Abstract: Objective　To discuss the reasons, surgical procedures and prognosis of multipleoperations for intra and extrahepatic cholangiolithiasis.
Methods　The retrospective cohort study was adopted. The clinical data of 85 patients with intra and extrahepatic cholangiolithiasis who underwent multipleoperations at the Second Affiliated Hospital of Anhui Medical University from January 2006 to January 2015 were collected. Individualized operations were determined according to the distribution of stones and liver functional reserve, including stones removal by incising bile duct and external biliary drainage, RouxenY hepaticojejunostomy and hepatolobectomy or segmental hepatectomy. The treatment followed the principles as complete removal of stones, complete resection of lesions, correction of stenosis and adequate drainage. Bile was extracted during operation for bacilli culture. Patients received the postoperative symptomatic treatments, including antiinflammation, hemostasis, liver protection, acid inhibition and nutritional support. The observation indicators included reoperation reasons, operation method, operation time, volume of intraoperative blood loss and transfusion, hepatic inflow occlusion, stone clearance rate, postoperative complications and treatments, bacilli culture of bile, results of pathological examination and duration of hospital stay, results of followup. The followup using outpatient examination and telephone interview was performed to detect postoperative living conditions and results of abdominal ultrasound once every 3 or 6 months in patients without stone residue and once every 1 month in patients with stone residue from postoperative week 6 to December 2015. Measurement data with normal distribution and with skewed distribution were represented as ±s and M (range), respectively.
Results　(1) Reasons of reoperation: 85 patients had stone residue or recurrence, including 7 combined with stenosis of bilioenteric anastomosis, 5 with secondary malignant biliary tumors and 2 with gastrointestinal stromal tumor invading intrahepatic bile duct. (2) Intraoperative status of reoperation: of 85 patients, 25 received partial hepatectomy+stones removal by incising common bile duct+choledochoscopy exploration+Ttube drainage, 21 received partial hepatectomy+stones removal by incising common bile duct+choledochoscopy exploration+RouxenY hepaticojejunostomy, 13 received stones removal by incising common bile duct+choledochoscopy exploration+Ttube drainage, 8 received stones removal by incising common bile duct+choledochoscopy exploration+RouxenY hepaticojejunostomy, 5 received partial hepatectomy+removal of former bilioenteric anastomosis+choledochoscopy exploration+Ttube drainage, 4 received former intestinal Yloop resection+stones removal by choledochoscopy+RouxenY hepaticojejunostomy, 3 received stones removal by incising intrahepatic bile duct+choledochoscopy exploration+Ttube drainage, 3 received partial hepatectomy+residual gallbladder resection+stones removal by incising common bile duct+choledochoscopy exploration+RouxenY hepaticojejunostomy, 2 received partial hepatectomy+residual gallbladder resection+stones removal by incising common bile duct+choledochoscopy exploration+Ttube drainage and 1 received residual gallbladder resection+removal of former bilioenteric anastomosis+choledochoscopy exploration+RouxenY hepaticojejunostomy. Operation time and volume of intraoperative blood loss of the 85 patients were (259±66)minutes and (180±142)mL, respectively. Seven patients underwent intraoperative blood transfusion and 17 underwent first hepatic hilum occlusion. ALl the 85 patients received intraoperative choledochoscopy exploration. The immediate and final stone clearance rates were 62.4%(53/85) and 87.0%(67/77). (3)Postoperative status of reoperations: of 85 patients, 45 had postoperative complications. Sixteen patients with incision infection were improved by wound drainage and dressing, antiinfection and supporting treatments without other treatments. Ten patients with pleural effusion were out of hospital after effective antiinfection and nutritional support treatments. Eight patients with biliary fistula were discharged from hospital after abdominal drainage. Six patients with incision infection combined with pleural effusion were discharged from hospital after wound drainage and dressing, antiinfection and nutritional support treatments. Among 5 patients with bile duct bleeding, 1 was selfhealing, 1 underwent reoperation and 3 were improved by conservative treatment. The bacilli culture of bile in 68 patients was positive, and bacteria mainly consisted of Escherichia coli, Enterobacter cloacae, Pseudomonas aeruginosa and Klebsiella pneumoniae. Of 85 patients, 78, 5 and 2 patients were respectively confirmed with hepatolithiasis, bile duct cell adenocarcinoma combined with stone recurrence and choledocholithiasis combined with interstitialoma by pathological examination. Duration of hospital stay was (21±8)days. (4) Results of followup: 77 patients were followed up for a median time of 32 months (range, 6- 108 months) with an overall followup rate of 90.6%(77/85). During followup, 50 patients had good survival, 27 had poor survival including 11 with stone residue, 9 with stone recurrence and 7 with bile duct canceration, and 7 died of no operation of secondary tumors.
Conclusions　Stone residue and recurrence are the main reasons for reoperation. The individualized surgical methods are determined according to preoperative stone distribution, with or without atrophy of liver lobe, with or without canceration and condition of liver function, which can increase the stone clerance rate, reduce the stone residue and recurrence rates and avoid reoperation.