hepatolithiasis - Department of Surgery at SUNY Downstate Medical ...
hepatolithiasis - Department of Surgery at SUNY Downstate Medical ...
hepatolithiasis - Department of Surgery at SUNY Downstate Medical ...
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HEPATOLITHIASIS<br />
ALIREZA SADEGHI, MD<br />
KINGS COUNTY HOSPITAL CENTER<br />
<strong>SUNY</strong> DOWNSTATE MEDICAL CENTER
Surgical Management <strong>of</strong><br />
HEPATOLITHIASIS<br />
ALIREZA SADEGHI, MD<br />
<strong>SUNY</strong> DOWNSTATE MEDICAL CENTER
Overview<br />
• HEPATOLITHIASIS:<br />
– Historical Perspectives<br />
– Definition<br />
– Epidemiology & N<strong>at</strong>ural<br />
History<br />
– Etiology <strong>of</strong> Biliary Stones<br />
– Classific<strong>at</strong>ion Systems<br />
– Symptoms<br />
– Diagnosis<br />
– Tre<strong>at</strong>ment Regiments<br />
– Conclusion
Historical Perspectives<br />
• Vachell & Stevens (1906)<br />
– First published report <strong>of</strong> Intrahep<strong>at</strong>ic Calculi<br />
• By 1930, multiple descriptions<br />
– Recurrent Pyogenic Cholangitis<br />
– Hong Kong Disease<br />
– Biliary Obstruction Syndrome <strong>of</strong> the Chinese<br />
– Oriental Cholangitis<br />
– Oriental Infest<strong>at</strong>ional Cholangitis<br />
– Intrahep<strong>at</strong>ic Lithiasis<br />
Vachell HR, Stevens WM: Case <strong>of</strong> Intrahep<strong>at</strong>ic Calculi. Br Med J1906;1:434-36
Definition<br />
• Calculi or concretions<br />
– loc<strong>at</strong>ed proximal to the confluence <strong>of</strong> the<br />
right and left hep<strong>at</strong>ic ducts<br />
• Stones are present in Right and/or Left<br />
hep<strong>at</strong>ic ducts and/or their tributaries<br />
irrespective <strong>of</strong> the coexistence <strong>of</strong><br />
choledocholithiasis or cholecystolithiasis<br />
Nakayama F. Intrahep<strong>at</strong>ic Stones; Blumgart’s <strong>Surgery</strong> <strong>of</strong> the Liver & Biliary Tract. 765-774. 1994
Epidemiology<br />
• Occurs mainly in Southeast Asia:<br />
– China, Korea, Japan, Taiwan, Philippines, Vietnam,<br />
Thailand, Malaysia, Brazil, Indonesia and India<br />
– Incidence reported to be 20-30% <strong>of</strong> all p<strong>at</strong>ients<br />
undergoing surgery for gallstone disease.<br />
– Low incidence in Europe and North America<br />
– With increased immigr<strong>at</strong>ion more cases are being<br />
reported in the North American institutions however<br />
there is little experience in tre<strong>at</strong>ing the condition<br />
Nakayama F. Intrahep<strong>at</strong>ic Stones; Blumgart’s <strong>Surgery</strong> <strong>of</strong> the Liver & Biliary Tract. 765-774. 1994
Epidemiology<br />
•St<strong>at</strong>istics<br />
Nakayama F. Intrahep<strong>at</strong>ic Stones; Blumgart’s <strong>Surgery</strong> <strong>of</strong> the Liver & Biliary Tract. 765-774. 1994
Epidemiology<br />
• Incidence<br />
– Equal gender distribution<br />
– Affects p<strong>at</strong>ients in 3rd to 7th decades on life<br />
– More common in rural areas <strong>of</strong> Southeast<br />
Asia among the lower socio-economic class<br />
– Overall incidence in East Asia is declining<br />
• China & Taiwan: 20%<br />
• Japan: 2.2%<br />
Nakayama F. Intrahep<strong>at</strong>ic Stones; Blumgart’s <strong>Surgery</strong> <strong>of</strong> the Liver & Biliary Tract. 765-774. 1994
Epidemiology<br />
• Incidence in Europe & North America<br />
• Very low prevalence
Classific<strong>at</strong>ion<br />
• Most recent system: Nakayama in 1982<br />
• Presence <strong>of</strong> stones in the intra-hep<strong>at</strong>ic bile ducts: I<br />
• Presence <strong>of</strong> stones in the intra & extra-hep<strong>at</strong>ic bile<br />
ducts: IE<br />
• Right & Left hep<strong>at</strong>ic ducts distal to the confluence<br />
• Segmental ducts are divided into central &<br />
peripheral<br />
– Central: Ducts <strong>of</strong> first and second branches<br />
Nakayama F. Hep<strong>at</strong>olithiasis in East Asia. Digestive Diseases & Sciences. 1986; 30(1):21-26
Classific<strong>at</strong>ion<br />
Nakayama F. Hep<strong>at</strong>olithiasis in East Asia. Digestive Diseases & Sciences. 1986; 30(1):21-26
Classific<strong>at</strong>ion<br />
• Nakayama: 1982<br />
– Strictures (S): decrease in the diameter <strong>of</strong> bile<br />
ducts rel<strong>at</strong>ive to adjacent parts.<br />
• S0: Absence <strong>of</strong> stricture<br />
• S1: Slight stricture (Diameter > 2mm)<br />
• S2: Marked stricture (Diameter < 2 mm)<br />
Nakayama F. Hep<strong>at</strong>olithiasis in East Asia. Digestive Diseases & Sciences. 1986; 30(1):21-26
Classific<strong>at</strong>ion<br />
• Nakayama: 1982<br />
– Dil<strong>at</strong><strong>at</strong>ion (D): increase in diameter <strong>of</strong> bile<br />
duct beyond physiological range<br />
– D0: Absence <strong>of</strong> dil<strong>at</strong><strong>at</strong>ion<br />
– D1: Slight dil<strong>at</strong><strong>at</strong>ion<br />
– D2: Marked dil<strong>at</strong><strong>at</strong>ion<br />
– Extrahep<strong>at</strong>ic Bile Ducts:<br />
» 20 mm divides D1 and D2<br />
– Intrahep<strong>at</strong>ic Bile Ducts:<br />
» 10 mm divides D1 and D2<br />
Nakayama F. Hep<strong>at</strong>olithiasis in East Asia. Digestive Diseases & Sciences. 1986; 30(1):21-26
Classific<strong>at</strong>ion<br />
• Additional Criteria<br />
• Gallbladder (G)<br />
– Cholesterol stones: “Gc”<br />
– Calcium Bilirubin<strong>at</strong>e: “Gb”<br />
– Uncertain type <strong>of</strong> stone: “Gx”<br />
• Extrahep<strong>at</strong>ic Bile Ducts (B)<br />
• Intrahep<strong>at</strong>ic Bile Ducts (H)<br />
Nakayama F. Hep<strong>at</strong>olithiasis in East Asia. Digestive Diseases & Sciences. 1986; 30(1):21-26
Classific<strong>at</strong>ion<br />
Nakayama F. Hep<strong>at</strong>olithiasis in East Asia. Digestive Diseases & Sciences. 1986; 30(1):21-26
Etiology<br />
• Intrahep<strong>at</strong>ic Lithiasis<br />
– East vs. West<br />
– In the west is generally thought to be secondary to<br />
stones origin<strong>at</strong>ing in the gall bladder or primarily<br />
resulting from benign strictures, sclerosing cholangitis,<br />
choledochal cysts or malignant biliary tumors.<br />
– In the East it is regarded as a separ<strong>at</strong>e entity altogether.<br />
The majority <strong>of</strong> cases are associ<strong>at</strong>ed with recurrent<br />
pyogenic cholangitis in regions with parasitic<br />
infest<strong>at</strong>ions<br />
Rao et al. Intrahep<strong>at</strong>ic Stones – an etiological quagmire. Indian J Gastroenterology 2004;23:201-2
Etiology<br />
• Ethnic vs. Environmental factors<br />
• Survey by Nakayama looked <strong>at</strong> the proportion <strong>of</strong><br />
HL in different provinces <strong>of</strong> China as compared<br />
to th<strong>at</strong> <strong>of</strong> HL in Japan:<br />
– Taiwan 53.1%<br />
– Hong Kong 3.1%<br />
– Singapore 1.7%<br />
– Japan 4.1%<br />
• In spite <strong>of</strong> a similar ethnic background (Chinese<br />
descent) the rel<strong>at</strong>ive proportion <strong>of</strong> HL is marked<br />
different in Taiwan, Hong Kong & Singapore<br />
Nakayama F. Hep<strong>at</strong>olithiasis in East Asia. Digestive Diseases & Sciences. 1986; 30(1):21-26
Etiology<br />
• Environmental factors<br />
– Parasitic Infest<strong>at</strong>ions<br />
• Clonorchis Sinensis & Ascaris Lumbricoides<br />
– Despite <strong>of</strong> epidemiologic associ<strong>at</strong>ion, evidence<br />
supporting the role <strong>of</strong> these infections in p<strong>at</strong>hogenesis<br />
is inconclusive.<br />
– Infest<strong>at</strong>ions can only be demonstr<strong>at</strong>ed in 30% <strong>of</strong><br />
p<strong>at</strong>ients with HL.<br />
– HL is common in some Asian countries in which<br />
Parasites are not endemic<br />
» Certain areas <strong>of</strong> Malaysia, China & Taiwan with<br />
high prevalence <strong>of</strong> HL are virtually free <strong>of</strong><br />
Clonorchis<br />
Yellin AE et al Biliary lithiasis and helminthiasis. Am J Surg 1981;142:128.
Etiology<br />
• Parasites<br />
• Theory:<br />
– Analysis <strong>of</strong> stones have shown debris & ova<br />
which may have served as a nidus for stone<br />
form<strong>at</strong>ion<br />
– This is probably incidental r<strong>at</strong>her than<br />
caus<strong>at</strong>ive and may merely be an associ<strong>at</strong>ion<br />
with stones in endemic areas <strong>of</strong> infest<strong>at</strong>ion<br />
Yellin AE et al Biliary lithiasis and helminthiasis. Am J Surg 1981;142:128.
Etiology<br />
• Environmental factors<br />
– Bacterial Infections<br />
• Human bile is Sterile under normal circumstances<br />
• Incidence <strong>of</strong> Bacteria in bile <strong>of</strong> p<strong>at</strong>ients with HL is almost<br />
100% in most series<br />
• Bacteria commonly found:<br />
– Klebsiella sp<br />
– E. Coli<br />
– Pseudomonas sp<br />
– Entercoccous sp<br />
– Bacteroides sp<br />
• Entry route: access biliary tree by injury from a parasitic<br />
infection<br />
Sheen-Chen SM et al. Bacteriology & Antimicrobial choices in Hep<strong>at</strong>olithiasis. AJIC 2000;28:298-301
Etiology<br />
• Bacterial Infection<br />
• Polymicrobial infection usually prevails<br />
• Most bacterial species present show Bglucoronidase<br />
activity<br />
Nakayama F. Intrahep<strong>at</strong>ic Stones; Blumgart’s <strong>Surgery</strong> <strong>of</strong> the Liver & Biliary Tract. 765-774. 1994
Etiology<br />
• Bacterial infection<br />
• B-Glucuronidase is responsible for c<strong>at</strong>alyzing the<br />
hydrolysis <strong>of</strong> direct bilirubin to the indirect<br />
unconjug<strong>at</strong>ed form<br />
• Unconjug<strong>at</strong>ed bilirubin is w<strong>at</strong>er-insoluble &<br />
combines with calcium bilirubin<strong>at</strong>e to form<br />
Calcium Bilirubin<strong>at</strong>e (PIGMENT) stones which<br />
comprise the majority <strong>of</strong> the cases <strong>of</strong><br />
Hep<strong>at</strong>olithiasis (80%)<br />
• Cholesterol & mixed stones are increasing (10%)<br />
as the western diet invades Asia<br />
Nakayama F. Intrahep<strong>at</strong>ic Stones; Blumgart’s <strong>Surgery</strong> <strong>of</strong> the Liver & Biliary Tract. 765-774. 1994
Etiology<br />
Nakayama F. Intrahep<strong>at</strong>ic Stones; Blumgart’s <strong>Surgery</strong> <strong>of</strong> the Liver & Biliary Tract. 765-774. 1994
Etiology<br />
• Bile Stasis<br />
• Main cause <strong>of</strong> Intrahep<strong>at</strong>ic Stones in the West<br />
• Stenosis & Strictures<br />
– Benign strictures<br />
» Postoper<strong>at</strong>ive: Most Common Etiology<br />
– Sclerosing Cholangitis<br />
– Choledochal cysts<br />
– Malignant biliary tumors<br />
Rao et al. Intrahep<strong>at</strong>ic Stones – an etiological quagmire. Indian J Gastroenterology 2004;23:201-2
Etiology<br />
• Other factors<br />
– Diet<br />
• Asian diet:<br />
– high in carbohydr<strong>at</strong>es and low in f<strong>at</strong> & protein.<br />
• S<strong>at</strong>ur<strong>at</strong>ed f<strong>at</strong>s causes CCK release & relax<strong>at</strong>ion <strong>of</strong><br />
the sphincter <strong>of</strong> Oddi<br />
– Low f<strong>at</strong> diet leads to biliary stasis<br />
• Low protein diet<br />
– Low level <strong>of</strong> Glucaro-1.4-lactone which is an inhibitor<br />
<strong>of</strong> B-Glucuronidase, potenti<strong>at</strong>ing the deconjung<strong>at</strong>ion<br />
reaction<br />
Rao et al. Intrahep<strong>at</strong>ic Stones – an etiological quagmire. Indian J Gastroenterology 2004;23:201-2
Etiology<br />
• Rare causes:<br />
– I<strong>at</strong>rogenic Factors
Loc<strong>at</strong>ion<br />
• Left duct involvement > Right ducts<br />
– Reason for preponderance is unknown<br />
– Left duct courses horizontally in rel<strong>at</strong>ion to<br />
the CHD as compared to the right duct<br />
forming an acute angle<br />
– Unusual branching <strong>of</strong> the right segmental<br />
ducts draining into the left hep<strong>at</strong>ic duct<br />
– No st<strong>at</strong>istically proven difference on<br />
necropsy studies
P<strong>at</strong>hophysiology<br />
• Recurrent Pyogenic Cholangitis<br />
• Recurrent bouts <strong>of</strong> cholangitis<br />
• Inflamm<strong>at</strong>ory changes in the bile ducts leading to<br />
further stricture form<strong>at</strong>ion and causing bile stasis<br />
• Walls <strong>of</strong> the ducts are thickened and fibrosed<br />
• Hep<strong>at</strong>ic parenchyma associ<strong>at</strong>ed with stones<br />
within the intrahep<strong>at</strong>ic ducts show mild to severe<br />
<strong>at</strong>rophy and fibrosis leading to cirrhosis<br />
Nakayama F. Intrahep<strong>at</strong>ic Stones; Blumgart’s <strong>Surgery</strong> <strong>of</strong> the Liver & Biliary Tract. 765-774. 1994
N<strong>at</strong>ural History<br />
• If left untre<strong>at</strong>ed Hep<strong>at</strong>olithiasis leads to<br />
• Recurrent pyogenic cholangitis<br />
• Progressive biliary strictures<br />
• Form<strong>at</strong>ion <strong>of</strong> liver abscesses<br />
• Atrophy <strong>of</strong> the affected liver<br />
• Secondary biliary cirrhosis<br />
• Portal Hypertension<br />
• Cholangiocarcinoma<br />
Nakayama F. Intrahep<strong>at</strong>ic Stones; Blumgart’s <strong>Surgery</strong> <strong>of</strong> the Liver & Biliary Tract. 765-774. 1994<br />
Jan YY et al. Surgical tre<strong>at</strong>ment <strong>of</strong> Hep<strong>at</strong>olithiasis: Long-term results. <strong>Surgery</strong> 1996;120:509-514<br />
Kusano T et al. N<strong>at</strong>ural Progression <strong>of</strong> Untre<strong>at</strong>ed Hep<strong>at</strong>olithiasis. J Clin Gastroenterol 2001;33(2):114-17
N<strong>at</strong>ural History<br />
• 122 p<strong>at</strong>ients with CT & CT-Cholangiography<br />
findings <strong>of</strong> Hep<strong>at</strong>olithiasis<br />
– 14/122 became symptom<strong>at</strong>ic <strong>at</strong> mean 3.4 yrs<br />
– Symptoms:<br />
• Recurrent abdominal pain, hep<strong>at</strong>ic abscesses,<br />
lobar <strong>at</strong>rophy, cholangitis & cholangiocarcinoma<br />
• Lobar Atrophy: Major role in development<br />
symptoms<br />
– 13/14 (93%) <strong>of</strong> symptom<strong>at</strong>ic group<br />
– 14/108 (13%) <strong>of</strong> asymptom<strong>at</strong>ic group<br />
Kusano T et al. N<strong>at</strong>ural Progression <strong>of</strong> Untre<strong>at</strong>ed Hep<strong>at</strong>olithiasis. J Clin Gastroenterol 2001;33(2):114-17
N<strong>at</strong>ural History<br />
• 122 p<strong>at</strong>ients with CT & CT-Cholangiography<br />
findings <strong>of</strong> Hep<strong>at</strong>olithiasis<br />
– Summary:<br />
• Recurrence <strong>of</strong> HL in the <strong>at</strong>rophic liver causes<br />
persistent chronic inflamm<strong>at</strong>ion which leads to<br />
form<strong>at</strong>ion <strong>of</strong> strictures and more HL and possibly<br />
cholangiocarcinoma.<br />
• Lobar Atrophy is a risk factor for<br />
cholangiocarcinoma & hep<strong>at</strong>ectomy is indic<strong>at</strong>ed<br />
Kusano T et al. N<strong>at</strong>ural Progression <strong>of</strong> Untre<strong>at</strong>ed Hep<strong>at</strong>olithiasis. J Clin Gastroenterol 2001;33(2):114-17
N<strong>at</strong>ural History<br />
• Cholangiocarcinoma & Hep<strong>at</strong>olithiasis<br />
– Incidence: 2.36% - 10 %<br />
– Proposed mechanisms<br />
• Prolonged irrit<strong>at</strong>ion <strong>of</strong> biliary epithelium by calculi<br />
• Long term exposure to bile & its products<br />
• Repe<strong>at</strong>ed infections<br />
• Metabolic byproducts <strong>of</strong> bacteria in the biliary tree<br />
• Dynamic irrit<strong>at</strong>ion by unstable bile flow<br />
– Bile Stasis, reflux & turbulence<br />
Nakanuma Y et al. Are Hep<strong>at</strong>olithiasis and cholangiocarcinoma etiologically rel<strong>at</strong>ed? Virchows Arch<br />
1985;406: 45-58.<br />
Jan YY et al. Surgical tre<strong>at</strong>ment <strong>of</strong> Hep<strong>at</strong>olithiasis: Long-term results. <strong>Surgery</strong> 1996;120:509-514.
Cholangiocarcinoma & Hep<strong>at</strong>olithiasis<br />
• China<br />
– Sixteen <strong>of</strong> 20 (80%) <strong>of</strong> p<strong>at</strong>ients with peripheral<br />
intrahep<strong>at</strong>ic cholangiocarcinoma had associ<strong>at</strong>ed<br />
intrahep<strong>at</strong>ic stones.<br />
Chen MF, Jan YY et al. Clinical experience in 20 hep<strong>at</strong>ic resections for peripheral cholangiocarcinoma.<br />
Cancer 1989;64:2226-2232
Cholangiocarcinoma & Hep<strong>at</strong>olithiasis<br />
•Taiwan<br />
– Five cases <strong>of</strong> Cholangiocarcinoma in 101 p<strong>at</strong>ients<br />
(5%) with Hep<strong>at</strong>olithiasis<br />
Sheen-Chen SM et al. Intrahep<strong>at</strong>ic cholangiocarcinoma in Hep<strong>at</strong>olithiasis: a frequently overlooked disease. J<br />
Surg Oncol 1991;47:131-135<br />
•Japan<br />
– Eight cases <strong>of</strong> Cholangiocarcinoma developing in<br />
109 p<strong>at</strong>ient (7.3%) with intrahep<strong>at</strong>ic stones<br />
Chijiiwa K et al. L<strong>at</strong>e development <strong>of</strong> cholangiocarcinoma after the tre<strong>at</strong>ment <strong>of</strong> Hep<strong>at</strong>olithiasis. Surg<br />
Gynecol Obstet 1993;177:279-282.
Cholangiocarcinoma & Hep<strong>at</strong>olithiasis<br />
• Hong Kong<br />
– Ten <strong>of</strong> 103 (10%) p<strong>at</strong>ients <strong>of</strong> undergoing<br />
hep<strong>at</strong>ectomy for Hep<strong>at</strong>olithiasis had<br />
cholangiocarcinoma<br />
– In addition 3 p<strong>at</strong>ients developed<br />
cholangiocarcinoma <strong>at</strong> interval <strong>of</strong> 7 – 36 months<br />
after the first oper<strong>at</strong>ion for Hep<strong>at</strong>olithiasis<br />
Chen DW et al. Immedi<strong>at</strong>e and long-term outcomes <strong>of</strong> hep<strong>at</strong>ectomy for Hep<strong>at</strong>olithiasis. <strong>Surgery</strong><br />
2004;135:386-93.
Cholangiocarcinoma & Hep<strong>at</strong>olithiasis<br />
• Hong Kong:<br />
– Follow up <strong>of</strong> 91<br />
p<strong>at</strong>ients.<br />
– 5 yr survival<br />
• Group I: 9%<br />
• Group II: 93%<br />
Conclusion:<br />
Cholangiocarcinoma is an<br />
independent prognostic<br />
factor <strong>of</strong> the survival <strong>of</strong><br />
p<strong>at</strong>ients with Hep<strong>at</strong>olithiasis<br />
who underwent hep<strong>at</strong>ectomy<br />
Chen DW et al. Immedi<strong>at</strong>e and long-term outcomes <strong>of</strong> hep<strong>at</strong>ectomy for Hep<strong>at</strong>olithiasis. <strong>Surgery</strong> 2004;135:386-93.
Symptoms<br />
• No p<strong>at</strong>hognomonic symptoms<br />
• RUQ Pain<br />
• Fever<br />
• Bouts <strong>of</strong> Cholangitis<br />
• Less frequently jaundice<br />
• Abnormal LFTs with elev<strong>at</strong>ion <strong>of</strong> Alk Phos<br />
• In study <strong>of</strong> 54 p<strong>at</strong>ients <strong>at</strong> Johns Hopkins<br />
– 1. Cholangitis 67%<br />
– 2. Abdominal Pain 63%<br />
– 3. Jaundice 39%<br />
Rao et al. Intrahep<strong>at</strong>ic Stones – an etiological quagmire. Indian J Gastroenterology 2004;23:201-2<br />
Pitt HA, Cameron JL et al. Intrahep<strong>at</strong>ic Stones; The Transhep<strong>at</strong>ic Team Approach. Annals <strong>of</strong> <strong>Surgery</strong><br />
1994;219: 527-37
Diagnostics<br />
• RUQ Ultrasonography<br />
– Ductal dil<strong>at</strong>ion & calculi seen in 85-90%<br />
• CT Scan<br />
– Hep<strong>at</strong>ic Architecture & <strong>at</strong>rophy<br />
• Mapping <strong>of</strong> the biliary tree<br />
– MRCP<br />
– ERCP- therapeutic<br />
– PTC- therapeutic
Tre<strong>at</strong>ment<br />
• Aims <strong>of</strong> tre<strong>at</strong>ment<br />
– Prevention <strong>of</strong> liver damage by early clearance <strong>of</strong> stones and<br />
elimin<strong>at</strong>ion <strong>of</strong> bile stasis<br />
• Removal <strong>of</strong> stones<br />
• Removal <strong>of</strong> strictured bile ducts<br />
• Providing good drainage <strong>of</strong> bile<br />
– Minimizing bacterial infection<br />
• Resection <strong>of</strong> source <strong>of</strong> recurrent infection & biliary stasis<br />
• Removal <strong>of</strong> cholangiocarcinoma<br />
• Removal <strong>of</strong> <strong>at</strong>rophic liver<br />
• Removal <strong>of</strong> hep<strong>at</strong>ic abscess<br />
– Residual stones should be able to spontaneously enter the GI<br />
tract<br />
Pitt HA, Cameron JL et al. Intrahep<strong>at</strong>ic Stones; The Transhep<strong>at</strong>ic Team Approach. Annals <strong>of</strong> <strong>Surgery</strong><br />
1994;219: 527-37.
Tre<strong>at</strong>ment<br />
• Team Approach to tre<strong>at</strong>ment<br />
– Combined Interventional Radiological,<br />
Gastroenterological & Surgical Regimen using the<br />
Transhep<strong>at</strong>ic approach<br />
• Percutaneous Placement <strong>of</strong> transhep<strong>at</strong>ic access<br />
c<strong>at</strong>heters<br />
• <strong>Surgery</strong> for underlying biliary disease & stone<br />
removal<br />
• Postoper<strong>at</strong>ive percutaneous choledochoscopy &<br />
residual or recurrent stone removal through<br />
transhep<strong>at</strong>ic stents<br />
Pitt HA, Cameron JL et al. Intrahep<strong>at</strong>ic Stones; The Transhep<strong>at</strong>ic Team Approach. Annals <strong>of</strong> <strong>Surgery</strong><br />
1994;219: 527-37.
Tre<strong>at</strong>ment<br />
• Percutaneous Options<br />
– In the Jaundice P<strong>at</strong>ient<br />
– PTC with PT Biliary Drainage (PTBD):<br />
• Sinus tract dil<strong>at</strong>ed to 18 Fr to ease introduction <strong>of</strong><br />
– Choldechoscope<br />
– Basket/Balloon c<strong>at</strong>heters/Stents<br />
– Microwave, Electrohydraulic lithotripsy and Laser<br />
probes for stone fragment<strong>at</strong>ion & piecemeal removal<br />
Nakayama F. Intrahep<strong>at</strong>ic Stones; Blumgart’s <strong>Surgery</strong> <strong>of</strong> the Liver & Biliary Tract. 765-774. 1994
Tre<strong>at</strong>ment<br />
• Percutaneous Transhep<strong>at</strong>ic Choledoscopic<br />
removal <strong>of</strong> intrahep<strong>at</strong>ic stones<br />
– Retrospective study <strong>of</strong> 79 p<strong>at</strong>ients with early<br />
diagnosed intrahep<strong>at</strong>ic stones over 8 years<br />
• Success r<strong>at</strong>e <strong>of</strong> 76.8 %<br />
• Removal <strong>of</strong> right sided stones was difficult<br />
• Cholangitis recurred in 1/3 <strong>of</strong> p<strong>at</strong>ients within 3-5<br />
years<br />
• Intrahep<strong>at</strong>ic strictures was the major determinant for<br />
recurrence <strong>of</strong> stones and symptoms.<br />
Cheung MT et al. Percutaneous Transhep<strong>at</strong>ic Choledoscopic removal <strong>of</strong> intrahep<strong>at</strong>ic stones. Brit J Surg<br />
2003;90:1409-1415
Tre<strong>at</strong>ment<br />
• Percutaneous Transhep<strong>at</strong>ic Placement <strong>of</strong><br />
Metallic Stents in the Tre<strong>at</strong>ment <strong>of</strong><br />
Complic<strong>at</strong>ed Intrahep<strong>at</strong>ic Biliary Stricture<br />
With Hep<strong>at</strong>olithiasis<br />
– No recurrent strictures or formed calculi were found in<br />
the six p<strong>at</strong>ients during follow-up periods <strong>of</strong> up to 64<br />
months.<br />
– Metallic stents are a well-toler<strong>at</strong>ed and promising<br />
altern<strong>at</strong>ive in the management <strong>of</strong> refractory intrahep<strong>at</strong>ic<br />
long-segment biliary strictures with Hep<strong>at</strong>olithiasis.<br />
Jeng KS et al. Percutaneous Transhep<strong>at</strong>ic Placement <strong>of</strong> Metallic Stents in the Tre<strong>at</strong>ment <strong>of</strong> Complic<strong>at</strong>ed<br />
Intrahep<strong>at</strong>ic Biliary Stricture With Hep<strong>at</strong>olithiasis. Am J Gastroenterol 1999;94:3507–3512.
Tre<strong>at</strong>ment<br />
• Endoscopic Retrograde Approach<br />
– Absence <strong>of</strong> Jaundice<br />
– Removal <strong>of</strong> both Intra & Extrahep<strong>at</strong>ic biliary<br />
stones<br />
• Introduction <strong>of</strong> basket/balloon c<strong>at</strong>heters<br />
• Avoids injury to the hep<strong>at</strong>ic parenchyma<br />
• Difficult technique with high failure r<strong>at</strong>es<br />
Nakayama F. Intrahep<strong>at</strong>ic Stones; Blumgart’s <strong>Surgery</strong> <strong>of</strong> the Liver & Biliary Tract. 765-774. 1994
Tre<strong>at</strong>ment<br />
• Extracorporeal Shock Wave Lithotripsy<br />
– Limited success if there is no predetermined<br />
evacu<strong>at</strong>ion route for the stone fragments<br />
– Frequent presence <strong>of</strong> bile duct strictures makes<br />
removal difficult in spite <strong>of</strong> successful<br />
fragment<strong>at</strong>ion<br />
– Stone clearance r<strong>at</strong>e <strong>of</strong> up to 95% reported<br />
– When combined with ERCP and Electrohydraulic<br />
lithotripsy.<br />
Nakayama F. Intrahep<strong>at</strong>ic Stones; Blumgart’s <strong>Surgery</strong> <strong>of</strong> the Liver & Biliary Tract. 765-774. 1994<br />
Binmoeller KF et al. Tre<strong>at</strong>ment <strong>of</strong> difficult bile duct stones using mechanical, electrohydraulic and<br />
extracorporeal shock wave lithotripsy. Endoscopy1993 Mar;25(3):201-6
Tre<strong>at</strong>ment<br />
• Choledochostomy Approach<br />
– Previous CBD explor<strong>at</strong>ion with T-tube<br />
placement with tract m<strong>at</strong>ur<strong>at</strong>ion<br />
– Insertion <strong>of</strong> balloon/basket c<strong>at</strong>heters<br />
– Choledoch<strong>of</strong>ibrescopy<br />
– Limited to the Left hep<strong>at</strong>ic ducts<br />
– Difficult to reach the Right biliary tree<br />
• Unfavorable angle<br />
Nakayama F. Intrahep<strong>at</strong>ic Stones; Blumgart’s <strong>Surgery</strong> <strong>of</strong> the Liver & Biliary Tract. 765-774. 1994
Tre<strong>at</strong>ment<br />
• Postoper<strong>at</strong>ive Choledoscopic Removal <strong>of</strong><br />
Intrahep<strong>at</strong>ic Stones via a T-tube tract<br />
– Retrospective study <strong>of</strong> 44 p<strong>at</strong>ients in Hong Kong<br />
• Successful procedure in 22/44 p<strong>at</strong>ients<br />
• Presence <strong>of</strong> Stricture associ<strong>at</strong>ed with higher failure<br />
r<strong>at</strong>es (P=0.002)<br />
• Invaluable access route but a limited procedure when<br />
strictures present<br />
Cheung MT. Postoper<strong>at</strong>ive Choledoscopic Removal <strong>of</strong> Intrahep<strong>at</strong>ic Stones via a T-tube tract Brit J Surg<br />
1997;84:1224-28
Tre<strong>at</strong>ment<br />
• Surgical Options<br />
– Based on presence <strong>of</strong> I or IE Hep<strong>at</strong>olithiasis<br />
• Choledochotomy with CBD Explor<strong>at</strong>ion<br />
• Choledochostomy with drainage<br />
• Hep<strong>at</strong>ico/Cholangioenterostomy<br />
• Placement <strong>of</strong> Access Loops<br />
• Hep<strong>at</strong>ic Resection<br />
– Lobectomy (L>R)<br />
– Segmental Resection<br />
• Hep<strong>at</strong>ic Transplant<strong>at</strong>ion<br />
Nakayama F. Intrahep<strong>at</strong>ic Stones; Blumgart’s <strong>Surgery</strong> <strong>of</strong> the Liver & Biliary Tract. 765-774. 1994
Tre<strong>at</strong>ment<br />
• Access Loop Procedures<br />
– Provide continuous postoper<strong>at</strong>ive access to the biliary tree for<br />
residual/recurrent stone retraction<br />
– Percutaneous/Cutaneous<br />
• Permanent cutaneous access<br />
– Hep<strong>at</strong>icocutaneous jejunosotomy<br />
» Side effects: bile leakage, cutaneous excori<strong>at</strong>ion, electrolyte<br />
imbalances<br />
• Percutaneous access<br />
– Subparietal hep<strong>at</strong>icojejunal access<br />
– Endoscopic<br />
• Interposition jejunal segment between hep<strong>at</strong>ic hilum & duodenum<br />
• Side to side Roux-en-Y jejuno-duodenal access loop<br />
Rao et al. Intrahep<strong>at</strong>ic Stones – an etiological quagmire. Indian J Gastroenterology 2004;23:201-2<br />
Beckingham IJ et al. Subparietal hep<strong>at</strong>icojejunal access loop for the long-term management <strong>of</strong> intrahep<strong>at</strong>ic<br />
stones. Brit J Surg 1998;85:1360-63
Tre<strong>at</strong>ment<br />
• Access Loops<br />
Beckingham IJ et al. Subparietal hep<strong>at</strong>icojejunal access loop for the long-term management <strong>of</strong> intrahep<strong>at</strong>ic<br />
stones. Brit J Surg 1998;85:1360-63
Tre<strong>at</strong>ment<br />
• Current surgical approaches<br />
– Tre<strong>at</strong>ment is fashioned on individual basis<br />
• Hep<strong>at</strong>ic Resection<br />
• Explor<strong>at</strong>ion <strong>of</strong> CBD and intrahep<strong>at</strong>ic ducts with<br />
biliary drainage or cholangioenterostomy<br />
• Percutaneous techniques<br />
Rao et al. Intrahep<strong>at</strong>ic Stones – an etiological quagmire. Indian J Gastroenterology 2004;23:201-2
Tre<strong>at</strong>ment<br />
• Indic<strong>at</strong>ions for Hep<strong>at</strong>ic Resection<br />
– Advantage<br />
• Removal <strong>of</strong> all stones along with p<strong>at</strong>hologic bile ducts Including<br />
the carcinom<strong>at</strong>ous bile ducts<br />
– Atrophic & Fibrotic / Abscess <strong>of</strong> a liver segment or lobe<br />
• Left > Right<br />
– Possibility <strong>of</strong> concomitant cholangiocarcinoma<br />
– Localized intrahep<strong>at</strong>ic calculi with irreversible biliary<br />
strictures<br />
Nakayama F. Intrahep<strong>at</strong>ic Stones; Blumgart’s <strong>Surgery</strong> <strong>of</strong> the Liver & Biliary Tract. 765-774. 1994<br />
Otani K et al. Comparison <strong>of</strong> Tre<strong>at</strong>ments for Hep<strong>at</strong>olithiasis: Hep<strong>at</strong>ic resection versus Cholangioscopic<br />
Lithotomy. J Am Coll Surg 1999;189:177-182<br />
Fan ST et al. Tre<strong>at</strong>ment <strong>of</strong> Hep<strong>at</strong>olithiasis: Improvement <strong>of</strong> result by a systemic approach. <strong>Surgery</strong><br />
1991;109:474-480
Hep<strong>at</strong>ic Resection<br />
• Immedi<strong>at</strong>e and long-term outcomes <strong>of</strong><br />
hep<strong>at</strong>ectomy for Hep<strong>at</strong>olithiasis<br />
– Retrospective study <strong>of</strong> 103 p<strong>at</strong>ients over<br />
13 years in Hong Kong
Hep<strong>at</strong>ic Resection<br />
• Immedi<strong>at</strong>e and long-term outcomes <strong>of</strong> hep<strong>at</strong>ectomy<br />
for Hep<strong>at</strong>olithiasis<br />
• Immedi<strong>at</strong>e & Final clearance r<strong>at</strong>e <strong>of</strong> 90 % & 98 %<br />
• Morbidity & 30 Day Mortality <strong>of</strong> 28 % & 2 %<br />
• R Hep<strong>at</strong>ectomy & Preoper<strong>at</strong>ive Hyperbilirubinemia<br />
– Predictive <strong>of</strong> post oper<strong>at</strong>ive complic<strong>at</strong>ions<br />
– 10% cholangiocarcinoma<br />
• At 56 months recurrence in 8/103 p<strong>at</strong>ients<br />
• Conclusion<br />
• Safe & effective method with high immedi<strong>at</strong>e stone clearance<br />
r<strong>at</strong>e & low long term stone recurrence r<strong>at</strong>e<br />
Chen DW et al. Immedi<strong>at</strong>e and long-term outcomes <strong>of</strong> hep<strong>at</strong>ectomy for Hep<strong>at</strong>olithiasis. <strong>Surgery</strong><br />
2004;135:386-93.
Left Hep<strong>at</strong>ic Resection<br />
• The surgical tre<strong>at</strong>ment <strong>of</strong><br />
isol<strong>at</strong>ed left-sided<br />
Hep<strong>at</strong>olithiasis<br />
• Retrospective analysis <strong>of</strong><br />
128 p<strong>at</strong>ients with HL<br />
isol<strong>at</strong>ed to the left hep<strong>at</strong>ic<br />
ducts over 22 years in<br />
China<br />
• Concomitant strictures<br />
were present in 72% <strong>of</strong><br />
p<strong>at</strong>ients<br />
Sun WB et al. The surgical tre<strong>at</strong>ment <strong>of</strong> isol<strong>at</strong>ed left-sided Hep<strong>at</strong>olithiasis: A 22 year experience. <strong>Surgery</strong><br />
2000;127-493-7
Left Hep<strong>at</strong>ic Resection<br />
• Left Hep<strong>at</strong>ic lobectomy is the most effective tre<strong>at</strong>ment to<br />
remove all lesions, stones, strictures or potential<br />
cholangiocarcinoma<br />
Sun WB et al. The surgical tre<strong>at</strong>ment <strong>of</strong> isol<strong>at</strong>ed left-sided Hep<strong>at</strong>olithiasis: A 22 year experience. <strong>Surgery</strong><br />
2000;127-493-7
Hep<strong>at</strong>ic Resection vs. PTCSL<br />
• Comparison <strong>of</strong> Tre<strong>at</strong>ments for Hep<strong>at</strong>olithiasis:<br />
Hep<strong>at</strong>ic Resection Versus Cholangioscopic<br />
Lithotomy<br />
– Retrospective review <strong>of</strong> 54 p<strong>at</strong>ients over 16 years in<br />
Japan<br />
– 26 p<strong>at</strong>ients under went Hep<strong>at</strong>ic Resection<br />
• Mainly Left sided stones<br />
– 28 p<strong>at</strong>ients under went PTCSL<br />
• Mainly Right and some B/L stones<br />
• Average <strong>of</strong> 6 tre<strong>at</strong>ments per p<strong>at</strong>ient<br />
Otani K et al. Comparison <strong>of</strong> Tre<strong>at</strong>ments for Hep<strong>at</strong>olithiasis: Hep<strong>at</strong>ic Resection Versus<br />
Cholangioscopic Lithotomy. J Am Coll Surg 1999;189:177-182
Hep<strong>at</strong>ic Resection vs. PTCSL<br />
Otani K et al. Comparison <strong>of</strong> Tre<strong>at</strong>ments for Hep<strong>at</strong>olithiasis: Hep<strong>at</strong>ic Resection Versus Cholangioscopic<br />
Lithotomy. J Am Coll Surg 1999;189:177-182
Hep<strong>at</strong>ic Resection vs. PTCSL<br />
• R<strong>at</strong>e <strong>of</strong> complete removal <strong>of</strong> intrahep<strong>at</strong>ic stones was<br />
similarly high in the hep<strong>at</strong>ic resection and the PTCSL<br />
groups<br />
• Complic<strong>at</strong>ion and 5-year survival r<strong>at</strong>es were comparable<br />
• Recurrence r<strong>at</strong>e was significantly higher in the PTCSL<br />
group<br />
• Conclusion:<br />
– Localized Hep<strong>at</strong>olithiasis with strictures is better<br />
managed by hep<strong>at</strong>ic resection<br />
– Resection <strong>of</strong> the dominant segment followed by<br />
POCSL is also recommended for bil<strong>at</strong>eral stones.<br />
Otani K et al. Comparison <strong>of</strong> Tre<strong>at</strong>ments for Hep<strong>at</strong>olithiasis: Hep<strong>at</strong>ic Resection Versus Cholangioscopic Lithotomy. J Am<br />
Coll Surg 1999;189:177-182
Johns Hopkins Experience<br />
• Intrahep<strong>at</strong>ic Stones:Transhep<strong>at</strong>ic Team Approach<br />
– Retrospective study <strong>of</strong> 54 p<strong>at</strong>ients over 18 years<br />
• 2 hep<strong>at</strong>ic resection in total due to earlier present<strong>at</strong>ion<br />
• PTBD routinely done all pts & achieved complete removal<br />
in 14 p<strong>at</strong>ients<br />
• 40 pts underwent surgery for stone clearance & stricture<br />
tre<strong>at</strong>ment with bilioenteric anastamosis and access loops<br />
• Postoper<strong>at</strong>ive percutaneous procedures were required in<br />
20/40 pts for residual stones & persistent intrahep<strong>at</strong>ic<br />
stones.<br />
• Multidisciplinary team approach<br />
– Recurrence <strong>of</strong> r<strong>at</strong>e <strong>of</strong> 20%<br />
– Final Stone clearance r<strong>at</strong>e <strong>of</strong> 94%<br />
Pitt HA, Cameron JL et al. Intrahep<strong>at</strong>ic Stones; The Transhep<strong>at</strong>ic Team Approach. Annals <strong>of</strong> <strong>Surgery</strong><br />
1994;219: 527-37.
Hong Kong Experience<br />
• Tre<strong>at</strong>ment <strong>of</strong> Hep<strong>at</strong>olithiasis: improvement<br />
<strong>of</strong> result by a system<strong>at</strong>ic approach<br />
– Retrospective review <strong>of</strong> 127 p<strong>at</strong>ients over 6 years<br />
– Recurrence r<strong>at</strong>e independent <strong>of</strong> biliary drainage<br />
– Stone recurrence <strong>of</strong> 15.8 % which is lowest ever<br />
reported<br />
» Highest reported r<strong>at</strong>e 70%<br />
– Complete stone clearance r<strong>at</strong>e <strong>of</strong> 89.9 %<br />
– Tre<strong>at</strong>ment <strong>of</strong> recurrence facilit<strong>at</strong>ed through<br />
permanent cutaneous access loops<br />
Fan ST et al. Tre<strong>at</strong>ment <strong>of</strong> <strong>hep<strong>at</strong>olithiasis</strong>:improvement <strong>of</strong> result by a systemic approach. <strong>Surgery</strong><br />
1991;109:474-80
Conclusion<br />
• HL is complex disease which requires a<br />
transhep<strong>at</strong>ic team approach individualized for<br />
each p<strong>at</strong>ient according to the site <strong>of</strong><br />
involvement & presence <strong>of</strong> strictures.<br />
• Multidisciplinary approach including surgical,<br />
endoscopic and interventional radiological<br />
techniques has the best outcome.