| Background and Objective:Hepatolithiasis occurs prevalently in the asia-pacific region and this is a major disease with extensive lesion,complicated condition,high recurrence rate of bile duct stones,and a wide range of surgical complications.Hepatolithiasis treatment mainly relies on surgery,and many surgical treatment methods are available for complicated and extensive biliary and hepatic lesions induced by hepatolithiasis.However,biliary stones recur in some patients after surgery.Stone recurrence is a major clinical problem restricting the effects of surgical treatment for hepatolithiasis.With the further understanding of the pathogenesis and pathophysiological evolution of hepatolithiasis,as well as the improvement of examination and surgical techniques,great progress has been achieved in the localization,diagnosis,and treatment of the disease.At present,individualized treatment is advocated according to the specific conditions of patients,but biliary stones still recurr in many patients after the treatment which is considered to be ideal.Therefore,how to reduce the recurrence of stones after surgery is an urgent problem in the hepatolithiasis research.Hepatic atrophy-hyperplasia syndrome is a distinct manifestation of hepatolithiasis.In our clinical work,it was showed that some patients with high stone recurrence rate suffered from hepatolithiasis accompanied with hypertrophied perihilar liver(Sg Ⅰ,Ⅳb,Ⅴ)after receiving conventional surgery.The preoperative contrast-enhanced computed tomographic(CT)and magnetic resonance cholangiopancreatography of these patients showed that the hypertrophied perihilar liver directly compressed the hilar bile duct or biliary-enteric anastomosis.Can perihilar hepatectomy relieve the stricture of the hilar bile duct in such patients and reduce the recurrence rate of biliary stone? In the meanwhile,we find that the angle between the right posteroinferior bile duct and the longitudinal axis of the human body was smaller in the patients with stones in the right posteroinferior bile duct.Is there correlation between the angle of the right posteroinferior bile duct and stone formation? Is there other treatment can effectively reduce the recurrence of biliary stones in such patients? In view of the above problems,we plan to make a preliminary research through retrospective study.Methods:1.The primary hepatolithiasis patients with hilar bile duct compressed by Perihilar hyperplasia of liver were collected from January 2011 to July 2016 in our hospital.These patients were divided into two groups according to whether the perihilar hepatectomy was performed in the operation: control group and perihilar hepatectomy group.The recurrence of bile duct stone and cholangitis was oberserved.The end point of follow-up was set in February 2018.2.Patients for the same period as the first section were collected.These patients were divided into two groups according to whether the hilar bile duct was compressed by the hypertrophied perihilar liver.The ratio of perihilar hepatic volume to total hepatic volume was calculated and compared between the two groups.3.Patients with primary hepatolithiasis were collected from January 2011 to July 2016 in our hospital.These patients were divided into two groups according to whether the right posteroinferior bile duct was affected by gallstone.Statistical analysis for the the relevant factors associated with bile duct stone formation in right posteroinferior bile duct was performed.4.Based on the conclusions of the study from the third part,patients with angulation of the right posteroinferior bile duct were included according to the standard of the angle of the right posteroinferior the bile duct.The included patients were divided into two groups according to wether the postural drainage was performed after surgery.The recurrence of bile duct stone and cholangitis was oberserved.The end point of follow-up was set in February 2018.Results:1.There were no significant differences in preoperative general characteristics and surgical complications between control group and perihilar hepatectomy group.During the follow-up time,26 patients(35.6%)in the control group and 3 patients(5.5%)in the perihilar hepatectomy group developed intrahepatic duct stone recurrence(35.6%,n = 73 vs.5.5%,n = 55;p = 0.000).There were 18 patients(23.4%)in the control group and 3 patients(5.2%)in the perihilar hepatectomy occurred group recurrence attack of acute cholangitis(24.7%,n = 73 vs.5.5%,n = 55;p = 0.004).The 40-and 80-month cumulative stone recurrence rates were 11% and 69%,respectively,in the control group,and 0% and 17% respectively,in the perihilar hepatectomy group(P = 0.018).2.The ratio of perihilar hepatic volume to total hepatic volume in the compressed hilar bile duct group was greater than that in the normal hilar bile duct group(42.75%(39.55%-46.31%),n = 135 vs.31.79%(26.42%-37.21%),n = 924;p = 0.000).Receiver-Operatin g Characteristic Curve(ROC curve)indicated that when the ratio of perihilar hepatic volume to total hepatic volume was greater than 36.17%,it was easier to induce pathologica l change that the hilar bile duct or biliary-enteric anastomosis was compressed and stenosis by hypertrophied perihilar liver.3.The binary logistic regression results presented stenosis of right hepatic duct(OR,7.313;CI,4.131-12.945)and angle of right posteroinferior bile duct(OR,0.896;CI,0.877-0.916)was risk factors associated with the formation of right posteroinferior bile duct stone.ROC curve indicated that when the angle of right posteroinferior bile duct was lesser than 44.58°,it was easier to form stone in the right posteroinferior bile duct.In the patients of right posteroinferior bile duct with stone,the ratio of Sg Ⅳ,Ⅴ,Ⅷ volume to total hepatic volume was greater than that in the patients of right posteroinferior bile duct without stone(67.49%(60.67%-74.17%),n = 184 vs.49.74%(48.01%-51.91%),n = 266;p = 0.000).4.There were no significant differences in preoperative general characteristics and surgical complications between control group and postural drainage group.During the follow-up time,29 patients(55.8%)in the control group and 4 patients(7.7%)in the postural drainage group developed right posteroinferior bile duct stone recurrence(55.8%,n = 50 vs.7.7%,n = 52;p = 0.000).There were 19 patients(24.4%)in the control group and 3 patients(3.6%)in the postural drainage group occurred recurrence attack of acute cholangitis(24.4%,n = 78 vs.3.6%,n = 84;p = 0.000).The 40-and 80-month cumulative right posteroinferior bile duct stone recurrence rates were 4% and 46%,respectively,in the control group,and 0% and 7.7% respectively,in the postural drainage group(P = 0.021).Conclusions:1.In patients with complicated hepatolithiasis,hypertrophied perihilar liver may induce stenosis of the hilar bile duct or biliary-enteric anastomosis.The stricture of hilar bile duct can be relieved by perihilar hepatectomy.Perihilar hepatectomy is a safe and effective operation to decrease the recurrence of bile duct stone.Accurate plann ing for the range of hypertrophied perihilar liver requires further research.2.When the ratio of perihepatic hilar hepatic volume to total hepatic volume in patients with hepatolithiasis is greater than 36.17%,it is easier to occur that the hilar bile duct or biliary-enteric anastomosis is compressed by hypertrophied perihilar liver.This value can be used as an indicator to predict the perihilar bile duct is compressed by hypertrophied perihilar liver,because the compression of the hilar bile duct is affected by the space of the first hilum and the direction of the protrusion of hypertrophied perihilar liver.3.The hyperplasia of Sg Ⅳ and/or Ⅴ,Ⅷ may induce the angulation of right posteroinferior bile duct.The hyperplasia of Sg Ⅳ and/or Ⅴ,Ⅷ and angle of right posteroinferior bile duct becoming small may promote the formation of gallstone in right posteroinferior bile duct.When the angle of the right posteroinferior bile duct is less than 44.58°,it is easier to form gallstone in right posteroinferior bile duct.4.Conventional operation including segmental hepatectomy combined with postoperative postural drainage can effectively reduce the recurrence rate of postoperative cholangitis and bile duct stone in patients with hepatolithiasis accompanied by angulation of the right posteroinferior bile duct. |
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