Multimodal Treatment of Intrahepatic Stones

Kim, Dong Heon

Abstract

The management of intrahepatic stones is very difficult and troublesome because of the high incidence of residual stones and complications. A retrospective study was undertaken to evaluate the results of multimodal treatment for 50 patients with intrahepatic stones who had been treated at the Department of Surgery, Pusan National University Hospital from March 1992 to February 1996. The results obtained are as follows: 1) The incidence of the intrahepatic-stones in the 413 gallstone patients was 12.1% (50 cases). The mean age of intrahepatic stone patients was 50.8 years old, and the ratio of males to females was 1.17:1. Of these 50 cases of intrahepatic stones, 23 cases involved the left hepatic duct, 7 cases the right hepatic duct, and 20 cases both ducts. 2) The most frequent drainage procedure was an end to side hepaticocutaneous jejunostomy (28 cases, 56.0%). This include 8 cases involving a combination of surgeries with hepatic resections. The other major treatment modality was a hepatic resection (16 cases, 32.0%). After the initial operations, the overall incidence of residual stones was 28.0%. The treatment by hepatic resection had the lowest incidence of residual stones, 2 cases (12.5%) of 16 patients. In the 20 cases involving a hepaticocutaneous jejunostomy, 5 (25.0%) had residual stones. Among the 5 choledocoduodenostomies, 2 patients (40.0%) had residual stones. Among the 5 transduodenal sphincteroplasties 2 patients (40.0%) had residual stones. For the 4 cases of other operations, 3 had residual stones (75.0%). 3) Of the 14 cases with residual stones, 11 cases underwent an additional lithotomy: 7 cases of a percutaneoustranshepatic cholangiographic lithotomy (PTC-L), and 4 cases of a choledochoscopic lithotomy through an anchored subcutaneous jejunal limb (Endo-L). All the PTC-Ls were successful. However, two Endo-Ls failed, and these patients were later successfully treated with a PTC-L. In conclusion, the data showed a high incidence of intrahepatic stones in gallstone patients. For the treatment of intrahepatic stones, hepatic resections seemed to be the best choice, showing the lowest incidence of residual stones. For the drainage procedure, the hepaticocutaneous jejunostomy seemed to be the best choice for the following reasons: the ease of performing the frequently required lithotomy using a choledochoscope after the initial operation, and the ease of intervening in case of complications during a PTC-L.