Subacute liver and respiratory failure after segmental hepatectomy for complicated hepatolithiasis with secondary biliary cirrhosis: A case report

Abstract

BACKGROUND

Despite being a benign disease, hepatolithiasis has a poor prognosis because of its intractable nature and frequent recurrence. Nonsurgical treatment is associated with high incidences of residual and recurrent stones. Consequently, surgery via hepatic lobectomy or segmental hepatectomy has become the main treatment modality. Clinical management and resolution of complicated hepatolithiasis with bilateral or diffuse intrahepatic stones remain very difficult and challenging. Repeated cholangitis and calculous obstruction may result in secondary biliary cirrhosis, a limiting factor in the treatment of hepatolithiasis.

CASE SUMMARY

A 53-year-old woman with a 5-year history of intermittent abdominal pain and fever was admitted to the hepatopancreatobiliary surgery department following worsening symptoms over a 3-d period. Blood tests revealed elevated transaminases, alkaline phosphatase, γ-glutamyl transpeptidase, and total bilirubin, as well as anemia. Magnetic resonance cholangiopancreatography showed dilatation of the intrahepatic, left and right hepatic, common hepatic, and common bile ducts, and multiple short T2 signals in the intrahepatic and common bile ducts. Abdominal computed tomography showed splenomegaly and splenic varices. The diagnosis was bilateral hepatolithiasis and choledocholithiasis with cholangitis. Surgical treatment included hepatectomy of segments II and III, cholangioplasty, left hepaticolithotomy, second biliary duct exploration, choledocholithotomy, T-tube drainage, and accretion lysis. Surgical and pathological findings confirmed secondary biliary cirrhosis. Liver-protective therapy and anti-infectives were administered. The patient developed liver and respiratory failure, severe abdominal infection, and septicemia. Eventually, her family elected to discontinue treatment.

CONCLUSION

Liver transplantation, rather than hepatectomy, might be a treatment option for complicated bilateral hepatolithiasis with secondary liver cirrhosis.

Keywords: Hepatolithiasis; Hepatectomy; Liver failure; Biliary cirrhosis; Septicemia; Case report

Core Tip: Treatment of complicated hepatolithiasis with bilateral intrahepatic stones is challenging. In this case of complicated hepatolithiasis with diffuse intrahepatic stones, liver imaging before surgery showed a normal morphology, but nodular and atrophic changes observed during segmental hepatectomy indicated cirrhosis. Preoperatively, the patient’s liver function was Child-Pugh class B, and the presence of splenomegaly indicated decompensated liver cirrhosis. Postoperatively, the patient experienced persisting elevated total bilirubin and worsened coagulation function. The patient ultimately experienced liver failure, respiratory failure, and septicemia resulting from severe biliary infection. Further treatment was discontinued at the family’s request.