Hepatolithiasis in Japan: present status

Difficult to Treat Recurrent Pyogenic Cholangitis With Portal Pylephlebitis in the Setting of Idiopathic CD4+ Lymphocytopaenia

Recurrent pyogenic cholangitis (RPC) is a disease characterized by multiple strictures of the biliary tree, impaired biliary drainage, formation of intrahepatic biliary pigment stones and recurrent bouts of cholangitis. We report the case of a 39-year-old businessman with diagnosed chronic calcific pancreatitis, who presented to us with recurrent episodes of cholangitis, leading to portal pyaemia, and progressive liver failure, which could not be controlled despite adequate biliary drainage. The patient rapidly developed progressive liver failure and sepsis-related coagulation failure. He was also found to have idiopathic CD4+ T cell lymphocytopenia (ICL), which resulted in refractory sepsis and formation of metastatic abscesses in the lung and spleen. ICL is now recognised in patients with recurrent and difficult to treat opportunistic infections. The combination of RPC, sepsis and liver failure in the setting of an acquired immunosuppressed state makes this a unique management scenario.

Robotic Liver Resection For Primary Hepatolithiasis: Is It Beneficial?

BACKGROUND

Primary hepatolithiasis is a disease characterized by primary biliary ductal abnormality with stone formation predominantly within the intrahepatic bile ducts. Its management is difficult, but liver resection has emerged as a promising treatment option.

METHODS

Robotic liver resection (RLR) has been adopted in our center for the management of patients with hepatolithiasis. The operative and short-term outcomes of this cohort of patients were compared with a historical cohort of patients using open approach (OLR). A subgroup analysis was performed for left lateral sectionectomy.

RESULTS

Between September 2010 and April 2015, 15 RLRs were performed on patients with primary hepatolithiasis. The historical cohort consisted of 42 OLRs with operation done between January 2005 and January 2014. No differences were found in patient demographics, disease characteristics, or types of resection. No operative deaths occurred, and no difference was seen in complication rates. RLR had significantly less blood loss (100 vs. 235 ml; p = 0.011) and shorter hospital stays (6 vs. 8 days; p = 0.003). After a median follow-up of 19.4 months for RLRs and 79.2 months for OLRs (p < 0.001), there were no differences in residual stone rate, recurrent stone rate, or rate of recurrent cholangitis. Subgroup analysis of lateral sectionectomy (10 RLRs vs. 27 OLRs) revealed similar outcomes, i.e., less blood loss and shorter hospital stays in RLR.

CONCLUSIONS

Robotic liver resection reduces blood loss and shortens hospital stays compared with OLR. A longer follow-up is needed to assess the long-term outcomes of RLR regarding prevention of recurrent stones and cholangitis.

Etiologic Significance of Anatomic Variations in the Main Intrahepatic Bile Ducts in Hepatolithiasis

Abnormal union of intrahepatic bile ducts has been suggested as a possible etiologic factor in the occurrence of intrahepatic stones. A series of 241 patients were examined by direct cholangiography, and anatomic variations in the intrahepatic bile ducts were classified into four types: Type A-1, normal union having a true right hepatic duct; Type A-2, absence of a right hepatic duct, with a trifurcation; Type B, posterior segmental duct draining into left hepatic duct; Type C, anterior segmental duct draining into left hepatic duct. The most dominant type was Type A-1, which occurred in 58.3 to 66.0 per cent of the cases, followed by Type A-2 with 12.5 to 19.8 per cent. Type B showed the lowest incidence, occurring in 4.5 to 10.4 per cent. No statistical difference existed in the distribution of the type of union of intrahepatic bile ducts on the one hand and the presence or absence of intrahepatic stones on the other. Thus, anatomic variations in the main intrahepatic bile ducts do not seem to be associated with hepatolithiasis, and their etiologic significance seems to be unlikely.

The role of endoscopy in the management of recurrent pyogenic cholangitis: a review

Recurrent pyogenic cholangitis (RPC) is a clinical syndrome characterized by repeated episodes of suppurative cholangitis due to hepatolithiasis and extrahepatic stones in the biliary ducts. It is now recognized as a distinct syndrome with a different natural history and pathoetiology than spontaneously occurring liver abscesses. Most commonly seen in East Asian populations, this syndrome is growing increasingly common in Western Nations due to migration patterns. The exact pathogenesis of RPC remains elusive; although colonization of the biliary tract with particular enteric bacterial species, in combination with possible dietary factors, has been attributed as causative factors. Hepatobiliary surgery, in particular segmental hepatectomy, is often described as the definitive treatment of choice for RPC. The exact role of endoscopic intervention has been less clearly described in the literature. This review focuses on the management of RPC while highlighting situations in which endoscopic retrograde cholangiopancreatography may be preferred over surgery as an initial or salvage therapeutic measure.

Surgical management of recurrent pyogenic cholangitis: 10 years of experience in a tertiary referral centre in Hong Kong

BACKGROUND

Recurrent pyogenic cholangitis (RPC) is common in Asia. Its management differs from centre to centre.

METHODS

A retrospective review of 80 patients undergoing surgery for RPC was performed. Immediate and longterm outcomes were analysed.

RESULTS

All patients underwent hepaticocutaneousjejunostomy (HCJ) for biliary drainage and stone removal. Additional hepatectomy was performed in 38 patients with intrahepatic ductal stricture or liver segmental atrophy. Twenty-three patients had residual stones and 25 had recurrent stones. All patients with residual stones underwent repeated choledochoscopy (median: four sessions) for stone removal and obtained confirmation of ductal clearance. Four patients developed cholangiocarcinoma, of which two died. The complication rate was 17.5%. Most of the complications were wound infections. No mortality related to surgery occurred. Multivariate analysis found that gender, disease extent (unilobar versus bilobar) and surgery type (HCJ alone versus HCJ with hepatectomy) were not associated with increased risk for residual or recurrent stones. A raised preoperative bilirubin level was the only risk factor identified as associated with an increased risk for recurrent stones (P < 0.001); it was not associated with an increased risk for residual stones.

CONCLUSIONS

Recurrent pyogenic cholangitis is a distinct disease, the management of which requires a high level of surgical expertise. Hepaticojejunostomy is recommended as the primary drainage procedure, but hepatectomy should be reserved for complicated RPC.

Management of intrahepatic stones: the role of subcutaneous hepaticojejunal access loop. A prospective cohort study

BACKGROUND

Patients with intrahepatic stones usually present with recurrent cholangitis, biliary sepsis and intrahepatic abscesses, may develop liver atrophy and may progress to cholangiocarcinoma. Treatment of intrahepatic stones is difficult and the disease progresses in most patients even after adequate treatment. Surgical removal of stones has been the standard management but residual stones and stone recurrence occur frequently whatever the technique. Because of the need for repeated biliary instrumentation, long-term access routes involving percutaneous transhepatic cholangioscopic lithotripsy (PTCSL), hepaticocutaneousjejunostomy (HCJ) and subparietal hepaticojejunal access loop to permit stone retrieval or stricture dilatation have been developed.

PURPOSE

The aim of this work was to evaluate the outcome of subcutaneous hepaticojejunal access loop in the management of intrahepatic stones.

PATIENTS AND METHODS

Between January 2009 and January 2013, 42 patients with intrahepatic stones underwent surgical treatment at the Gastrointestinal Surgery Unit, Main Alexandria University Hospital. Demographic data, details of operative findings, follow up details, and treatment of recurrent stones were analyzed. After approval of local ethics committee, all patients included in the study were informed well about the procedure and an informed written consent was obtained from every patient before carrying the procedure.

RESULTS

Forty-two patients (17 males and 25 females) with intrahepatic stones underwent surgery with construction of a subcutaneous hepaticojejunal access loop. Stones were confined to the left lobe in 25 patients, the right lobe in 3 patients and bilobar in 14 patients. Associated extrahepatic stones were found in 33 patients. Twenty-two patients had associated intrahepatic duct strictures. Five patients with atrophy of segments II and III underwent hepatic resection at the time of access loop formation. The mean operation time was 4.9 h and mean blood loss was 440 mL. Mean postoperative hospital stay was 10 days. Wound infection was the commonest complication, occurring in 5 (12%) patients. There were no specific complications attributable to the construction of the access loop. The subcutaneous access loop was used to gain access to the biliary tree in 28 patients with residual or recurrent stones. A total of 55 procedures (range 1-5) were attempted with successful access achieved in all cases and successful stone clearance in 21 of the 28 patients, and all of them were symptom free for at least 12 months after the last procedure. Partial stone clearance was achieved in the remaining seven patients. These seven patients had different degrees of biliary strictures.

CONCLUSION

The subcutaneous access loop offers the advantage of permanent access for the successful management of retained or re-formed intrahepatic stones with minimal morbidity since it permitted easy access to intrahepatic ducts using the conventional forward-viewing endoscope or the choledochoscope, without the additional morbidity of a biliary-cutaneous fistula or transhepatic access.

Primary hepatolithiasis, recurrent pyogenic cholangitis, and oriental cholangiohepatitis: a tale of 3 countries

Primary hepatolithiasis (HL), recurrent pyogenic cholangitis, and oriental cholangiohepatitis are terms commonly used in Japan, Hong Kong, and Korea respectively, and describing the different aspects of the same disease, with "HL" indicating the pathologic changes, "recurrent pyogenic cholangitis" emphasizing the clinical presentation and suppurative inflammation, and "oriental cholangiohepatitis" highlighting its ethnic preference and mysterious nature. HL is predominantly a disease of the far east and shows great regional differences in the incidence and the type of intrahepatic stones. Pathologically, it is characterized by pigmented calcium bilirubinate stones within dilated intrahepatic bile ducts featuring chronic inflammation, mural fibrosis, and proliferation of peribiliary glands, without extrahepatic biliary obstruction. Episodes of suppurative inflammation cumulate in sclerosing cholangitis in peripheral ducts and parenchymal fibrosis from scarring and collapse. Mass-forming inflammatory pseudotumor and neoplasms-like intraductal papillary neoplasms and cholangiocarcinoma are increasingly recognized complications. Bacterial infection and dietary factors are believed to be important in the formation of pigment stones within intrahepatic bile ducts, whereas parasitic infestation is likely coincidental. With improvement of environmental conditions and westernization of diet, the incidence of pigment stones has decreased. At the same time, cholesterol stones with milder clinical manifestations and pathologic changes are increasingly recognized, and for which stone dissolution therapy can be considered. Understanding the underlying pathology avoids confusion with other diseases more prevalent in the western world, and allows correct selection of the appropriate treatment.

Outcome of surgical treatment for recurrent pyogenic cholangitis: a single-centre study

BACKGROUND

Recurrent pyogenic cholangitis (RPC) is still a common disease in East Asia. The present study reviews the operative results for this disease in a single centre.

METHODS

The records of 85 patients who underwent surgical treatment for RPC from August 1995 to March 2008 were retrospectively reviewed.

RESULTS

Patients included 35 men and 50 women with a median age of 61 years. Types of surgery included: hepatectomy (65.9%); hepatectomy plus drainage (9.4%); drainage alone (14.1%), and percutaneous choledochoscopy (10.6%). There was no operative mortality. Complications occurred in 40% of patients and half the complications involved wound infections. The overall incidences of residual stone, stone recurrence and biliary sepsis recurrence were 21.2%, 16.5% and 21.2%, respectively, over a median follow-up of 45.4 months. The drainage-alone group and percutaneous choledochoscopy group had higher incidences of residual stone, stone recurrence and biliary sepsis recurrence. In hepatectomy patients, regardless of whether or not a drainage procedure had been performed, rates of residual stone, stone recurrence and biliary sepsis recurrence were 15.6%, 7.8% and 9.4%, respectively, over a median follow-up of 42.7 months.

CONCLUSIONS

Hepatectomy is safe and yields the best treatment outcome for RPC. It should be considered as the treatment of choice for suitable patients with RPC.

Lifestyle risk factors for intrahepatic stone: findings from a case-control study in an endemic area, Taiwan

BACKGROUND AND AIM

To examine associations between lifestyle risk factors and intrahepatic stone (IHS), we conducted a case-control study in Taiwan, which has the highest incidence of IHS in the world.

METHODS

Study subjects were 151 patients newly diagnosed with IHS at Chang Gung Memorial Hospital between January 1999 and December 2001. Two control subjects per case were selected randomly from patients who underwent minor surgery at the same hospital and from family members or neighbors of the hospital staff. Controls were matched to each case by age and gender. Information on lifestyle factors was collected using a self-administered questionnaire. Strength of associations was assessed using odds ratios derived from conditional logistic models.

RESULTS

Female patients were significantly shorter than female controls. Compared to subjects with two or fewer children, odds ratios for those with six or more children were 20.4 in men (95% confidence interval, 1.89-221) and 2.82 (0.97-8.22) in women. Increasing level of education lowered the risk of intrahepatic stone (trend P = 0.004 for men and < 0.0001 for women). Women who had consumed ground-surface water for a long period had a somewhat increased risk (trend P = 0.05).

CONCLUSION

Lower socioeconomic status and poor hygiene may be involved in the development of intrahepatic stones.

Diagnosis of intrahepatic and common duct stones: combined unenhanced and contrast-enhanced helical CT in 1090 patients

BACKGROUND

We determined the accuracy of combined unenhanced and contrast-enhanced helical computed tomography (CT) for diagnosis of bile duct stones.

METHODS

During a 12-month period, 1090 patients who underwent combined CT and endoscopic retrograde cholangiography (ERC) or percutaneous transhepatic cholangioscopy (PTC) were enrolled in this study. The results of prospective CT interpretation regarding the presence of bile duct stones were compared with results of endoscopic stone removal, PTC and with surgical results. In 70 patients, detectability of stones on CT was evaluated depending on stone types.

RESULTS

Of 1090 study patients, 175 and 299 patients were confirmed to have intrahepatic and common duct stones, respectively. The sensitivity and specificity of combined CT were 73% and 98% for diagnosis of intrahepatic stones and 71% and 97% for common duct stones. Of 70 patients 24, 25, and 21 patients had cholesterol, black pigment, and brown pigment stones, respectively. Eleven of 24 cholesterol stones, 21 of 25 black pigment stones, and 15 of 21 brown pigment stones were detected on combined CT.

CONCLUSION

Combined CT is of limited sensitivity for detection of bile duct stones, especially in Western countries where cholesterol stones predominate. It may be of greater value in populations with a higher incidence of pigment stones. Other complementary imaging modalities are needed for patients with negative CT findings who are highly suspected to have biliary stones.

Gallstone disease: Epidemiology, pathogenesis, and classification of biliary stones (common bile duct and intrahepatic)

Gallstones are common in Western countries and Japan. Most gallstones are found in the gallbladder, but they sometimes pass through the cystic duct into extrahepatic and/or intrahepatic bile ducts to become bile-duct stones, causing conditions known as choledocholithiasis and hepatolithiasis. Some 10-15% of gallstone patients concomitantly suffer from bile-duct stones. Bile-duct stones can also be formed in the absence of gallbladder stones, and such primary bile-duct stones are more common in East Asian countries than in the Western world. Thus pathogenesis of primary and secondary bile-duct stones is unlikely to be similar. Furthermore, the gallbladder stones are primarily cholesterol or black-pigment stones, whereas most bile-duct stones are brown-pigment stones (calcium bilirubin stones). Thus, epidemiology, pathogenesis and classification of biliary stones are very likely to differ according to stone location (intrahepatic and/or extrahepatic bile duct).

Gallstone disease: Management of intrahepatic stones

Hepatolithiasis (oriental cholangiohepatitis) has reportedly been endemic only in East Asia. The disease is now occasionally recognized in Western societies, especially in people who have lived in the Orient. Hepatolithiasis is characterized by its intractable nature and frequent recurrence, requiring multiple operative interventions, which is in distinct contrast to gallbladder stones. In addition to frequent cholangitis and chronic sepsis, it is widely known that longstanding intrahepatic stones lead to intrahepatic cholangiocarcinoma. Symptoms of hepatolithiasis include abdominal pain, jaundice and cholangitis. Pyogenic cholangitis due to strictures and hepatolithiasis tends to recur, and sometimes patients may present with liver abscesses. Radiological studies and percutaneous procedures are keys in the diagnosis and treatment of hepatolithiasis. Non-invasive imaging modalities such as ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI) accurately depict the normal anatomy and presence of intrahepatic stones. It should be stressed that each modality has its pros and cons, and imaging studies should be performed on the basis of understanding the pathophysiology. As the diagnostic role of magnetic resonance cholangiopancreatography (MRCP) evolves, the roles of both endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC), and their most significant advantage, is primarily therapeutic with their ability to extract stones, biopsy intraductal lesions, and place stents easily. The primary goals of treatment are to eliminate attacks of cholangitis and to stop the progression of the disease (which leads to biliary cirrhosis). Surgery has a primary role in hepatolithiasis because hepatolithiasis tends to recur, so that multiple sessions of the endoscopic approach (i.e. two or three times a year) are often required. PTC is an alternative when surgical resection of the affected lobe is difficult. Techniques for lithotripsy, including shockwave and laser, can be applied in endoscopic sessions, offering a better chance of clearing the stones.

Peroral cholangioscopic treatment of hepatolithiasis: Long-term results

BACKGROUND

Peroral cholangioscopic lithotomy is an effective treatment for extrahepatic bile duct stones. However, an evaluation of the usefulness and long-term results of peroral cholangioscopic lithotomy for hepatolithiasis has not been reported. The aim of this study was to evaluate the usefulness and long-term results of peroral cholangioscopic lithotomy for hepatolithiasis.

METHODS

From August 1987 to July 1998, 36 consecutive patients underwent peroral cholangioscopic lithotomy for hepatolithiasis; 34 were followed for a mean of 93 months (range, 14 to 164 months).

RESULTS

The rate of complete stone removal was 64%; the morbidity rate was 2.8%. The recurrence rate for patients in whom stones were completely removed was 21.7%. Two patients (5.9%) had cholangiocarcinoma develop during follow-up.

CONCLUSION

Although incomplete stone removal and recurrence are common, peroral cholangioscopic lithotomy is a sufficiently safe and effective method for the treatment of hepatolithiasis.

Natural progression of untreated hepatolithiasis that shows no clinical signs at its initial presentation

GOALS

To elucidate the natural progression of hepatolithiasis that showed no signs at the time of initial presentation.

STUDY

Over a 17-year period, we observed 122 of 311 patients with hepatolithiasis who reported no symptoms and, thus, who received no treatment at initial presentation. The follow-up period was for up to 15 years (mean, 10.08 years).

RESULTS

Fourteen of 112 patients (11.5%) developed some symptoms attributed to hepatolithiasis. The interval until the onset of symptoms ranged from 9 months to 7.33 years (mean, 3.42 years ). The developing symptoms included abdominal pain, hepatic abscess, cholangitis, and cholangiocarcinoma. Nine of the 14 patients (64.3%) developed stone migration to the extrahepatic bile duct at the onset of clinical symptoms. The incidence of lobar liver atrophy on computed tomography in the patients with symptomatic hepatolithiasis (13 of 14 patients; 92.9%) was significantly higher than that in the patients with asymptomatic hepatolithiasis (14 of 108 patients; 13.0%). The prognosis of the patients with symptomatic hepatolithiasis were as follows: 2 died of cholangiocarcinoma, 1 died of hepatic failure, and 11 survived. Fifteen of asymptomatic patients died, but none of these deaths were attributed to hepatolithiasis.

CONCLUSIONS

Close observation is an alternative management at initial presentation for patients with asymptomatic hepatolithiasis without extrahepatic stones or lobar liver atrophy.

Long-Term Results of Hepaticojejunostomy for Hepatolithiasis

The results of a hepaticojejunostomy as a biliary-enteric bypass for benign disease are usually excellent. On the other hand, hepatolithiasis features a high rate of residual and recurrent stones with cholangitis after surgery. This study aims to evaluate the long-term results of a hepaticojejunostomy for hepatolithiasis regarding both the degree of the occurrence of postoperative cholangitis and the outcome. The clinical records of 159 patients with hepatolithiasis who underwent surgical treatment over a 23-year period were also retrospectively reviewed. Ninety-four of 159 patients underwent a hepatecetomy and 65 patients were subjected to liver-preserving surgery by means of intra- and postoperative endoscopic lithotripsy. In addition 72 patients underwent a hepaticojejunostomy. The rate of residual or recurrent stones was 31.4 per cent after complete stone removal. Twenty-two (30.6%) of the 72 patients developed some kind of cholangitis. This rate was significantly higher than that (three of 87 patients) of the non-biliary-enteric anastomosis group regarding the occurrence of biliary complications. We conclude that the use of a hepaticojejunostomy for patients with possible residual stones or intrahepatic bile duct lesions remains controversial.

Drug-associated cholelithiasis: a case of sulindac stone formation and the incorporation of sulindac metabolites into the gallstones

A case of drug-associated cholelithiasis (sulindac chlecystohepatolithiasis) in a 63-yr-old woman is reported. The patient was admitted to our hospital to undergo treatment for rheumatoid arthritis of 20 yr duration. She was treated with nonsteroidal anti-inflammatory drugs (NSAID: sulindac). Two months later, she presented with right upper quadrant pain. Diagnostic studies including ultrasonography (US), computed tomography (CT) and endoscopic retrograde cholangiography (ERC), led to the diagnosis of cholecystohepatolithiasis. She underwent cholecystectomy and choledochotomy with an extraction of intrahepatic stones. The intrahepatic stones were light yellow in color with a claylike appearance. Unexpectedly, an infrared spectroscopic analysis of the stone showed it to consist of sulindac metabolites. In addition, the dilated segment of the intrahepatic bile duct naturally returned to its normal size after the discontinuation of the drug administration. This is the first reported case of sulindac stone formation in the bile duct. No similar problems with other NSAIDs have been reported previously.

Subparietal hepaticojejunal access loop for the long-term management of intrahepatic stones

BACKGROUND

The subparietal hepaticojejunal biliary access loop is a recognized technique for the long-term management of primary intrahepatic stone disease. This paper assesses the results of this approach in a series of South African patients.

METHODS

Between 1985 and 1997, 21 patients, of mean age 34 (range 24-66) years, underwent surgical extraction of intrahepatic stones and formation of an hepaticojejunal access loop. The access loop was subsequently used for further stone removal and stricture dilatation. Patients were followed prospectively (median 47 months) and details of the number and type of procedures performed, stone clearance rates, morbidity and subsequent outcome were recorded.

RESULTS

The distribution of intrahepatic stones was left lobe in 13 of 21 patients, right lobe in one and bilateral in seven. Six patients underwent additional left lobectomy at the initial operation because of associated atrophy of the left lobe. Following operation, stone removal and/or stricture dilatation was performed on 97 occasions (median 4 (range 0-24) procedures per patient). Complete stone clearance was achieved in 17 of 21 patients with partial clearance in the remaining four. There were no major complications and no deaths associated with the procedures.

CONCLUSION

The subparietal access loop permits long-term access to the intrahepatic ducts allowing removal of stones and dilatation of strictures with minimal patient discomfort and low morbidity.

Hepatolithiasis and biliary parasites

Hepatolithiasis, or the presence of intrahepatic stones, is prevalent in East Asia and is characterized by the finding of stones within the intrahepatic bile ducts proximal to the confluence of the right and left hepatic ducts. Bile stasis and bacterial infection have been incriminated as the major aetiopathogenic factors. Clinical features include recurrent pyogenic cholangitis, multiple liver abscesses, secondary biliary cirrhosis and cholangiocarcinoma. The goals of management include accurate localization of pathologies, control of biliary sepsis and the elimination of stones and stasis. Ultrasonography, computed tomography and direct cholangiography complement each other in defining the stones, strictures and degree of liver damage. Non-operative biliary decompression by endoscopy and interventional radiology is effective in controlling the infection, but surgery remains the mainstay for the treatment of stones and strictures. Intra-operative ultrasound and flexible choledochoscopy, combined with percutaneous transhepatic cholangioscopy and intraductal lithotripsy, facilitate stone removal. Balloon dilatation and biliary stenting serve to open the bile duct strictures. The creation of a hepaticocutaneous jejunostomy after conventional surgery allows atraumatic access to the biliary system for the removal of recurrent stones. The management of biliary parasites begins with conservative measures, including analgesics and anti-helminthic therapy. In refractory cases or patients with acute cholangitis, endoscopic biliary drainage and the extraction of worms may be necessary. Improvement in sanitation plays a crucial role in the epidemiological control of these biliary diseases.

Recurrent pyogenic cholangitis or "oriental cholangiohepatitis' in occidentals: case reports of four patients

The first description of recurrent pyogenic cholangitis occurring in four occidentals is presented. While recurrent pyogenic cholangitis is a common syndrome of uncertain aetiology among orientals (also known as oriental cholangiohepatitis), it has not previously been described in occidentals. Four such patients are described. They presented with recurrent attacks of ascending cholangitis and associated hepatolithiasis, biliary stricturing and dilation. Focal hepatic involvement was treated by segmental liver resection and recurrent disease by interventional endoscopy or radiology.

Structure and composition of primary intrahepatic stones in Korean patients

We have analyzed the chemical composition of primary intrahepatic stones from 72 Korean patients. Two types of concretions have been identified: brown pigment (calcium bilirubinate) stones and black-colored mixed stones. Brown pigment stones were found in 68% of all cases and the remainder (32%) consisted of mixed stones. Intrahepatic mixed stones had mean cholesterol and bilirubin contents of 46.6% and 25.9%, respectively, whereas calcium bilirubinate stones had mean cholesterol and bilirubin contents of 14.1% and 43.6%, respectively. Intrahepatic mixed stones had a smooth black-colored surface and on cross section, exhibited a distinct outer shell surrounding an inner yellow, cholesterol-rich body. The finding of intrahepatic mixed stones with high cholesterol content suggests that primary hepatolithiasis may result from at least two different conditions or disorders and points to different approaches to their treatment.

Primary dual defect of cholesterol and bile acid metabolism in liver of patients with intrahepatic calculi

BACKGROUND/AIMS

Intrahepatic calculi, which are characterized by cholesterol-rich pigment stones, are highly prevalent in East Asia. Their pathogenesis remains unknown. To elucidate the etiological factors underlying the formation of cholesterol-supersaturated bile, which leads to the formation of cholesterol-rich pigment stones cholesterol and bile acid de novo syntheses in the liver were studied.

METHODS

Liver specimens were assayed for the catalytic activities and steady-state messenger RNA levels of 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase and cholesterol 7 alpha-hydroxylase.

RESULTS

The activity of HMG-CoA reductase, consistent with the messenger RNA level, was significantly higher in 13 patients with intrahepatic grown pigment stones (11.2 +/- 1.3 pmol.min-1.mg protein-1 [mean +/- SEM; P < 0.0001] for affected hepatic lobes and 13.4 +/- 1.7 [P < 0.0001] for unaffected ones [P < 0.0001]) than in 19 control subjects (6.4 +/- 0.4) and in 29 patients with gallbladder cholesterol stones (2.1 +/- 0.1). On the other hand, the activity of 7 alpha-hydroxylase, consistent with the messenger RNA level, was significantly lower in patients with intrahepatic brown pigment stones (2.8 +/- 0.5 pmol.min-1.mg protein-1 [P < 0.0001] for affected lobes and 2.6 +/- 0.5 [P < 0.0001] for unaffected ones) than in control subjects (6.0 +/- 0.6) and in patients with cholesterol stones (5.1 +/- 0.5).

CONCLUSIONS

In intrahepatic calculi, the formation of supersaturated bile and cholesterol-rich pigment stones may be attributed to the primary dual defect of up-regulated cholesterogenesis and down-regulated bile acid synthesis in the liver.

Histological evaluation of the intrahepatic biliary tree in intrahepatic cholesterol stones, including immunohistochemical staining against apolipoprotein A-1

Apolipoprotein A-1 is known to be one of inhibiting factors of cholesterol nucleation in bile, and decreased activity of apolipoprotein A-1 is considered to predispose cholesterol-supersaturated bile to formation of cholesterol crystals. To study the pathogenesis of the intrahepatic formation of cholesterol stones, we examined surgically resected liver specimens from six patients with intrahepatic cholesterol stones and compared the characteristic histopathological features with those of intrahepatic calcium bilirubinate stones, using morphological examination and immunohistochemical staining against apolipoprotein A-1. Morphologically, in all six patients with cholesterol stones the severity of chronic proliferative cholangitis with proliferation of the mucus-producing glandular elements in the walls of the large bile duct or periductal tissues was less extensive than that seen with calcium bilirubinate stones, and cholesterol crystals had formed in the septal and interlobular bile ducts. Immunohistochemically, unlike the normal liver and calcium bilirubinate stone-containing lobes, the hepatocytes and the epithelial lining of the bile ducts and peribiliary glands of the cholesterol stone-containing lobes did not react completely (some of the epithelial cells reacted only faintly) with apolipoprotein A-1 antibody. These findings suggest that an abundance of mucous substance and bacterial infection of the biliary tree may not be necessary for the formation of cholesterol stones, compared with findings in cases of calcium bilirubinate stones. We suggest that cholesterol crystals may be produced in the septal and interlobular bile ducts in the microenvironment of cholesterol-supersaturated bile and decreased activity of apolipoprotein A-1.

Complications of hepatolithiasis

Hepatolithiasis or intrahepatic stone is associated with a variety of complications of which biliary sepsis is one. Left untreated, infection results in formation of micro-abscesses, portal thrombophlebitis and fistulation into adjacent structures. With repeated infection, biliary strictures and severe destruction of liver parenchyma occur. Biliary cirrhosis, portal hypertension and bleeding varices are the terminal manifestations. Early recognition and proper treatment are essential for the prevention of severe complications and functional deterioration.

Relative prevalence of gallstone diseases in Taiwan. A nationwide cooperative study

For many years, it has been said that Taiwan has the highest relative prevalence of hepatolithiasis among the Asian countries. To confirm this, and to reevaluate the chronological changes regarding gallstone disease in Taiwan, a retrospective nationwide cooperative study was conducted in this country. A total of 17,182 patients from 28 medical centers are included in this survey. A gradual increase during the past 20 years in gallstone prevalence with a concomitant decrease of choledocholithiasis and hepatolithiasis are well demonstrated. Both nutritional and environmental factors are involved in these changes. With respect to hepatolithiasis, Taiwan continues to have the highest prevalence among Asian countries, and 20% may be the average figure for the whole country.

Intrahepatic biliary stones in children

Intrahepatic biliary stones in seven non-Oriental patients were studied in all by sonography, in four patients by computed tomography and in four patients by percutaneous transhepatic cholangiography. For patients had extrahepatic biliary atresia treated with portoenterostomies, one patient had undergone partial liver transplantation and of the remaining two, one had cystic fibrosis and the other immunodeficiency syndrome. All sonograms were abnormal and showed echogenic foci within the liver, with or without associated signs of biliary tract dilatation. CT confirmed the biliary tract dilatation yet calculi were identified in one patient only. PTC was particularly helpful in the patient with immunodeficiency in whom features typical of sclerosing cholangitis were found. This report emphasizes the variable radiological appearance of bile stones which to our knowledge have rarely been described in children with entities other than Oriental cholangitis.

Mucosal dysplasia of the liver and the intraductal variant of peripheral cholangiocarcinoma in hepatolithiasis

Four cases are reported of the intraductal variant of peripheral cholangiocarcinoma among surgical specimens from 32 cases of hepatolithiasis. The cancers arose from the periphery of the stone-containing bile duct and spread chiefly along the luminal surface. Microscopically, these tumors showed papillary proliferation and therefore were diagnosed as the intraductal spreading type of peripheral cholangiocarcinoma. Mucosal dysplasia also was noticed in the vicinity of the tumors. In six other cases, mucosal dysplasia was observed in the periphery of the stone. Immunohistochemically, anti-CA 19-9 staining was observed diffusely in the cytoplasm of dysplastic lesions and carcinomas. Anti-carcinoembryonic antigen staining was restricted to the luminal surface and/or the supranuclear region of the cytoplasm in carcinomas. It was not identified in dysplastic cells. These results suggest that the mucosal dysplasia occasionally observed near stones is a precursor of the intraductal spreading type of peripheral cholangiocarcinoma in the presence of hepatolithiasis. The authors hypothesize that the lining epithelium of the large bile duct, when persistently exposed to biochemically altered bile, may undergo a carcinomatous transformation through a stage of mucosal dysplasia.

Mucosal dysplasia of the liver and the intraductal variant of peripheral cholangiocarcinoma in hepatolithiasis

Four cases are reported of the intraductal variant of peripheral cholangiocarcinoma among surgical specimens from 32 cases of hepatolithiasis. The cancers arose from the periphery of the stone-containing bile duct and spread chiefly along the luminal surface. Microscopically, these tumors showed papillary proliferation and therefore were diagnosed as the intraductal spreading type of peripheral cholangiocarcinoma. Mucosal dysplasia also was noticed in the vicinity of the tumors. In six other cases, mucosal dysplasia was observed in the periphery of the stone. Immunohistochemically, anti-CA 19-9 staining was observed diffusely in the cytoplasm of dysplastic lesions and carcinomas. Anti-carcinoembryonic antigen staining was restricted to the luminal surface and/or the supranuclear region of the cytoplasm in carcinomas. It was not identified in dysplastic cells. These results suggest that the mucosal dysplasia occasionally observed near stones is a precursor of the intraductal spreading type of peripheral cholangiocarcinoma in the presence of hepatolithiasis. The authors hypothesize that the lining epithelium of the large bile duct, when persistently exposed to biochemically altered bile, may undergo a carcinomatous transformation through a stage of mucosal dysplasia.

Hepatolithiasis in East Asia: comparison between Japan and China

The incidence of hepatolithiasis is high throughout East Asia compared with the West, but the marked difference in the relative proportion of hepatolithiasis to all cholelithiasis cases exists even among countries of similar ethnic backgrounds. A retrospective study of cases was conducted in two areas in China with the aim of clarifying the presence of such regional difference in China itself. The relative proportion of hepatolithiasis was 21.2% in Shenyang, 9.2% in Beijing and 4.1% in Fukuoka, Japan. A significant difference in the location of stones was also found between Shenyang, Beijing and Fukuoka. Intra- and extrahepatic hepatolithiasis in all hepatolithiasis cases was 95% in Shenyang and 75% in Beijing. Involvement of both hepatic lobes was found in 73% in Shenyang and less than 60% in the other two, suggesting that hepatolithiasis of the old form or of an advanced stage still lingers in Shenyang. In conclusion, regional differences in the proportion and the type of hepatolithiasis exist in China itself, as well as in the Chinese population in Taiwan, Hong Kong and Singapore, as previously reported. The possible contribution of environmental factors to the occurrence of hepatolithiasis is again emphasized.

Balloon dilatation of intrahepatic biliary strictures for percutaneous extraction of residual intrahepatic stones

Intrahepatic ductal strictures in cholangiohepatitis present an obstacle to successful removal of retained ductal stones via T-tube tracts. We studied the effectiveness of stricture dilatation for stone removal. Fifteen patients with intrahepatic gallstones retained behind strictures underwent balloon dilatation of their strictures to allow stone extraction. All had prior surgical T-tube placement allowing percutaneous access. Balloon dilatation was successful in reducing or eliminating strictures in 86.7% (13 of 15 patients), and complete stone extraction after the successful dilatation was possible in 76.9% (10 of 13 patients). The reasons for failure were impacted stones and acute ductal angulation which prevented passage of catheters. It is concluded that balloon dilatation of intrahepatic biliary strictures is an effective adjunct for extraction of intrahepatic biliary calculi associated with recurrent pyogenic cholangiohepatitis.

A clinicopathological study on intrahepatic cholesterol gallstones

In order to clarify the pathogenesis and process of the formation of intrahepatic cholesterol gallstones, we examined the clinical features, cholangiograms and pathological findings of eight patients with intrahepatic cholesterol gallstones. When examining the clinical features, one patient was found to have developed intrahepatic cholesterol gallstones 3 years after a complete lithotomy. The cholangiograms of two patients revealed small gallstones in the peripheral bile ducts of the lateral segment of the liver, and these bile ducts showed localized cystic dilatation and were tightly filled with gallstones. Conversely, their other bile ducts which contained no gallstones showed an entirely normal cholangiogram. Pathologically, these two cases showed mild chronic cholangitis, and cholesterol crystals in the peripheral bile ducts. The other six cases showed moderate or severe dilatation of the bile duct and severe chronic proliferative cholangitis. From the above results, we proposed the following theory to explain the pathogenesis and process of the formation of intrahepatic cholesterol stones: The cholesterol crystals in the peripheral intrahepatic bile ducts may be a primitive form of intrahepatic cholesterol gallstones, and the formation of intrahepatic cholesterol gallstones may precede and cause such deformities of the bile ducts as strictures or dilatations.

Bilateral intrahepatic lithiasis without extrahepatic bile duct stones

Bilateral intrahepatic lithiasis is a rare condition, and for this reason a nationwide survey was conducted. Reports on 675 patients with bilateral intrahepatic lithiasis over a 10-year-period were collected. Among these, 258 patients with bilateral intrahepatic lithiasis having no extrahepatic bile duct stones were analyzed. The peak incidence was seen in the fourth to sixth decades. Males and females were equally effected. The stones removed were mainly calcium bilirubinate stones (75.6%). The main clinical symptoms were abdominal pain, fever and jaundice. Charcot's triad was seen in 29.7%, while 12.4% of the patients had no symptoms. Visualization of each segmental duct of the liver by direct cholangiography was excellent in this survey and ranged from 88 to 97.3% of the patients. The most frequent site of stones was the left hepatic duct (60.1%). The site of bile duct dilatation coincided with the location of stones. The most common sites of stenosis were the central part of the lateral segmental duct (32.5%) and the left hepatic duct (37.6%). Hepatic resection was employed in 49.2% of the patients, and drainage procedures were added in 95.6%. Follow-up studies of 236 patients treated by surgery revealed good results in 67.4%, fair in 13.6%, and poor in 7.6%. In these patients, however, endoscopic lithotomy was often employed intra- and/or post-operatively. Conducting hepatic resection, with adequate biliary drainage procedure and cholangiofiberscopic lithotomy may help to improve the therapeutic results of bilateral intrahepatic lithiasis.

The role of bacteria in gallbladder and common duct stone formation

Debate continues as to the role that bacteria play in gallstone pathogenesis in Western countries. We therefore, examined gallbladder and common duct stones from 67 consecutive patients undergoing cholecystectomy and/or common bile duct exploration. Bile was cultured and stone cholesterol content was measured. Stones were examined by scanning electron microscopy (SEM) for bacteria. Individual calcium salts were classified by windowless energy-dispersive x-ray microanalysis. Gallbladder stones in 65 patients were identified as cholesterol in 46 (71%), black pigment in 17 (26%), and brown pigment in 2 patients (3%). Common bile duct stones from ten patients were cholesterol in 4, black pigment in 2, and brown pigment in 4 patients. The five patients with brown pigment stones were significantly (p less than 0.05) older, more likely to be men and to present with bile duct obstruction. Bile cultures were positive in 13% of patients with cholesterol stones, in 14% of those with black pigment stones, and in all of the patients with brown pigment stones (p less than 0.001). By SEM, bacteria were observed only within the calcium bilirubinate-protein matrix of brown pigment stones (p less than 0.001). In comparison to black pigment stones, brown stones were more likely to contain calcium palmitate (p less than 0.005) and cholesterol (p less than 0.001). We conclude that black and brown pigment stones have different pathogenic mechanisms and that bacterial infection is important only in the formation of brown pigment stones.

The effect of decreased portal blood flow on the biliary system

A disturbance in the regional portal blood flow adjacent to the dilated bile duct in the liver is often observed in patients with hepatolithiasis. The effects of this disturbed portal blood flow on the biliary system, with or without cholangitis, were therefore investigated. Young rabbits were divided into the following four groups; (1) controls that had a laparotomy only (n = 3), (2) those that had a ligation of the portal branch of the right posterior lobe (RP lobe) (PL) (n = 10), (3) those that had tubing inserted into the bile duct through the duodenal papilla (BS) (n = 10), and (4) PL + BS (n = 10). Despite marked atrophy of the RP lobe, no distinct changes were seen in the biliary systems of groups 1 or 2. In groups 3 and 4, however, infiltration of inflammatory cells and glandular proliferation in the wall of the markedly dilated extrahepatic bile duct (proliferative cholangitis (PC), characteristic to hepatolithiasis) were seen. Findings of PC were also noted in the intrahepatic bile duct of the atrophied RP lobes of these 2 groups. The incidence of PC was 20 per cent in group 3 and 60 per cent in group 4, respectively, but the PC of the intrahepatic bile ducts in group 3 was more localized than in group 4. Goblet cell metaplasia was seen in the epithelial cells of PC. Bacteriologically, bile samples were aseptic in groups 1 and 2, however, samples of bile from groups 3 and 4 were all contaminated with Escherichia coli or Streptococcus Faecalis. The biliary contents of phospholipids, total cholesterol and total bile acid were significantly decreased in groups 3 and 4, when compared with groups 1 and 2. In conclusion, a disturbance in portal blood flow, accompanied by cholangitis and segmental liver atrophy, may play an important role in the clinical course of hepatolithiasis.

Childhood recurrent pyogenic cholangitis

Recurrent pyogenic cholangitis (RPC) is characterized by repeated attacks of bacterial infection of the biliary tract by enteric organisms resulting in formation of strictures and stones in the intrahepatic as well as the extrahepatic bile ducts. Between 1973 and 1984, we managed ten children with RPC. Presentation was acute, septicemia being invariably present. Four children responded to vigorous intravenous (IV) fluid and antibiotic therapy; of these, three subsequently required elective transduodenal sphincteroplasty. Six children required emergency biliary tract decompression surgically and three of them also had concomitant definitive drainage procedures (transduodenal sphincteroplasty, two; supraduodenal choledochoduodenostomy, one). The other three had T-tube drainage initially followed by elective drainage procedures (transduodenal sphincteroplasty, one; supraduodenal choledochoduodenostomy, two). At exploration, pigment stones and/or mud were invariably present in the bile ducts. One child required reexploration for hemostasis following sphincteroplasty, and one child died from septicemia and respiratory failure following operation. The rest are well, having been followed for 3 to 12 years. Major advances in recent years include (1) endoscopic retrograde cholangiopancreatography (ERCP) for accurate definition of the biliary tract and confirmation of the presence and location of stones during the quiescent phase, (2) the intraoperative choledochoscopic extraction of intrahepatic and extrahepatic stones, and (3) postoperative stone removal via the T-tube tract.

Composition of intrahepatic calculi. Etiological significance

Gallstones in intrahepatic (N = 42) and extrahepatic (N = 22) bile ducts and gallbladder (N = 23) were subjected to chemical analysis modified to suit the analysis of brown pigment stones with the aim of determining if stone location at surgery influenced stone composition. Dimethylsulfoxide-acetone-1 N HCl (90:9:1, v/v/v) was used to dissolve gallstone specimens. Intrahepatic calculi were divided into two groups, ie, nine cholesterol stones and 33 brown pigment stones. Cholesterol stones in the intrahepatic bile ducts had a similar composition to those in the gallbladder and extrahepatic bile ducts, suggesting a similar pathogenesis wherever formed throughout the biliary tract. Intrahepatic brown pigment stones contained significantly less bilirubin (P less than 0.001) and more cholesterol (P less than 0.05) by chi-square analysis than brown pigment stones found in the extrahepatic bile ducts, suggesting that the site of formation affects stone composition and modifies stone pathogenesis.

Clinical experience of intrahepatic cholangiocarcinoma associated with hepatolithiasis

Between 1960 and 1986, seven patients with intrahepatic cholangiocarcinoma and one patient with intrahepatic bile duct adenoma, related to hepatolithiasis, were seen among 112 cases of hepatolithiasis. Histopathologically, the tumors associated with hepatolithiasis arose from the periphery of the stone-containing bile duct, spread chiefly along the luminal surface, and invaded the ductal wall or periductal tissue. The tumors showed papillary to papillo-tubular proliferation and were diagnosed as the intraductal or periductal spreading type of cholangiocarcinoma. In addition, atypical epithelial hyperplasia was noted in the vicinity of the tumor area. These findings suggest that chronic relapsing cholangitis in patients with hepatolithiasis can induce progressive changes to atypical epithelial hyperplasia which may develop into cholangiocarcinoma.

Human biliary beta-glucuronidase: correlation of its activity with deconjugation of bilirubin in the bile

Total and conjugated bilirubin contents of gall-bladder and hepatic biles before and after 24-h incubation at 37 degrees C and beta-glucuronidase activity of hepatic biles were determined in forty-eight patients divided equally into four groups: no stones or control (C), cholesterol stones (CS), black pigment stones (black PS), and brown pigment stones (brown PS). The percent conjugation of bilirubin is lower in gall-bladder biles and hepatic biles after incubation, particularly in black PS and brown PS, when compared with hepatic biles before incubation. Mean endogenous beta-glucuronidase activities at pH 5.2 were 12.0, 15.5, 44.5 and 147.7 nmol min-1 ml-1 for C, CS, black PS, and Brown PS, respectively, which correlated well with the degree of deconjugation of bilirubin in gall-bladder and hepatic biles and with the rate of deconjugation of hepatic bile incubated at 37 degrees C. Only four biles in brown PS exhibited bacterial enzyme activity. We concluded that though bacterial beta-glucuronidase might be responsible for deconjugation of bilirubin in some patients in brown PS, endogenous biliary beta-glucuronidase could play a key role in the pathogenesis of pigment cholelithiasis.

Intrahepatic calculi associated with cholangiocarcinoma

A unique case of hepatolithiasis associated with cholangiocarcinoma is described. The intrahepatic calculi consisted mainly of cholesterol rather than calcium bilirubinate. A bacteriological study of the intrahepatic and gallbladder bile was negative, though bacterial infection of the bile duct has been considered a main factor responsible for formation of intrahepatic calculi.

Changes in biliary lipid concentrations in bile duct obstruction: an experimental study

Changes in biliary concentrations of bile acids, phospholipids and cholesterol and biliary pressures were measured in dogs. These parameters were studied during 7-day periods of partial biliary obstruction, of varying degrees, and after 24-hour and 48-hour periods of complete obstruction. The sample were obtained via an exteriorized but intact enterohepatic circulation allowing the introduction of varying degrees of obstruction and bile sampling. Biliary obstruction reduced the concentration of all biliary lipids especially when the obstruction produced pressures in excess of 75% of the maximum biliary secretion pressure. Only immediately after the release of a 48-hour period of complete obstruction did the risk of cholesterol supersaturation of bile occur. However, at that time there was a greatly reduced concentration of lipids in the bile and the amount of cholesterol that could potentially have precipitated was very small. It is suggested that this supersaturation would not play a significant role in the formation of gallstones.

Pigment gallstone composition in patients with hemolysis or infection/stasis

The effect of hemolysis and infection/stasis on pigment gallstones was assessed by comparing the composition of stones from (1) U.S. patients without hemolysis or cirrhosis, (2) U.S. patients with sickle cell disease, and (3) Japanese patients with biliary infections. Gallstone composition was quantitated by infrared spectroscopy and chemical analyses. Gallstones from patients with sickle cell anemia contained more pigment, carbonate, calcium, and measured components than stones from U.S. patients without hemolysis (P less than 0.05). However, the similar types of calcium salts in black stones from patients with and without sickle cell anemia suggested that intermittent hemolysis may be a potential mechanism in the formation of black stones found in the general population. In Japanese patients with brown pigment stones, there was an absence of calcium carbonate, low levels of calcium phosphate, and the presence of calcium salts of fatty acids (P less than 0.05). Thus, the accompanying stasis and/or infection in this latter group was associated with the formation of a distinctive stone type and was not involved in the formation of the black stones. The similarly small proportion of cholesterol in each of these groups suggested that it was present due to coprecipitation rather than to cholesterol supersaturation.

Postoperative flexible choledochoscopy for residual primary intrahepatic stones

Postoperative flexible choledochoscopy was carried out in 103 patients with residual biliary calculi. Forty-one patients had residual stones in the common duct, and 63 patients had residual stones in the intrahepatic ducts with or without stones in the common duct. The majority of the intrahepatic stones were primary stones. Postoperative choledochoscopy was very effective in removing residual common duct stones (95% removed, no morbidity). For intrahepatic stones, removal was more difficult and was associated with a higher morbidity (11.2%). Stone extraction through the stenotic intrahepatic ducts was made possible by the balloon dilatation of the ducts. Repeated endoscopic access to the biliary system was made easier by the construction of a hepatico-cutaneous-jejunostomy, which also provides a route to the biliary tree for future stone removal if stone reformation occurs. Complimented by these procedures, postoperative choledochoscopy was successful in removing the residual intrahepatic stones in 82.3% of the patients. At a median follow-up of 17 months, the majority of the patients who had all the stones removed as well as those who had stones left behind were symptom free.

Hepatolithiasis in East Asia. Retrospective study

Hepatolithiasis is a major disease in Asia but differences in operative incidence between countries have not been examined. A retrospective study was conducted in Taiwan, Hong Kong, and Singapore, and the results were compared with those in Japan with the aim of defining factors involved in the etiology of the condition. In order to ensure uniformity of the data collected, the same form was used throughout the study and was completed by the same personnel after reviewing the patient's record and radiographs in each case. The years 1976-1980 were chosen for the study, since the newer methods of diagnosis such as ultrasound, endoscopic retrograde cholangiography, and percutaneous transhepatic cholangiography became available during that period. The most significant finding was the difference in the relative prevalence of hepatolithiasis as a proportion of all gallstone cases in Taiwan, Hong Kong, and Singapore, where the majority of the population consisted of patients of Chinese descent. The highest prevalence, 53.5%, was found in Taiwan, while in Hong Kong it was 3.1% and in Singapore 1.7%. Environmental rather than ethnic factors are implicated in the cause of hepatolithiasis.

Long-term results of surgical treatment for intrahepatic stones

One hundred and nineteen patients with intrahepatic stones treated surgically in Nagasaki University Hospital from 1969 to 1984 were reviewed. The patients were divided into four types according to location of the stones and the presence or absence of stenotic lesions and/or localized dilatation of the intrahepatic bile ducts. Types I and II patients were treated with choledocholithotomy or choledochojejunostomy, while type III patients underwent hepatic resection and type IV patients were treated by partial hepatic resection with bilioenteric anastomosis, including extended hepatico-choledochojejunostomy. The majority of operative or early deaths belonged to type IV and residual stones were present in almost all patients. The long-term results for the 88 patients revealed that the rate of improvement was 100 per cent for type I, 87 per cent for type II, 83 per cent for type III and 84 per cent for type IV. In type IV, the most excellent results (92 per cent) were obtained by extended hepaticocholedochojejunostomy, especially with hepatectomy. It is suggested that extended hepaticocholedochojejunostomy with partial hepatic resection is a reasonable procedure for treating patients with type IV intrahepatic stones.