Surgical treatment of biliary ductal stricture complicating localized left hepatolithiasis

Abstract

AIM: To summarize the experience in the clinical treatment of biliary duct strictures complicating localized left hepatolithiasis in the last two decades.

METHODS: A retrospective analysis of 67 cases of biliary duct strictures complicating localized left hepatolithiasis treated in our center in the last two decades was made with regards to each patient’s age, gender, results of various preoperative examinations, operative findings, treatment and postoperative courses.

RESULTS: The incidence of left hepatic duct (LHD) stricture was 59.8% and that of a left external hepatic duct (LEHD) stricture was 84.0 % and 84.8% respectively, in which a severe degree dominated. Among the operative procedures used in the treatment of LHD strictures, plastic operation plus biliary enteric anastomosis ranks first in frequency (52.2%), with a re-stricture rate of 17.1%. Left lobectomy ranks third (19.4%) with no re-stricture. Simple plastic performance or dilation had a high occurrence rate of re-stricture and usually needed subsequent surgery. Most LEHD strictures were eradicated by lateral segmentectomy or lobectomy, whereas most LMHD strictures were just the opposite. The rate of preoperative diagnosis of LMHD by endoscopic retrograde cholangiography, percutaneous transhepatic cholangiography, computed tomography or intraoperative and postoperative trans-T-tube cholangiography was much lower than that of LEHD or extrahepatic duct.

CONCLUSION: Too much attention paid to LEHD disorders in the treatment of localized left hepatolithiasis potentially results in negligence or omission in LMHD disorders. Malpractice treatments of LHD strictures are important factors affecting the long term results of localized left hepatolithiasis, for which left lobectomy is usually the therapy of choice.

Key Words: Cholelithiasis/surgery; Bile duct diseases/surgery; Hepatic duct, common/surgery; Cholelithiasis/complication; Hepatectomy

INTRODUCTION

Solitary left hepatolithiasis with left intrahepatic ductal calculi is a common and peculiar type of hepatolithiasis which is prevalent in East Asia[1,2]. In order to treat left hepatolithiasis, it is necessary to deal with the intrahepatic biliary strictures[3], the occurrence of which is a sign of complexity, difficulty, repetition and severity. Theoretically, lateral segmentectomy or left lobectomy could be used to solve the problem concerning the left hepatic duct (LHD) strictures[4]. However, recently some problems have been noticed, such as a high incidence of residual stones after surgery[5] and a high stone recurrence rate[6] in the treatment of patients with left hepatolithiasis, some of whom have had subsequent surgery. In this paper, 67 cases of left sided hepatic duct strictures complicating localized left hepatolithiasis surgically treated at our center in the last two decades were analyzed.

MATERIALS AND METHODS

Subjects

One thousand and eighteen patients with primary intrahepatic lithiasis were treated at our center between June 1976 and June 1996, among whom 133 had localized left hepatolithiasis, 112 underwent operations with no deaths and 67 (29 males and 38 females) had complications with LHD strictures. A retrospective study of patients with LHD or second class hepatic ductal strictures was made with regards to each patient’s age, gender, results of various preoperative examinations, operative findings, treatment and postoperative courses. The mean age was 40.7 years (range, 27 to 72 years).

Standard of inclusion

All diagnoses were confirmed by cholangiography or at surgery.

Standard of stricture degree

The criteria for stricture degree used in this paper was proposed by the Chinese Surgical Association in 1983 (a mild or severe stricture refers to a stricture with a diameter > or ≤ respectively half of the greatest diameter of the dilated ducts proximal to the stricture).

Statistical analysis

All data are expressed as ¯x ± s. Statistical analysis was conducted with the Chi squared test.

RESULTS

Hepatic duct stricture

Left hepatolithiasis commonly becomes complicated due to biliary duct strictures and the occurrence rate of LHD stricture was 598%. In view of the difficulty and magnitude of the operation, the left external hepatic duct (LEHD) and the left medial hepatic duct (LMHD) were not routinely explored. Definitive diagnoses in some cases indicated that the occurrence rates of the second hepatic ducts are significantly higher than those of LHD (P < 0.01) (Table 1).

Table 1 The occurrence rate of each hepatic duct stricture.

Location	n	Mild stricture (%)al	Severe stricture (%)a2	Total (%)
Left hepatic duct	112	26 (23.2)	41 (36.6)	67 (59.8)
Left medial hepatic duct	33	9 (27.3)	19 (42.4)	28 (84.8)b
Left external hepatic duct	75	29 (38.7)	34 (45.3)	63 (84.0)d

Mild or severe stricture refers to a stricture with a diameter > or ≤ respectively half of the greatest diameter of the dilated ducts proximal to the stricture. ^a1χ² = 5.26, P > 0.05;

^a2χ² = 4.90, P > 0.05, among 3 groups.

^bχ² = 6.00, P < 0.01;

^dχ² = 11.82, P < 0.01, vs left hepatic duct.

Treatment of LHD stricture

Table 2 shows the various procedures used for the treatment of LHD stricture in the current group, from which we can see that plastic operation plus biliary enteric anastomosis ranks first in frequency followed by stricture dilation, left lobectomy and simple repair. The incidence of re-stricture after left lobectomy was 0.0%, 17.1% following plastic operation plus biliary enteric anastomosis (not significantly higher than the former probably because of the limited cases). Simple plastic performance or dilation had a high occurrence rate of re-stricture and usually needed subsequent surgery, especially for the latter. The treatment profiles of strictures of severe and mild degrees were not significantly different.

Table 2 Surgical treatment of left hepatic duct stricture and the subsequent re-stricture rates (¯x ± s).

Operative procedures	Cases(%)	Mean follow up period (y)	Re-strictures (%)
Plastic operation plus
Biliary enteric anastomosis	35 (52.2)	9.8 ± 2.7	6 (17.1)f
Severe degree	21 (51.2)	10.6 ± 2.3	4 (19.0)
Mild degree	14 (53.8)	8.6 ± 3.2	2 (14.3)
Left lobectomy	13 (19.4)	9.7 ± 3.0	0 (0.0)e
Severe degree	7 (17.1)	9.1 ± 3.1	0 (0.0)
Mild degree	6 (23.1)	10.3 ± 2.8	0 (0.0)
Stricture repair	6 (9.0)	8.5 ± 3.2	3 (50.0)
Severe degree	4 (9.8)	8.2 ± 3.5	2 (50.0)
Mild degree	2 (7.7)	7.8 ± 10.1	2 (100.0)
Stricture dilation	13 (19.4)	9.9 ± 2.2	12 (92.3)
Severe degree	9 (22.0)	10.7 ± 2.7	9 (100.0)
Mild degree	4 (15.4)	8.1 ± 2.4	3 (75.0)
Total	67 (100.0)	10.1 ± 2.9	21 (31.3)

^fχ² = 19.76, P < 0.01;

^eχ² = 4.69, P < 0.05, vs stricture dilation. No significant difference between severe degree and mild degree.

Treatment of LEHD and LMHD strictures

Practically, there is no specific procedure for strictures of LEHD and LMHD, although in some ways, segmentectomy or lobectomy is the only practical method. Lateral segmentectomy can be used for LEHD stones, strictures, etc. while left lobectomy can be used for disorders of LEHD, LMHD or LHD. Based on this theory, we judged the effect of strictures of LEHD or LMHD on the treatment decision from the present data by analyzing the operative procedure profiles in combination with the incidence of strictures. Table 3 shows that the LEHD stricture is usually treated with segmentectomy or lobectomy. Eighty of 112 cases with left hepatolithiasis underwent lateral segmentectomy or lobectomy (71.4%), which was similar to the occurrence rate of LEHD stricture (P > 0.05). Whereas, LMHD stricture is seldom treated with segmentectomy or lobectomy (12.5%), significantly lower than the incidence of LMHD stricture (P < 0.01) and suggesting that the performance rate of left lobectomy was much less than clinically needed.

Table 3 Treatment of strictures of left external hepatic duct and left medial hepatic duct.

	Cases	%
Lateral segmentectomy	66	58.9
+Bile duct exploration	39	34.8
+Biliary enteric anastomosis	27	24.1
Left lobectomy	14	12.5
+Bile duct exploration	10	8.9
+Biliary enteric anastomosis	4	3.6
Biliary enteric anastomosis	15	13.4
Bile duct exploration	17	15.2
Total	112	100

Rate of preoperative diagnosis

The present data suggests a significantly lower chance for LMHD than LEHD disorders to undergo an eradication treatment. One of the reasons is the difference between the rates of preoperative diagnosis of LEHD and LMHD. The rate of preoperative diagnosis of LMHD by endoscopic retrograde cholangiography (ERC), percutaneous transhepatic cholangiography (PTC), computed tomography (CT) or intraoperative and postoperative trans-T-tube cholangiography (TTC) was much lower than that of LEHD or extrahepatic duct (Table 4).

Table 4 The rate of correct diagnosis of various bile ducts by different diagnostic procedures.

	ERC (%)	PTC (%)	TTC (%)	CT (%)
Total	78	18	106	40
Left external hepatic duct	69 (88.5)	18 (100.0)	96 (90.6)	29 (72.5)
Left medial hepatic duct	16 (20.5)	6 (33.3)	21 (19.8)	12 (30.0)
Extrahepatic duct	78 (100.0)	15 (83.3)	106 (100.0)	36 (90.0)

ERC: Endoscopic retrograde cholangiography; PTC: Percutaneous transhepatic cholangiography; TTC: Trans-T-tube cholangiography; CT: Computed tomography.

DISCUSSION

Localized left hepatolithiasis needs some special clinical treatment with the following characteristics: [WTBZ] (1)[WTB1] the intrahepatic calculi are localized in the left intrahepatic bile duct system; (2)the extrahepatic biliary duct may or may not be involved; and (3) theoretically, it can be cured by lateral segmentectomy or left lobectomy which brings about a thorough elimination of stones and the accompanying strictures. For the sake of acceptable results for clinical treatment in comparison with right hepatolithiasis[7], no special consideration has been given.

Biliary stricture is defined by Matsumoto et al[8] as a localized diminution in bile duct caliber proximal to the common hepatic duct. In this paper, the standard of classification of mild or severe degrees of stricture was suggested by the Chinese Surgical Association.

The stricture narrows the intraductal lumen and slows down the speed of bile flow[8,9], leading to stasis of bile which leads to the greater generation of minute calculi and increases the size or number of stones. Besides, the increased pressure gradient of bile flow between the proximal duct and the stricture results in the distention of the duct between the wave of contraction and the point of obstruction, resulting in the gradual increase of proximal ductal lumen. The increased size or number of stones and the discrepancy between ductal lumens may contribute to bile turbulence within the dilated ductal lumen. A vicious cycle thus develops. Moreover, bacteria grow further following chronic bile stasis[9]. So it is evident that bile duct stricture contributes to the complexity of pathological changes and difficulties in treating the recurrence of stones with unsatisfactory long term results.

In our limited experience, LHD stricture often occurs secondary to left hepatolithiasis, especially left lateral hepatolithiasis. Its occurrence implies a new stage of left hepatolithiasis in which LMHD becomes more susceptible to stricture, dilation or stones. Some factors contributing to the prognosis include calculi, stricture or dilation[7,10], bile stasis and liver function damage[11].

Although a bias in counting the incidence of LEHD and LMHD strictures resulting from the incomplete case records of the present group cannot be excluded, we can still deduce that LEHD and LMHD strictures are comparable in frequency although commonly different in severity, demonstrating that localized LMHD disorders are rare and that clinical treatment should be concentrated on the strictures of both LEHD and LMHD. So theoretically speaking, left lobectomy is sometimes the eradication treatment of choice for left biliary duct strictures, although the facts are almost quite the opposite. Left lobectomy is much less frequently performed than lateral segmentectomy in the clinical management of localized left hepatolithiasis.

Preoperative misdiagnosis is another important factor responsible for the current situation. The present data indicate that most of the omitted LMHD disorders result from no available radiological observations of LMHD preoperatively. So it is urgent to try to improve the preoperative diagnosis rate of LMHD. Since the mouth of LMHD is too low in a supine position to be filled up in cholangiography-inducing preoperative omission, attention should be paid to patients with intrahepatic lithiasis, especially left hepatolithiasis, to achieve a definitive diagnosis of LMHD pre and intra-operatively with some improvements in cholangiography, including a prone ERC position, selective PTC and intraoperative B ultrasound. CT seems to be a great help in some patients by demonstrating the location of calculi directly and elucidating the bulk of hepatic lobe as an indirect sign of the disorders.