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Background: Intrahepatic stones are very uncommon in Western societies. In comparison, hepatolithiasis occurs more frequently in Southeast Asia because of the high prevalence of congenital biliary cysts and hepatobiliary parasites. Many Asian patients present with advanced disease which is usually managed with left hepatectomy. In North America both the underlying biliary pathology and the timing of presentation differ, but management has not been standardized, in part, because of the rarity of the disease. This analysis documents the etiology, presentation and outcomes of a transhepatic team approach for management of hepatolithiasis at a Western referral center.
Methods: The records of patients with hepatolithiasis managed by interventional radiologists (IR) and surgeons from 2002 through 2012 were reviewed. Surgery was undertaken when required to repair the biliary pathology and/or when the stone burden was extensive. All but one patient were managed with 20F transhepatic stent(s) placed either percutaneously or during surgery. Choledochoscopy was performed in almost all patients either percutaneously or intraoperatively to assist with stone removal. Laser lithotripsy and balloon dilation were undertaken for difficult stones and strictures. Transhepatic stents were removed when patients were stone and stricture free. A successful outcome was defined as stent removal without symptoms requiring more procedures.
Results: Seventy-four patients were managed by IR alone (66%) or by IR and surgery (34%). The mean age was 55.6 years, and 51.4% were women. The majority of patients were Caucasian (80%), and only five (7%) were Asian. Underlying biliary pathology included benign strictures (55%), choledocholithiasis (22%), sclerosing cholangitis (12%), choledochal cysts (10%), and biliary parasites (1%). Twenty patients (27%) had biliary cirrhosis, and 17 of these patients developed hepatolithiasis after undergoing orthotopic liver transplantation. Fifteen additional patients (20%) had a prior biliary-enteric anastomosis. Upper abdominal pain (65%), cholangitis (47%) and jaundice (34%) were the most common presenting symptoms. The median number of IR procedures was 11, and choledochoscopy (88%) laser lithotripsy (68%) and balloon dilation (47%) were performed frequently. Surgical management included cholangio- or hepatico-jejunostomy in 22 patients (88%) and hepatectomy in one (4%). Recurrent stone and stricture rates were both 26% and were managed with further biliary stenting. None of the patients have developed a cholangiocarcinoma with a median follow-up of 29 months.
Conclusions: A combined interventional radiologic and surgical approach employing large bore transhepatic stents is a safe, but labor intensive, method for managing hepatolithiasis. This approach preserves hepatic parenchyma and prevents malignant degeneration.