The Role Of Postoperative Choledochoscopy And Hepatectomy In The Treatment Of Hepatolithiasis

[Objectives]To evaluate the effect of postoperative choledochoscopy and hepatectomy on the treatment of hepatolithiasis.[Methods]From January2003to December2011, a total of2583postoperative percutaneous choledochoscopy sessions were performed in847patients with T tubes in situ. Intrahepatic duct stones with or without common bile duct (CBD) stones were detected in526patientswho were treated with a total of1998percutaneous choledochoscopy sessions. All patients with intrahepatic stones underwent postoperative choledochoscopy for stones extraction. The distribution and classification of intrahepatic stones, type of previous operations, causes of residual intrahepatic stones, complications of postoperative choledochoscopy, stones clearance rate and recurrence rate of gallstones were retrospectively analyzed in these526patients with residual intrahepatic stones that were treated with postoperative choledochoscopy. Partial hepatectomies were performed in140patients due to intrahepatic duct strictures, fibrosis and atrophy of the affected liver parenchyma. The stones clearance rate and the mean frequency of postoperative choledochoscopy procedure were compared between the patients with partial hepatectomy and without. Two hundred and thirty three patients who underwent postoperative choledochoscopy responded to our follow-up telephone and were divided into2groups:liver resection group (65patients) and no liver resection group (168patients). The recurrence rate of gallstones between the two groups was compared. [ResuIts]The mean frequency of the postoperative choledochoscopy is3.79times in these526patients with postoperative residual intrahepatic stones. The clearance rate of intrahepatic stones in this series is92.4%(486/526). Forty patients (7.6%) had residual stones due to various causes including dislodgement of T tube, stricture of intrahepatic duct, acute angulation of the biliary duct, and T tube sinus tract duodenal fistula. The clearance rate of residual intrahepatic stones in patients with or without previous partial hepatectomies are96.4%(135/140) and90.9%(351/386) respectively (X2=4.417, P=0.036). The mean frequency of postoperative choledochoscopy is2.82times in liver resection group and4.55in no liver resection group (p<0.05). The recurrence rate of gallstones is9.2%(6/65) in liver resection group and23.2%(39/168) in no liver resection group (X2=5.881, P=0.015). Severe complications such as major bleeding, rupture of the T tube sinus tract, T tube sinus tract duodenal fistula were developed in17patients with a morbidity rate of3.2%.[Conclusions]Liver resection is the effective and radical surgical procedure for treatment of intrahepatic stones, especially in patients with intrahepatic duct strictures, fibrosis and atrophy of the affected liver parenchyma. Liver resection can increase the clearance rate of the intrahepatic stones and lower the recurrence rate of gallstones. Choledochoscopy is a safe and effective modality for treatment of postoperative residual intrahepatic stones with a high clearance rate and low morbidity rate. But even combined with segment-selected hepatectomy, choledochoscopy still cannot completely clear the intrahepatic stones in some patients with complicated intrahepatic stones.