Original Communications
Evaluation of long-term results
and recurrent factors after operative
and nonoperative treatment for
hepatolithiasis
Young Koog Cheon, MD, Young Deok Cho, MD, Jong Ho Moon, MD, Joon Seong Lee, MD, and
Chan Sup Shim, MD, Seoul, Korea
Background. Hepatolithiasis is a common disease in East Asia. Operative and nonoperative procedures
for the management of hepatolithiasis have been discussed, but long-term follow-up results of such
treatments are only reported rarely. We evaluated the long-term results of operative and nonoperative
treatments and examined risk factors for the recurrence of stones or cholangitis.
Methods. We conducted a retrospective study of case records of patients with hepatolithiasis who
underwent treatment by operative therapy or nonoperative percutaneous transhepatic cholangioscopy
(PTCS), or peroral cholangioscopy. Of 311 patients with hepatolithiasis, 236 underwent follow-up after
operative (n =90), PTCS (n =97), or peroral cholangioscopy (n =49) treatment.
Results. Complete stone clearance was achieved in 83.3% of hepatectomy, 63.9% of PTCSL, and
57.1% of peroral cholangioscopy patients. After a median follow-up period of 8.0 years (up to 37 years),
we observed stone recurrence in 30.9% (73/236) of patients, secondary biliary cirrhosis in 8.5%
(19/224), late development of cholangiocarcinoma in 4.8% (11/227), and a mortality rate of 8.1%
(19/236). Stricture, stones in both lobes, and nonoperative treatments were significant risk factors for
incomplete stone clearance on multivariate analysis. In addition, recurrent stones and/or cholangitis
were associated with nonoperative therapy (hazard ratio [HR], 2.01; 95% confidence interval [CI],
1.10--3.65), biliary cirrhosis (HR, 2.22; 95% CI, 1.24--3.98), residual stones (HR, 1.98; 95% CI,
1.24--3.17), and stricture (HR, 1.86; 95% CI, 1.01--3.43).
Conclusion. In this long-term follow-up study, nonoperative therapy, biliary cirrhosis, residual stones,
and biliary stricture were associated with recurrent stones and/or cholangitis after treatment. (Surgery
2009;146:843-53.)
From the Institute for Digestive Research and Digestive Disease Center, Soon Chun Hyang University College
of Medicine, Seoul, Korea
H
EPATOLITHIASIS
, the presence of intrahepatic duct
calculi, is characterized by a high rate of treatment
failure and recurrence. Intrahepatic duct calculi
associated with repeated cholangitis can lead to
progressive biliary strictures, liver abscess, liver
cirrhosis, atrophy of the affected liver, and even
cholangiocarcinoma.
1-3
Hepatic resection and
percutaneous transhepatic cholangioscopic lithot-
omy (PTCSL) are, at present, the 2 primary modal-
ities of treatment. Resection of the liver segment
or lobe that contains a multisegmental distribution
of stones, strictures, or atrophy has been reported to
be effective in decreasing the recurrence of
stones.
4,5
Intraoperative or even postoperative chol-
angioscopy can decrease markedly the recurrence
rate. However, sometimes operative intervention is
not an option for patients who are poor surgical can-
didates or who refuse operation, or for those with a
history of previous biliary surgery or stones distrib-
uted in multiple segments.
6
PTCSL, rather than
hepatectomy, can conserve more liver cell mass
and preserve liver function, and it is especially suit-
able for the patients who are poor surgical risks or
Accepted for publication April 6, 2009.
Reprint requests: Young Koog Cheon, MD, Associate Professor,
Digestive Disease Center, Soon Chun Hyang University Hospital,
657 Hannam-Dong, Yongsan-Ku, Seoul 140-743, Korea. E-mail:
yksky001@hanmail.net.
0039-6060/$ - see front matter
Ó 2009 Mosby, Inc. All rights reserved.
doi:10.1016/j.surg.2009.04.009
SURGERY 843