ORIGINAL ARTICLE

Indication and Procedure

for Treatment of Hepatolithiasis
Kazuhisa Uchiyama, MD; Hironobu Onishi, MD; Masaji Tani, MD;
Hiroyuki Kinoshita, MD; Masaki Ueno, MD; Hiroki Yamaue, MD

Hypothesis: Because of its complicated clinicopatho-
logic features, hepatolithiasis is difficult to treat, and there
is no established method of treating patients with intra-
hepatic stones.
Design: Retrospective case-control study.
Setting: Second Department of Surgery, Wakayama Med-
ical University, School of Medicine, Wakayama, Japan
(January 1, 1971-December 31, 2000).
Patients: Eighty-nine patients treated for hepatolithia-
sis (43 male; median age, 56.9 years).
(17 of 42 patients) in 1971 through 1985, but decreased
to 11% (5 of 47 patients) in 1986 through 2000 (P=.001).
The rate of residual stones after cholangioenterostomy
or T-tube insertion was 43.8% (21 of 48 patients), but
the rate of residual stones after hepatectomy or percu-
taneous transhepatic cholangioscopic lithotripsy (PTCSL)
was 2.4% (1 of 41 patients, P⬍.001). In cases treated by
PTCSL, we used a holmium (Ho):YAG laser in 3 cases
since 1999. To our knowledge, there have been no re-
ports describing the use of Ho:YAG lasers to treat hepa-
tolithiasis. Also, board-shaped stones can be suffi-
ciently pulverized without inducing hemorrhage from the
bile duct wall.

Main Outcome Measures: The rate of residual stones
and complications after the treatments of hepatolithiasis.
Results: Between 1971 and 1985, 17 patients (41%) had
stones located in the left or right intrahepatic duct, and
25 patients (60%) had stones located in the bilateral in-
trahepatic duct. From 1986 through 2000, 32 patients
(68%) had stones located in the left or right intrahepatic
duct, and 15 patients (32%) had stones located in the bi-
lateral intrahepatic duct (P = .009). The rate of residual
stones after surgical and nonsurgical treatment was 41%
Conclusions: According to the current therapeutic strat-
egy for hepatolithiasis, hepatectomy seems to be the most
effective treatment for selected patients with isolated left
hepatolithiasis if other surgical procedures cannot re-
move all the related lesions. In addition, PTCSL seems to
be performed first in isolated right hepatolithiasis and bi-
lateral lobe type hepatolithiasis. In PTCSL procedures,
favorable results have been obtained using the Ho:YAG la-
ser for fracturing intrahepatic stones.
Arch Surg. 2002;137:149-153

From the Second Department
of Surgery, Wakayama Medical
University, School of Medicine,
Wakayama, Japan.
H
EPATOLITHIASIS is a com-
mon disease in Southeast
Asia, and the relative in-
cidence of hepatolithia-
sis is 20% in China and
Taiwan.1,2 However, our study3 in Japan in-
vestigated 105062 patients with choleli-
thiasis between 1989 and 1992 and found
that 2353 of these patients (2.2%) had hepa-
tolithiasis. In Japan, the number of pa-
tients with hepatolithiasis also is lower
compared with previous nationwide sta-
tistics.3 This decrease could be attribut-
able to the fact that as the number of pa-
tients undergoing laparoscopic chol-
ecystectomy increased, the size of the pa-
tient pool increased, thus lowering the rela-
tive incidence of choledocholithiasis and
hepatolithiasis.4
As ultrasonography and computed to-
mography have come into wider use, it has
become possible to not only identify the lo-
cation of hepatic stones but also assess these
stones qualitatively. With magnetic reso-
nance cholangiopancreatography or heli-
cal computed tomography, the 3-dimen-
sional structure of the bile duct can now
be described; thus, the accuracy in diag-
nosing hepatolithiasis has been greatly im-
proved.1 Recent advances in medical tech-
nology have been marked, and the results
of surgical procedures, such as hepatec-
tomy, have improved.2 Furthermore, non-
invasive treatments, such as percutaneous
transhepatic cholangioscopic lithotripsy
(PTCSL) and extracorporeal shock wave
lithotripsy (ESWL), have been estab-
lished.3 However, postoperative residual

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 PATIENTS AND METHODS
Between January 1, 1971, and December 31, 2000, 2104
patients with cholelithiasis were admitted to Wakayama
Medical University Hospital, Wakayama, Japan. Cholecys-
tolithiasis accounted for 78% of the cases, whereas hepa-
tolithiasis accounted for 4% (43 men and 46 women). Pa-
tients ranged in age from 20 to 72 years, with a mean age
of 56.9 years. Sixty-eight patients (54%) had previously un-
dergone 1 or more biliary procedures. We classified the 89
patients with hepatolithiasis by pathologic types. Based on
the location of stones in the hepatic bile duct, patients were
grouped into the following types: intrahepatic (type I), ex-
trahepatic (type E), and both (type IE). Based on the lobe
localization of hepatolithiasis, patients were grouped into
the following types: left lobe (L type), right lobe (R type),
and bilateral lobe (LR type).
All patients underwent surgical or nonsurgical inter-
vention, and the presence of hepatolithiasis was con-
firmed. In terms of the treatment procedures, 34 patients
(38%) underwent hepatectomy; 36 (40%), cholangioen-
terostomy (choledochojejunostomy or cholangioduode-
nostomy); 12 (13%), T-tube insertion; and 7 (8%), PTCSL.
Intraoperative cholangioscopy (external diameter, 4.9 mm;
CHF-P20; Olympus, Tokyo, Japan) was routinely used
instead of intraoperative cholangiography for visualizing
the residual stones, ductal strictures, and tumors. Postop-
erative cholangiography and cholangioscopy were rou-
tinely performed to detect residual stones. In cases treated
by PTCSL, a cholangioscope was inserted through the
Table 1. Clinical Data of Patients With Cholelithiasis
Variable Hepatolithiasis
No. (%) of patients [1971-1985/1986-2000] 89 (4.2) [42/47]*
Age, mean ± SD, y 56 ± 10.9†
Sex, M/F 43/46
History of biliary surgery, yes/no‡ 68/21
*P⬍.05 compared with cholecystolithiasis.
†P⬍.01 compared with cholecystolithiasis and choledocholithiasis.
‡P⬍.01 compared with cholecystolithiasis and choledocholithiasis.
and recurrent stones occur in 20% of treated patients.1 To
decrease residual and recurrence rates, it will be neces-
sary to accurately diagnose the complex pathologic fea-
tures of hepatolithiasis and select the most effective treat-
ment for each type of hepatolithiasis. In the present study,
we clarify the indication of invasive and noninvasive treat-
ments and procedures for patients with hepatolithiasis.
RESULTS
Patients with hepatolithiasis were older (mean age, 56.9
years) than patients with cholecystolithiasis (P⬍.001),
but were younger than those with choledocholithiasis
(P⬍.001). There were no differences among the 3 dis-
ease entities in terms of age or sex (Table 1). Compar-
ing data from 1971 through 1985 with those from 1986
through 2000, the number of patients with cholecysto-
lithiasis increased, whereas there was no change ob-
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percutaneous transhepatic choloangiodrainage (PTCD) fis-
tula orifice, where grasping forceps could be inserted
through the cholangioscope to remove any stones. Giant
and impacted stones were fragmented by introducing an
electrohydraulic shock wave lithotripter probe or pulsed
dye laser before 1997, but were fragmented by introduc-
ing holmium (Ho):YAG lasers after 1998. We established
the following treatment conditions: 0.8 J, 20 Hz, and
16 W. Under these conditions, 1-cm stones can be pulver-
ized in 10 seconds. Also, board-shaped stones can be suf-
ficiently pulverized without inducing hemorrhage from the
bile duct wall.
In combination with other treatments such as PTCSL,
ESWL is performed on patients with intractable hepatoli-
thiasis, such as IE and LR types, in whom hepatectomy would
not be sufficient for complete remission. We used a litho-
triptor (Lithostar 2-plus lithotriptor; Siemens Inc, Erlan-
gen, Germany). Under imaging guidance via PTCD or an
endoscopic nasal bile draining tube, we established the maxi-
mum voltage and shot count as 19 kV and 4000 times, re-
spectively, and we performed irradiation 1 to 10 times. The
lithotriptor is equipped with ultrasonography and x-ray
modes. Although ultrasonography is affected by gastroin-
testinal gas, pneumobilia, and subcutaneous fat thickness,
tests can be performed using the lithotriptor regardless of
these conditions. We analyzed chronological changes in treat-
ment methods for patients with hepatolithiasis and investi-
gated the most appropriate treatments for each disease type.
All data are expressed as mean±SD. Statistical analy-
sis was performed with the ␹2 test and t test. Probability
differences of .05 or less were considered significant.
Cholecystolithiasis Choledocholithiasis Total
1635 (77.7) [606/1029] 380 (18.1) [192/188] 2104 [840/1264]
50.5 ± 14.5 64.4 ± 13.9 54.8 ± 15.2
793/842 185/195 1021/1083
306/1329 162/118 536/1468
served in the number of those with choledocholithiasis
and hepatolithiasis (P⬍.05).
There were chronological changes in the preva-
lence of various hepatolithiasis types. The L or R type
comprised 17 cases (13 L type and 4 R type), whereas
the LR type comprised 25 cases in 1971 through 1985;
however, in 1986 through 2000, the L or R type in-
creased to 32 cases (22 L type and 10 R type) and the LR
type decreased to 15 (P=.009). When hepatolithiasis was
classified according to IE typing, IE type accounted for
30 cases (71%) in 1971 through 1985 and 26 cases (55%)
in 1986 through 2000, and I type accounted for 12 cases
in 1971 through 1985 and 21 cases in 1986 through 2000.
When hepatolithiasis was classified according to LR typ-
ing, the patients with LR type hepatolithiasis accounted
for 25 cases (60%) in the first 15-year period, but this
decreased to 15 cases (32%) in the second 15-year pe-
riod (P⬍.01).
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 Table 2. Treatment Procedures for Hepatolithiasis*

Treatment Procedures

Years Hepatectomy Cholangioenterostomy T Tube PTCSL Total

1971-1985 9 (0) 25 (14) 8 (3) 0 (0) 42 (17)†
1986-2000 25 (0) 11 (4) 4 (0) 7 (1) 47 (5)
Total 34 (0)‡ 36 (18) 12 (3) 7 (1) 89 (22)

*Data in parentheses indicate the number of patients with residual stones. PTCSL indicates percutaneous transhepatic cholangioscopic lithotripsy.
†P⬍.05 compared with residual stones in 1986 through 2000.
‡P⬍.05 compared with cholangioenterostomy.

There were chronological changes in treatment pro-

cedures for hepatolithiasis (Table 2). Before 1985, chol-
angioenterostomy (cholangiojejunostomy or cholangio-
duodenostomy) was performed more frequently than
hepatectomy (9 vs 25); after 1986, hepatectomy was per-
formed more frequently than cholangioenterostomy (25
vs 14, P=.001). The rates of residual stones after treat-
ment were higher in 1971 through 1985 (41%, 17 of 42
patients) than in 1986 through 2000 (11%, 5 of 47 pa-
tients, P=.01). Compared with cholangioenterostomy, he-
patectomy demonstrated a lower rate of residual stones
(0% vs 50%, P⬍.001). However, after 1986, noninvasive
treatments such as PTCSL have been performed more of-
ten (7 cases). In the past, PTCSL was performed using me-
chanical or electrohydraulic forces or pulsed dye laser, but
after 1999, PTCSL has been performed using Ho:YAG la-
sers (3 cases). Consequently, the rate of residual stones
decreased to 0 after PTCSL procedures.
Table 3 gives a breakdown of treatments for the 3
different LR types. Hepatectomy was performed more
frequently on patients with L type hepatolithiasis than
other types (29 vs 5). Hepatectomy was performed on pa-
tients with R or LR type hepatolithiasis when the absence
of residual stones was ensured by such a procedure. Chol-
angioenterostomy or PTCSL was performed more fre-
quently for R or LR type hepatolithiasis than L type hepa-
tolithiasis (40 vs 4). Thus, the incidence of residual
stones was lower in the L type than in the LR type (0.03%
vs 42.5%, P = .001) or in the R type (0.03% vs 28.6%,
P=.02).
All lateral segmentectomies (n = 18) were per-
formed on patients with L type hepatolithiasis, and left
lobectomy was performed on those with L (10 patients)
or LR (3 patients) type hepatolithiasis. Right lobectomy
(n=2) was performed on patients with R type hepatoli-
thiasis. In addition, an extended left lobectomy was per-
formed on 1 patient with L type hepatolithiasis.
There were no surgical deaths among the 89 pa-
tients. The surgical procedure duration was longer for he-
patectomy (256±102 minutes) than for cholangioenter-
ostomy (236±146 minutes) or T-tube insertion (186±90
minutes). The intraoperative blood loss for hepatectomy
(962±364 mL) was greater than for cholangioenteros-
tomy (542±182 mL) or T-tube insertion (486±144 mL,
P⬍.001), whereas the durations of hospitalization were
similar for hepatectomy (29±22 days), cholangioenter-
ostomy (38±28 days), and T-tube insertion (36±30 days).
Table 4 gives the type and incidence of postoperative
complications. Common complications included distur-
Table 3. Treatment for Hepatolithiasis
According to the Location of Stones*
Stone Location
Treatment L LR R
Hepatectomy (n = 34) 29 (0) 3 (0) 2 (0)
Cholangioenterostomy (n = 36) 4 (1) 25 (14) 8 (3)
T-tube drainage (n = 12) 2 (0) 7 (2) 3 (1)
PTCSL (n = 7) 0 (0) 6 (1) 1 (0)
Total 35 (1)† 41 (17) 14 (4)
*Data in parentheses indicate the number of patients with residual stones.
L indicates left intrahepatic duct; LR, bilateral intrahepatic duct; R, right
intrahepatic duct; and PTCSL, percutaneous transhepatic cholangioscopic
lithotripsy.
†P⬍.01 compared with LR and R types of residual stones.
bance of liver function (n=10), bile leakage (n=7), and
wound infection (n=7). There were no deaths after sur-
gery. Moreover, the incidence of mortality was similar
among these groups.
COMMENT
The biggest advantage associated with performing hepa-
tectomy to treat hepatolithiasis is that all hepatic stones
can be removed together with the pathologic bile ducts
(including carcinomatous bile ducts), thus reducing
the risk of recurrent intrahepatic stones.5 Hepatectomy
is most often indicated for the treatment of L type hepa-
tolithiasis,6 and lateral segment resection or left lobe re-
section is performed to remove intrahepatic stones and
pathologic bile ducts.2 The incidence of I and L type hepa-
tolithiasis is increasing in Japan, and hepatectomy now
accounts for more than half of the surgical treatments
performed for I and L type hepatolithiasis.3
The indications for hepatectomy are as follows: (1)
hepatolithiasis is localized in the unilateral lobe, (2) the
hepatic bile duct containing stones is markedly con-
stricted or dilated, (3) combination with intrahepatic bile
duct carcinoma, or (4) hepatolithiasis is accompanied by
hepatic lesions including hepatic abscess or atrophy.7
Thus, hepatectomy is usually performed on patients with
L type hepatolithiasis and rarely on patients with R type
hepatolithiasis. Our data showed that left hepatic resec-
tion was performed more frequently than right hepatic
lobectomy (32 vs 3).
When hepatectomy is not indicated, choledochoje-
junostomy is often performed to treat hepatolithiasis. There

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 Table 4. Morbidity and Mortality After Surgery for Hepatolithiasis
Hepatectomy
Complication
Death
Liver failure
Renal failure
Disturbance of liver function
Bile leakage
Wound infection
Intra-abdominal abscess
Ileus
Pneumonia
Other*
Patients with complications, No. (%)
*Other complications included intra-abdominal bleeding in the hepatectomy group, acute gastric mucosal lesion in the cholangioenterostomy group, and acute
pancreatitis in the T-tube drainage group.
are 2 problems with choledochojejunostomy. First, cho-
ledochojejunostomy is indicated when the bile duct be-
low the hepatic portal is constricted, but contraindicated
when the intrahepatic bile duct is constricted.6 Intrahe-
patic bile duct constriction could lead to severe postop-
erative intrahepatic cholangitis, and careful postopera-
tive care is needed.6 Second, choledochojejunostomy is
indicated when intrahepatic stones are seen in both lobes
and residual stones are expected to remain even though
extensive lithotripsy has been performed.4 To facilitate post-
operative natural stone elimination, the T tube is placed
in the common bile duct, or a retrograde transhepatic bili-
ary drainage tube is inserted into an area of the bile duct
where residual stones are found.3
Therapeutic planning for hepatolithiasis begins with
accurate diagnosis. An attempt should be made to per-
form PTCSL before other procedures to ascertain the con-
dition of the intrahepatic biliary tract, the location of
stones, and the location and severity of biliary stricture
or dilatation.6 One of the reasons that multiple surgical
procedures for hepatolithiasis are often performed is that
the initial treatment is not appropriate, thus further com-
plicating the condition due to residual or recurrent stones.
In addition, PTCSL is performed for patients with in-
tractable hepatolithiasis (ie, LR or R types where hepa-
tectomy is not indicated).8
Residual stones are the most troublesome problem
after treatment for hepatolithiasis.9 The incidence of re-
sidual stones has markedly decreased from 19.8% to
62.3%3,10 without cholangioscopy to 10.0% to 30.2% with
intraoperative and postoperative cholangioscopy.1-10 In
our study, the residual stone rate after PTCSL for hepa-
tolithiasis is 14.3%. Cholangiojejunostomy was one of
the major treatment procedures for hepatolithiasis be-
fore 1985, but the rate of residual stones was 56%
(14/25) after this treatment. However, after 1986, hepa-
tectomy and noninvasive treatments, including PTCSL,
have been performed with greater frequency, and the rate
of residual stones has decreased to 31% (1/32) after these
treatments. Lee et al11 reported only a 4.2% recurrent stone
rate after hepatectomy. Jan et al1 reported that recurrent
stone rates after complete stone clearance for hepatoli-
thiasis by hepatectomy and PTCSL were 9.5% and 36.4%.
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Cholangioenterostomy T-Tube Drainage
(n = 34) (n = 36) (n = 13)
0 0 0
0 0 0
0 0 0
4 3 3
3 2 2
2 3 2
2 1 0
0 2 0
1 0 0
1 1 1
8 (24) 9 (25) 5 (38)
In another report of 19 patients who underwent com-
plete lithotomy, calculi recurred in 4 (21%), 3 of which
had disease recurrence less than 1 year after PTCSL.9 The
rate of recurrent stones has been high after PTCSL, and
the reason is that even when initial therapy is successful
in completely eliminating stones, the structure of the bile
duct remains unchanged.11
In the past, lithotripsy was performed mechani-
cally or electrohydraulically using basket forceps.12 In re-
cent years, favorable results have been obtained using la-
sers.13 At our institution, we have recently used the
Ho:YAG laser in 3 cases, which has been used with in-
creasing frequency in the field of urology in recent years.14
To our knowledge, there have not been any previous re-
ports on the use of Ho:YAG lasers for the treatment of
hepatolithiasis. The Ho:YAG laser fragments the com-
ponents and achieves high stone-free success rates clini-
cally.15 Extracorporeal shock wave lithotripsy is a non-
invasive treatment technique for patients. The decision
whether to perform ESWL is based on the type of stone
and is indicated for the treatment of cholesterol stones.16
Also, stones can become trapped in the common bile duct
during ESWL for hepatolithiasis, leading to severe acute
suppurative cholangitis.16 Therefore, it is necessary to per-
form drainage procedures such as PTCD beforehand.17
Because 4% to 7% of patients with hepatolithiasis have
intrahepatic bile duct carcinoma, it is necessary when per-
forming PTCS or ESWL to perform a bile duct biopsy to
ascertain the hardness and color of the bile duct wall and
determine whether dilatation or constriction of the bile
duct has resulted from inflammation or cancer.18
These findings suggest that cholangiojejunostomy
or T-tube drainage is sufficient for the treatment of stacked
intrahepatic stones secondary to choledocholiths when
unaccompanied by hepatic atrophy or intrahepatic bile
duct constriction. However, in the case of primary hepa-
tolithiasis, ESWL should be performed first for choles-
terol stones, hepatectomy should be performed first for
L and R type bilirubin calcium stones, and PTCSL should
be performed first for LR type and recurrent stones. In
the case of secondary hepatolithiasis (following choledo-
cholithiasis), if there is no liver atrophy and no stenosis
of intrahepatic duct, cholangioenterostomy, T-tube drain-
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IN OTHER AMA JOURNALS

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An Update on Hypercoagulable Disorders
Daniel G. Federman, MD; Robert S. Kirsner, MD

V enous thrombosis is a cause of considerable morbidity and is often responsible for chronic venous disorders that
frequently lead to visits to dermatologists and others involved in wound healing. Over the past several years, many
new causes of thrombophilia have been identified and have dramatically altered the approach to patients present-
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tein C resistance, the prothrombin 20210A mutation, hyperhomocysteinemia, and elevated levels of coagulation factors VIII
and XI. Clinicians can now frequently determine causes of thromboses that have previously been deemed idiopathic. (2001;
161:1051-1056 )
Corresponding author: Daniel G. Federman, MD, VA Connecticut HCS (11ACSL), 950 Campbell Ave, West Haven, CT 06516
(e-mail: Federman.Daniel_G+@west-haven.va.gov).

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