Reappraisal of the systematic management of complicated hepatolithiasis with bilateral intrahepatic biliary strictures
K. S. Jeng, I. Ohta and F. S. Yang
Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan.
OBJECTIVE: To compare the results, limitations, and complications of the
surgical treatment of bilateral hepatolithiasis and intrahepatic biliary
strictures with left hepatectomy and without left hepatectomy. DESIGN:
Case-controlled study. SETTING: Referral center. PATIENTS: During a 12-year
period, 103 patients with bilateral hepatolithiasis and intrahepatic
biliary strictures underwent surgical treatment. Group A (n = 73) received
left hepatic resection (lateral segmentectomy or lobectomy) and
postoperative biliary dilatation with residual stone extraction. Group B (n
= 30) underwent the same procedures except for left hepatectomy.
INTERVENTIONS: Left lateral segmentectomy or left lobectomy,
choledocholithotomy, postoperative cholangioscopic treatments
(electrohydraulic lithotripsy, other lithotripsy, lithotomy, balloon
dilatation, etc. via T tube or precutaneous transhepatic route). MAIN
OUTCOME MEASURES: Days of hospitalization, incidence of major and minor
complications, mortality rates, and the rates of residual stones and stone
recurrence were compared. RESULTS: Group A and B had similarly low
postoperative 1-month mortality rates of 5.5% and 6.7%, respectively. The
main cause of death in both groups was uncontrollable septicemia. The main
major complications in group A were intra-abdominal abscess and upper
gastrointestinal bleeding; the major complication in group B was massive
hemobilia. Group B had a significantly higher overall rate of complications
(53.3% vs 23.3%, P < .01) and a longer hospital stay than group A
(median, 72 days vs 28 days, P < .03). When complications were
classified as major or minor, only minor complications showed a significant
difference (30% vs 13.7%, P = .05). After using biliary stricture
dilatation and stone extraction, the rate of residual stones in the right
lobe was similar in both groups, but patients in group B had a
significantly higher rate of residual stones (12.5% vs 0%, P < .02) and
stone recurrence in the left lobe (19% vs 0%, P < .003) than those in
group A. CONCLUSIONS: Partial resection of the left lobe in cases of
bilateral hepatolithiasis and biliary strictures can effectively simplify
problems in the treatment of bilateral hepatolithiasis and intrahepatic
biliary strictures. In addition, not only were surgical complications not
increased, but a decrease in complications from postoperative manipulations
for stone clearance was noted in our series.
