title: Management of intrahepatic stones: the role of subcutaneous hepaticojejunal access loop. A prospective cohort study.
abstract: BACKGROUND
  Patients with intrahepatic stones usually present with recurrent cholangitis, biliary sepsis and intrahepatic abscesses, may develop liver atrophy and may progress to cholangiocarcinoma. Treatment of intrahepatic stones is difficult and the disease progresses in most patients even after adequate treatment. Surgical removal of stones has been the standard management but residual stones and stone recurrence occur frequently whatever the technique. Because of the need for repeated biliary instrumentation, long-term access routes involving percutaneous transhepatic cholangioscopic lithotripsy (PTCSL), hepaticocutaneousjejunostomy (HCJ) and subparietal hepaticojejunal access loop to permit stone retrieval or stricture dilatation have been developed.
  
  
  OBJECTIVE
  The aim of this work was to evaluate the outcome of subcutaneous hepaticojejunal access loop in the management of intrahepatic stones.
  
  
  METHODS
  Between January 2009 and January 2013, 42 patients with intrahepatic stones underwent surgical treatment at the Gastrointestinal Surgery Unit, Main Alexandria University Hospital. Demographic data, details of operative findings, follow up details, and treatment of recurrent stones were analyzed. After approval of local ethics committee, all patients included in the study were informed well about the procedure and an informed written consent was obtained from every patient before carrying the procedure.
  
  
  RESULTS
  Forty-two patients (17 males and 25 females) with intrahepatic stones underwent surgery with construction of a subcutaneous hepaticojejunal access loop. Stones were confined to the left lobe in 25 patients, the right lobe in 3 patients and bilobar in 14 patients. Associated extrahepatic stones were found in 33 patients. Twenty-two patients had associated intrahepatic duct strictures. Five patients with atrophy of segments II and III underwent hepatic resection at the time of access loop formation. The mean operation time was 4.9 h and mean blood loss was 440 mL. Mean postoperative hospital stay was 10 days. Wound infection was the commonest complication, occurring in 5 (12%) patients. There were no specific complications attributable to the construction of the access loop. The subcutaneous access loop was used to gain access to the biliary tree in 28 patients with residual or recurrent stones. A total of 55 procedures (range 1-5) were attempted with successful access achieved in all cases and successful stone clearance in 21 of the 28 patients, and all of them were symptom free for at least 12 months after the last procedure. Partial stone clearance was achieved in the remaining seven patients. These seven patients had different degrees of biliary strictures.
  
  
  CONCLUSIONS
  The subcutaneous access loop offers the advantage of permanent access for the successful management of retained or re-formed intrahepatic stones with minimal morbidity since it permitted easy access to intrahepatic ducts using the conventional forward-viewing endoscope or the choledochoscope, without the additional morbidity of a biliary-cutaneous fistula or transhepatic access.
authors: Department of Surgery, Faculty of Medicine, University of Alexandria, Egypt.
authors: Mohamed I
authors: MI
authors: Kassem
authors: Department of Surgery, Faculty of Medicine, University of Alexandria, Egypt. Electronic address: magdysorour@hotmail.com.
authors: Magdy A
authors: MA
authors: Sorour
authors: Department of Surgery, Faculty of Medicine, University of Alexandria, Egypt.
authors: Abdel-Hamid A
authors: AH
authors: Ghazal
authors: Department of Surgery, Faculty of Medicine, University of Alexandria, Egypt.
authors: Hany M
authors: HM
authors: El-Haddad
authors: Department of Surgery, Faculty of Medicine, University of Alexandria, Egypt.
authors: Mohamed T
authors: MT
authors: El-Riwini
authors: Department of Surgery, Faculty of Medicine, University of Alexandria, Egypt.
authors: Hassan A
authors: HA
authors: El-Bahrawy
mesh_terms: D000328:Adult; D000368:Aged; D000713:Anastomosis, Roux-en-Y / Q000379:methods*; D001649:Bile Duct Diseases / Q000601:surgery*; D001653:Bile Ducts, Intrahepatic; D015331:Cohort Studies; D016145:Endoscopy, Digestive System / Q000379:methods; D005260:Female; D042882:Gallstones / Q000601:surgery*; D006500:Hepatic Duct, Common / Q000601:surgery*; D006801:Humans; D007583:Jejunum / Q000601:surgery*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D016896:Treatment Outcome
keywords: Hepaticojejunostomy; Intrahepatic stones; Subcutaneous jejunal access loop