bleeding, or signs of bleeding can also be treated simultaneously with bile duct disease and portal hypertension.
If jaundice is prolonged, coagulation dysfunction, ascites is severe, and liver function is poor, PTCD or ERBD should be performed first, and esophageal vein ligation can be performed first if there is bleeding. After the jaundice decreases and the coagulation function is basically corrected, then operate.
11. In end-stage liver disease with extensive stone lesions, severe cirrhosis, portal hypertension and liver function loss, liver transplantation is the only treatment.
Prevention and treatment of stone recurrence
The rate of residual stones after intrahepatic bile duct stone surgery is 20%-40%, and most of the residual stones can be removed by postoperative choledochoscopy.
1.In case of extensive intrahepatic bile duct stones and liver fibrosis, appropriate hepatectomy should be selected. To avoid removing too much liver, multi-directional and multi-segmental hepatic lobectomy is feasible.
2, Principle of liver resection: release the stenosis, get rid of the lesion, and remove the severely destroyed liver.
3. Repeatedly remove and flush the stone under direct vision during surgery.
4.Do not perform biliary intestinal drainage at the distal end of bile duct stricture.
5.Intraoperative choledochoscopic assisted stone extraction.
6.Intraoperative ultrasound should be used to guide lithotripsy and hepatotomy.
7.Imposed external drainage for postoperative cholangiography, flushing and choledochoscopic stone extraction.
8.Intraoperative placement of T-tube should follow the principle of “short, straight and thick”.
9.Postoperative cholangiography, hepatobiliary ultrasound and cholangioscopy should be used to evaluate the residual bile duct stones.