World J Surg DOI 10.1007/s00268-015-2942-7
ORIGINAL SCIENTIFIC REPORT
Laparoscopic Approach for Right-Sided Intrahepatic Duct Stones: A Comparative Study of Laparoscopic Versus Open Treatment Young Ki Kim • Ho-Seong Han • Yoo-Seok Yoon Jai Young Cho • Woohyung Lee
•
Ó Socie´te´ Internationale de Chirurgie 2015
Abstract Background Despite several attempts to treat intrahepatic duct (IHD) stones by laparoscopy, most cases have been limited to left-sided IHD stones. The aim of this study was to evaluate the therapeutic feasibility and effectiveness of a laparoscopic approach for right-sided IHD stones compared with the open approach for this disease. Methods This study included 34 consecutive patients who underwent laparoscopic (n = 17) and open (n = 17) treatment for right-sided IHD stones from March 2005 to December 2011. Clinical data including the operative time, intraoperative blood loss, postoperative hospital length of stay, postoperative complications, stone clearance, and recurrence rate were retrospectively analyzed and compared between the two groups. Results Of the 17 patients who underwent laparoscopic treatment, three were treated using laparoscopic intrahepatic duct exploration alone and 14 patients were treated using laparoscopic liver resection. The operative time in the laparoscopic group was longer than that in the open group (432 ± 158 vs. 335 ± 85 min, p = 0.03). The laparoscopic group showed a lower postoperative complication rate than the open group (29 vs. 64 %, p = 0.039). There were no significant differences in intraoperative blood loss (988 ± 929 vs. 879 ± 942 ml, p = 0.737) or postoperative length of hospital stay (16 ± 22 vs. 12 ± 14 days, p = 0.221). Conclusions This study demonstrated that laparoscopic treatment could be an effective and safe therapeutic modality in selected patients with right-sided IHD stones.
Abbreviations IHD Intrahepatic duct CT Computed tomography ERCP Endoscopic retrograde cholangiopancreatography MRCP Magnetic resonance cholangiopancreatography CBD Common bile duct
LIHDE LLR OLR PCD
Laparoscopic intrahepatic duct exploration Laparoscopic liver resection Open liver resection Percutaneous drainage
Introduction Y. K. Kim H.-S. Han (&) Y.-S. Yoon J. Y. Cho W. Lee Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 166 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do 463-707, Korea e-mail: [email protected] Y. K. Kim e-mail: [email protected]
The treatment of intrahepatic duct (IHD) stone disease is occasionally frustrating due to high rates of remnants and recurrence of stones. There are various treatment modalities for this disease, including interventional treatments, such as percutaneous transhepatic cholangioscopic lithotripsy, and operative treatments, such as IHD exploration
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and liver resection [1–4]. Among these treatment modalities, liver resection is the definitive treatment option for IHD stones because it simultaneously eliminates stones and the associated strictures of IHD, thus reducing the risk of recurrent stones and the development of cholangiocarcinoma [5–12]. The development of laparoscopic approaches has had a large impact on surgical practice worldwide. We previously reported on laparoscopic IHD exploration and laparoscopic liver resection (LLR) for left-sided IHD stones, and our experience demonstrated that the laparoscopic approach was a safe and effective treatment modality in selected patients with left-sided IHD stones. [13, 14] However, the laparoscopic approach for right-sided IHD stones has rarely been reported due to its technical difficulty. Nevertheless, with increasing experience in the performance of LLR, the laparoscopic approach for right-sided IHD stones could become more widely adopted. The aim of this study was to evaluate the therapeutic feasibility and effectiveness of the laparoscopic approach for right-sided IHD stones by comparing it with the open approach for treating this disease.
Materials and methods From March 2005 to December 2011, 17 consecutive patients with right-sided IHD stones underwent laparoscopic treatment in the Department of Surgery at Seoul National University Bundang Hospital. During the same period, 17 patients who underwent open surgery for rightsided IHD stones based on the same sign and symptom were included for comparison. The operation type was selected based on the patient’s preference after a detailed explanation of both procedures. Laparoscopy was performed in young adult patients and patients concerned about cosmesis. Open surgery was usually applied for patients with a previous history of upper abdominal surgery and for patients who cared less about cosmesis or with relative contraindications to laparoscopic surgery. Preoperative ultrasonography, computed tomography (CT), endoscopic retrograde cholangiopancreatography (ERCP), or magnetic resonance cholangiopancreatography (MRCP) was performed to determine the distribution of stones and to evaluate stricture of the IHD. The clinical data for these patients were retrospectively analyzed by reviewing medical records, radiological images, and pathological reports. The parameters for comparison were perioperative outcomes and the rate of stone clearance. Postoperative follow-up was performed with CT and cholangiography. This retrospective data analysis was approved by the institutional ethical committee of our hospital.
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Fig. 1 Algorithm of treatment for IHD stones 250 9 186 mm (96 9 96 DPI)
Algorithm for the laparoscopic approach The laparoscopic approach was applied according to the treatment algorithm shown in Fig. 1. The decision for liver resection was based on the grade of the intrahepatic ductal stricture, the presence of impacted stones, or liver atrophy, which was determined by preoperative radiological studies and intraoperative choledochoscopy. Ductal strictures were classified into 4 grades on the basis of the feasibility of choledochoscopic removal of stones. The strictures of the IHD were classified as follows: (1) grade 0, no stricture; (2) grade 1, ductal diameter of strictured site larger than 5 mm, but peripheral IHD more dilated than the strictured orifice; (3) grade 2, ductal diameter of the strictured site between 2 and 5 mm; and (4) grade 3, ductal diameter of stricture below 2 mm. Grade 1 was regarded as a mild stricture, and grades 2 and 3 as high-grade strictures. [13] If the preoperative radiological studies revealed that right-sided IHD stones were associated with the above indications for liver resection, LLR was performed. When liver resection was not indicated, LIHDE was performed as an initial procedure. During exploration of the IHD, if there was no or only mild stricture or there were no impacted stones, the operation was completed with LIHDE alone. If moderate to severe stricture or impacted stones were encountered during LIHDE, we performed LLR. Operative technique Laparoscopic IHD exploration Cholecystectomy was performed with the usual technique. The operative methods for LIHDE have been described in
World J Surg
previous reports. [13] A dual camera system was used, in which one camera was used for the laparoscope on the peritoneal side and the other camera was used for flexible choledochoscope (5 mm, 4 directions, CHF-P20Q, Olympus, Tokyo, Japan) of the lumen of the IHD. This system enabled both the intraabdominal view and intraductal images to be visible simultaneously. The stones detected in the common bile duct (CBD) and IHD were eliminated with saline irrigation, a stone basket (Stone forceps, FG24SX-1, Olympus, Tokyo, Japan), or a balloon-tipped catheter (Fogarty Arterial Embolectomy CatheterÒ, 1120805F, Baxter, USA). The stones that could not be removed using these methods were fragmented using an electrohydraulic lithotripter (EHL, 4.5Fr, 150 W, Karl Storz, Germany) or laser lithotripter (Holmium-YAG Laser, Trimedyne, California). After confirming complete removal of the stones, a 16- to 18-French T-tube was inserted into the CBD, and the choledochotomy was repaired with intracorporeal sutures. Laparoscopic liver resection Under general anesthesia, the patient was placed in the lithotomy position in a 30° reverse Trendelenburg position. Cholecystectomy was initially performed in the usual manner. For mobilization of the right liver, the ligaments around the right liver were sharply dissected. Thereafter, the liver was dissected from the inferior vena cava and the right adrenal gland. During mobilization of the right liver, several retrohepatic venous branches were carefully isolated and divided between clips or energy device such as a
Fig. 2 Laparoscopic approach of right glissonian pedicle. a Laparoscopy showing isolated RAGP (arrow) and RPGP (arrowhead) b Laparoscopic view after ligation and dissection of RPGP
Harmonic Scalpel (Ethicon Endo-Surgery Inc., Cincinnati, OH, USA) or LigaSureÒ (Valleylab, Boulder, CO, USA) as necessary. On the cranial side of this caval dissection, if a vena caval ligament was encountered lateral to the right hepatic vein, it was isolated and cut with clip ligation or an endoscopic linear stapler. When performing right hemihepatectomy, the right hepatic artery and right portal vein were isolated and ligated individually. In cases of right posterior sectionectomy, dissection of the right posterior hepatic artery was performed, and the right posterior portal vein was also isolated individually. The territory of the right lobe or right posterior section was confirmed by clamping the corresponding vessels and marking the ischemic lines. The superficial hepatic parenchyma was transected using ultrasonic shears (Harmonic scalpel, Ethicon, Cincinnati, USA or Sonosurg, Olympus, Tokyo, Japan), and the deeper portion of the parenchyma was dissected using a laparoscopic cavitron ultrasonic surgical aspirator (CUSA, Valleylab, Boulder, CO, USA). After transection of the liver parenchyma, the right hepatic duct or right posterior duct was exposed and isolated. Then, the isolated duct was divided with endo-scissors (Fig. 2). Through the opening of the severed end, the stones in the remaining side of the IHD were explored, and the duct was then closed with intracorporeal sutures. The right hepatic vein or venous branch from the right posterior section was divided with a vascular endoscopic stapler. The specimen was inserted into a protective vinyl bag and extracted through a wound made at the suprapubic or extended trocar site.
(arrowhead), RAGP right anterior glissonian pedicle, RPGP right posterior glissonian pedicle 250 9 124 mm (95 9 95 DPI)
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World J Surg Fig. 3 Patient enrollment chart 371 9 267 mm (96 9 96 DPI)
Statistical analysis Categorical parameters of each group were compared by the v2 or Fisher’s exact test, and continuous parameters were compared using the independent-sample t test. All the analyses were performed using SPSS software, version 20.0 (SPSS Inc., Chicago, IL, USA). p value \ 0.05 was considered statistically significant.
Results There were total of 165 consecutive patients who managed an IHD stones during the study period (Fig. 3). Of these patients, 17 underwent laparoscopic approaches and 17 underwent open approaches. Patient characteristics The characteristics of both groups are listed in Table 1. There were no significant differences in preoperative demographic characteristics, including age, gender, liver function, and operative history, between the two groups.
Table 1 Comparison of patients’ characteristics between the laparoscopic group and the open group Variables
Laparoscopy (n = 17)
Open (n = 17)
p value
Age (mean years)
60.6
63.5
0.510
Sex (male:female)
5:12
6:11
1.000
Liver status Child A
17 (100 %)
17 (100 %)
Previous biliary surgery (%)
3 (18 %)
5 (30 %)
1.000
Operative procedure
0.688 1.000
Liver resection
14
13
IHDE
3
4
IHDE intrahepatic duct exploration
posterior sectionectomy (n = 7) or right hemihepatectomy (n = 7). Of the 17 patients in the open liver resection (OLR) group, ten underwent right hemihepatectomy. One patient each underwent central bisectionectomy, right anterior sectionectomy, and S6 segmentectomy. The remaining four patients underwent IHD exploration. Comparison of perioperative clinical outcomes between the laparoscopic and open groups
Operation types Table 2 summarizes the operative procedures performed in the two groups. There were no conversions to open surgery in the LLR group. Of the 17 patients, three were treated by LIHDE alone and 14 were treated by LLR, including right
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Table 3 summarizes the comparative results of the perioperative outcomes in both groups. The mean operative time was longer in the LLR group than in the OLR group (432 ± 158 vs. 335 ± 85 min, p = 0.03). The intraoperative blood loss was 988 ± 929 ml in the LLR group and
World J Surg Table 2 Operative procedures of the laparoscopic group and the open group Laparoscopy (n = 17)
Open (n = 17)
Right hemihepatectomy
7
10
Right posterior segmentectomy
7
Right anterior segmentectomy
1
Central bisectionectomy
1
S6 segmentectomy IHDE
1 3
4
S6 segment6, IHDE intrahepatic duct exploration
879 ± 942 ml in the OLR group (p = 0.737). A significantly lower number of postoperative complications were observed in the LLR group than in the OLR group (29 vs. 64 %, p = 0.039). The detailed postoperative results are listed in Table 4. In the LLR group, a wound problem developed in one patient, and intraabdominal fluid collection occurred in two patients. Percutaneous drainage (PCD) was performed in patients with fluid collection. Bile leakage did not occur. Pleural effusion was observed in one patient, which resolved after thoracentesis. In the OLR group, a wound problem developed in one patient, and intraabdominal fluid collection occurred in eight patients. PCD was inserted for fluid collection. Bile leakage occurred in one patient and was treated by PCD insertion as well. Pleural effusion was observed in five patients in the OLR group, three of whom were treated by thoracentesis. In the OLR group, acute vestibulopathy occurred in one patient, who was treated and improved well by conservative treatment. All the complications improved by the time of discharge in both groups. The mean postoperative hospital stay was 16.3 ± 12 days in the LLR group and 22 ± 14 days in the OLR group (p = 0.221). No significant differences were found in intraoperative blood loss or postoperative length of hospital stay between the two groups.
Comparison of stone clearance between the laparoscopic and open groups The outcomes of stone clearance rates are listed in Table 3. The immediate clearance rate of the stones was 88 % (15 of 17) in the LLR group. Two patients with remaining stones had remnant stones removed by a choledochoscopic stone removal procedure at approximately 6 weeks postoperatively. The immediate clearance rate of stones was 82 % (14 of 17) in the OLR group. For three patients with remaining stones, postoperative choledochoscopic stone removal failed. The final stone clearance rates in the LLR and OLR groups were 100 and 82 % (p = 0.227), respectively. Over a mean follow-up of 35 (range 1–84) months, there were no recurrent stones in the LLR group. However, recurrent stones were detected in four patients (25 %) in the OLR group. The recurrent stones were located in the CBD in one patient and in the IHD in three patients.
Discussion The treatment of IHD stones remains difficult and challenging, as the postoperative remnant stone rate is still significant, and recurrent stones occur during the follow-up period. The main reason for remnant or recurrent stones is IHD strictures, which are common in patients with IHD stones. The treatment of IHD stones demands the complete elimination of intrahepatic stones and the prevention of recurrent stones. Liver resection has advantages in that it removes the portion of the liver that contains both IHD stones and diseased ducts. This procedure is reported to have a high stone clearance rate and a low long-term stone recurrence rate [15–17]. Because patients with IHD stones can develop associated cholangiocarcinoma, liver resection is a good method for preventing the development of cholangiocarcinoma as well [18, 19]. With the introduction of laparoscopic surgery, laparoscopic approaches have been applied in many fields of
Table 3 Comparison of perioperative clinical outcomes and stone clearance between the laparoscopic group and the open group Variables
Laparoscopy (n = 17)
Open (n = 17)
p value
Operation time (min)
432 ± 158
335 ± 85
0.03
Intraoperative blood loss (ml)
988 ± 929
879 ± 942
0.737
Postoperative complication (%)
5 (29 %)
11 (64 %)
0.039 0.221
Postoperative hospital stay (day)
16 ± 22
12 ± 14
Initial stone clearance rate (%)
15 (88 %)
14 (82 %)
1.00
Final stone clearance rate (%)
17 (100 %)
14 (82 %)
0.227
Recurrent stones (%)
0 (0 %)
4 (18 %)
0.103
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World J Surg Table 4 The postoperative complications of the laparoscopic group and the open group Complication
Laparoscopy (n = 17)
Open (n = 17)
Management
Grade I Intraabdominal fluid collection
2
Conservative treatment
Pleural effusion
2
Conservative treatment
Urinary retention
1
Wound problems
1
Catheterization 1
Dressing
1
Conservative treatment
Grade II Acute vestibulopathy Grade IIIa Intraabdominal fluid collection
2
6
PCD
Pleural effusion
1
3
Thoracentesis
Bile leakage Total
1 5 (n = 5)
PCD a
16 (n = 11)
a
Two complications occurred simultaneously in five patients: three pleural effusion and intraabdominal fluid collection, wound infection and intraabdominal fluid collection, bile leakage and intraabdominal fluid collection PCD percutaneous drainage
surgery. We previously reported that laparoscopic IHD exploration could be an effective method for treating patients with IHD stones when liver resection is not needed [13]. We also reported that LLR could be an effective option for patients with IHD stones for whom left-sided liver resection is necessary [14]. Perioperative results have shown similar outcomes regarding stone clearance rates and postoperative morbidity [1, 2, 6, 8, 16, 17, 20]. The indications for liver resection in the preoperative work-up were moderate to severe strictures in the right intrahepatic ducts, with possible fibrosis and atrophy of the hepatic lobes or segments. An intraoperative duct stricture grading system was used as an algorithm in this study to decide between LIHDE and LLR. When there were no or mild strictures in the IHD, only IHD exploration was performed. This procedure was effective in eliminating IHD stones. LLR was performed in patients with IHD stones who had more than a moderate degree of ductal stricture or impacted stones. This laparoscopic approach can offer the benefits of minimally invasive surgery, including less postoperative pain, earlier recovery, and good cosmesis, as well as accomplishment of the same therapeutic goals as OLR. Based on our experience with laparoscopic right liver resection for other diseases, such as hepatocellular carcinoma, we have widened our indications for LLR to include the treatment of right-sided IHD stones [21–24]. Laparoscopic approaches have similar outcomes in the treatment of IHD stones, while maintaining minimal invasiveness. Therefore, LLR could be a good option for minimally invasive treatment of right-sided IHD stones with stricture. If the patients are well selected, a minimally invasive approach for treating IHD stones could become possible by
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adhering to the same principles of treatment as open surgery. In our study, there were no significant differences in intraoperative blood loss, postoperative hospital length of stay, or final stone clearance rate between the two groups. However, the operative time was slightly longer in the LLR group than in the OLR group, and the postoperative complication rate was lower in the LLR group than in the OLR group. This lower postoperative morbidity may have resulted from the decreased invasiveness of laparoscopic surgery. The precise reasons why the OLR group had higher stone recurrence rates are not known, but we consider that the operative types performed by laparoscopy were simple procedures, including right hemihepatectomy and right posterior sectionectomy, as shown in Table 2. In contrast, operations performed by open surgery tend to be more complicated procedures, including central bisectionectomy, S6 segmentectomy, and bilio-enteric anastomosis. This distinction may have contributed to the higher immediate and final stone recurrence rates in this group. However, this study was limited due to the small number of patients in each group. To provide strong evidence of the superiority of laparoscopic treatment for IHD stones, large numbers of patients and prospective, randomized, controlled comparative studies between the laparoscopic and open approaches are needed in the future. In conclusion, this study suggests that LLR could be an effective and feasible treatment option for the management of right-sided IHD stones in selected patients. With further accumulation of experience, we feel assured that LLR will become a cornerstone treatment modality for eliminating right-sided IHD stones.
World J Surg Conflict of interest
None.
References 1. Jan YY, Chen MF, Wang CS et al (1996) Surgical treatment of hepatolithiasis: long-term results. Surgery. 120:509–514 2. Cheung MT, Kwok PC (2005) Liver resection for intrahepatic stones. Arch Surg 140:993–997 3. Huang MH, Chen CH, Yang JC et al (2003) Long-term outcome of percutaneous transhepatic cholangioscopic lithotomy for hepatolithiasis. Am J Gastroenterol 98:2655–2662 4. Lee SK, Seo DW, Myung SJ et al (2001) Percutaneous transhepatic cholangioscopic treatment for hepatolithiasis: an evaluation of long-term results and risk factors for recurrence. Gastrointest Endosc 53:318–323 5. Fan ST, Lai EC, Wong J (1993) Hepatic resection for hepatolithiasis. Arch Surg 128:1070–1074 6. Uchiyama K, Kawai M, Ueno M et al (2007) Reducing residual and recurrent stones by hepatectomy for hepatolithiasis. J Gastrointest Surg 11:626–630 7. Nuzzo G, Clemente G, Giovannini I et al (2008) Liver resection for primary intrahepatic stones: a single-center experience. Arch Surg 143:570–573 8. Chen DW, Poon RT, Liu CL et al (2004) Immediate and longterm outcomes of hepatectomy for hepatolithiasis. Surgery 135:386–393 9. Tang CN, Tai CK, Siu WT et al (2005) Laparoscopic treatment of recurrent pyogenic cholangitis. J Hepato Biliary Pancreat Surg 12:243–248 10. Tang CN, Li MK (2003) Hand-assisted laparoscopic segmentectomy in recurrent pyogenic cholangitis. Surg Endosc 17:324–327 11. Tang CN, Tai CK, Ha JP et al (2005) Laparoscopy versus open left lateral segmentectomy for recurrent pyogenic cholangitis. Surg Endosc 19:1232–1236 12. Cai X, Wang Y, Yu H et al (2007) Laparoscopic hepatectomy for hepatolithiasis: a feasibility and safety study in 29 patients. Surg Endosc 21:1074–1078
13. Han HS, Yi NJ (2004) Laparoscopic treatment of intrahepatic duct stone. Surg Laparosc Endosc Percutan Tech. 14:157–162 14. Yoon Yoo-Seok, Han Ho-Seong et al (2009) Laparoscopic treatment for intrahepatic duct stones in the era of laparoscopy. Ann Surg 249:286–291 15. Uchiyama K, Onishi H, Tani M, Kinoshita H, Ueno M, Yamaue H (2002) Indication and procedure for treatment of hepatolithiasis. Arch Surg 137:149–153 16. Sun WB, Han BL, Cai JX (2000) The surgical treatment of isolated left-sided hepatolithiasis: a 22-year experience. Surgery 127:493–497 17. Otani K, Shimizu S, Chijiiwa K, Ogawa T, Morisaki T, Sugitani A, Yamaguchi K, Tanaka M (1999) Comparison of treatments for hepatolithiasis: hepatic resection versus cholangioscopic lithotomy. J Am Coll Surg 189:177–182 18. Chen MF, Jan YY, Jeng LB, Hwang TL, Wang CS, Chen SC, Chao TC, Chen HM, Lee WC, Yeh TS, Lo YF (1999) Intrahepatic cholangiocarcinoma in Taiwan. J Hepatobiliary Pancreat Surg 6:136–141 19. Kim YT, Byun JS, Kim J, Jang YH, Lee WJ, Ryu JK, Kim SW, Yoon YB, Kim CY (2003) Factors predicting concurrent cholangiocarcinomas associated with hepatolithiasis. Hepatogastroenterology 50:8–12 20. Lee TY, Chen YL, Chang HC, Chan CP, Kuo SJ (2007) Outcomes of hepatectomy for hepatolithiasis. World J Surg 31:479–482. doi:10.1007/s00268-006-0441-6 21. Yoon YS, Han HS, Choi YS et al (2006) Total laparoscopic right posterior sectionectomy for hepatocellular carcinoma. J Laparoendosc Adv Surg Tech A. 16:274–277 22. Cho JY, Han HS, Yoon YS, Shin SH (2008) Experiences of laparoscopic liver resection including lesions in the posterosuperior segments of the liver. Surg Endosc 22:2344–2349 23. Cho JY, Han HS, Yoon YS, Shin SH (2008) Feasibility of laparoscopic liver resection for tumors located in the posterosuperior segments of the liver, with a special reference to overcoming current limitations on tumor location. Surgery 144:32–38 24. Yoon YS, Han HS, Cho JY, Ahn KS (2010) Total laparoscopic liver resection for hepatocellular carcinoma located in all segments of the liver. Surg Endosc 24:1630–1637
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ORIGINAL SCIENTIFIC REPORT
Laparoscopic Approach for Right-Sided Intrahepatic Duct Stones: A Comparative Study of Laparoscopic Versus Open Treatment Young Ki Kim • Ho-Seong Han • Yoo-Seok Yoon Jai Young Cho • Woohyung Lee
•
Ó Socie´te´ Internationale de Chirurgie 2015
Abstract Background Despite several attempts to treat intrahepatic duct (IHD) stones by laparoscopy, most cases have been limited to left-sided IHD stones. The aim of this study was to evaluate the therapeutic feasibility and effectiveness of a laparoscopic approach for right-sided IHD stones compared with the open approach for this disease. Methods This study included 34 consecutive patients who underwent laparoscopic (n = 17) and open (n = 17) treatment for right-sided IHD stones from March 2005 to December 2011. Clinical data including the operative time, intraoperative blood loss, postoperative hospital length of stay, postoperative complications, stone clearance, and recurrence rate were retrospectively analyzed and compared between the two groups. Results Of the 17 patients who underwent laparoscopic treatment, three were treated using laparoscopic intrahepatic duct exploration alone and 14 patients were treated using laparoscopic liver resection. The operative time in the laparoscopic group was longer than that in the open group (432 ± 158 vs. 335 ± 85 min, p = 0.03). The laparoscopic group showed a lower postoperative complication rate than the open group (29 vs. 64 %, p = 0.039). There were no significant differences in intraoperative blood loss (988 ± 929 vs. 879 ± 942 ml, p = 0.737) or postoperative length of hospital stay (16 ± 22 vs. 12 ± 14 days, p = 0.221). Conclusions This study demonstrated that laparoscopic treatment could be an effective and safe therapeutic modality in selected patients with right-sided IHD stones.
Abbreviations IHD Intrahepatic duct CT Computed tomography ERCP Endoscopic retrograde cholangiopancreatography MRCP Magnetic resonance cholangiopancreatography CBD Common bile duct
LIHDE LLR OLR PCD
Laparoscopic intrahepatic duct exploration Laparoscopic liver resection Open liver resection Percutaneous drainage
Introduction Y. K. Kim H.-S. Han (&) Y.-S. Yoon J. Y. Cho W. Lee Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 166 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do 463-707, Korea e-mail: [email protected] Y. K. Kim e-mail: [email protected]
The treatment of intrahepatic duct (IHD) stone disease is occasionally frustrating due to high rates of remnants and recurrence of stones. There are various treatment modalities for this disease, including interventional treatments, such as percutaneous transhepatic cholangioscopic lithotripsy, and operative treatments, such as IHD exploration
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and liver resection [1–4]. Among these treatment modalities, liver resection is the definitive treatment option for IHD stones because it simultaneously eliminates stones and the associated strictures of IHD, thus reducing the risk of recurrent stones and the development of cholangiocarcinoma [5–12]. The development of laparoscopic approaches has had a large impact on surgical practice worldwide. We previously reported on laparoscopic IHD exploration and laparoscopic liver resection (LLR) for left-sided IHD stones, and our experience demonstrated that the laparoscopic approach was a safe and effective treatment modality in selected patients with left-sided IHD stones. [13, 14] However, the laparoscopic approach for right-sided IHD stones has rarely been reported due to its technical difficulty. Nevertheless, with increasing experience in the performance of LLR, the laparoscopic approach for right-sided IHD stones could become more widely adopted. The aim of this study was to evaluate the therapeutic feasibility and effectiveness of the laparoscopic approach for right-sided IHD stones by comparing it with the open approach for treating this disease.
Materials and methods From March 2005 to December 2011, 17 consecutive patients with right-sided IHD stones underwent laparoscopic treatment in the Department of Surgery at Seoul National University Bundang Hospital. During the same period, 17 patients who underwent open surgery for rightsided IHD stones based on the same sign and symptom were included for comparison. The operation type was selected based on the patient’s preference after a detailed explanation of both procedures. Laparoscopy was performed in young adult patients and patients concerned about cosmesis. Open surgery was usually applied for patients with a previous history of upper abdominal surgery and for patients who cared less about cosmesis or with relative contraindications to laparoscopic surgery. Preoperative ultrasonography, computed tomography (CT), endoscopic retrograde cholangiopancreatography (ERCP), or magnetic resonance cholangiopancreatography (MRCP) was performed to determine the distribution of stones and to evaluate stricture of the IHD. The clinical data for these patients were retrospectively analyzed by reviewing medical records, radiological images, and pathological reports. The parameters for comparison were perioperative outcomes and the rate of stone clearance. Postoperative follow-up was performed with CT and cholangiography. This retrospective data analysis was approved by the institutional ethical committee of our hospital.
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Fig. 1 Algorithm of treatment for IHD stones 250 9 186 mm (96 9 96 DPI)
Algorithm for the laparoscopic approach The laparoscopic approach was applied according to the treatment algorithm shown in Fig. 1. The decision for liver resection was based on the grade of the intrahepatic ductal stricture, the presence of impacted stones, or liver atrophy, which was determined by preoperative radiological studies and intraoperative choledochoscopy. Ductal strictures were classified into 4 grades on the basis of the feasibility of choledochoscopic removal of stones. The strictures of the IHD were classified as follows: (1) grade 0, no stricture; (2) grade 1, ductal diameter of strictured site larger than 5 mm, but peripheral IHD more dilated than the strictured orifice; (3) grade 2, ductal diameter of the strictured site between 2 and 5 mm; and (4) grade 3, ductal diameter of stricture below 2 mm. Grade 1 was regarded as a mild stricture, and grades 2 and 3 as high-grade strictures. [13] If the preoperative radiological studies revealed that right-sided IHD stones were associated with the above indications for liver resection, LLR was performed. When liver resection was not indicated, LIHDE was performed as an initial procedure. During exploration of the IHD, if there was no or only mild stricture or there were no impacted stones, the operation was completed with LIHDE alone. If moderate to severe stricture or impacted stones were encountered during LIHDE, we performed LLR. Operative technique Laparoscopic IHD exploration Cholecystectomy was performed with the usual technique. The operative methods for LIHDE have been described in
World J Surg
previous reports. [13] A dual camera system was used, in which one camera was used for the laparoscope on the peritoneal side and the other camera was used for flexible choledochoscope (5 mm, 4 directions, CHF-P20Q, Olympus, Tokyo, Japan) of the lumen of the IHD. This system enabled both the intraabdominal view and intraductal images to be visible simultaneously. The stones detected in the common bile duct (CBD) and IHD were eliminated with saline irrigation, a stone basket (Stone forceps, FG24SX-1, Olympus, Tokyo, Japan), or a balloon-tipped catheter (Fogarty Arterial Embolectomy CatheterÒ, 1120805F, Baxter, USA). The stones that could not be removed using these methods were fragmented using an electrohydraulic lithotripter (EHL, 4.5Fr, 150 W, Karl Storz, Germany) or laser lithotripter (Holmium-YAG Laser, Trimedyne, California). After confirming complete removal of the stones, a 16- to 18-French T-tube was inserted into the CBD, and the choledochotomy was repaired with intracorporeal sutures. Laparoscopic liver resection Under general anesthesia, the patient was placed in the lithotomy position in a 30° reverse Trendelenburg position. Cholecystectomy was initially performed in the usual manner. For mobilization of the right liver, the ligaments around the right liver were sharply dissected. Thereafter, the liver was dissected from the inferior vena cava and the right adrenal gland. During mobilization of the right liver, several retrohepatic venous branches were carefully isolated and divided between clips or energy device such as a
Fig. 2 Laparoscopic approach of right glissonian pedicle. a Laparoscopy showing isolated RAGP (arrow) and RPGP (arrowhead) b Laparoscopic view after ligation and dissection of RPGP
Harmonic Scalpel (Ethicon Endo-Surgery Inc., Cincinnati, OH, USA) or LigaSureÒ (Valleylab, Boulder, CO, USA) as necessary. On the cranial side of this caval dissection, if a vena caval ligament was encountered lateral to the right hepatic vein, it was isolated and cut with clip ligation or an endoscopic linear stapler. When performing right hemihepatectomy, the right hepatic artery and right portal vein were isolated and ligated individually. In cases of right posterior sectionectomy, dissection of the right posterior hepatic artery was performed, and the right posterior portal vein was also isolated individually. The territory of the right lobe or right posterior section was confirmed by clamping the corresponding vessels and marking the ischemic lines. The superficial hepatic parenchyma was transected using ultrasonic shears (Harmonic scalpel, Ethicon, Cincinnati, USA or Sonosurg, Olympus, Tokyo, Japan), and the deeper portion of the parenchyma was dissected using a laparoscopic cavitron ultrasonic surgical aspirator (CUSA, Valleylab, Boulder, CO, USA). After transection of the liver parenchyma, the right hepatic duct or right posterior duct was exposed and isolated. Then, the isolated duct was divided with endo-scissors (Fig. 2). Through the opening of the severed end, the stones in the remaining side of the IHD were explored, and the duct was then closed with intracorporeal sutures. The right hepatic vein or venous branch from the right posterior section was divided with a vascular endoscopic stapler. The specimen was inserted into a protective vinyl bag and extracted through a wound made at the suprapubic or extended trocar site.
(arrowhead), RAGP right anterior glissonian pedicle, RPGP right posterior glissonian pedicle 250 9 124 mm (95 9 95 DPI)
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World J Surg Fig. 3 Patient enrollment chart 371 9 267 mm (96 9 96 DPI)
Statistical analysis Categorical parameters of each group were compared by the v2 or Fisher’s exact test, and continuous parameters were compared using the independent-sample t test. All the analyses were performed using SPSS software, version 20.0 (SPSS Inc., Chicago, IL, USA). p value \ 0.05 was considered statistically significant.
Results There were total of 165 consecutive patients who managed an IHD stones during the study period (Fig. 3). Of these patients, 17 underwent laparoscopic approaches and 17 underwent open approaches. Patient characteristics The characteristics of both groups are listed in Table 1. There were no significant differences in preoperative demographic characteristics, including age, gender, liver function, and operative history, between the two groups.
Table 1 Comparison of patients’ characteristics between the laparoscopic group and the open group Variables
Laparoscopy (n = 17)
Open (n = 17)
p value
Age (mean years)
60.6
63.5
0.510
Sex (male:female)
5:12
6:11
1.000
Liver status Child A
17 (100 %)
17 (100 %)
Previous biliary surgery (%)
3 (18 %)
5 (30 %)
1.000
Operative procedure
0.688 1.000
Liver resection
14
13
IHDE
3
4
IHDE intrahepatic duct exploration
posterior sectionectomy (n = 7) or right hemihepatectomy (n = 7). Of the 17 patients in the open liver resection (OLR) group, ten underwent right hemihepatectomy. One patient each underwent central bisectionectomy, right anterior sectionectomy, and S6 segmentectomy. The remaining four patients underwent IHD exploration. Comparison of perioperative clinical outcomes between the laparoscopic and open groups
Operation types Table 2 summarizes the operative procedures performed in the two groups. There were no conversions to open surgery in the LLR group. Of the 17 patients, three were treated by LIHDE alone and 14 were treated by LLR, including right
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Table 3 summarizes the comparative results of the perioperative outcomes in both groups. The mean operative time was longer in the LLR group than in the OLR group (432 ± 158 vs. 335 ± 85 min, p = 0.03). The intraoperative blood loss was 988 ± 929 ml in the LLR group and
World J Surg Table 2 Operative procedures of the laparoscopic group and the open group Laparoscopy (n = 17)
Open (n = 17)
Right hemihepatectomy
7
10
Right posterior segmentectomy
7
Right anterior segmentectomy
1
Central bisectionectomy
1
S6 segmentectomy IHDE
1 3
4
S6 segment6, IHDE intrahepatic duct exploration
879 ± 942 ml in the OLR group (p = 0.737). A significantly lower number of postoperative complications were observed in the LLR group than in the OLR group (29 vs. 64 %, p = 0.039). The detailed postoperative results are listed in Table 4. In the LLR group, a wound problem developed in one patient, and intraabdominal fluid collection occurred in two patients. Percutaneous drainage (PCD) was performed in patients with fluid collection. Bile leakage did not occur. Pleural effusion was observed in one patient, which resolved after thoracentesis. In the OLR group, a wound problem developed in one patient, and intraabdominal fluid collection occurred in eight patients. PCD was inserted for fluid collection. Bile leakage occurred in one patient and was treated by PCD insertion as well. Pleural effusion was observed in five patients in the OLR group, three of whom were treated by thoracentesis. In the OLR group, acute vestibulopathy occurred in one patient, who was treated and improved well by conservative treatment. All the complications improved by the time of discharge in both groups. The mean postoperative hospital stay was 16.3 ± 12 days in the LLR group and 22 ± 14 days in the OLR group (p = 0.221). No significant differences were found in intraoperative blood loss or postoperative length of hospital stay between the two groups.
Comparison of stone clearance between the laparoscopic and open groups The outcomes of stone clearance rates are listed in Table 3. The immediate clearance rate of the stones was 88 % (15 of 17) in the LLR group. Two patients with remaining stones had remnant stones removed by a choledochoscopic stone removal procedure at approximately 6 weeks postoperatively. The immediate clearance rate of stones was 82 % (14 of 17) in the OLR group. For three patients with remaining stones, postoperative choledochoscopic stone removal failed. The final stone clearance rates in the LLR and OLR groups were 100 and 82 % (p = 0.227), respectively. Over a mean follow-up of 35 (range 1–84) months, there were no recurrent stones in the LLR group. However, recurrent stones were detected in four patients (25 %) in the OLR group. The recurrent stones were located in the CBD in one patient and in the IHD in three patients.
Discussion The treatment of IHD stones remains difficult and challenging, as the postoperative remnant stone rate is still significant, and recurrent stones occur during the follow-up period. The main reason for remnant or recurrent stones is IHD strictures, which are common in patients with IHD stones. The treatment of IHD stones demands the complete elimination of intrahepatic stones and the prevention of recurrent stones. Liver resection has advantages in that it removes the portion of the liver that contains both IHD stones and diseased ducts. This procedure is reported to have a high stone clearance rate and a low long-term stone recurrence rate [15–17]. Because patients with IHD stones can develop associated cholangiocarcinoma, liver resection is a good method for preventing the development of cholangiocarcinoma as well [18, 19]. With the introduction of laparoscopic surgery, laparoscopic approaches have been applied in many fields of
Table 3 Comparison of perioperative clinical outcomes and stone clearance between the laparoscopic group and the open group Variables
Laparoscopy (n = 17)
Open (n = 17)
p value
Operation time (min)
432 ± 158
335 ± 85
0.03
Intraoperative blood loss (ml)
988 ± 929
879 ± 942
0.737
Postoperative complication (%)
5 (29 %)
11 (64 %)
0.039 0.221
Postoperative hospital stay (day)
16 ± 22
12 ± 14
Initial stone clearance rate (%)
15 (88 %)
14 (82 %)
1.00
Final stone clearance rate (%)
17 (100 %)
14 (82 %)
0.227
Recurrent stones (%)
0 (0 %)
4 (18 %)
0.103
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World J Surg Table 4 The postoperative complications of the laparoscopic group and the open group Complication
Laparoscopy (n = 17)
Open (n = 17)
Management
Grade I Intraabdominal fluid collection
2
Conservative treatment
Pleural effusion
2
Conservative treatment
Urinary retention
1
Wound problems
1
Catheterization 1
Dressing
1
Conservative treatment
Grade II Acute vestibulopathy Grade IIIa Intraabdominal fluid collection
2
6
PCD
Pleural effusion
1
3
Thoracentesis
Bile leakage Total
1 5 (n = 5)
PCD a
16 (n = 11)
a
Two complications occurred simultaneously in five patients: three pleural effusion and intraabdominal fluid collection, wound infection and intraabdominal fluid collection, bile leakage and intraabdominal fluid collection PCD percutaneous drainage
surgery. We previously reported that laparoscopic IHD exploration could be an effective method for treating patients with IHD stones when liver resection is not needed [13]. We also reported that LLR could be an effective option for patients with IHD stones for whom left-sided liver resection is necessary [14]. Perioperative results have shown similar outcomes regarding stone clearance rates and postoperative morbidity [1, 2, 6, 8, 16, 17, 20]. The indications for liver resection in the preoperative work-up were moderate to severe strictures in the right intrahepatic ducts, with possible fibrosis and atrophy of the hepatic lobes or segments. An intraoperative duct stricture grading system was used as an algorithm in this study to decide between LIHDE and LLR. When there were no or mild strictures in the IHD, only IHD exploration was performed. This procedure was effective in eliminating IHD stones. LLR was performed in patients with IHD stones who had more than a moderate degree of ductal stricture or impacted stones. This laparoscopic approach can offer the benefits of minimally invasive surgery, including less postoperative pain, earlier recovery, and good cosmesis, as well as accomplishment of the same therapeutic goals as OLR. Based on our experience with laparoscopic right liver resection for other diseases, such as hepatocellular carcinoma, we have widened our indications for LLR to include the treatment of right-sided IHD stones [21–24]. Laparoscopic approaches have similar outcomes in the treatment of IHD stones, while maintaining minimal invasiveness. Therefore, LLR could be a good option for minimally invasive treatment of right-sided IHD stones with stricture. If the patients are well selected, a minimally invasive approach for treating IHD stones could become possible by
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adhering to the same principles of treatment as open surgery. In our study, there were no significant differences in intraoperative blood loss, postoperative hospital length of stay, or final stone clearance rate between the two groups. However, the operative time was slightly longer in the LLR group than in the OLR group, and the postoperative complication rate was lower in the LLR group than in the OLR group. This lower postoperative morbidity may have resulted from the decreased invasiveness of laparoscopic surgery. The precise reasons why the OLR group had higher stone recurrence rates are not known, but we consider that the operative types performed by laparoscopy were simple procedures, including right hemihepatectomy and right posterior sectionectomy, as shown in Table 2. In contrast, operations performed by open surgery tend to be more complicated procedures, including central bisectionectomy, S6 segmentectomy, and bilio-enteric anastomosis. This distinction may have contributed to the higher immediate and final stone recurrence rates in this group. However, this study was limited due to the small number of patients in each group. To provide strong evidence of the superiority of laparoscopic treatment for IHD stones, large numbers of patients and prospective, randomized, controlled comparative studies between the laparoscopic and open approaches are needed in the future. In conclusion, this study suggests that LLR could be an effective and feasible treatment option for the management of right-sided IHD stones in selected patients. With further accumulation of experience, we feel assured that LLR will become a cornerstone treatment modality for eliminating right-sided IHD stones.
World J Surg Conflict of interest
None.
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