Sỏi trong gan: dịch tễ, chỉ định và kết quả phẫu thuật

Nghieân cöùu Y hoïc<br /> <br /> Y Hoïc TP. Hoà Chí Minh * Taäp 8 * Phuï baûn cuûa Soá 1 * 2004<br /> <br /> 62 SOÛI TRONG GAN: DÒCH TEÃ, CHÆ ÑÒNH VAØ KEÁT QUAÛ PHAÃU THUAÄT<br /> Vaên Taàn*, Nguyeãn Cao Cöông*, Hoaøng Danh Taán*<br /> <br /> TOÙM TAÉT<br /> Ñaët vaán ñeà: Soûi trong gan thöôøng gaëp ôû caùc nöôùc chaâu AÙ, laø moät beänh khoù ñieàu trò, coù theå gaây bieán chöùng<br /> vaø töû vong cao. ÔÛ nöôùc ta, nhieàu nghieân cöùu veà soûi trong gan ñaõ ñöôïc baùo caùo, ñaëc bieät laø ôû mieàn Baéc.<br /> Muïc tieâu vaø phöông phaùp: nghieân cöùu hoài cöùu taát caû caùc tröôøng hôïp bò soûi trong gan ñeán ñieàu trò taïi beänh<br /> vieän Bình Daân töø ñaàu naêm 1995 ñeán heát thaùng 9/2002. Taát caû caùc beänh aùn ñeàu ñöôïc phaân tích ñeå tìm nhöõng<br /> ñaëc ñieåm veà: Dòch teã, Chæ ñònh ñieàu trò,, Phaãu thuaät vaø keát quaû.<br /> Keát quaû: Coù 989 tröôøng hôïp bò soûi trong gan ñeán ñieàu trò taïi beänh vieän Bình Daân trong gaàn 8 naêm (19959/2002). Tæ leä nam/nöõ: 0.55, tuoåi trung bình ôû nam: 41 vaø ôû nöõ: 50. 60% töø caùc tænh ñeán ñieàu trò vaø ña soá laø<br /> ngöôøi lao ñoäng chaân tay. Vieâm ñöôøng maät laø lyù do nhaäp vieän cuûa haàu heát tröôøng hôïp. Nhaäp vieän trong beänh<br /> caûnh caáp cöùu: 30%, soác nhieãm truøng ñöôøng maät: 2%. Tieàn caên moå soûi maät ít nhaát moät laàn: 27.5% Sieâu aâm cho<br /> thaáy soûi trong gan traùi chieám moät tæ leä khaù cao vaø phaàn lôùn keøm theâm soûi oáng maät chuû. Soûi oáng maät chuû laø lyù do<br /> ñieàu trò chính cho ña soá tröôøng hôïp. Haàu heát caùc tröôøng hôïp ñöôïc chæ ñònh phaãu thuaät do soûi gaây taéc maät ngoaøi<br /> gan vaø nhieãm truøng. 67.36% tröôøng hôïp ñöôïc moå hôû vaø 95% tröôøng hôïp doïc ÑM chính laáy soûi. Caùc phaãu thuaät<br /> laáy soûi phoái hôïp nhö xeû nhu moâ gan (9.45%) vaø caét gan (24%) ñaõ ñöôïc öùng duïng thöôøng quy khi soûi khoâng theå<br /> laáy heát ñöôïc qua xeû ÑM chính. Xeû gan, ngoaøi vieäc laáy soûi coøn nong choã heïp, taïo hình choã daõn cuûa ñöôøng maät<br /> trong gan. Caét gan thöïc hieän ña soá laø gan traùi, qua maët caét coù theå laáy soûi trong gan coøn laïi. Ñeå phoøng ngöøa soûi<br /> khoâng laáy ñöôïc hay taùi phaùt coù theå di chuyeån laøm ngheït ñöôøng maät, noái maät-ruoät (10%) hay taïo hình cô voøng<br /> Oddi (5%) cuõng ñaõ ñöôïc thöïc hieän ôû nhöõng tröôøng hôïp coù chæ ñònh. ÔÛ nhöõng tröôøng hôïp naøy, tuùi maät ñöôïc caét<br /> boû. Keát quaû cho thaáy 50% soûi trong gan ñöôïc laáy saïch, ñöôøng maät thoâng suoát ngay töø laàn moå ñaàu. Bieán chöùng<br /> phaãu thuaät laø 20.3% (86/423) vaø töû vong phaãu thuaät laø 2.13% (9/423). Trong theo doõi, 26% caùc tröôøng hôïp phaûi<br /> nhaäp vieän laïi vì vieâm ñöôøng maät, ña soá do soûi chöa laáy heát hay taùi phaùt ñaõ di chuyeån, laøm ngheït maät vaø 2/3<br /> trong soá treân phaûi can thieäp phaãu thuaät hôû.<br /> Baøn luaän vaø Keát luaän: Soûi trong gan coøn laø moät beänh phöùc taïp cuûa chuùng ta, ngay caû khi coù nhöõng<br /> phöông tieän ñieàu trò hieän ñaïi. Phoøng ngöøa khoâng cho soûi hình thaønh hay taùi phaùt trong gan vaø ñieàu trò tröø caên<br /> laø nhöõng vaán ñeà maø chuùng ta caàn nghieân cöùu.<br /> <br /> SUMMARY<br /> INTRAHEPATIC STONES (IHS): EPIDEMIOLOGY, SURGICAL INDICATIONS AND<br /> RESULTS<br /> Van Tan, Nguyen Cao Cuong, Hoang Danh Tan * Y Hoc TP. Ho Chi Minh * Vol. 8 * Supplement of<br /> No 1 * 2004: 412 - 419<br /> <br /> ABSTRACT<br /> Background: IHS are a special pathology of the Asian countries. The etiologies and the mechanism of<br /> stone formation are not the same as in the extrahepatic stones (EHS). Deformation of the IHBD are often seen.<br /> Bile stasis and infections might be 2 predipose factors. The radical treatment is difficult and the prevention of<br /> the recurrence is still a challenge.<br /> Purpose: We study the IHS for the aims of researching: The patients characteristics, The Indications of<br /> <br /> 412<br /> <br /> Chuyeân ñeà Hoäi nghò Khoa hoïc Kyõ thuaät BV. Bình Daân 2004<br /> <br /> Y Hoïc TP. Hoà Chí Minh * Taäp 8 * Phuï baûn cuûa Soá 1 * 2004<br /> <br /> Nghieân cöùu Y hoïc<br /> <br /> treatment, The Surgical procedures and the Results.<br /> Material and Method: Retrospectively, we analyse the chart of the IHS patients treated at Binh Dan<br /> Hospital from 1995 to 2002. In this period, there are 989 cases of IHS admitted and treated in our hospital.<br /> Results: The male/female ratio is 1.83 and the middle age is 46 for the male and 48 for the female. 60% of<br /> the patients came from the provinces and almost were farmers. Majority of them admitted with a clinical<br /> picture of cholangitis that 30% in urgent state, 1.5% in septic shock, 20.32% having had at least one operation<br /> for biliary stones in their past history. Different preoperative complications (11.3%), such as liver abscesses,<br /> localized atrophic liver, acute pancreatitis, biliary peritonitis, septic shock, hemobilia are noted. On operation,<br /> we found 77% of patients that the stones are in the left liver. 64% has had associated EHS; 58.44%, multiple<br /> alternant dilatation-stenosis of the intrahepatic bile duct (IHBD); 7.88%, liver cirrhosis; 2.52%, biliary liver<br /> abscesses; 1.41%, round worm in the BD; 1.11%, BD carcinoma; 2%, other liver lesions. Majority of stones are<br /> brown pigment type. The surgical treatment is indicated in 61% of patients. Almost of the surgical procedures<br /> are removal of stones through a CBD incision (86.75%). Hepatotomies (4.5%), partial hepatectomies (16%) or<br /> a lithotripsy (12%) were applied to clear the stones in special and complicated cases. A biliary-intestinal<br /> anastomosis or a sphinteroplasty (7.2%) are also performed for preventing cholangitis due to CBD obstruction<br /> by emigrated stones. In 26.33% of choledochotomy is closed without drainage. As results of surgical treatment,<br /> in 51% of patients, the IHBD are free of stones and of stenosis. Complications and deads in surgical cases are<br /> 15.23% and 2.13%. In the middle and long term follow-up, 26% of patients readmitted by cholangitis due to<br /> residual or recurrent stones that 2/3 of them must be reoperated.<br /> Discussion and Conclusion: IHS are still a difficult disease to treat even with the advanced techniques.<br /> Radical treatment for clearing the IHS and for repairing the intrahepatic BD defect can prevent the recurrent<br /> stones and their consequences.<br /> IHS, a disease of BD system usually met in Viet<br /> Nam. Their incidence varied from 15% to 50% of the<br /> biliary stones according to the region(43,44). The<br /> etiology and the pathogenesis are unclear(1,2,3,4,5,6,7,8,9),<br /> but bile stasis and infections due to deformation of<br /> the IHBD might be 2 important factors. Almost<br /> stones found are brown pigment type. The radical<br /> treatment is difficult relating to clear the stones from<br /> the BD system, to detect the residual stones and to<br /> prevent their recurrence(20,21,22,23). There aren’t<br /> consent for therapeutic indications, conservative or<br /> invasive techniques(17,24,58). In the recent years, for the<br /> invasive techniques, minimally invasive surgery was<br /> applied and had a big improvement but conventional<br /> surgery is still needed(35,36,40,41,42 43, 44,45,46).<br /> PURPOSE: The study is aiming to find:<br /> - The epidemiology, the hepatobiliary lesions<br /> related to the stones and the clinical characteristics.<br /> <br /> - The therapeutic indications and the surgical<br /> treatment results.<br /> From these standpoints, we can recommand a<br /> standard treatment.<br /> <br /> MATERIALS AND METHOD<br /> It is a retrospective study of all patients having<br /> IHS treated at Binh Dan Hospital from 1995 to<br /> September 2002 in analysing the details illustrated in<br /> the charts of patients about the epidemiology, the<br /> clinical, the lab data, the hepatobiliary lesions, the<br /> therapeutic indications and the results. In this period,<br /> there are 989 patients of IHS in 14.835 patients having<br /> BD stones (15%) admitted and treated in our hospital.<br /> A choledochotomy is performed through a median<br /> supraumbilical laparotomy for BD exploration and for<br /> removing the stones. For controlling and clearing the<br /> residual stones, we use at first the finger then the<br /> instruments. If the stones can’t be removed, a C-arm<br /> <br /> Chuyeân ñeà Hoäi nghò Khoa hoïc Kyõ thuaät BV. Bình Daân 2004<br /> <br /> 413<br /> <br /> Nghieân cöùu Y hoïc<br /> <br /> Y Hoïc TP. Hoà Chí Minh * Taäp 8 * Phuï baûn cuûa Soá 1 * 2004<br /> <br /> cholangiography, an IOUS, a choledoscope with a<br /> lithotriptor probe can be used for pulverisating the big<br /> and incarcerated stones before removing them by<br /> dormia basket and by irrigating. An ERCP-ES, a<br /> hepatotomy, a hepatectomy or a hepato-hepatectomy<br /> are also needed in special cases. In the postoperative<br /> period, we remove the residual, the retained and the<br /> recurrent stones either by ERCP, through the T tube<br /> tunnel or percutaneously through a new fistulae toward<br /> the dilatated BD by a puncture needle with progressive<br /> dilatation directed by an IOUS.<br /> <br /> RESULTS<br /> There are 35.5% male and 64.5% female that the<br /> middle age is 46 for male and 48 for female. Majority<br /> of them are sea fishmen and farmers that 40% living<br /> in Ho chi minh city, 60% in the South and the Center<br /> of Viet Nam.<br /> 90% of patients have had episodic epigastric pain<br /> or even acute cholangitis (30%) and septic shock<br /> (1.5%). A prehistory of biliary surgery were found in<br /> 198 cases (21%) that 62 at other hospital and 136 at<br /> Binh Dan hospital.<br /> There are only 1/3 of patients having pure IHS.<br /> Association of EHS is frequent.<br /> Pure IHS:<br /> <br /> 36.6%, IHS + EHS:<br /> <br /> 63.4%<br /> <br /> A half of IHS found in the left liver<br /> <br /> Table 3<br /> Other lesions of BD and liver<br /> BD cancer<br /> GB cancer<br /> HCC<br /> Liver hemangioma<br /> Acute hepatitis<br /> IHBD cysts (fig 8)<br /> Macrocopic liver cirrhosis<br /> BD round worm<br /> <br /> Cases<br /> 5<br /> 1<br /> 5<br /> 8<br /> 2<br /> 3<br /> 22<br /> 9<br /> <br /> The complications related to BD stones on<br /> admission are found in 106 patients (11.3%)<br /> Table 4a<br /> Complications<br /> Liver abscesses<br /> Acute pancreatitis<br /> Necrotizing, hemorrhagic<br /> pancreatitis<br /> Chronic pancreatitis<br /> Septic schock<br /> Bile peritonitis, necrotic GB<br /> Obstruction of BD<br /> Stenosis of biliary-digestive<br /> stoma 3<br /> Hemobilia<br /> <br /> Cases<br /> 30<br /> 15<br /> 3<br /> 3<br /> 20<br /> 7<br /> 22<br /> <br /> %<br /> 3<br /> 1.5<br /> <br /> 2<br /> 1<br /> 2.3<br /> <br /> 3<br /> <br /> A bile culture for 55 cases, there are 59 bacteries<br /> found. All of them are sensible to 3rd generation<br /> cephalosporine and aminoglycoside.<br /> Table 4b<br /> <br /> Table 1<br /> Sites of IHS/US<br /> Right<br /> Left<br /> Bilateral IHS<br /> <br /> %<br /> 18%<br /> 50%<br /> <br /> IHS<br /> IHS<br /> 32%<br /> <br /> Multiple intrahepatic bile duct (IHBD) and liver<br /> lesions are observed<br /> Table 2<br /> IHBD-Liver disorders<br /> IHBD dilatation+stenosis<br /> IHBD dilatation<br /> Liver abscesses<br /> Liver cirrhosis<br /> (HBsAg(+)11%)<br /> Segmental liver cirrhosis<br /> <br /> 414<br /> <br /> The other BD and liver lesions are also found in<br /> 55 patients (5.6%)<br /> <br /> Rate<br /> 66%<br /> 9%<br /> 3%<br /> 10%<br /> <br /> Cases<br /> 653 (fig 4)<br /> 89 (fig 5)<br /> 30 (fig 6)<br /> 98<br /> <br /> 2%<br /> <br /> 15 (fig 7)<br /> <br /> Bacteries<br /> E Coli<br /> Enterobacter<br /> Proteus<br /> Klebsiella<br /> Pseudomonas<br /> Strept A hemolyis<br /> <br /> N<br /> 20<br /> 12<br /> 11<br /> 3<br /> 2<br /> 1<br /> <br /> ATB Sensibilities<br /> Cepha 3, Aminosides<br /> same<br /> same<br /> same<br /> Aminosides, Quinolone<br /> Cepha 3<br /> <br /> Other concommitent diseases found in 36 cases<br /> (3.5%).<br /> Table 5<br /> Associated diseases<br /> Gastroduodenal ulcer or gastritis<br /> Diabetes mellitus<br /> Hyperthyroid and Grave’s diseases<br /> Duodenal diverticula<br /> <br /> Cases<br /> 16<br /> 6<br /> 3<br /> 2<br /> <br /> Chuyeân ñeà Hoäi nghò Khoa hoïc Kyõ thuaät BV. Bình Daân 2004<br /> <br /> Y Hoïc TP. Hoà Chí Minh * Taäp 8 * Phuï baûn cuûa Soá 1 * 2004<br /> Associated diseases<br /> Colon carcinoma<br /> Splenomegaly<br /> Heart diseases<br /> <br /> Cases<br /> 2<br /> 1<br /> 6<br /> <br /> According to the distribution, the number, the<br /> size, the nature of stones and the lesions of the BD<br /> and the liver, we have different therapeutic<br /> procedures either single or associated<br /> Table 6<br /> Therapeutic procedures<br /> Conservative treatment: (small stones,<br /> asymptomatic, very high risk non<br /> emergency patients)<br /> ERCP for removing EHS and IHS<br /> Laparotomy for removing biliary stones by<br /> different procedures<br /> <br /> Cases<br /> 267<br /> <br /> %<br /> 27<br /> <br /> 59<br /> 663<br /> <br /> 6<br /> 67<br /> <br /> In 663 cases of invasive procedures (conventional<br /> surgery), choledochotomy in 94%, hepatectomy 22%,<br /> hepatotomy 8.5%<br /> Table 7<br /> Procedures<br /> Choledochotomy<br /> Hepatotomy<br /> Hepatectomy<br /> (Hepato- hepatectomy)<br /> Biliodigestive anastomosis<br /> Sphincteroplasty<br /> Cholecystectomy<br /> <br /> Cases<br /> 623<br /> 43<br /> 146<br /> 26<br /> 90<br /> 44<br /> 107<br /> <br /> Rate<br /> 94<br /> 8.5<br /> 22<br /> 4<br /> 10<br /> 5<br /> 17<br /> <br /> Surgical results: After the 1st operation, the<br /> retained and residual IHS is 49.6% that 28% due to<br /> biliary decompression in emergency, 19% due to deep<br /> location and small size stones, especially in the right<br /> liver, 3%, really residual stones.<br /> Except the asymptomatic small stones, the<br /> majority of the remaining cases underwent a radical<br /> cure within a month.<br /> There are 19% of postoperative complications in<br /> which wound infections, bile fistula and post ERCPES cholangitis are usually met. For the other<br /> complications as liver failure, respiration problems,<br /> coagulation defect, renal failure, intraabdominal<br /> infections are found in emergency cases (126/663).<br /> <br /> Nghieân cöùu Y hoïc<br /> <br /> Table 8<br /> -<br /> <br /> Complications<br /> Wound infection<br /> Bile fistula<br /> Post ERCP-ES Cholangitis<br /> Liver failure<br /> Respiratory problems<br /> Coagulation disorder<br /> Renal failure<br /> Peritonitis, residual abscesses<br /> Incisional dehiscence and hernia<br /> <br /> Cases<br /> 39<br /> 25<br /> 16<br /> 12<br /> 9<br /> 8<br /> 8<br /> 6<br /> 3<br /> <br /> %<br /> 6<br /> 4<br /> 2.4<br /> 1.8<br /> <br /> All the bacteries found in the infected wound are<br /> similar to the bacteries of the bile culture and sensible<br /> to the same antibiotics.<br /> 17 cases (1.72%) died in hospital, almost in the<br /> group of patients having complications before<br /> operations or having one or more concommittant<br /> diseases that 3 (0.92%) in the group of conservative<br /> treatment, 14 (2.1%) in the group of invasive<br /> treatment: 13 conventional surgery for the recurrent<br /> cases, 1 ERCP-ES. The causes of death.<br /> Table 9<br /> Death causes<br /> - Septic shock<br /> - Liver failure<br /> - Respiratory failure<br /> - Cerebral vascular accident<br /> <br /> Cases<br /> 9<br /> 5<br /> 2<br /> 1<br /> <br /> Almost of the patients are followed up from 1 to 5<br /> years. The middle and long term results are:<br /> recurrent stones with cholangitis, readmitted after<br /> the 1st radical cure in 26% (257 cases) and 17.5%<br /> (172/ 257 cases) must be reoperated at least 1 time<br /> since 1995, 8.3% (84/257 cases) conservative<br /> treatment (no surgical indications or not consent to<br /> operate).<br /> <br /> DISCUSSION<br /> IHS are usually found in Viet Nam, that appear<br /> mostly as brown pigment stones (calcium<br /> bilirubinate) but contain more cholesterol in<br /> composition, like in japanese study(5,15). In Viet Nam,<br /> the incidence of IHS varied from region to region. A<br /> statistic study from 1955 to 1999 on 4862 patients<br /> bearing biliary stones admitted at Binh Dan Hospital,<br /> <br /> Chuyeân ñeà Hoäi nghò Khoa hoïc Kyõ thuaät BV. Bình Daân 2004<br /> <br /> 415<br /> <br /> Nghieân cöùu Y hoïc<br /> <br /> Y Hoïc TP. Hoà Chí Minh * Taäp 8 * Phuï baûn cuûa Soá 1 * 2004<br /> <br /> South of Viet Nam, the incidence of IHS is 13%(44)<br /> with 4.5% pure IHS and 8.5.% associated IHS and<br /> EHS. Another study of Viet-Duc Hospital, North of<br /> Viet Nam in the period from 1976 to 1996 with 5390<br /> patients having biliary stones, that incidence is 55%:<br /> pure IHS: 10%, IHS+EHS: 45%(43).<br /> The rate male/female is 0.55; that rate is higher<br /> than the rate of biliary stones in general (0.25). Male<br /> middle age is younger than female: 46/48.<br /> The clinical and pathologic characteristics, 21%<br /> had a history of biliary operation at least one time, so<br /> the IHS recur frequently. The rate of associated IHS<br /> and EHS is 63.4%, that is very high. No body knows<br /> the IHS or the EHS is primary stone. The IHS are<br /> found mostly in the left liver:<br /> Left liver stones (50%) > bilateral stones (32%)<br /> > Right liver stones (18%).<br /> There are 66% of associated dilatation and<br /> stenosis of IHBD. That rate is higher than the other<br /> studies in the foreign countries(20,21,22,23,24). It is the<br /> main cause of high recurrence of our IHS.<br /> The preoperative complications are high (10.6%),<br /> especially due to bile stasis and infection that the<br /> aerobic(11,44) and anaerobic bacteries(12), even the H.<br /> pylori are found(13,14); that rate is higher than the<br /> other studies in the foreign countries(17,19), it’s<br /> possible that patients coming to hospital lately. They<br /> relate closely to the postoperative complications and<br /> mortality rate: 19% and 1.72%.<br /> The concommittent hepatobiliary disorders is<br /> 5.6%, that may be the cause-effect of biliary stones.<br /> The main liver lesions are abscesses, liver atrophy<br /> and chronic hepatitis. In long standing IHS patients,<br /> some cases have had cholangiocarcinoma, especially<br /> for the patients which have brown pigment stone(56).<br /> The incidence of viral hepatitis (HBsAg + in 11%) is<br /> the same as in the normal population of our country.<br /> In the results of surgical treatment, there is high<br /> rate of retained and residual stones (50%) and<br /> complications (19%) after the 1st operations. For<br /> reducing this rate, the patients must be operated soon<br /> <br /> 416<br /> <br /> before having complications and the advanced<br /> techniques must be applied as cholangiography,<br /> IOUS, intra-operative endoscopic lithotripsy,<br /> dilatation-stenting of BD and ERCP for detecting and<br /> clearing the IHS then repairing the IHBD defects.<br /> The rate of reccurrent stones in our study in<br /> middle and long term follow up is 26% for the elective<br /> cases, like in other studies (30%). With advanced<br /> techniques as endoscopy(25,26,27), percutaneous<br /> endoscopic lithotripsy(28,29,30,31,32), associated extra and<br /> intrahepatic lithotripsy(33,34,35,36) or a cutaneous<br /> hepaticojejunostomy(37,38,39,40,41,42) with one or two<br /> subcutaneous loop, opened in the subcostal area for<br /> removing the retained, residual and recurrent stones,<br /> the rate of radical cure may increase. A hepatectomy,<br /> a hepatotomy or a hepato-hepatectomy are performed<br /> in cases of stones can’t be cleared by any of the above<br /> procedures, especially when the lesions of the BD and<br /> liver area dvanced and localized(43,44,45,46,47,48,49,50,57,58).<br /> For the associated disorders of the IHBD as<br /> cystic, neoplatic, a radical hepatectomy must be<br /> carried out(53,54), For IHBD cholangiocarcinoma, even<br /> a large hepatectomy is applied, the long term<br /> outcome depends on the localized or the diffuse<br /> lesions(55,56,57).<br /> Though many techniques are used, the residual<br /> and recurrent stones after operations in our study are<br /> still high (9% and 26%). The biliary tract and the liver<br /> are more and more damaged until hepatic failure<br /> either by stones and infections or by repeated<br /> invasive techniques. The succeding operations are<br /> more and more difficults and more and more<br /> complicated(51,52).<br /> For recommandations, we propose an allogorith<br /> of therapeutic indications:<br /> 1- For the cases of pure IHS, especially,<br /> asymptomatic small stones (