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KMID : 0371319680100060387
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Journal of the Korean Surgical Society
1968 Volume.10 No. 6 p.387 ~ p.399
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Clinical and Roentgenological Peculiarity of the Intrahepatic Stone
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許景渤/Hur, K. B.
金昇薰/朴基一/孫宇鍾/金光洙/閔珖植/崔炳肅/Kim, S. H./Park, K. I./Soh, W. J./Kim, K. S./Min, K. S./Choi, B. S.
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Abstract
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A biliary calculus may be found in the intrahepatic biliary duct, and yet its clinical symptomatology has not been thoroughly studied, for a rearity of such patients and its radiological findings and surgical treatments are similarly not been well studied.
However, it is suggested by many surgeons that an incidence of the intrahepatic calculi imay be high in orientals as well in Korean gall stone patients.
For the last nine and a half years 68 cases of the intrahepatic calculi were encoutered among the 283 cases of the gall stone patients seen at the Dept. of Surgery Yonsei University Medicl College, and its clinical incidence, symptomatology, radiological manifestation, and results of surgical experiences were reviewed and analysed.
Incidence of the intrahepatic calculi to the all gall stone patients is about 24% and majority of them(86.8%) are associated with gall bladder or common bile duct calculi and only 13.2% are considered pure primary intrahepatic calculi.
Peak incdence was noted at the 4th decade and youngest patient was 17 years old and oldest patient was 74 years old.
There were no specific symptom complex which is particularly characteristic of the intrahepatic calculi.
Of the 68 patients, X-ray films are available only in 50 cases. Preoperative radiological studies including G.B. series, I.V. cholangiograms, Upper G.I. series and the others did not help to confirm the presence of the intrahepatic calculi but in sporadic cases X-ray signs of positive biliary pathology such as air in the biliary tree were occasionally noted. On the operative cholangiograms and the follow up postoperative cholangiograms, radiolucent stone shadow were noted 46-62% of the cases reviewed.
Stenosis and dilatation of the intrahepatic biliary duct were noted in 68-92% and poor visualization of the peripheral hepatic duct was noted in 50-80% of the 50 cases studied. This findings are due to a stone blocking further filling of the peripheral intrhepatic biliary duct during the cholangiography studies.
The so called cut off sign that is similarly produced by presence of an intrahepatic calculi, is noted in 4-14% of the cases.
From these radiological findings it may be suggested that if any of the above mentioned radiological findings are observed a strong possibility of the intrahepatic calculi would be considered and a matter of fact patient better be treated as case of intrahe-patic calculi. Typical X-ray findings of four intrahepatic calculi patient are illustrated together with gross appearance of the intrahepatic calculi. The total number of surgical porcedures were 242. The most common procedure was choledochostomy and this was done 70 times and cholecystectomy was done 52 times. Roux-en-Y choledocho-jejunostomy was done in 27 patients either as a primary procedure of the intrahepatic calculi or as a secondary procedure for the recurrency.
One left hepatic lobectomy and one Longmire´s procedure were also done for the recurrent cases.
The period of observation was devided into two in order to compare a recurrent rate and a policy of the surgical treatment. First period of early 5 years, 25 cases were observed and at the primary surgery 22 cases had non-by-pass procedure but cholecystectomy, choledochostomy or trans-duodenal sphincterotomy. Of the 22 patients. 18 cases(81.8%) had recurrency.
At second period of later 5 years 22 out of 43 had non-by-pass procedure and 16 recurred(71.2%) contrary 21 out of 43(48.8%) had by-pass procedure and only 4 cases had recurrency. It is estimatied that recurrent rate of pain or of residual calculi after non-by-pass procedure is over 70%.
Through-out the first and second period of observation each recurrent rate is 72% in the first period and 46.5% in the 2nd period. This marked reduction of the recurrency may be contributed by the fact that 48.8% of entire cases at the 2nd period were undergone by the By-pass pass procedure.
It is reamrkable, however, that 4 patients or 19% of total by-pass-procedures had recurrency after the Roux-enY choledocho-jejunostomy. These all four patients similarly had long standing history of the biliary symptoms usually over 30 years and they also had stenosis and dilatation in the intrahepatic biliary tree and one required the Longmire´s operation.
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