Abstract: Objective:To investigate the clinical efficacy of precision liver surgery in the management of hepatolithiasis.
Methods:The clinical data of 68 patients with hepatolithiasis who were admitted to the First Affiliated Hospital of Anhui Medical University from August 2011 to December 2012 were retrospectively analyzed. The distribution of stones and the hepatic function were analyzed using the color Doppler ultra sonography, magnetic resonance imaging and magnetic resonance cholangiopancreatography. Individualized surgical plan was made according to preoperative evaluation and typing. Choledochoscope was applied to detect the distribution of stones and help to extract the stones. The function of sphincter of Oddi at the lower part of common bile duct was evaluated. The methods of biliary drainage were selected according to the function of sphincter of Oddi and whether the stones were cleared: patients with normal function of sphincter of Oddi were treated by T tube drainage; patients with sphincter of Oddi dilatation received biliojejunal Roux en Y anastomosis+internal drainage, gastric tube was not installed, and the bile was collected for bacilli culture and drug sensitivity test. Liquid diet was given to the patients at postoperative 48 hours. Patients were encouraged to take off bed activity in the early period after operation. Broad spectrum antibiotics were selected and adjusted according to the results of bacilli culture. The hepatic function was tested at postoperative day 1, 3, 7, and the short term complications were treated symptomatically. Follow up began at postoperative week 4 -6, and ended in December 2013. The general condition and hepatic function were monitored during the follow up. Patients with T tube drainage received choledochoscopy at postoperative week 6.
Results:Two or more than 2 types of imaging examinations were applied to all the patients before operation. The accurate rates of color Doppler ultra sonography, computed tomography and magnetic resonance imaging were 97.1%(66/68), 91.9%(57/62) and 95.0%(57/60), respectively. Two patients were with cholesterol stones and 66 with bile pigment stone. Stones located at the left lobe in 32 patients, the right lobe in 15 patients and the bilateral lobes in 21 patients. Thirty six patients were complicated with extrahepatic bile duct stones. The numbers of patients with type I, IIa, IIb,IIc and E hepatolithiasis were 47, 3, 15, 3 and 36. The numbers of patients with hepatic function in Child A and Child B were 50 and 18. Fifty two patients received choledocholithotomy+hepatectomy, including 30 of left lateral lobectomy, 5 of left hemihepatectomy, 1 of left lateral lobectomy+caudate lobectomy, 9 of partial resection of right lobe, 1 of right hemihepatectomy and 6 of partial resection of bilateral lobes. Sixteen patients received choledocholithotomy. Forty nine patients received T tube drainage, 19 received internal drainage and 3 received biliojejunal anastomosis+T tube drainage. The operation time was (237±65)minutes. Sixty eight patients received intraoperative fiber choledochoscopy, 66 received function evaluation of sphincter of Oddi (17 patients with sphincter of Oddi dilatation were detected). The immediate stone clearance rate was 73.5%(50/68), and the final stone clearance rate was 94.1%(64/68). The bile of 58 patients underwent bacilli culture and drug sensitivity test, and the result was positive in 45 patients (35 with gram negative bacteria infection and 12 with gram positive bacteria infection). Sixteen patients had postoperative complications, including 7 with bile leakage, 6 with pulmonary infection, 4 with wound infection and 2 with postoperative intra abdominal bleeding (1 with bleeding and adhesive intestinal obstruction was cured by enterodialysis), and all of them were cured by symptomatic treatment. No patient died perioperatively, and the duration of postoperative hospital stay was (13±7)days. The time and rate of follow up were (16±4)months and 86.8%(59/68). Of the 5 patients with cholangiocarcinoma, 3 patients died postoperatively and 2 patients did not have tumor recurrence during the follow up. Fifty four patients had good life situation with the rate of 91.5%(54/59).
Conclusion:It is helpful to reduce the residual rate of stones and improve the clinical efficacy of treatment for hepatolithiasis with the guidance of precision liver surgery.