Hepatolithasis; the Past, Present, and Future

Abstract

Hepatolithiasis had gradually decreased in Taiwan at present. It was mostly composed of calcium bilirubinate stone but cholesterol or fatty acid was sporadically reported recently. There were 1,149 patients with hepatolithiasis encountered since 1970 to 2004. The trend of the incidence of hepatolithiasis among gallstone surgery decreased from 50.3% (148/294, before 1979), to 3.0% (79/2659, 2000-2004). The incidence of hepatlithiasis had really declined in Taiwan, but it will increase in Southern Asian countries. The symptoms and sign were not specific for diagnosis of hepatolithiasis usually.Treatment for hepatolithiasis was essentially surgical. However, the choice of the method was based on the morphology of the intrahepatic ducts. Treatments of intra- hepatic stones included choledocho-lithotomy with post-operative choledocho-scopic lithotripsy, liver resection and biliary by-pass drainage procedures if indicated according to the morphology of intrahepatic ducts and location of stones. Liver resection was strongly advised in the patients of segmental or subsegmental types. However, non-surgical treatment such as percutaneous or endoscopic technique could be applied in some patients.The operative mortality was measured at 4.9% for the re-operation group and none for the group of the first time operation for hepatolithiasis in the period of 1990-1995, but 1.2% (1/79) total in the years of 2000-2004 compared with that of 10.1% in the 1970s. Sepsis was a main cause of death in the early period, but secondary biliary cirrhosis due to repeated cholangitis was found commonly in recent years. Relation between the hepatolithiasis and bile duct cancer was usually linked together. The co-existence bile duct cancer in hepato-lithiasis at present was reported about 5% in Taiwan.In conclusion: Therapeutic difficulties re-sulted in the high incidence of residual stones, a high recurrence rate and death due to biliary sepsis or secondary biliary cirrhosis at the end result of hepatolithiasis. Liver resection is an ideal surgical method for eradicating the diseased lesion and to minimize the malignant changes from the bile ducts due to the longevity of irritation with calculi especially in the primary hepatolithiasis. Choledocho-jejunostomy was only reserved for the secondary type if indicated and not encuraged. Long-term follow-up study of those patients with hepatolithiasis should be careful for the possibility of combination of malignant changes in diseased intrahepatic ducts in their future.