Clinical Study Of Hepatectomy For Hepatolithiasis And A Meta-analysis

Part 1.Clinical study of hepatectomy for hepatolithiasisObjectiveHepatolithiasis is prevalent in East Asia.Various therapeutic methods have been reported in the literature,but their clinical outcomes are not satisfactory.This study aimed to discuss the outcomes of hepatectomy in hepatolithiasis management,and to compare the differences due to diverse strategies in the course of surgical treatment.MethodsWe included 283 patients with hepatolithiasis,who underwent hepatectomy in Sir Run Run Shaw Hospital from Jan 2008 to Mar 2016.Their basic characteristics,preoperative status,intraoperative conditions,postoperative outcomes and stone recurrence rates were analyzed.ResultsIn the patients underwent hepatectomy,the initial stone clearance and final stone clearance were 7.1%and 3.5%,respectively.The stone recurrence rate of 3 years,5 years and 10 years after operation was 3.5%,11.8%,16%,respectively.Cox’s proportional hazard regression model showed that Child-Pugh class(HR=5.388,p=0.009),presence of right intrahepatic stones(HR=4.574,p<0.001)and presence of previous operations(HR=2.423,P=0.033)were 3 independent risk factors. Compared with the open hepatectomy group(n=121),less intraoperative blood loss(200 ml vs 300 ml,p<0.001),shorter postoperative hospital stay(8 d vs 10 d,p<0.001),lower intraoperative transfusion rate(6.2%vs 21.5%,p<0.001)and postoperative complication rate(13.6%vs 24%,p=0.025)were seen in the laparoscopic hepatectomy group(n=162).There’s no significant difference in stone clearance and stone recurrence rate between the two groups.For unilateral left hepatolithiasis patients with atrophy and biliary strictures limited in left lateral segment,left lateral segmentectomy(n=85)showed less intraoperative blood loss(150 ml vs 200 ml,p<0.001)and shorter postoperative hospital stay(8 d vs 10 a,p=0.001)than left hemihepatectomy(62).For hepatolithiasis patients with common bile duct stones,preoperative endoscopic retrograde cholangiopancreatography(ERCP)with sphincterotomy didn’t have any advantage in clinical outcomes compared with intraoperative choledochohthotomy.In addition,preoperative ERCP may bring a higher financial burder(4223.8±1 161.93 yuan vs 4675.5±1769.62 yuan,p=0.411)to the patients.ConclusionsSurgical hepatectomy is a safe and effective treatment for the patients with hepatolithiasis.Laparoscopic hepatectomy is not only as effective as open hepatectomy,but also even more advantageous in some respects.For unilateral left hepatolithiasis patients with atrophy and biliary strictures limited in left lateral segment,left lateral segmentectomy showed less intraoperative blood loss and shorter postoperative hospital stay than left hemihepatectomy.For hepatolithiasis patients with common bile duct stones,preoperative ERCP may bring a higher financial burden.Part 2.Laparoscopic VS open hepatectomy for hepatolithiasis:a meta-analysisObjectiveOpen hepatectomy is considered the current standard treatment of hepatolithiasis.This study aimed to compare the clinical outcomes of open hepatectomy and laparoscopic hepatectomy in the patients with hepatolithiasis.MethodsA systematic literature search on Embase,PubMed,Cochrane Library and Web of Science was conducted.We performed a meta-analysis to compare the intraoperative status and postoperative outcomes between the two surgical procedures.Their operation time,intraoperative blood 1oss,intraoperative transfusion rate,postoperative hospital stay,postoperative complication rate,initial stone clearance,final stone clearance and stone recurrence rate were analyzed and discussed.Results17 studies and 1627 patients were included in total.Compared with open hepatectomy,laparoscopic hepatectomy has less intraoperative blood loss(SMD=-0.521;95%CI=-0.937～-0.105;p=0.014),lower intraoperative transfusion rate(OR=0.437;95%CI=0.307～0.623;p<0.001),shorter postoperative hospital stay(SMD=-0.720;95%CI=-0.932～-0.507;P<0.001),lower Postoperative complication rate(OR=0.481;95%CI=0.367-0.629;p<0.001)and lower postoperative stone recurrence rate(OR=0.520;95%CI=0.319-0.847;p=0.009).With further subgroup analysis,our results demonstrated that left lateral segmentectomy and left hemihepatectomy can also achieve satisfactory effects in the treatment of hepatolithiasis.ConclusionsLaparoscopic hepatectomy is a safe and effective surgical treatment of hepatolithiasis,with less intraoperative blood loss,lower intraoperative transfusion rate,shorter postoperative hospital stay,lower postoperative complication rate,and even lower stone recurrence rate.