Published online Mar 28, 2015. doi: 10.3748/wjg.v21.i12.3564
Peer-review started: September 21, 2014
First decision: October 29, 2014
Revised: November 24, 2014
Accepted: January 16, 2015
Article in press: January 16, 2015
Published online: March 28, 2015
Processing time: 191 Days and 17.2 Hours
AIM: To evaluate the feasibility of hepatectomy and primary closure of common bile duct for intrahepatic and extrahepatic calculi.
METHODS: From January 2008 to May 2013, anatomic hepatectomy followed by biliary tract exploration without biliary drainage (non-drainage group) was performed in 43 patients with intrahepatic and extrahepatic calculi. After hepatectomy, flexible choledochoscopy was used to extract residual stones and observe the intrahepatic bile duct and common bile duct (CBD) for determination of biliary stricture and dilatation. Function of the sphincter of Oddi was determined by manometry of the CBD. Primary closure of the CBD without T-tube drainage or bilioenteric anastomosis was performed when there was no biliary stricture or sphincter of Oddi dysfunction. Dexamethasone and anisodamine were intravenously injected 2-3 d after surgery to prevent postoperative retrograde infection due to intraoperative bile duct irrigation, and to maintain relaxation of the sphincter of Oddi, respectively. During the same period, anatomic hepatectomy followed by biliary tract exploration with biliary drainage (drainage group) was performed in 48 patients as the control group. Postoperative complications and hospital stay were compared between the two groups.
RESULTS: There was no operative mortality in either group of patients. Compared to intrahepatic and extrabiliary drainage, hepatectomy with primary closure of the CBD (non-drainage) did not increase the incidence of complications, including residual stones, bile leakage, pancreatitis and cholangitis (P > 0.05). Postoperative hospital stay and costs were nevertheless significantly less in the non-drainage group than in the drainage group. The median postoperative hospital stay was shorter in the non-drainage group than in the drainage group (11.2 ± 2.8 d vs 15.4 ± 2.1 d, P = 0.000). The average postoperative cost of treatment was lower in the non-drainage group than in the drainage group (29325.6 ± 5668.2 yuan vs 32933.3 ± 6235.1 yuan, P = 0.005).
CONCLUSION: Hepatectomy followed by choledochoendoscopic stone extraction without biliary drainage is a safe and effective treatment of hepatolithiasis combined with choledocholithiasis.
Core tip: We performed hepatectomy with primary closure of the common bile duct for hepatolithiasis combined with choledocholithiasis. Postoperative complications including residual stones, bile leakage, pancreatitis and cholangitis were equivalent in the drainage and non-drainage groups. Postoperative hospital stay and costs were nevertheless significantly less in the non-drainage than in the drainage group. Additional biliary drainage is not necessary for all patients with intrahepatic and extrahepatic calculi, thus avoiding unnecessary discomfort and extra costs. Anatomic hepatectomy followed by intraoperative choledochoendoscopic stone extraction without biliary drainage in selected patients is a safe and effective treatment.