The Comparison Of Surgical Treatments For 368 Hepatolithiasis Cases

Background:As a common and frequently-occurred disease, hepatolithiasis has the characters of intractability and recurring tendency featuring high rates of residual stone and recurred stone/cholangitis,which makes it a troublesome and tough problem. Hepatectomy,bilio-enteric anastomosis and CBD exploration plus T-track drainage are the long-term and widely utilized methods in our country. Although hepatectomy has the definitive efficacy in its indications, it can't resolve all the problems in the hepatolithiasis. Thus, the hepatolithiasis still requires multidisciplinary methods in its treatment.Purpose:Analyze and discuss the advantages and shortcomings of the above three procedures and provide some referent and supportive information in the making of systematic,individual and radical treatment strategy.Methods:We retrospectively collected the demographic details of the 368 hepatolithiasis cases which underwent surgical treatment and analyzed the immediate and long-time outcomes(residual stone rate, incidence of peri-operative complications, recurrent stone rate, cholangitis recurrence etc.) to evaluate the clinical efficacy of the forehand described procedures.Results:As for short-time results, the residual stone rate in A group of 11.52% at the completion of operation was significantly lower than B group of 34.78% and C group of 29.10%(P<0.01). However after post-operative choledochoscopy lithotripsy, residual stone rate in C group of 14.18% was prominently lower than B group of 26.09% (P<0.05). Meanwhile in the peri-operative complication incidence, no significant difference was shown between these three procedures. When the incision infection was excluded, the other complication incidences were compared. A group (19.39%) is significantly higher than B group(9.52%) and C group(10.74%)(P<0.05). 3 deaths occurred in the peri-operative period, in that,2 from A group died of liver failure and 1 from B group died of subphrenic infection.About the long-term outcome, the stone recurrence in A group (10.78%) was prominently lower than B group (27.02%) and C group (23.17%). Meanwhile the recurrent cholangitis rate in the A,B,C group were respectively 14.68%,28.57%,30.30%. A group was lower than B group (P<0.05) and C group (P<0.05). In the B group, the recurrent cholangitis rate in hepaticojejunostomy plus strictroplasty subgroup (19.05%) was lower than choledochojejunostomy subgroup (38.10%) significantly. And preserved subcutaneous tunnel was beneficial for decreasing the hospital stay and re-laparatomy rate.Conclusions:1.The treatment of hepatolithiasis should stick to the principle of "individual,systematic and multidisciplinary" therapeutic protocol, and ultimately reaches the goal of radical cure.2. As up to now, hepatectomy is still the optimal option in the treatment of hepatolithiasis (especially the unilobar distributed hepatolithiasis) presenting with lower residual stone rate, recurrent stone/cholangitis rate.3. Bilio-enteric anastomosis still can be of some supplementary use for hepatolithiasis, whereas in its strict indications. Preserved subcutaneous tunnel can be beneficial for the post-operative choledochoscopic lithotripsy.4,CBD exploration plus choledochoscopic lithotripsy can be used as a symptomatic method in the emergent and severe hepatolithiasis cases but can be considered as the definitive treatment only in the very simple situation.