Reappraisal of the Systematic Management of Complicated Hepatolithiasis With Bilateral Intrahepatic Biliary Strictures

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Abstract
Objective: To compare the results, limitations, and complications of the surgical treatment of bilateral hepatolithiasis and intrahepatic biliary strictures with left hepatectomy and without left hepatectomy. Design: Case-controlled study. Setting: Referral center. Patients: During a 12-year period, 103 patients with bilateral hepatolithiasis and intrahepatic biliary strictures underwent surgical treatment. Group A (n=73) received left hepatic resection (lateral segmentectomy or lobectomy) and postoperative biliary dilatation with residual stone extraction. Group B (n=30) underwent the same procedures except for left hepatectomy. Interventions: Left lateral segmentectomy or left lobectomy, choledocholithotomy, postoperative cholangioscopic treatments (electrohydraulic lithotripsy, other lithotripsy, lithotomy, balloon dilatation, etc, via T tube or percutaneous transhepatic route). Main Outcome Measures: Days of hospitalization, incidence of major and minor complications, mortality rates, and the rates of residual stones and stone recurrence were compared. Results: Groups A and B had similarly low postoperative 1-month mortality rates of 5.5% and 6.7%, respectively. The main cause of death in both groups was uncontrollable septicemia. The main major complications in group A were intra-abdominal abscess and upper gastrointestinal bleeding; the major complication in group B was massive hemobilia. Group B had a significantly higher overall rate of complications (53.3% vs 23.3%, P<.01) and a longer hospital stay than group A (median, 72 days vs 28 days, P<.03). When complications were classified as major or minor, only minor complications showed a significant difference (30% vs 13.7%, P=.05). After using biliary stricture dilatation and stone extraction, the rate of residual stones in the right lobe was similar in both groups, but patients in group B had a significantly higher rate of residual stones (12.5% vs 0%, P<.02) and stone recurrence in the left lobe (19% vs 0%, P<.003) than those in group A. Conclusions: Partial resection of the left lobe in cases of bilateral hepatolithiasis and biliary strictures can effectively simplify problems in the treatment of bilateral hepatolithiasis and intrahepatic biliary strictures. In addition, not only were surgical complications not increased, but a decrease in complications from postoperative manipulations for stone clearance was noted in our series. (Arch Surg. 1996;131:141-147)

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