Long-term results of surgical treatment for intrahepatic stones

Long-Term Results of Surgical Treatment for Intrahepatic Stones

Tsukasa TSUNODA, Ryoichi TSUCHIYA, Noboru HARADA, Ryozo YOSH1NO, Takatoshi NODA, Kunihide IZAWA,

Takashi YAMAGUCHI and Kensuke YAMAMOTO

ABSTRACT: One hundred and nineteen patients with intrahepatic stones treated surgically in Nagasaki University Hospital from 1969 to 1984 were re- viewed. The patients were divided into four types according to location of the stones and the presence or absence of stenotic lesions and /or localized dilatation of the intrahepatic bile ducts. Types I and II patients were treated with choledocholithotomy or choledochojejunostomy, while type I I I patients underwent hepatic resection and type IV patients were treated by partial hepatic resection with bilioenteric anastomosis, including extended hepaticocholedochojejunostomy. The majority of operative or early deaths belonged to type IV and residual stones were present in almost all patients. The long- term results for the 88 patients revealed that the rate of improvement was 100 per cent for type I, 87 per cent for type II, 83 per cent for type I I I and 84 per cent for type IV. In type IV, the most excellent results (92 per cent) were obtained by extended hepaticocholedochojejunostomy, especially with hepatectomy. It is suggested that extended hepaticocholedochojejunostomy with partial hepatic resection is a reasonable procedure for treating patients with type IV intrahepatic stones.

KEY WORDS: pr imary and secondary intrahepatic stones, extended hepaticocholedochojejunostomy, hepatic resection

INTRODUCTION

It is assumed that the main etiologic factor of intrahepatic stones is cholangitis caused by continuous bacterial infection accompanying bile stasis, a,2 Therefore, the principle of treatment for intrahepatic stones may be complete removal of the stones and the elimination of

The Second Department of Surgery, Nagasaki University School of Medicine, Nagasaki, Japan

Reprint requests to: Tsukasa Tsunoda, MD, The Second Department of Surgery, Nagasaki University School of Medicine, Nagasaki 852,

Japan

bile stasis. However, the distribution of intrahepatic stones is not uniform and it is difficult to judge whether stenosis or dilation of the intrahepatic bile duct, or both, are causes of bile stasis, whether they are congenital or secondary, or whether they are reversible or irreversible. In the actual t reatment of each individual case, an appropriate surgical procedure should be chosen with the aim of re- moving the gallstones as thoroughly as possible, and establishing suitable biliary drainage to eliminate bile stasis in order to prevent re- current formation of intrahepatic stones.

In our application of the principles of surgical treatment, cases of intrahepatic stones were divided into four types, and surgical pro-

JAPANESE JOURNAL OF SURGERY, VOL. 15, No. 6 pp. 455-462, 1985

456 Tsunoda et al. Jpn. J. Surg. November 1985

cedures appropriate to each type were chosen. The present article is a report of the long- term results of these forms of treatment, with special reference to the effectiveness of ex- t en de d hep a t icocholedochoje junos tomy which is a method of bile drainage employed by our department.

MATERIAL AND METHODS

One hundred and nineteen patients with intrahepatic stones were treated surgically in the Second Department of Surgery, Nagasaki University Hospital, between September 1969 and October 1984. Ages ranged from 18 to 80 with an average age of 49.6 years. The ratio of men to women was 1:1.9. Patients were diagnosed as having intrahepatic stones when calculi were found in the intrahepatic segment, area and more peripheral bile ducts. Stones in the right, left or common hepatic duct were excluded from this series. Anatomi- cal descriptions of the intrahepatic biliary sys- tem conform to the nomenclature of Healey and Schroy. s

Patients with intrahepatic stones were divided into four types according to location of the stones and the presence or absence of stenotic lesions and/or localized dilatation of the intrahepatic bile ducts (Table 1). Type I had no marked dilatation of intrahepatic bile ducts. Small stones and sludge were demon- strated in the intrahepatic biliary tree. This type is seen in some cases with hemolytic anemia and duodenal diverticulum. Type II had diffuse dilatation of the intrahepatic biliary tree and often an obstructive lesion of the distal common bile duct. Both types I and II had multiple common duct stones, with or without gallbladder stones. The intrahepatic stones in these two types seemed to be caused by an extrahepatic factor and may be called secondary intrahepatic stones. Type III had unilateral solitary or multiple cystic localized dilatation which was frequently accompanied by stenosis of the left or right intrahepatic bile ducts. Type IV also had such disorders in the bilateral hepatic lobes. The majority of calculi in these latter two types were located in the intrahepatic bile duct, and 30 per cent of

Table 1. Stones

Classification and Definitive Operation of 119 Patients with Intrahepatic

(from September 1969 to October 1984)

~ ~ Secondary Type I

Procedure

Choledochostomy or 4 9 no drainage

Choledochoduodenostomy 6 Jejunal Interposition Choledochojejunostomy 8 Intrahepatic

Cholangiojejunostomy Extended Hepatico- 1

choledochojejunostomy Papilloplasty 1 1

Total 5 25

Primary Type II Type III Type IV

7 29 (24) 1

2 (1) 2 2 1 7 (5) 13 (7)

2 (2) 6 (6)

6 (4) 15 (6)

2 (2) 1

50 (38) 39 (19) ( ): cases of hepatic resection

Volume 15 Intrahepat ic stones 457 N u m b e r 6

type I I I and 21 per cent of type IV had stones in the intrahepatic duct only. Therefore, types I I I and IV were thought to be cases of pr imary intrahepatic stones.

In four of the 5 cases of type I choledocho- l i thotomy alone was performed, while in the remaining case papilloplasty was also carried out. In the 25 type II cases surgery was performed in accordance with the procedure used for common duct stones: where stenosis of the lower common bile duct was present, bilioenteric bypass including papilloplasty was carried out in 16 cases, whereas in the absence of stenosis, choledocholi thotomy alone was performed in 9 cases. Out of 50 cases of type III , a left group consisted of 42 cases and a right group consisted of 8 cases. In the left group, there were stenotic lesions at the level of the left hepatic duct or left intrahepatic ducts, whereas the right group had stenotic lesions at the level of the right hepatic duct or the anterior or the posterior segmental duct. Dilated lesions of the upstream intrahepatic

duct were filled with soft, friable, brown cal- c ium bilirubinate stones. The diseased lobe of the liver often becomes fibrous or atrophic and hepatic resection is a suitable procedure. The present authors have been employing hepatic resection decisively in cases o f type I I I , left hepatectomy has been performed in 7 cases, lateral segmentectomy in 27 cases, right hepatec tomy in 2 cases and anterior segmentectomy in 2 cases with or without bilioenteric anastomosis. Thirty-nine cases of type IV dis- played wide distribution o f stones in the intrahepatic bile ducts on both sides, as well as fre- quent occurrence of confined stenosis at the confluence of the hepatic ducts or the left and right hepatic duct or of both intrahepat ic segmental bile ducts. This type was the most difficult of all to treat surgically. Extended hepaticocholedochojejunostomy with lateral segmentectomy was performed for type IV and is an ideal operat ion (Fig. 1). A longi- tudinal incision of the extrahepatic bile duct was extended up to the resection s tump of the

Fig. 1. Left lateral segmentectomy and extended hepaticocholedochojejunostomy.

458 Tsunoda et aL Jpn. J. Surg. November 1985

left hepatic duct in lateral segrnentectomy and bile duct plasty was performed to relieve the stenotic lesion of the segmental bile duct. In some cases, however, right partial hepatic resection should be added when the stones lodge in either or both inferior branches of the anterior segment. These branches join the segmental duct at an acute angle, and it is very hard to remove them by instrumenta- tion. After removal of the stones th rough these segmental ducts, this widely opened bile duct was utilized for bilio=enteric bypass surgery to prevent further bile stasis. This procedure can also facilitate spontaneous evacuation of any residual stones into the intestinal tract. Extended hepaticocholedochojejuno- storey was performed in 15, a l though hal f of type IV cases could not be treated by this procedure because of preoperative complica- tions, polysurgery and high risk. In these cases choledochojejunostomy or intrahepat ic cholangiojejunostomy was performed.

Eighty-eight patients survived more than 2 years after the final operat ion and a follow-up study was performed on them by mail, a n d / o r ul trasonographic and computed tomographic examination. To evaluate the postoperative condition of the patients, the following cri- teria were used: good- -absence of hepato- biliopancreatic symptoms, complete re turn to social life; fa i r - -occasional hepatobil iopan- creatic symptoms, no limitation to daily life; poor - - f r equen t or persistent hepatobil iopan- creatic symptoms, with medical t reatment necessary. Cases of good and fair results were

designated as "improved".

RESULTS

Death within one month after surgery occurred in one patient with type II and three patients with type IV. The causes of death in four patients were acute obstructive suppura- tive cholangitis, sepsis, hemobilia and hepatic failure, respectively, and residual stones were present in all four cases. Death within 2 years excluding operative death occurred in one case of type I I I and 6 cases of type IV. Re- sidual stones were present in 6 out of 7 cases. The causes of death were liver abscess in three patients, hepatic failure in two patients, and both sepsis and bleeding of the gastrointes- tinal tract in one patient. The 11 patients who died within 2 years were treated with papilloplasty in the case of one patient, choledochoduodenostomy and choledochojejunostomy in two, respectively, and choledochostomy and intrahepatic cholangiojejunostomy in three, respectively.

A follow-up study was performed on the 88 patients according to types (Table 2). The follow-up period ranged from 2 to 14.5 years with an average period o f 6 : 9 years. The rate of improvement was 100 per cent for type I, 87 per cent for type II, 83 per cent for type I I I and 84 per cent for type IV. Even in pr imary intrahepatic stone patients of types I I I and IV, the results were quite satisfactory when more than two years had passed postopera- tively.

Table 2. Long-Term Results (2 years after final operation)

(November 1984)

No. of Follow-Up Results Rate of Type Patients Period Good Fair Poor Death Lost Improvement*

I 5 (1) 9.9 yrs 4 (1) 1 100% II 23 (7) 8.4 yrs 14 (4) 6 (3) 1 1 1 87% III 35 (9) 6.1 yrs 22 (4) 7 2 (2) 3 (1) 1 (1) 83% IV 25 (15) 6.0 yrs 13 (6) 8 (6) 2 (1) 2 (2) 0 84%

Total 88 (32) 6.9 yrs 53 (15) 22 (9) 5 (3) 6 (4) 2 (1) 84% ( ): cases of residual stones

* : good or fair cases

Volume 15 Number 6 Intrahepatic stones 459

Long- term results in the 28 cases of types I and II were studied according to the surgical procedure which they had received. Twelve patients who underwent choledochostomy showed an improvement rate of 100 per cent, 8 patients who underwent choledochojejuno- storey 88 per cent, and 2 patients who underwent papilloplasty 100 per cent, but 6 patients who received choledochoduodenostomy revealed the poorest rate of 67 per cent.

The thirty-five cases of type I I I showed an improvement rate of 83 per cent (Table 3). Cases of poor results and death were those in which choledochoduodenostomy, jejunal interposition and intrahepatic cholangio-

jejunostomy were performed for biliary drainage. The causes of three deaths were sepsis, liver abscess and hepatic failure, respectively.

The follow-up results of the 25 cases of type IV and the operative procedures used are shown in Table 4. Nine patients who underwent choledochojejunostomy showed an improvement rate o f 78 per cent and three patients who underwent intrahepat ic cholangiojejunostomy a rate of 67 per cent, but twelve patients who received extended hepaticocholedochojejunostomy showed 92 per cent. Three out o f the four patients who showed poor results and death underwent choledochojejunostomy in 2 cases and intrahepatic

Table 3. Long-Term Results of Type Il l Patients

(November 1984)

Surgical Procedure No. of Results Rate of Cases Good Fair Poor Death Lost Improvement*

Choledochostomy or no drainage 19 (16) 15 (13) 2 (2) 1 (1) I 89%

Choledochoduodenostomy 1 1 0 % Jejunal Interposition 2 (1) 1 1 (1) 50% Choledochojejunostomy 7 (5) 5 (3) 1 (1) 1 (1) 86% Intrahepatic

Cholangiojejunostomy 1 (1) 1 (1) 0% Extended Hepatico-

3 (2) 2 (1) 1 (1) 100% choledochojejunostomy Papilloplasty 2 (2) 2 (2) 100%

Total 35 (27) 22 (17) 7 (6) 2 (2) 3 (2) 1 83%

Table 4.

( ): cases of hepatic resection * : good or fair cases

Long-Term Results of Type IV Patients

(November 1984)

Surgical Procedure No. of Results Rate of Cases Good Fair Poor Death Improvement*

Jejunal Interposition Choledochojejunostomy Intrahepatic

Cholangiojejunostomy Extended Hepatico-

choledochojejunostomy

Total

1 1 100% 9 (4) 5 (2) 2 (1) 1 (1) 1 78%

3 (3) 2 (2) 1 (1) 67%

t2 (5) 7 (3) 4 (2) 1 92%

25 (12) 13 (5) 8 (5) 2 (2) 2 84% ( ): cases of hepatic resection

*: good'gr fair cases


Table 5. Surgical Results in Patients with Extended Hepaticocholedochojejunostomy

(November 1984)

No. Age Sex Final Operation Follow-Up Residual Stone on

Residual Location Period Follow-Up Study Results Stone by CT and US

1 39 F + p-c 9.6 yrs disappeared good 2 50 F + p-c 3.5 yrs disappeared good 3 32 F + a-c 7.6 yrs decreased good 4 48 F + a-c 4.0 yrs unchanged fair 5 37 F ~+ a-c, 1-c 7.3 yrs increased fair 6 54 M +F p-c, 1-c 5.3 yrs increased poor

2.0 yrs disappeared fair 7 32 M + a-p 7.2 yrs disappeared good 8 60 F + a-p 7.1 yrs disappeared good 9 36 M + a-p 6.7 yrs decreased fair

Abbreviations: p-c, central portion of posterior segmental duct; a-c, central portion of anterior segmental duct; l-c, central portion of lateral segmental duct; a-p, peripheral portion of anterior seg-

menta l duct; CT, computed tomography; US, ultrasonography

cholangioje junos tomy in one, bu t in these cases, residual stones a n d stenotic lesions re- m a i n e d in the in t rahepa t i c bile duct . T h e pa- t ient who died was t rea ted with ex tended hepa t icocholedochoje junos tomy and d id not have any hepa tob i l i opanc rea t i c symptoms over the 6 years unti l he d ied of esophageal cancer . Ex tended hepa t icocholedochoje juno- s tomy was pe r fo rmed in 15 cases of type IV. In nine pat ients who h a d res idual stones at the t ime of discharge the res idual stones were followed by using c o m p u t e d t o m o g r a p h y and u l t r asonography with fol low-up per iods rang- ing f rom 2 to 9.6 years (Tab le 5). In 6 cases, res idual stones were recognized in the centra l po r t ion of the in t rahepa t i c bi le duct at the t ime of discharge. Residual stones disap- p e a r e d in 2 out of the 6 cases b u t increased in 2 o ther cases. One of the two pat ients in whom residual stones increased compla ined of a b d o m i n a l pa in and fever suggestive of re- flux cholangit is . He was r e a d m i t t e d to hos- p i ta l a n d underwent endoscopic l i thotomy by means of external je junos tomy. H e h a d no re- s idual stones and was d i scharged in good con- d i t ion two years ago. Fol low-up studies of 3 cases, in which residual stones had been recognized in the pe r iphe ra l por t ion of the in t r ahepa t i c bile duct , however, revealed tha t

all the stones h a d d i sappeared spontaneously . These results ind ica te the necessity of remov- ing stones f rom the central po r t ion of the in t rahepa t i c bi le duct as tho rough ly as possible, and then evacuat ion of res idual stones in the pe r iphe ra l por t ion into the intest inal t rac t can be fac i l i ta ted spontaneously. They also suggest a degree of effectiveness of ex- t ended hepa t icocholedochoje junos tomy.

DISCUSSION

It is well known tha t i n t r ahepa t i c stones occur most f requent ly in East Asia. T h e incidence of the disease in J a p a n f rom 1945 to 1955 was 10 per cent or 15 per cent of cholelithiasis. Recently, the incidence has been de- creasing, with a ra te of 4.1 pe r cent, 4 and in our d e p a r t m e n t the incidence of in t r ahepa t i c stones in all pa t ien ts with cholel i thiasis oper- a ted on is 8 pe r cent. This t r end in J a p a n m a y be a t t r i bu tab le to changes in habi ts , especially as re la ted to diet , shift ing f rom main ly car- bohydra tes to a ba l anced diet with pro te in and fat , together with a m a r k e d decrease of r o u n d w o r m infestat ion, and the fact tha t pig- men t stones have been decreas ing a n d choles- terol stones increas ing in incidence. I t was re- po r t ed tha t f l -g lucuronidase in bile, especially

Volume 15 Intrahepatic stones 461 Number 6

during biliary infection with Escherichia coff, plays a substantial role in producing the calcium bilirubinate stones which are common in the Asian area. 1,5

The exact diagnosis of intrahepatic stones should be established preoperatively by direct cholangiographic methods such as percuta- neous transhepatic cholangiography (PTC), endoscopic re t rograde cholangiography (ERC) and ultrasound (US)-guided PTC. 6 It is most important to visualize the entire fea- tures of the intrahepatic biliary tree in patients with stenosis at the proximal end of a dilated bile duct containing stones. An appropriate surgical procedure should be applied after making an accurate diagnosis including the location of the stones, the site of the stenosis and dilatation of the intrahepatic bile ducts.

In our types I and II, or cases of secondary intrahepatic stones, satisfactory results can be obtained by carrying out surgical procedures selected on the basis of the location, and the presence or absence, of stenosis of the extrahepatic bile duct. We found that with regard to the addition of biliary diversion in types I and I I cases, there is no difference in the surgical results among papilloplasty, choledochoduodenostomy and choledochojejunostomy. In our types I I I and IV, or cases of primary intrahepatic stones, however, it is assumed that the chief location on stone formation is the cystic or dilated intrahepatic duct with stenosis. When there is stenosis of the intrahepatic bile duct, the stones are not completely removed and the diseased lobe or segment of the liver often becomes atrophic or fibrous.

One of the present authors (K.Y.) ex- amined histopathologically the resected hepatic tissues of 24 patients with primary intrahepatic stones. 7 Calcium bilirubinate stones, cellular debris and mucinous sub- stances occupied the lumen of large dilated intrahepatic bile ducts. Numerous mucin- secreting glands were seen within or around the walls of these bile ducts. He concluded that production of intrahepatic stones may be

caused not only by bile stasis and infection, but also by intraductal mucin and slow-flow- ing bile in combination with cellular debris, bile pigments and other bile components. Nakanuma et al.S reported that in hepatolithiasis, stone-containing bile ducts revealed dilatation and relative stenosis, and histologi- cally disclosed chronic proliferative cholangitis characterized by fibrosis, inflammatory cell infiltration and proliferation of glandular elements. Secreted mucin from these prolifer- ated glandular elements might contribute much to the genesis of hepatolithiasis. There- fore, hepatic resection is a suitable procedure for primary intrahepatic stones confined to one hepatic lobe,6,7, 9-aa as shown in the present study.

In the left group of type III , lateral segmentectomy or left hepatic lobectomy is the operation of choice. When stones are found in the medial segmental duct, left lobectomy should be done, since it may be difficult to ex- tract the stones in these areas by instrumenta- tion and irrigation without hepatic resection. Although it is rare, when stones are mostly present in the right lobe, a right lobectomy should be performed after extended extrahepatic duct exploration.

The surgical t reatment for type IV is the most difficult. We have obtained good surgical long-term results in cases of type IV by adding to extended biliotomy and extended bilioenterostomy, 11 such procedures as left lateral segmentectomy, anterior inferior segmentectomy, and plasty of the stenosis of the segmental bile ducts.

There is considerable controversy over whether to select choledochoduodenostomy or choledochojejunostomy as a method of biliary diversion, but in type I I I and IV cases, choledochoduodenostomy yielded extremely poor surgical results. Choledochoduodenostomy and papilloplasty are contraindicated when stenosis of the intrahepatic bile duct is present, because of the possible occurrence of as- cending cholangitis. For bilioenterostomy, the p-shaped Roux-Y jejunal limb was always used. In our studies on biliary diversion, a


choledochojejunostomy with p-shaped Roux- Y l imb revealed a low frequency of develop- men t of postoperative cholangitis, liver abscess and regurgi ta t ion of intest inal content into the bil iary duct compared to that without p-shaped l imb. 12

Patients with pr imary in t rahepat ic stones who were evaluated as positive for residual stones had early or late complicat ion of the disease and a high mortal i ty rate. The site of the residual stones, often recognized as primary intrahepat ic stones at discharge, was the lateral segmental bile duct and anterior or posterior inferior bile duct . Such stones may be difficult to remove completely even if extended biliotomy is performed. Lateral seg- mentec tomy or right par t ia l hepat ic resection should be done for stones in these areas.

By extended hepaticocholedochojejunostomy, however, we confirmed that if the stones in the central por t ion of the intrahepatic bile duct are removed, and duct plasty is done to relieve stenosis of the segmental bile duct, evacuation of residual stones in the peripheral port ion into the intest inal tract can be facilitated spontaneously. It is suggested that extended hepaticocholedocho- je junostomy with partial hepat ic resection is a reasonable procedure for pr imary intrahepatic stones in the bi lateral lobes of the liver.

ACKNOWLEDGEMENTS

These data were presented at the 6th An- nua l Meeting of the In te rna t iona l Biliary As- sociation, Houston (USA), May, 1984.

This study was supported in par t by a Re- search Grant from the Division of In t ractable

Disease, Public Heal th Bureau, Ministry of Heal th and Welfare, Japan .

(Received for publ ica t ion on Apr. 16, 1985)

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Long-term results of surgical treatment for intrahepatic stones