Clinical features management and long-term surgical outcome of hepatolithiasis.

Background: Hepatolithiasis (presence of stones within the intrahepatic bile ducts proximal to the confluence of right and left hepatic ducts) is prevelant in Southeast Asia and is also common in Kashmir. This disease features a high stone residual and recurrence and its long-term outcome is far from satisfactory. Selection of surgical technique is based on the location of stone, the morphology of the intrahepatic ducts and the general condition of the patient. Objectives: 1) To evaluate the clinical profile of the patient presenting with hepatolithiasis; 2) Analyzing different modalities of treatment in the management of hepatolithiasis; 3) To study the long term out come of surgical treatment of hepatolithiasis, in terms of recovery, morbidity and mortality Materials & Methods: The study was conducted jointly in the departments of Surgical Gastroenterology, medical Gastroenterology, General Surgery and pathology over a period of 2 years (40 prospective & 60 retrospective cases) Results: The male:female ratio was 38:62 and the age range was12-75 (mean 40.7). Majority of patients belonged to unskilled group. Biliary colic was the main presenting feature (97%) followed by cholangitis (56%) and cholestasis (54%). Previous biliary surgeries were performed in 27% of patients. ERCP was done in 96% of patients. MRCP was done in 40% of cases and was useful in detecting subsegmental anatomy. Predominantly left side of liver was involved (52%). Choledochoduodenostomy was the commonest procedure performed (61%) followed by liver resections (52%), which included left lateral segmentectomy (40%) and left hepatectomy (12%). Wound infection was the commonest morbidity (9%) followed by bile leak (4%). After an average follow up of 15 months, 89 (89%) patients were symptom free. There were 2 (2%) deaths and Recurrence was seen in 9 (9%) patients. Conclusions: Hepatic resection is the treatment of choice in patients with single-lobe hepatolithiasis, whereas Choledochoduodenostomy /Hepatico jejunostomy with access loop are effective surgical options in bilateral disease. A combination of different treatment modalities (surgical and endoscopic interventional) may be necessary to improve the outcome of these patients. Long term follow up is recommended to detect early recurrence and development of a cholangiocarcinoma