Reasons And Prognosis Of Multiple-operations For Intra-and Extrahepatic Cholangiolithiasis

Objective:To discuss the reasons,surgical procedures and prognosis of multiple-operations for intra-and extrahepatic cholangiolithiasis.Methods:A retrospective cohort study.The clinical data of 124 patients with intra and extra-hepatic bile duct stones who underwent multiple-operations at First Affiliated Hospital of Anhui Medical University were collected.Individualized operations were determined according to the distribution of stones and liver functional reserve,including stones removal by incising bile duct and external biliary drainage,Roux-en-Y hepaticojejunostomy and hepatolobectomy or segmental hepatectomy.The treatment followed the principles which is completed removal of stones,completed removal of stones,completed resection of lesions,correction of stenosis and adequate drainage.Bile was extracted during operation for bacilli cultivate.Patients received the postoperative symptomatic treatments,including anti-inflammation,hemostasis,liver protection,acid inhibition,and nutritional support.The observation indicators included reoperation reasons,operation method,operation time,volume of intraoperative blood loss and transfusion,hepatic inflow occlusion,stone clearance rate,postoperative complications and treatments,bacilli cultivate of bile,results of pathological examination and duration of hospital stay,results of follow up.The follow-up usingoutpatient examination and telephone interview was performed to detect postoperative living conditions and results of abdominal ultrasound once every 3 or 6 months in patients without stone residue once every 1 month in patients with stone residue from postoperative week 6 to June 2016.Measurement data with normal distribution and with skewed distribution were represented as X ± S and M(range),respectively.All dates were analyzed by chi-square test?fisher's exact probability?student's test or logistic regression analyzed.The test standard is 0.05,p<0.05 for the difference was statistically significant.Results:(1)Reasons of reoperation: 124 patients are combined with stones,including11 combined with stenosis of bilioenteric anastomosis,6 with secondary malignant biliary tumors and 2 with gastrointestinal stromal tumor invading intrahepatic bile duct.(2)Intraoperative status of reoperation: Operation time and volume of intraoperative blood loss of the 124 patients were(250±69)min and(180±165)m L,respectively.17 patients underwent intraoperative blood transfusion and 23 underwent first hepatic hilum occlusion.All the 124 patients received intraoperative choledochoscopy exploraton.The immediate and final stone clearance rates were75.8%(94/124)and 89.2%(99/111).(3)Postoperative status of reoperations: Of the 124 patients,54.8%(68/124)had postoperative complications.Of which 17.7%(22/124)patients with incision infection,after wound dressing,anti-infection and nutritional support after treatment improved,no other special treatment.15.3%(19/124)patients with pleural effusion,the effective puncture and drainage and nutritional support after symptomatic treatment were discharged.6.4%(8/124)patients with bile leakage,the abdomen drainage tube to maintain smooth drainage after discharge.4.8%(6/124)patients with pulmonary infection,after effective anti-infection,atomization and other support after treatmentwere cured.4.8%(6/124)patients with incision infection with pleural effusion,the wound dressing,chest puncture,anti-infection and nutritional support treatment were improved after discharge.4.0%(5/124)patients with biliary bleeding,self-cure in 1case,and then surgery to stop bleeding in 1 case,after conservative treatment improved in 3 cases.1.6%(2/124)patients with ascites,the liver,diuretic and nutritional support after treatment improved discharge.75.0%(93/124)patients with bile bacterial culture positive.Patient pathology findings for the hepatolithiasis in 116 cases,bile duct adenocarcinoma with stones in 6 cases,bile duct stones associated with gastrointestinal stromal tumors in 2 cases.Patient hospitalization was 20±8 days.(4)Follow-up results: 111 patients received postoperative follow-up,the overall follow-up rate was 89.5%(111/124),followed up the median time of 24 months(3 to108 months).During the follow-up period,72 patients had excellent postoperative status,39 patients had poor postoperative status(19 cases of stones,12 cases of recurrence of stones,2 cases of cholangiocarcinoma and associated stromal tumors).During the follow-up period,8 patients died of secondary tumors without surgery,4 patients were unable to tolerate surgery,3 cases due to other social factors and no surgical treatment,1case of tumor proliferation can not be surgery.(5)Analysis of clinical factors of recurrence of stones: Analysis of clinical factors of recurrence of stones: single factor analysis showed that the number of previous biliary surgery ? 2times,bile bacterial culture positive,the location of stones,Oddi sphincter function is the risk of recurrence of stones risk factors.Multivariate analysis showed that the number of previous biliary operations?2times,bile bacterial culture positive,the location of stones,Oddi sphincter function is an independent risk factors for the recurrence of stones.Conclusions:1.Stone residue and recurrence are the main reasons for reoperations.Preoperativeimproper manner,Oddi sphincter function to determine the wrong,anastomotic and bile duct stenosis and other factors to promote recurrence and residual stones.2.The individualized surgical methods are determined according to stone distribution,with or without atrophy of liver lobe,with or without canceration and condition of liver function,which can increase the stone clearance rate and avoid reoperations.3.The number of previous biliary operations,bile bacterial cultivate positive,double leaf stones,Oddi sphincter dysfunction are independent risk factors for postoperative residual stone recurrence.