What are the management options for hepatolithiasis?

Management of Hepatolithiasis

Hepatolithiasis management requires a multidisciplinary approach with surgical resection being the most definitive treatment for localized disease, while endoscopic and percutaneous techniques are valuable alternatives for patients who are poor surgical candidates or have diffuse disease. 1, 2

Risk Factors and Epidemiology

• Hepatolithiasis is more prevalent in East Asian countries but incidence is increasing in Western countries 2
• Associated with recurrent cholangitis, biliary strictures, and liver abscess 1
• 5-10% of patients with hepatolithiasis may develop intrahepatic cholangiocarcinoma (iCCA) 1
• Risk factors for malignant transformation include:
  • Older age, smoking, family history of cancer
  • Long symptom duration, bile duct strictures
  • Liver atrophy, left-sided stone location
  • Residual/recurrent stones
  • History of choledocho-enterostomy 1

Diagnostic Approach

• Ultrasound is the first-line imaging modality for initial evaluation 3
• CT scan can identify stones, strictures, and liver atrophy
• MRCP provides detailed biliary anatomy and identifies strictures
• Laboratory assessment including liver function tests to evaluate complications 3
• Tumor biopsy is recommended if cholangiocarcinoma is suspected 1

Management Options

1. Surgical Management

• Hepatectomy (partial liver resection):
  • Most definitive treatment for localized disease
  • Indicated for recurrent, troublesome, localized disease affecting specific liver segments 4
  • Immediate stone clearance rates of 65.9-81.5% after unilateral or bilateral hepatectomy 4
  • Can reach 81.7-85.2% clearance when combined with postoperative choledochoscopic lithotripsy 4
  • Offers low long-term stone recurrence rate and good survival 4
  • Should be considered in cases of:
    • Single lobe hepatolithiasis
    • Atrophy of affected liver
    • Stricture duration >10 years
    • Long history of biliary-enteric anastomosis 1

2. Laparoscopic Approaches

• Laparoscopic hepatectomy (LH):

  • Complete stone clearance achieved in up to 94.6% of cases 5
  • Less trauma, reduced blood loss, faster recovery compared to open surgery 6

• Laparoscopic intrahepatic duct exploration (LIDE):

  • Stone clearance rate of approximately 78% 5
  • Option for patients with stones but without significant liver atrophy

3. Endoscopic Management

• Endoscopic retrograde cholangiopancreatography (ERCP):

  • Stone clearance rate of approximately 67.4% 5
  • Less invasive but higher recurrence rates compared to surgical options
  • May be first-line for elderly or high-risk surgical patients

• Peroral cholangioscopy (POC) with SpyGlass™:

  • Technical success in 71.4% of cases
  • Clinical success in 57% of cases 7
  • Allows for direct visualization and targeted lithotripsy
  • Can be combined with electrohydraulic lithotripsy (EHL)

4. Percutaneous Approaches

• Percutaneous transhepatic cholangioscopic lithotomy (PTCSL):
  • Option when endoscopic approaches fail or are not suitable 6
  • Allows access to intrahepatic ducts not accessible by ERCP

Treatment Algorithm

1. Asymptomatic patients:

   • Close monitoring if no complications present
   • Consider intervention if high risk for malignancy

2. Symptomatic patients:

   • Localized disease (single lobe): Hepatectomy (open or laparoscopic) is preferred
   • Diffuse disease (bilateral):
     • Good surgical candidate: Consider bilateral hepatectomy with intraoperative choledochoscopy
     • Poor surgical candidate: Endoscopic (ERCP, SpyGlass) or percutaneous approaches

3. Complicated cases (with strictures, atrophy, or suspected malignancy):

   • Hepatectomy is strongly recommended to prevent progression to cholangiocarcinoma

Outcomes and Follow-up

• Recurrence rates after treatment:

  • Stone recurrence: 26.6% after 5 years 5
  • Recurrent cholangitis: 24.2% after 5 years 5

• Risk factors for poor outcomes:

  • Biliary strictures
  • Stones in both lobes
  • Non-hepatectomy treatments
  • Sphincter of Oddi dysfunction
  • Residual stones 5

• Long-term follow-up is essential as cholangiocarcinoma is an independent prognostic factor for survival 1

Important Considerations

• The association between hepatolithiasis and cholangiocarcinoma is well-documented, with iCCA occurring in 5-10% of patients with hepatolithiasis 1
• Evidence regarding hepatectomy for preventing cholangiocarcinoma shows conflicting results, with some studies showing risk reduction and others showing no difference 1
• Management decisions should be made by a multidisciplinary team including hepatobiliary surgeons, interventional radiologists, and advanced endoscopists 7