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. 1994 May;219(5):527–537. doi: 10.1097/00000658-199405000-00011

Intrahepatic stones. The transhepatic team approach.

H A Pitt 1, A C Venbrux 1, J Coleman 1, C A Prescott 1, M S Johnson 1, F A Osterman Jr 1, J L Cameron 1
PMCID: PMC1243184  PMID: 8185402

Abstract

OBJECTIVE: The authors reviewed the combined interventional radiologic and surgical management of 54 patients with intrahepatic stones at the Johns Hopkins Hospital. The team approach used large-bore transhepatic stents to access the intrahepatic ducts until they were stone free. SUMMARY BACKGROUND DATA: Intrahepatic stones are uncommon in western countries. As a result, few American institutions have had much experience, and multiple management algorithms have been suggested. Nonoperative, operative, and combination surgical and nonoperative approaches have been advocated. At Johns Hopkins, combined surgical and percutaneous management has been used for 18 years. METHODS: This team approach includes (1) percutaneous placement of transhepatic access catheters, (2) surgery for underlying biliary disease and stone removal, and, when necessary (3) postoperative percutaneous choledochoscopy and stone removal through the transhepatic stents. RESULTS: The median age of the 54 patients was 50 years, and 32 were men. Biliary disease included 27 benign strictures, 7 sclerosing cholangitis, 5 choledochal cysts, 5 parasitic infections, 5 choledocholithiasis, and 5 biliary tumors. Fourteen patients (26%) were treated exclusively with percutaneous techniques. Forty patients (74%) had surgery, including 36 Roux-en-Y hepatico- or choledochojejunostomies with large-bore transhepatic stents. Eighteen of these 40 patients (45%) with multiple intrahepatic stones, strictures, or both required additional procedures after operation. No hospital deaths occurred after any of the percutaneous or surgical procedures. With a mean follow-up of 60 months, 94% of patients were stone free, 87% of patients were symptom free, and 73% have had their transhepatic stents removed. CONCLUSIONS: A combined radiologic and surgical approach with transhepatic stents is a safe and effective method for managing intrahepatic stones.

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Selected References

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  1. Adson M. A., Nagorney D. M. Hepatic resection for intrahepatic ductal stones. Arch Surg. 1982 May;117(5):611–616. doi: 10.1001/archsurg.1982.01380290067012. [DOI] [PubMed] [Google Scholar]
  2. Bonnel D. H., Liguory C. E., Cornud F. E., Lefebvre J. F. Common bile duct and intrahepatic stones: results of transhepatic electrohydraulic lithotripsy in 50 patients. Radiology. 1991 Aug;180(2):345–348. doi: 10.1148/radiology.180.2.2068295. [DOI] [PubMed] [Google Scholar]
  3. Cameron J. L., Pitt H. A., Zinner M. J., Kaufman S. L., Coleman J. Management of proximal cholangiocarcinomas by surgical resection and radiotherapy. Am J Surg. 1990 Jan;159(1):91–98. doi: 10.1016/s0002-9610(05)80612-9. [DOI] [PubMed] [Google Scholar]
  4. Carmona R. H., Crass R. A., Lim R. C., Jr, Trunkey D. D. Oriental cholangitis. Am J Surg. 1984 Jul;148(1):117–124. doi: 10.1016/0002-9610(84)90298-8. [DOI] [PubMed] [Google Scholar]
  5. Chen H. H., Zhang W. H., Wang S. S., Caruana J. A. Twenty-two year experience with the diagnosis and treatment of intrahepatic calculi. Surg Gynecol Obstet. 1984 Dec;159(6):519–524. [PubMed] [Google Scholar]
  6. Chen M. F., Jan Y. Y. Percutaneous transhepatic cholangioscopic lithotripsy. Br J Surg. 1990 May;77(5):530–532. doi: 10.1002/bjs.1800770519. [DOI] [PubMed] [Google Scholar]
  7. Chen M. F., Jan Y. Y., Wang C. S., Jeng L. B., Hwang T. L. Clinical experience in 20 hepatic resections for peripheral cholangiocarcinoma. Cancer. 1989 Dec 1;64(11):2226–2232. doi: 10.1002/1097-0142(19891201)64:11<2226::aid-cncr2820641107>3.0.co;2-1. [DOI] [PubMed] [Google Scholar]
  8. Chijiiwa K., Ichimiya H., Kuroki S., Koga A., Nakayama F. Late development of cholangiocarcinoma after the treatment of hepatolithiasis. Surg Gynecol Obstet. 1993 Sep;177(3):279–282. [PubMed] [Google Scholar]
  9. Choi T. K., Fok M., Lee M. J., Lui R., Wong J. Postoperative flexible choledochoscopy for residual primary intrahepatic stones. Ann Surg. 1986 Mar;203(3):260–265. doi: 10.1097/00000658-198603000-00007. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Choi T. K., Wong J. Partial hepatectomy for intrahepatic stones. World J Surg. 1986 Apr;10(2):281–286. doi: 10.1007/BF01658144. [DOI] [PubMed] [Google Scholar]
  11. Fan S. T., Choi T. K., Lo C. M., Mok F. P., Lai E. C., Wong J. Treatment of hepatolithiasis: improvement of result by a systematic approach. Surgery. 1991 Apr;109(4):474–480. [PubMed] [Google Scholar]
  12. Fan S. T., Lai E. C., Wong J. Hepatic resection for hepatolithiasis. Arch Surg. 1993 Sep;128(9):1070–1074. doi: 10.1001/archsurg.1993.01420210134022. [DOI] [PubMed] [Google Scholar]
  13. Fan S. T., Mok F., Zheng S. S., Lai E. C., Lo C. M., Wong J. Appraisal of hepaticocutaneous jejunostomy in the management of hepatolithiasis. Am J Surg. 1993 Mar;165(3):332–335. doi: 10.1016/s0002-9610(05)80837-2. [DOI] [PubMed] [Google Scholar]
  14. Hutson D. G., Russell E., Schiff E., Levi J. J., Jeffers L., Zeppa R. Balloon dilatation of biliary strictures through a choledochojejuno-cutaneous fistula. Ann Surg. 1984 Jun;199(6):637–647. doi: 10.1097/00000658-198406000-00002. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Jeng K. S., Chiang H. J., Shih S. C. Limitations of percutaneous transhepatic cholangioscopy in the removal of complicated biliary calculi. World J Surg. 1989 Sep-Oct;13(5):603–610. doi: 10.1007/BF01658880. [DOI] [PubMed] [Google Scholar]
  16. Jeng K. S., Yang F. S., Chiang H. J., Ohta I. Bile duct stents in the management of hepatolithiasis with long-segment intrahepatic biliary strictures. Br J Surg. 1992 Jul;79(7):663–666. doi: 10.1002/bjs.1800790722. [DOI] [PubMed] [Google Scholar]
  17. Jeng K. S., Yang F. S., Ohta I., Chiang H. J. Dilatation of intrahepatic biliary strictures in patients with hepatolithiasis. World J Surg. 1990 Sep-Oct;14(5):587–593. doi: 10.1007/BF01658796. [DOI] [PubMed] [Google Scholar]
  18. Kan F., Tsung-chih C. Subcutaneous bling loop--a new type of hepaticocholedochojejunostomy for bilateral intrahepatic calculi. Chin Med J (Engl) 1977 Nov;3(6):413–418. [PubMed] [Google Scholar]
  19. Kaufman H. S., Magnuson T. H., Lillemoe K. D., Frasca P., Pitt H. A. The role of bacteria in gallbladder and common duct stone formation. Ann Surg. 1989 May;209(5):584–592. doi: 10.1097/00000658-198905000-00011. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Ker C. G., Hwang C. H., Chen J. S., Lee K. T., Sheen P. C. Extracorporeal shockwave lithotripsy for treatment of intrahepatic stones: in vitro and in vivo studies. Hepatogastroenterology. 1993 Apr;40(2):159–162. [PubMed] [Google Scholar]
  21. Koga A., Miyazaki K., Ichimiya H., Nakayama F. Choice of treatment for hepatolithiasis based on pathological findings. World J Surg. 1984 Feb;8(1):36–40. doi: 10.1007/BF01658361. [DOI] [PubMed] [Google Scholar]
  22. Lillemoe K. D., Pitt H. A., Cameron J. L. Current management of benign bile duct strictures. Adv Surg. 1992;25:119–174. [PubMed] [Google Scholar]
  23. Ohta T., Nagakawa T., Takeda T., Fonseca L., Kanno M., Mori K., Kayahara M., Ueno K., Miyazaki I., Terada T. Histological evaluation of the intrahepatic biliary tree in intrahepatic cholesterol stones, including immunohistochemical staining against apolipoprotein A-1. Hepatology. 1993 Apr;17(4):531–537. doi: 10.1002/hep.1840170402. [DOI] [PubMed] [Google Scholar]
  24. Pitt H. A., Kaufman S. L., Coleman J., White R. I., Cameron J. L. Benign postoperative biliary strictures. Operate or dilate? Ann Surg. 1989 Oct;210(4):417–427. doi: 10.1097/00000658-198910000-00001. [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Pridgen J. E., Jr, Aust J. B., McInnis W. D. Primary intrahepatic gallstones. Arch Surg. 1977 Sep;112(9):1037–1043. doi: 10.1001/archsurg.1977.01370090019004. [DOI] [PubMed] [Google Scholar]
  26. Ros E., Navarro S., Bru C., Gilabert R., Bianchi L., Bruguera M. Ursodeoxycholic acid treatment of primary hepatolithiasis in Caroli's syndrome. Lancet. 1993 Aug 14;342(8868):404–406. doi: 10.1016/0140-6736(93)92817-d. [DOI] [PubMed] [Google Scholar]
  27. Saito K., Nakanuma Y. Lactoferrin and lysozyme in the intrahepatic bile duct of normal livers and hepatolithiasis. An immunohistochemical study. J Hepatol. 1992 May;15(1-2):147–153. doi: 10.1016/0168-8278(92)90028-n. [DOI] [PubMed] [Google Scholar]
  28. Sato T., Suzuki N., Takahashi W., Uematsu I. Surgical management of intrahepatic gallstones. Ann Surg. 1980 Jul;192(1):28–32. doi: 10.1097/00000658-198007000-00005. [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Savader S. J., Savader B. L., Fishman E. K., Venbrux A. C., Fletcher T. B., Osterman F. A., Jr Giant pseudoaneurysm of the hepatic artery--CT demonstration. Case report. Clin Imaging. 1992 Jul-Sep;16(3):175–179. doi: 10.1016/0899-7071(92)90045-b. [DOI] [PubMed] [Google Scholar]
  30. Sheen-Chen S. M., Chou F. F., Eng H. L. Intrahepatic cholangiocarcinoma in hepatolithiasis: A frequently overlooked disease. J Surg Oncol. 1991 Jun;47(2):131–135. doi: 10.1002/jso.2930470213. [DOI] [PubMed] [Google Scholar]
  31. Venbrux A. C. Interventional radiology in the biliary tract. Curr Opin Radiol. 1992 Jun;4(3):83–92. [PubMed] [Google Scholar]
  32. Venbrux A. C., Robbins K. V., Savader S. J., Mitchell S. E., Widlus D. M., Osterman F. A., Jr Endoscopy as an adjuvant to biliary radiologic intervention. Radiology. 1991 Aug;180(2):355–361. doi: 10.1148/radiology.180.2.2068296. [DOI] [PubMed] [Google Scholar]
  33. Yamakawa T. Percutaneous cholangioscopy for management of retained biliary tract stones and intrahepatic stones. Endoscopy. 1989 Dec;21 (Suppl 1):333–337. doi: 10.1055/s-2007-1012984. [DOI] [PubMed] [Google Scholar]
  34. Yoshimoto H., Ikeda S., Tanaka M., Matsumoto S., Kuroda Y. Choledochoscopic electrohydraulic lithotripsy and lithotomy for stones in the common bile duct, intrahepatic ducts, and gallbladder. Ann Surg. 1989 Nov;210(5):576–582. doi: 10.1097/00000658-198911000-00002. [DOI] [PMC free article] [PubMed] [Google Scholar]

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