Divergent effects of endoscopic sphincterotomy on the long-term outcome of hepatolithiasis

doi:10.1016/S0016-5107(96)70257-2

Gastrointestinal Endoscopy

Volume 43, Issue 1, January 1996, Pages 33-37

https://doi.org/10.1016/S0016-5107(96)70257-2 Get rights and content

Abstract

Background: The long-term value of endoscopic sphincterotomy in patients with hepatolithiasis has not been established. Methods: Long-term clinical effects of endoscopic sphincterotomy on hepatolithiasis were determined in 57 patients. All patients had sphincterotomy to remove their common bile duct stones. Intrahepatic stones were removed completely in 21 patients, while the stones partly remained in 36 patients despite combined use of surgery and/or percutaneous trans-hepatic choledochoscopy. Three patients of the latter group spontaneously passed all the remaining stones soon after the sphincterotomy. Results: Follow-up at 66 to 183 months (mean, 114 months) was available in 54 patients (94.7%). Late complications occurred in 10 patients with the remaining stones, including seven cases of cholangitis (two fatalities) and three of liver abscess (one fatality). In contrast, those with complete clearance developed no complications. Conclusions: Endoscopic sphincterotomy has divergent effects on the long-term outcome of patients with hepatolithiasis. Every effort should be made to remove the intrahepatic stones as completely as possible shortly after sphincterotomy if the patient is to be managed endoscopically and adverse effects are to be avoided. (Gastrointest Endosc 1996;43:33-7.)

Section snippets

MATERIALS AND METHODS

Fifty-seven patients with intrahepatic stones underwent ES for the treatment of coexistent common bile duct stones. Twenty-five patients were men and 32 women. The age ranged from 33 to 83 years with a mean of 56.7 years. The presence of the intrahepatic stones was known before ES in 32 patients (Group I), whereas it was demonstrated by post-ES investigations in the remaining 25 patients (Group II). ES was performed on an emergency basis to remove the common bile duct stones associated with

RESULTS

Follow-up data were available in 54 of 57 patients (95%). The mean follow-up period was 114 months (range, 66 to 183 months). Twenty-one patients were dead; 33 were alive. Causes of death were cholangiocarcinoma in 3 patients, late cholangitis in 2, liver abscess in 1, unknown in 2, and not related to hepatolithiasis in the other 13 (Table 1).

Intrahepatic stones had been completely cleared in 18 patients, whereas stones were only partially removed in 36 patients. Three patients in the latter

DISCUSSION

The present study demonstrates that ES has divergent effects on the long-term clinical outcome of patients with intrahepatic stones. Of 36 patients with incomplete clearance of the intrahepatic stones at the time of completion of ES and subsequent removal of common bile duct stones, 3 patients spontaneously passed all the remaining stones. Conversely, 10 of the 36 patients developed the potentially fatal complications of cholangitis (7) and liver abscess (3). The complications actually led to

Acknowledgements

We conclude that patients with intrahepatic stones after ES are at significant risk for subsequent biliary infection. Additional endoscopic, percutaneous, or surgical therapy is recommended to avoid serious cholangitis events associated with persistant intrahepatic stones.

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Cited by (20)

Chapter 39 - Intrahepatic stones
2016, Blumgart's Surgery of the Liver, Biliary Tract and Pancreas: Sixth Edition
Secondary Sclerosing Cholangitis. Pathogenesis, Diagnosis, and Management.
2013, Clinics in Liver Disease
Citation Excerpt :
Surgery focuses on drainage and exploration of the bile ducts. Endoscopic intervention may also be used when needed, and long-term drainage may be the only option in a few patients with widespread disease.15,51,52 Conversely, therapeutic options in patients with AIDS cholangiopathy are limited, because none have been shown to be beneficial in improving survival.
Left-sided hepatic resection for hepatolithiasis: A longitudinal study of 110 patients
2012, HPB
Citation Excerpt :
Treatment options include surgical treatment with biliary decompression and/or hepatic resection as the first approach.14,15 Non-surgical procedures such as percutaneous transhepatic lithotriphy or endoscopic therapy are usually reserved to treat stone recurrences.16,17 Morbidity and mortality rates for hepatic resection have decreased significantly in the last decade.5,18
Hepatolithiasis affecting the left hepatobiliary system is common in the Asia Pacific region. This aim of this study was to describe an experience with the diagnosis and treatment of patients with isolated left-sided hepatolithiasis.
One hundred and ten patients with isolated left-sided hepatolithiasis who underwent a left-sided hepatic resection between January 1999 and February 2010 were included for further analysis. The clinical profile, cholangiograms, operative procedures and early and late results were examined.
Analysis of magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) findings revealed left hepatic ductal anatomical details in 101 patients. Three types of left hepatic ductal variations were observed (type 1 in 90.1%, type 2 in 5.9% and type 3 in 4.0% patients). Eighty-four (76.4%) patients had the presence of strictures in the left hepatic ductal system and in 26 (23.6%) patients no strictures could be seen. Out of 84 patients with strictures, 78 could be classified (type I in 89.7% and type II in 10.3%). Of the 110 patients, 75 (68.2%) underwent a left lateral sectionectomy, 33 (30%) a left hepatectomy and 2 (1.8%) patients were treated with a left hepatectomy combined with a caudate lobe resection. Of the patients who underwent a left hepatectomy 11.4% developed a bile leak. Eight per cent of patients who underwent a left lateral sectionectomy had infective complications. During a median follow-up period of 63 (range 3–134) months, 2 (2.1%) patients were discovered to have residual stones and five (5.2%) others possessed recurrent stones.
This study highlights the impact of the presence or absence of bile duct stricture on the clinical and histological profile of patients as well as their operative and the post-operative behaviour. It is concluded that hepatic resection is an appropriate treatment modality in localized left-sided hepatolithiasis.
Liver resection as the definitive treatment for unilateral non-oriental primary intrahepatic lithiasis
2006, American Journal of Surgery
Citation Excerpt :
Hepatic resection for the treatment of hepatolithiasis has been reported to be associated with a low incidence of long-term stone recurrence or recurrent cholangitis [12–17]. The global rate of 7.4% of late complications in our series is relatively low when compared with recurrent/residual disease rates ranging between 20% and 40% reported in most studies after percutaneous cholangioscopic lithotripsy, or endoscopic or other surgical approaches such as bilioenteric anastomosis without hepatic resection [6–10,17,18]. In this study, to our knowledge the largest western PIHL series, the indications for resection were irreversible parenchyma or biliary lesions.
The current study sought to evaluate the results of liver resection as the treatment for unilateral non-oriental primary intrahepatic lithiasis (PHIL).
Twenty-seven symptomatic patients (mean age 42 years) were submitted to liver resection; the indications were parenchymal fibrosis/atrophy in 22 and biliary stenosis in 5. Resection was associated with a Roux-en-Y hepaticojejunostomy in patients with a significant degree of dilation of the extrahepatic biliary duct.
There was no operative mortality and the morbidity rate was 7.4% (2 patients with biliary fistula). After a median follow-up of 41.2 months, the overall rate of good results was 92.6%. All patients submitted to liver resection alone presented good late results, while 80% of those with associated hepaticojejunostomy did not have complications (P = .12). Late complications were observed in 2 patients (7.4%): 1 with a liver abscess and 1 with cholangitis and recurrent stones. There was no mortality during long-term follow-up.
Liver resection showed low incidence of complications and good long-term results. None of the patients with unilateral disease without associated extrahepatic bile duct dilation presented complications and they were considered cured. We believe that resection indications should be expanded and the procedure should be indicated as routine in patients with unilateral PHIL even in the absence of parenchymal fibrosis/atrophy or biliary stenosis.
Endoscopic intervention for hepatolithiasis associated with sharp angulation of right intrahepatic ducts
2003, Gastrointestinal Endoscopy
Background: Hepatolithiasis (intrahepatic stones) is common in Asian patients. Hepatolithiasis with intrahepatic strictures and sharp ductal angulation poses a particularly difficult management problem.
Methods: Cases of hepatolithiasis with sharp angulation of right intrahepatic ducts were retrospectively reviewed.
Observations: Five patients with hepatolithlasis and right sharp intrahepatic ductal angulation were treated endoscopically via ERCP. Two patients died soon after the procedure. In the remaining 3 patients, treatment by dilation of the intrahepatic strictures and stent placement was only partially successful. Attempts to access the sharply angulated intrahepatic duct were unsuccessful.
Conclusions: Endoscopic management of hepatolithiasis associated with sharp angulation of a right intrahepatic duct is difficult and is generally managed best with percutaneous treatment modalities or surgery, where possible.
Is peripapillary choledochoduodenal fistula an indication for endoscopic sphincterotomy?
2001, Gastrointestinal Endoscopy
Background: Most patients with a peripapillary choledochoduodenal fistula undergo fistulotomy by endoscopic sphincterotomy for the treatment of bile duct stones. However, whether sphincterotomy should be performed in patients with the fistula but without stones is controversial. Methods: Among 165 patients in whom a benign peripapillary choledochoduodenal fistula was diagnosed at ERCP, the clinical outcome was retrospectively analyzed and compared between those who underwent fistulotomy by endoscopic sphincterotomy (group 1) and those whose fistula was left untreated (group 2). All patients with hepatolithiasis, residual stones, biliary diversion, or transduodenal papilloplasty were excluded (32, leaving 133). Fistulas were divided into types I and II according to the location of the fistula (Ikeda classification). Results: Follow-up data collected during a median period of 124 months were available for 127 of 133 patients (95%), 76 in group 1 and 53 in group 2. Late complications were bile duct stone recurrence (17 patients), acute cholangitis (7 patients), and biliary carcinoma (2 patients). The incidence of stone recurrence was not significantly different between the 2 groups (p = 0.1). In group 2, 4 patients (8%) with an untreated type II fistula had 1 to 3 episodes of presumed reflux cholangitis, which resolved quickly with conservative treatment. Conclusions: Endoscopic sphincterotomy is not always necessary for peripapillary choledochoduodenal fistulas if bile duct stones are absent because reflux cholangitis is a relatively rare complication that can be easily managed. (Gastrointest Endosc 2001;53:313-7.)

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^☆: From the Departments of Surgery I, Kyushu University Faculty of Medicine, and Fukuoka University School of Medicine, Fukuoka, Japan.

^☆☆: Reprint requests: Masao Tanaka, MD, Surgery I, Kyushu University Faculty of Medicine, Fukuoka 812, Japan.

^★: 0016-5107/96/4301-0033$5.00 + 0

^★★: GASTROINTESTINAL ENDOSCOPY

^♢: 37/1/65957

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Divergent effects of endoscopic sphincterotomy on the long-term outcome of hepatolithiasis☆,☆☆,★,★★,♢

Abstract

Section snippets

MATERIALS AND METHODS

RESULTS

DISCUSSION

Acknowledgements

Gastrointest Endosc

Gastroenterology

Am J Surg

Gastrointest Endosc

Am J Surg

Hepatolithiasis in East Asia: retrospective study

Dig Dis Sci

Intrahepatic stones: a clinical study

Ann Surg

The surgical management of primary intrahepatic stones

Br J Surg

Experience with routine postoperative choledochoscopy via the T-tube tract

World J Surg

Value of percutaneous transhepatic cholangioscopy (PTCS)

Surg Endosc