Original Article / Liver
Operative treatment for patients with cholelithiasis and liver cirrhosis Qing Xu, Lei Gu and Zhi-Yong Wu Shanghai, China
BACKGROUND: Liver cirrhosis and cholelithiasis are both familiar diseases in China. However, the rates of operative complications and death are still high in patients with these diseases. This study was designed to determine the operative indications as well as suitable procedures in the treatment of patients with cholelithiasis and liver cirrhosis. METHODS: We studied retrospectively 60 patients with cholelithiasis and liver cirrhosis who had undergone operation from January 2000 to July 2006. We analyzed the loss of blood during operation, postoperative complications and death rate to determine the proper treatment. RESULTS: Fifty patients were cured and 10 (16.7%) died postoperatively, i.e., six patients died from hepatic-renal failure and multisystem organ dysfunction and 4 from massive bleeding in the gallbladder bed. The 10 patients were clearly correlated with the Child-Pugh classification: Child A (8%), Child B (20%) and Child C (30%). Postoperative bleeding occurred in 10 patients (16.7%), intraabdominal in 6 and gastrointestinal in 4. Seven of the 10 patients with bleeding died postoperatively. CONCLUSIONS: The proper perioperative management of patients with cholelithiasis and liver cirrhosis can decrease the mortality. Cholelithiasis should be managed first by emergency operation. It is safe for the patients of Child A to undergo laparoscopy. It is very safe for patients with cirrhosis and cholelithiasis to undergo devascularization and shunt operation followed by biliary tract surgery. (Hepatobiliary Pancreat Dis Int 2007; 6: 479-482)
KEY WORDS: cholelithiasis; liver cirrhosis; portal hypertension; operation; bleeding; operative indications
Introduction
T
here are about 100 million hepatitis B virus (HBV) carriers in China, 20% of whom may develop liver cirrhosis. Cirrhosis patients have doubled the morbidity from cholelithiasis compared with non-cirrhosis patients.[1] Liver cirrhosis and cholelithiasis are both common diseases in China. Liver cirrhosis contributes significantly to complications and mortality in bile duct surgery. The patient suffering from liver cirrhosis and cholelithiasis faces the potential danger of abdominal and gastrointestinal bleeding after abdominal operations.[2] It is very challenging for surgeons to operate on patients suffering from cholelithiasis with liver cirrhosis. Arguments over operative indications and modality have been going on for many years, because they are highly related to the mortality and risk of patients. Yet there is still no standard treatment for such patients. In this study, we tried to define it from our experience and lessons from 60 patients.
Methods Author Affiliations: Department of General Surgery, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200127, China (Xu Q, Gu L and Wu ZY) Corresponding Author: Zhi-Yong Wu, MD, Department of General Surgery, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200127, China (Tel: 86-21-68383732; Fax: 86-21-58394262; Email:
[email protected]) © 2007, Hepatobiliary Pancreat Dis Int. All rights reserved.
Sixty cholelithiasis patients with portal hypertension (32 males and 28 females) aged from 30 to 86 years (mean 55) were treated from January 2000 to July 2006 in our hospital. All of them had undergone operation; 44 patients were operated upon for gallbladder stones and 16 for gallbladder and common bile duct (CBD) stones. Fifty-seven patients received elective operation, and the remaining emergency operation. Cirrhosis was confirmed by identification of
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pathogens, clinical manifestations, laboratory examinations, imaging findings, exploratory operations, and pathological findings. The Child-Pugh classification showed Child A in 25 patients, Child B in 25 and Child C in 10. In 30 patients, cholelithiasis was detected, and in the rest, portal hypertension (PHT).
Results In this group, 50 patients were cured, and 10 (16.7%) died postoperatively from hepatic-renal failure (6) and multisystem organ dysfunction or from massive bleeding of the gallbladder bed (4). The 10 patients were markedly correlated with the Child-Pugh classification: Child A (8%), Child B (20%) and Child C (30%). Twenty-one patients (35%) had bleeding >1000 ml during operation (primary diagnosis of PHT in 17 patients, cholelithiasis in 4). Postoperative bleeding occurred in 10 patients (16.7%), and all had PHT: Child A in 3 patients, Child B in 5 and Child C in 2. They included 6 patients with intra-abdominal bleeding and 4 patients with gastrointestinal bleeding. The 6 patients with intraabdominal bleeding showed the involvement of the gallbladder bed in 5 patients (4 died) and the pancreatic tail artery in 1. The 4 patients with gastrointestinal bleeding had hematemesis in 3 patients (all died) and hematochezia in (1) (Table).
Table. Operations & postoperative bleeding Intra-abdominal Gastrointestinal bleeding bleeding
Operation
n
Cholecystectomy Laparoscopic cholecystectomy Cholecystectomy+ drainage of CBD Devascularization+ cholecystectomy Devascularization+ cholecystectomy+ drainage of CBD Devascularization and shunt+cholecystectomy
16 1 (1)* 2 0
0 0
11 0
1 (1)*
17 4 (2)*
2 (1)*
1 0
0
9 0
0
* 1 1 (1)
1 (1)*
Devascularization and shunt+cholecystectomy+ drainage of CBD
1 0 Cholecystectomy+ drainage of CBD after devascularization and shunt 3 months later *: numbers in brackets indicate deaths.
0
Discussion In recent years, cirrhotic patients have proved to be at a high risk of cholelithiasis, especially pigment stones. The incidence of cholelithiasis with cirrhosis is about 29%,[3-5] but 67.2% in China.[6] Patients with PHT have different grades of hepatic injury, hypoalbuminemia and deficient coagulation. Despite reduction of ascites by abdominal operation, postoperative infection, anesthesia and surgical injury can lead to failure of hepatic function, multisystem organ dysfunction, and even death. Consequently, the death rate of PHT patients after cholecystectomy is ten times that of normal patients.[7-9] Obviously the death rate is correlated with hepatic function. The rate, which is clearly related to the Child-Pugh classification, was 16.7% in this group of patients. The death rates with liver function of Child A, B and C were 8%, 20% and 30%, respectively. When hepatic function is impaired, operation and anesthesia can give rise to hepatic failure, bleeding and infection more easily. These complications pose some problems in clinical treatment of the disease, including the establishment of operative indications and modalities. Hence we divided the patients into two groups according to the primary diagnosis of cholelithiasis or PHT. In the patients who had a primary diagnosis of cholelithiasis, we did not deal with PHT in principle. In the patients who had a primary diagnosis of PHT, the choice was puzzling. Operation by steps may double the risk, and a single operation may lead to a disaster. In our practice, the choice of operation depends on the severity and complexity of cholelithiasis. If the symptoms of cholelithiasis are mild, especially when difficulty of operation exists, operation is feasible for PHT. But, postoperative follow-up is necessary to decide whether to deal with the cholelithiasis. For patients with emergency cholelithiasis, conservative treatment is reasonable. Otherwise, simple methods such as cholecystostomy can be used to decrease operative bleeding and injury to the liver. In case of complex biliary tract operation for cholecystolithiasis with cholangiolithiasis and intraand extra-hepatic stones, with mild lithiasis but severe PHT, PHT should be managed with a shunt operation to depress the portal vein pressure. After the patient recovered from the operation, another operation for cholelithiasis was performed. Obstructive jaundice is treated by drainage of the biliary tract. Percutaneous transhepatic cholangial drainage is the first choice of treatment, because of varicose hemorrhage induced by
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Operative treatment for patients with cholelithiasis and liver cirrhosis
endoscopy. Devascularization and shunt operation are very effective to decrease the portal pressure after disappearance of the jaundice. Afterward the operation for lithiasis is more effective. A 51-yearold male patient in our study developed PHT because of endoscopic retrograde cholangiopancreatography and endoscopic nasobiliary drainage for relieving cholelithiasis and obstructive jaundice at another hospital. We dealt with the obstruction of the biliary tract through percutaneous transhepatic cholangial drainage, followed by selective devascularization and shunt operation two weeks after the disappearance of jaundice. Three months after cholecystojejunostomy, there was no obvious variation around the bile duct. The patient recovered uneventually and was discharged 14 days after operation. In spite of this case, operations by steps force the patient to face the high risks of anesthesia, surgery, bleeding and infection, which may lead to hepatic failure. In patients with cholelithiasis and PHT of Child C, liver transplantation is the only way.[10] During the operation, massive bleeding of the biliary tract with cirrhosis is a hard nut to crack.[11] Xu reported that the rate of bleeding >1000 ml is about 30.8%.[12] In this study it was 35%. That liver cirrhosis and atrophy tilt the gallbladder bed upward, rightward and backward is the possible reason for bleeding, making the exposure of the gallbladder difficult. Liver cirrhosis impairs the synthesis of clotting factors, but can reduce the probability of massive bleeding during operation. The vessel plexuses and any suspicious vessels should be ligated or coagulated. A bistoury should be shifted to the low or middle gear. Injection of octreotide or vasopressin with nitroglycerin can depress the pressure in the portal vein during operation. A low of central venous pressure (5 cmH2O) is also helpful to control bleeding. We should not pursue speedy and massive dissection in biliary tract operation. Appropriate techniques are selected, according to the local anatomy, such as retrograde cholecystectomy and cholecystostomy. This kind of gallbladder is considered as a "difficult gallbladder", and subtotal cholecystectomy is used.[13, 14] The frequent injury and bleeding are located at the gallbladder triangle, which is close to the liver. Bleeding is difficult to control in spite of electrocoagulation or ligation. Presumably, the high resistance in the liver and the adverse current of blood flow cause bleeding in the pinhole. Thus, it is feasible to leave the gallbladder wall on the bed in the original position after management of the gallbladder
duct, and then to cauterize its mucosa. In case of uncontrollable bleeding, gauze tamping is decidedly significant. Otherwise, repeated hemostasis increases the time of operation and the volume of bleeding, thus leading to hepatic failure. It is safe for patients with liver cirrhosis of Child A and B to undergo laparoscopic cholecystectomy, but the low pressure of the pneumoperitoneum is necessary.[15-20] Two patients who underwent laparoscopic cholecystectomy in this study also recovered favorably with no complications. When slicing off the CBD, the incision should be small. Bleeding still exists after operation. In this study, the 6 patients died from hepatic failure caused by intra-abdominal or gastrointestinal bleeding. Fresh frozen plasma, platelet concentrate and cryoprecipitate can postoperatively correct the deficiency of the coagulation mechanism. In case of definite active intra-abdominal bleeding after operation, immediate measures for hemostasis should be taken. The risk of fundus of the stomach and esophageal varicose hemorrhage increases after abdominal surgery.[21] This is likely due to acute liver swelling caused by stress and volume expansion in the operation. This kind of bleeding is mostly treated conservatively. The fatality from varicose hemorrhage should be evaluated before operation by wedged hepatic venous pressure (WHVP), endoscopy and abdominal CT. The patients who have high risk of bleeding should take transjugular intrahepatic portosystemic shunts (TIPS) before operation and undergo ligation of the coronary artery and vein. In case of postoperative varicose hemorrhage, octreotide or vasopressin is used as early as possible in addition to other measures. The bleeding of PHT after biliary tract operation is troublesome, and it is risky to perform PHT surgery after another operation. Hence it is necessary to take TIPS after failure of drug or endoscopic treatment. Using correct operative indications, better opportunity, and reasonable modality or techniques, we can improve the curative effect and prognosis in patients with cholelithiasis and liver cirrhosis. Funding: None. Ethical approval: Not needed. Contributors: XQ proposed the study and wrote the first draft. GL analyzed the data. All authors contributed to the design and interpretation of the study and to further drafts. WZY is the guarantor. Competing interest: No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
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