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Long-term outcome of percutaneous transhepatic cholangioscopic lithotomy for hepatolithiasis

OBJECTIVES:Percutaneous transhepatic cholangioscopic lithotomy (PTCSL) for the treatment of hepatolithiasis is particularly suited for those patients who are poor surgical risks or who refuse surgery and those with previous biliary surgery or stones distributed in multiple segments. However, hepatolithiasis is characterized by high rates of treatment failure and recurrence. We examined the long-term results of 245 patients with hepatolithiasis treated by PTCSL.METHODS:This was a retrospective study of 245 patients who underwent PTCSL for hepatolithiasis; the patients were followed for 1–22 yr to evaluate the immediate and long-term results. Sonography was used to search for stone recurrence every year or whenever the patients presented symptoms suggestive of cholangitis. Cholangiography and/or CT were performed to verify recurrence.RESULTS:PTCSL achieved complete clearance of hepatolithiasis in 209 patients (85.3%); the rate of incomplete clearance was higher in patients with intrahepatic duct stricture (29/118, 24.6% vs 7/127, 5.5%; p = 0.002). The rate of major complications was 1.6% (4/245) and included liver laceration (n = 2), intra-abdominal abscess (n = 1), and disruption of the percutaneous transhepatic biliary drainage fistula (n = 1). The overall recurrence rate of hepatolithiasis and/or cholangitis was 63.2%. The absolute rate of stone recurrence was not significantly related to the presence of intrahepatic duct stricture (51/89, 56.2% vs 53/120, 44.4%; p = 0.08), although the median time to recurrence was less in those with stricture (11 vs 18 yr; p = 0.007). In the patients without intrahepatic duct stricture, the rate of complete stone clearance was not related to the presence of dilation (34/38, 89.5% vs 86/89, 96.6%; p = 0.196), but the recurrence rate was higher in those with dilation (20/34, 58.8% vs 33/86, 38.4%; p = 0.042). Among the 209 patients with a successful initial PTCSL, the incidence of recurrent cholangitis or cholangiocarcinoma was significantly higher in those with incompletely removed recurrent hepatolithiasis than in those without coexisting hepatolithiasis (44.3%, 27/61 vs 16.2%, 24/148; p < 0.001 and 6.6%, 4/61 vs 0.7%, 1/148; p = 0.026).CONCLUSIONS:PTCSL is a relatively safe and effective procedure for treating hepatolithiasis. Long-term follow-up is required because the overall recurrence rate of hepatolithiasis and/or cholangitis is high. The rate of complete stone clearance and the median time to stone recurrence are less in the presence of stricture, but the absolute rate of stone recurrence is not significantly related to stricture. In the absence of stricture, the rate of stone recurrence is higher in patients with dilated intrahepatic duct. Complete stone clearance is necessary, because the incidence of recurrent cholangitis or cholangiocarcinoma is higher in patients with incomplete clearance of recurrent hepatolithiasis.

Percutaneous trans-hepatic cholangioscopy and lithotripsy in the treatment of intrahepatic stones: a study with 5 year follow-up

BACKGROUNDnIntrahepatic stones are characterized by high treatment failure and recurrence rates. In the past, surgery played a major role in the management of this disease, but surgical intervention may not be feasible in previously operated patients or those classified as poor surgical risks. The development of percutaneous trans-hepatic cholangioscopy and lithotripsy has played an important role in the treatment of these patients.nnnMETHODSnWe reviewed our results in 165 patients with intrahepatic stones treated by percutaneous trans-hepatic cholangioscopy and lithotripsy in the past 12 years.nnnRESULTSnThe rate of complete stone removal was 80% (132 cases) and the rate of recurrent biliary stones after a mean 58 month follow-up interval was 32.6% (43 of 132 cases). There were 2 deaths during the treatment period and 10 deaths during follow-up.nnnCONCLUSIONSnPercutaneous trans-hepatic cholangioscopy and lithotripsy are good alternatives in treating primary intrahepatic stones, especially for those patients unsuitable for surgery.