Fan Wen-Juan, Zou Xiao-Jing
Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China.
Emergency Department/Intensive Care Unit, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China.
World J Gastrointest Surg. 2022 Apr 27;14(4):341-351. doi: 10.4240/wjgs.v14.i4.341.
Despite being a benign disease, hepatolithiasis has a poor prognosis because of its intractable nature and frequent recurrence. Nonsurgical treatment is associated with high incidences of residual and recurrent stones. Consequently, surgery hepatic lobectomy or segmental hepatectomy has become the main treatment modality. Clinical management and resolution of complicated hepatolithiasis with bilateral or diffuse intrahepatic stones remain very difficult and challenging. Repeated cholangitis and calculous obstruction may result in secondary biliary cirrhosis, a limiting factor in the treatment of hepatolithiasis.
A 53-year-old woman with a 5-year history of intermittent abdominal pain and fever was admitted to the hepatopancreatobiliary surgery department following worsening symptoms over a 3-d period. Blood tests revealed elevated transaminases, alkaline phosphatase, γ-glutamyl transpeptidase, and total bilirubin, as well as anemia. Magnetic resonance cholangiopancreatography showed dilatation of the intrahepatic, left and right hepatic, common hepatic, and common bile ducts, and multiple short T2 signals in the intrahepatic and common bile ducts. Abdominal computed tomography showed splenomegaly and splenic varices. The diagnosis was bilateral hepatolithiasis and choledocholithiasis with cholangitis. Surgical treatment included hepatectomy of segments II and III, cholangioplasty, left hepaticolithotomy, second biliary duct exploration, choledocholithotomy, T-tube drainage, and accretion lysis. Surgical and pathological findings confirmed secondary biliary cirrhosis. Liver-protective therapy and anti-infectives were administered. The patient developed liver and respiratory failure, severe abdominal infection, and septicemia. Eventually, her family elected to discontinue treatment.
Liver transplantation, rather than hepatectomy, might be a treatment option for complicated bilateral hepatolithiasis with secondary liver cirrhosis.
尽管肝内胆管结石是一种良性疾病，但因其难治性和频繁复发，预后较差。非手术治疗与残留结石和复发结石的高发生率相关。因此，手术（肝叶切除术或肝段切除术）已成为主要的治疗方式。对于伴有双侧或弥漫性肝内结石的复杂性肝内胆管结石，其临床管理和解决仍然非常困难且具有挑战性。反复的胆管炎和结石梗阻可能导致继发性胆汁性肝硬化，这是肝内胆管结石治疗的一个限制因素。
一名53岁女性，有5年间歇性腹痛和发热病史，在症状持续3天加重后入住肝胆胰外科。血液检查显示转氨酶、碱性磷酸酶、γ-谷氨酰转肽酶和总胆红素升高，以及贫血。磁共振胆胰管造影显示肝内、左右肝、肝总管和胆总管扩张，肝内胆管和胆总管内有多个短T2信号。腹部计算机断层扫描显示脾肿大和脾静脉曲张。诊断为双侧肝内胆管结石、胆总管结石伴胆管炎。手术治疗包括肝Ⅱ、Ⅲ段切除术、胆管成形术、左肝内胆管切开取石术、二次胆管探查术、胆总管切开取石术、T管引流术和粘连松解术。手术和病理结果证实为继发性胆汁性肝硬化。给予保肝治疗和抗感染治疗。患者出现肝和呼吸衰竭、严重腹部感染和败血症。最终，其家属选择停止治疗。
对于伴有继发性肝硬化的复杂性双侧肝内胆管结石，肝移植而非肝叶切除术可能是一种治疗选择。
