Strategies of minimally invasive treatment for intrahepatic and extrahepatic bile duct stones

Abstract

Cholelithiasis is a kind of common and multiple diseases. In recent years, traditional laparotomy has been challenged by a minimally invasive surgery. Through literature review, the therapeutic method, effect, and complications of minimally invasive treatment of intrahepatic and extrahepatic bile duct stones by combining our practical experience were summarized as follows. (1) For intrahepatic bile duct stones, the operation may be selected by laparoscopic liver resection, laparoscopic common bile duct exploration (LCBDE), or percutaneous transhepatic cholangioscopy. (2) For concomitant gallstones and common bile duct stones, the surgical approach can be selected as follows: laparoscopic cholecystectomy (LC) combined with endoscopic sphincterotomy (EST) or endoscopic papillary balloon dilatation, LC plus laparoscopic transcystic common bile duct exploration, LC plus LCBDE, and T-tube drainage or primary suture. (3) For concomitant intrahepatic and extrahepatic bile duct stones, laparoscopic liver resection, choledochoscopy through the hepatic duct orifice on the hepatectomy cross section, LCBDE, EST, and percutaneous transhepatic cholangioscopic lithotripsy could be used. According to the abovementioned principle, the minimally invasive treatment approach combined with the surgical technique and equipment condition will be significant in improving the therapeutic effect and avoiding the postoperative complications or hidden dangers of intrahepatic and extrahepatic bile duct stones.

Keywords

laparoscopy / choledochoscopy / duodenoscopy / cholelithiasis / minimally invasive treatment

Introduction

Cholelithiasis is a kind of common and multiple diseases, mainly including gallstone, common bile duct (CBD), and intrahepatic bile duct (IBD) stone. The incidence of simple gallstone is 7%–10%. Choledocholithiasis is found in approximately 10%–15% of patients with cholelithiasis [1]. Hepatolithiasis, the disease with additional patients and further complications, has remained one of the key issues of biliary surgery despite the relative incidence decreasing significantly in terms of absolute number and has become one of the main causes of death of benign biliary disease in China. The traditional method of treating cholelithiasis is open surgery. In recent years, the traditional laparotomy has been challenged by minimally invasive surgery (MIS) with the rapid development of endoscopic techniques and MIS annually, and an increasing number of MISs is used to treat cholelithiasis [2–8]. However, the principle of minimally invasive treatment is nonstandardized, and the indication is nonuniform. This paper aims to summarize the current situation of minimally invasive treatment of cholelithiasis to explore a strategy for further improving the curative effects.

Hepatolithiasis

Laparoscopic hepatectomy (LH)

Hepatolithiasis characterized by the formation of stones in the IBDs is a common disease in East Asia and is prevalent in China, and patients are presented with repeated attacks of acute cholangitis. The surgical approaches of hepatolithiasis are different because of the division of the stone lesions, the number of the affected bile ducts, the damage of the liver parenchyma, and the different stages and complications of the disease.

The therapeutic principle of hepatolithiasis with “resecting the lesions, removing the stones, relieving the stricture, and retaining the drainage” is advocated by Prof. Huang ZQ [9]. The treatment of hepatolithiasis demands completely eliminating the IBD stones and preventing recurrent stones. Hepatectomy is advantageous because it removes the portion of the liver that contains the IBD stones and the diseased ducts, which has a high stone clearance rate and a low long-term stone recurrence rate [10]. Yang et al. reported that the immediate stone clearance rates after bilateral and unilateral hepatectomy were 81.5% and 65.9%, respectively; additional postoperative choledochoscopic lithotripsy increased the clearance rates to 85.2% and 81.7%, respectively [11].

Previously, the main treatment approach for hepatolithiasis was open hepatectomy (OH) with bile duct exploration and calculus removal. In recent years, LH has been used to treat hepatolithiasis in selected patients [2]. Compared with OH, LH has no significant difference in the operation time, intraoperative blood loss, intraoperative stone clearance rate, postoperative complication rate, and postoperative hospital stay. In addition, LH has the advantages of less pain, smaller scars, faster recovery, and less postoperative adhesions for hepatolithiasis within the left lateral lobes and even the left- or right-side IBD stones [4,5]. Ding et al. suggested that LH is superior to OH for hepatolithiasis within the left lateral lobes in terms of blood loss and hospital stay and in terms of short-term outcomes [4]. However, LH presents unique technical challenges not only to the potential risks of inadequate stone clearance, bile leakage, postoperative sepsis, iatrogenic bile duct injury, gas embolism, and massive hemorrhage but also to the potential difficulty with dense perihepatic adhesions caused by repeat chronic cholangitis.

Currently, the indications of LH for IBD stones include the following: (1) the unilateral IBD stones; (2) the irreversible unilateral disease (biliary strictures or severe parenchymal fibrosis or atrophy); (3) liver function of Child A to B classification; (4) the extensive IBD stones confined to semi-liver with the good compensation in another semi-liver; and (5) no biliary strictures within the remnant liver or extrahepatic bile duct, no acute suppurative cholangitis, no requirement for bilioplasty or bilioenteric anastomosis, and no history of the biliary operation, such as exploring the CBD [2].

The contraindications of LH for hepatolithiasis include the following: (1) the extensive IBD stones beyond semi-liver; (2) the hilar bile duct stricture; (3) the unilateral IBD stones, with other stones located in grade III or over of another hepatic duct, which cannot be removed by choledochoscopy; (4) the complicated IBD stones with history of biliary operations; and (5) complicated with portal hypertension [2].

LH for the patients with hepatolithiasis has been from the initial laparoscopic left lateral segmentectomy to the late laparoscopic minor hepatic resections (wedge resections, segmentectomy, and bisegmentectomy) [12] and gradually extended to the present laparoscopic left hemihepatectomy, laparoscopic right hemihepatectomy, and laparoscopic right posterior segmentectomy with improving the laparoscopic technique and developing a hemostatic device.

The principal indications, efficacy, and complications of MIS for IBDS are listed in Table 1. LH, as the surgical procedure for treating hepatolithiasis, should be performed with laparoscopic anatomical hepatectomy, which is the key point for achieving excellent efficacy and reducing residual stones and recurrence.

Laparoscopic common bile duct exploration (LCBDE)

The development of MIS over the last two decades has had a great impact on surgical practice worldwide. LCBDE has been one of the main treatment methods for CBD stones, with the wide application of laparoscopic surgery in biliary diseases [13–15]. The technique for stone removal in the CBD could be applied to IBD stones [13].

The indication of LCBDE for hepatolithiasis is the IBD stones without IBD stricture, and the stone is located over the proximal portion of the IBD, such as the left and/or right hepatic duct or partial grade II and/or III branch of hepatic duct [16–19].

LCBDE is performed via a laparoscopically created longitudinal choledochotomy. Intraoperative choledochoscopy is an indispensable treatment measure of LCBDE for hepatolithiasis. In general, the choledochoscopy enters the grade II branches of the hepatic duct. In the IBD dilatation, the choledochoscopy can enter grade III or over branches of the hepatic duct, thus not only visualizing and removing the stones via a basket but also accurately determining the IBD stricture and its extent and effectively reducing the incidence of postoperative complications and residual stones. However, the laparoscopic IBD stone removal is difficult, leading to the residual stone rate of 2%–87.3% [1]. Therefore, the T-tube should be selectively placed according to the requirement of the disease to obtain the residual stones removed conveniently via T-tube sinus. The postoperative residual stones can be removed through choledochoscopy provided that the IBD stricture is not obvious, even a mild IBD stricture; the stones can also be extracted using a basket through expanding choledochoscopy.

Percutaneous transhepatic cholangioscopy (PTCS)

PTCS is an option for treating hepatolithiasis without surgical resection, particularly useful to the IBD stones, which cannot be approached in a retrograde manner [20]. When conventional endoscopic techniques fail to remove IBD and/or CBD stones, PTCS may be considered a promising alternative tool to surgery [21].

PTCS is a minimally invasive method based on the percutaneous transhepatic biliary drainage. The cholangioscopy is used to treat IBD stones by expanding the sinus gradually. This method has the advantages of being minimally invasive, simple, effective, and easy to repeat. The indications of PTCS for hepatolithiasis are as follows: (1) old and weak patients, unsuitable or unwilling to accept traditional surgery, (2) the grade I and/or II branches of the hepatic duct blocked by the IBD stones, and (3) the complicated IBD stones with the history of multiple operations.

The principal indications, efficacy, and complications of PTCS for hepatolithiasis are listed in Table 1. The PTCS procedure has a relatively extensive operation time, usually between two and three weeks, with multiple expanding sheath sizes, leading to the potential for bleeding, biliary fistula, biliary tract infection, and peritonitis [20]. Currently, a shortfall of evidence emerges regarding PTCS in treating the difficult IBD stones [21].

Cholecystolithiasis and choledocholithiasis

Laparoscopic cholecystectomy (LC) + endoscopic sphincterotomy (EST) or endoscopic papillary balloon dilatation (EPBD)

For concomitant cholecystolithiasis and choledocholithiasis, achieving an ideal efficacy through a single treatment by laparoscopy or duodenoscopy is difficult. The combined application of laparoscopy and duodenoscopy for LC plus EST or EPBD by exploiting both treatment methods [26], will bring revolutionary changes in minimally invasive treatment for patients with gallbladder and CBD stones, compensating for the limitation of the single treatment.

The indication of LC+ EST/EPBD for concomitant gallstones and CBD stones is the CBD is not dilatated (diameter<8 mm), the diameter of CBD stones is no more than 8 mm, and the number of stones is less than five [27]. If the diameter of the CBD stones is 8–15 mm, and the number of stones is less than five, then EST should be selected; if the diameter of the stones is less than 8 mm, and the number of stones is less than three, EPBD can be selected [28]. If the shape of the CBD stone is elongated even if the length of stones >15 mm, then the stones can be extracted by EST by adjusting the position angle of stones. Based on EST, the removal of various shapes of CBD stones with the diameter >15 mm is possible through the mechanical lithotripsy, electrohydraulic lithotripsy, laser lithotripsy, and other methods under the skilled ERCP operating technology of an endoscopic doctor. However, the large CBD stones cannot be removed, and Mirizzi syndrome and periampullary diverticulum are unsuitable for EST or EPBD in principle.

Three approaches to performing LC+ EST/EPBD and LC with preoperative, intraoperative, or postoperative EST/EPBD, which procedure is ideal, are still controversial [29,30]. The intraoperative EST/EPBD should theoretically be an ideal surgical procedure because of the completion of LC and EST/EPBD simultaneously; this technique was first proposed in 1998 with the key operation as follows: during LC, a guide wire is inserted through the cystic duct into the CBD, advanced into the duodenum where it is endoscopically gripped and retrieved through the mouth, and then the EST/EPBD and stone extraction is completed with the standard ERCP techniques; finally, LC, which is the endolaparoscopic “rendezvous” described by Cavinaet al., is completed [31]. However, this procedure does not only add the difficulty of LC because of bowel distension but also increase the difficulty of the duodenal papilla intubation because of the supine position and therefore has not been widely promoted [32].

The EST/EPBD performed before LC has the advantage of (1) ERCP used before LC can provide a complete bile duct imaging to detect the possible presence of bile duct variation and reduce the intraoperative bile duct injury, making LC safe; (2) EST or EPBD can easily remove small stones of the distal CBD, which is more convenient than the intraoperative application of choledochoscopy for removing the stones; (3) EST or EPBD can diagnose and treat the duodenal papilla lesions, such as stricture and diverticulum; (4) after EST or EPBD, even the small stones in the gallbladder are drained into the CBD and are also easy from the CBD into the intestinal lumen, avoiding reoperation; (5) if EST or EPBD lithotomy failed, then the ENBD will be placed on reducing the probability of the occurrence of postoperative bile leakage and cholangitis to create an opportunity for further LCBDE with primary closure [28].

For the timeframe before the LC, the EST or EPBD should be performed without consensus. The interval between LC and EST or EPBD should be reduced extensively to avoid the small stones in the gallbladder to be drained into the CBD before LC. In general, a short LC interval is superior, if no serious complications of EST or EPBD usually selected within three days. The combined LC with EST or EPBD simultaneously is an ideal choice, with the advantages of completing operation at once, reducing the pain of patients, hospital stay, and overall medical expenses. However, this technique has limitations, such as the obvious bowel distension influencing LC operation and the requirement to set the radiological, endoscopic, and laparoscopic equipment in one operating room only in large-scale hospitals [33].

LC+ laparoscopic transcystic common bile duct exploration (LTCBDE)

The LC combined with LTCBDE is a procedure for exploring and removing CBD stones via the transcystic route during LC. This procedure is a MIS not only to retain the integrity of the CBD but also to avoid the recurrence of CBD stones induced by the changes of biliary tract hydromechanics. The operation can avoid the bile leakage caused by the opened CBD and the possible complications induced by the T-tube drainage, reduce the risk of CBD stricture and stone recurrence caused by CBD suture, and shorten the hospital stay and recovery time. The major advantage of this operation is solving the gallstones and CBD stones simultaneously without laparotomy and no incision in CBD. The inadequacies of this operation are subject to the anatomical factors of the cystic duct, CBD stone factors, and depend significantly on the skill of choledochoscopy, with the high technical requirements of the operator, especially exploring the branches of the hepatic duct. Moreover, the common hepatic duct is difficult; thus, the significant differences of the application and the success rate of this operation were reported at home and abroad [34,35].

The cystic duct, as the channel of choledochoscopic exploration and stone removal, must meet the following conditions: (1) the cystic duct is dissected clear, (2) the dilated cystic duct can undergo choledochoscopy, and (3) the size of the CBD stones can be removed through the cystic duct. Recently, LTCBDE was reported to be mainly suitable for patients without CBD dilatation (diameter<8 mm), the diameter of CBD stones<6 mm, and the number of stones<3 [36].

LC+ LCBDE with T-tube

The LC plus LCBDE with T-tube is considered the first choice of minimally invasive treatment of gallstones and CBD stones for patients with CBD dilatation. The advantage of this operation is that the concomitant gallstones and CBD stones can be solved simultaneously, can be used for the large CBD stones because of the large open space in the CBD than in the duodenal papilla, and reduced restrictions on the number of stones [37]. The limitations of this operation include destroying the integrity of the CBD, T-tube requires being placed, and the far-term risk of the CBD stricture and stone recurrence caused by the CBD suture, especially in patients without CBD dilatation. Some complications, such as bile leakage, hemobilia, cholangitis, and electrolyte disturbance, induced by the T-tube drainage may occur. The interference of the laparoscopic operation on abdominal organs is relatively mild, delaying the T-tube sinus formation, thus causing the extension of T-tube drainage time, which requires postoperative indwelling T-tube for approximately six weeks.

The LC+ LCBDE with T-tube drainage are suitable for the dilatated CBD (diameter > 0.8 cm) in principle to avoid the postoperative CBD stricture [27]. If serious inflammation and thickened wall occur in the CBD, then LCBDE will be difficult because of the complicated operation, extensive operation time, easy to cause postoperative biliary stricture, bile leakage, and other complications requiring considerable attention [38].

LC+ LCBDE with primary closure

The LC plus LCBDE with primary closure can be performed by using 4-0 or 5-0 Prolene or absorbable suture, intermittent, or continuous suturing, with the advantage of avoiding the hidden trouble of the T-tube drainage, fast recovery, and less pain. Recently, this operation is reported to be safe, feasible, and advantageous for the minimally invasive treatment of the CBD stones [39]. However, the necessity and indication of the CBD primary suture have been the focus and the popular issue at home and abroad because of the risk of postoperative bile leakage, abdominal infection, reoperation, and even threaten the life of the patients.

It is feasible to perform a primary suture of the CBD for the following conditions: CBD dilatation (diameter > 8 mm), complete removal of CBD stones confirmed by choledochoscopy, mild cholangitis, the normal function of Oddi’s sphincter, and the proximal CBD patency and no stenosis [39]. For safety, some scholars believe that the diameter of CBD should be >10 mm to facilitate the CBD incision and suture, otherwise can easily lead to the CBD stricture [40]. If the CBD is nondilatated (diameter<8 mm), then the CBD stones are minimal and in sandy shape, unable to accurately judge whether a residual stone exists by choledochoscopy or with suppurative cholangitis, which should not be treated with CBD primary closure in principle [39]. In the preoperative ENBD or intraoperative placement of biliary stent drainage, the risk of postoperative bile leakage will be reduced, indicating that the CBD primary suture may be appropriately relaxed.

Compared with the T-tube drainage, the advantages of LCBDE with primary suture include the hospitalization time is significantly shortened, no occurrence of T-tube-related complications, conducive to maintaining the water–electrolyte balance and enteral nutrition absorption, can avoid the pain of postoperative patients with T-tube, and can avoid the possible bile leakage after the T-tube is pulled out. Compared with LTCBDE, LCBDE with primary suture is not limited by the diameter of the cystic duct and the number of CBD stones, and the indication of LCBDE is increased significantly. Compared with EST, the indication of LCBDE is widened significantly, no damage of the anatomical and physiological function of Oddi’s sphincter, and no possible reflux cholangitis.

The principal indications, efficacy, and complications of MIS for concomitant gallbladder and CBD stones are listed in Table 2.

Intrahepatic and extrahepatic bile duct stones

LH+ EST or EPBD

For the patients with intrahepatic and extrahepatic bile duct stones, complicated by IBD stricture and even liver fibrosis or atrophy, if the extrahepatic bile duct stones are small (diameter<15 mm), then these stones can be considered for LH plus EST or EPBD.

In principle, LH combined with EST or EPBD must be according to the abovementioned indications of LH and EST or EPBD for intrahepatic and extrahepatic bile duct stones [50,51].

LH+ lithotomy via the bile duct orifice of hepatic cross section

For the abovementioned LH plus EST or EPBD patients, if EST fails based on LH in addition to the LCBDE and stone removal simultaneously, then the choledochoscopy can be used via the bile duct orifice of hepatic cross section to explore the IBD and CBD, extract the stones using a basket, and then close the bile duct orifice [52].

However, for patients with intrahepatic and extrahepatic bile duct stones who require laparoscopic liver resection, the large extrahepatic bile duct stones (diameter >15 mm) should be treated with laparoscopic liver resection plus CBD exploration and T-tube drainage or primary suture, which is unsuitable for the abovementioned procedure via the bile duct orifice of hepatic cross section.

LCBDE, lithotripsy, and stone removal

For the patients with intrahepatic and extrahepatic bile duct stones without IBD stricture, the LTCBDE and LCBDE with T-tube drainage or primary suture can be selected according to the aforementioned principle of size, quantity, and diameter of the CBD stones.

The combined application of laparoscopy, duodenoscopy, and choledochoscopy, namely, the combined three endoscopes, can obtain satisfactory efficacy to improve the success rate of stone removal and reduce the incidence of residual stones [53–55].

For the stone with a diameter equal to or larger than 20 mm, the extraction through the conventional lithotomy instrument is difficult when the impacted stone, cast stone, or stone peripheral and its distal spaces are narrow and small. Therefore, laparoscopy combined with FREDDY laser lithotripsy can be considered.

Percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) + EST

For the patients suffering from complicated intrahepatic and extrahepatic bile duct stones with liver fibrosis or atrophy, the small extrahepatic bile duct stones (diameter<15 mm) can be considered for PTCS plus EST or EPBD. The indication of EST and EPBD is consistent with the aforementioned situation.

Based on PTCS, PTCSL has been developed through a certain improvement to effectively enhance the minimally invasive treatment of complicated intrahepatic and extrahepatic bile duct stones. Compared with the conventional PTCS, PTCSL has the merits of minimal invasiveness, a short operation time, and less intraoperative blood loss, because of an optimized operation channel establishment and a short time period [24]. The rigid choledochoscope and pneumatic lithotripsy in treating hepatolithiasis under the guidance of 3-D visualization technology have recently achieved a digital minimally invasive treatment of hepatolithiasis, which may provide a new approach to the complicated hepatolithiasis and choledocholithiasis [56].

The principal indications, efficacy, and complications of MIS for concomitant IBDS with CBDS are listed in Table 3.

Conclusions

In summary, cholelithiasis is a kind of common and multiple diseases. Traditional open surgery has been challenged by the MIS. Based on the distribution of intrahepatic and extrahepatic bile duct stones, the existence of IBD stenosis, combined liver fibrosis or atrophy, bile duct dilatation, size and number of CBD stones, function of Oddi’s sphincter, and other factors, the strategies of the reasonably selected minimally invasive treatment approach, combined with the surgical technique and equipment condition, will be significant in improving the therapeutic effect and avoiding the postoperative complications or hidden dangers of intrahepatic and extrahepatic bile duct stones.

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