This document summarizes information about intrahepatic duct (IHD) stones. IHD stones are most common in East Asia and can cause abdominal pain or jaundice. Treatment aims to completely remove stones and prevent further attacks. For difficult bilateral stones, percutaneous transhepatic cholangioscopy with lithotripsy can be used to clear sectors over multiple procedures. Hepatectomy may be indicated for unilateral disease, strictures, atrophy or suspected cancer. Recurrence rates are high but choledochoscopic laser lithotripsy combined with surgery achieved 93.3% stone clearance in one study, higher than conventional methods. Complete clearance with drainage restoration is needed to minimize recurrence.

1. IHD stone
Kusuma Chinaroonchai,MD.
GenB Conference
7-01-2013

2. Definition
• Any stone that proximal to confluence of right
and left intrahepatic duct

3. Incidence
• Rare disease in Western
• High prevalence in East Asia
Prakash K et al. Multidisciplinary approach in the long-term management of intrahepatic
stones: Indian experience. Indian journal of gastroenterology : official journal of the Indian
Society of Gastroenterology. 2004;23(6):209-13.

4. Classification
• By location
– Right side (R)
– Left side (L) Most common
– Left and Right sides (LR)
– Caudate lobe (C)
Blumgart's Surgery of the Liver, Pancreas and Biliary Tract (5th Edition)

5. Type of stone
• Calcium bilirubinate stone (bilirubin + Chol +
Fatty acid + Ca) “brown pigmented stone”
• Cholesterol stone

6. Risk Factor
• Biliary stasis eg. Stricture of biliary
anastomosis
• Bacterial infection
• 3-18% progress to intrahepatic
cholangiocarcinoma

7. Symptoms&Signs
• 16% Asymptomatic
• Most common is RUQ abdominal pain
• Others are jaundice fever etc.

8. Imaging
• USG : Hyperechoic lesion with posterior
acoustic shadows or duct dilatation
• CT : Hyperdensity lesion at plane CT, evaluate
degree of affected lobe atrophy, other
complication from stone eg. Abscess, CA,
PortalHT
• MRCP : Location of stones

9. CT character suspected CA
• 1) presence of periductal soft-tissue density
• 2) higher enhancement of the duct than
adjacent bile duct on portal venous phase
images
• 3) ductal thickening
• 4) portal vein obliteration
• 5) lymph node enlargement

10. Treatment
• Main purposes
– Complete removal of the stones
– Preventing from further attacks of cholangitis
– Controlling disease progression to biliary cirrhosis

11. Treatment
• Asymptomatic: intervention >> controversy
• Acute obstructive suppurative cholangitis
>> Emergency PTBD
• Difficult bilateral intrahepatic stone
– 1.PTBD to left hepatic duct
– 2.Dilated tract step by step from 6-Fr to 16-Fr catheter
– 3.CT post PTBD 2 weeks evaluate pathological change
of liver (atrophy or stricture >> Sx)
– 4.Cholangioscopic lithotripsy in preserved sectors

12. Treatment

13. Article Informations
• Study design
– Retrospective case control study
• Study group
– 1 Jan 1971 – 31 Dec 2000 all patients with
cholelithiasis
– 89 patients hepatolithiasis

14. Article Informations
• Classification
• 1.Relative to liver
– I type: intrahepatic
– E type: extrahepatic
– IE type: intrahepatic + extrahepatic
• 2.Location in liver
– L type: left lobe
– R type: Right lobe
– LR type: Both lobes

15. Article Informations
• Treatment
– Hepatectomy
– Cholangioenterostomy
• Choledochojejunostomy
• Choledochoduodenostomy
– T-tube insertion
– Percutanous transhepatic cholangioscopic
lithotripsy (PTCSL)

16. Article Informations
• Evaluate post procedure residual stone
– Cholangiography
– Cholangioscopy

17. Results

18. Results

19. Results

20. Results
• 18 Lateral
segmentectomies
(L type)
• 13 Left lobectomy
– 10 from L type
– 3 from LR type
• 1 extended left
lobectomy (L type)
• 2 Right lobectomy (R
type)

21. Results

22. Discussion
• 4.2-9.5% recurrence stone post hepatectomy
• 36.4% recurrence stone post PTCSL
• Complete stone removal, but bile duct
stricture remained unchange
• Ho-YAG laser lithotripsy high success rate(3
cases)
• ESWL in cholesterol stone(bewared
suppurative cholangitis)

23. Summary
• Indication for hepatectomy
– Unilateral lobe
– Containing stone bile duct markedly constrict or
dilated
– Combination with suspected intrahepatic bile duct
carcinoma
– Complications: abscess, atrophy

24. Summary

25. Laser Lithotripsy

26. Article Informations
• Study design
– Retrospective review study
• Study group
– July 2009 – Oct 2012 all patients with
cholelithiasis
– 45 patients hepatolithiasis who had undergone
choledochoscopic FREDDY laser lithotripsy
combined with or without hepatectomy in
Hepatobiliary and Pancreatic Surgery Center

28. Methods
• 48 patients got conventional methods
• 45 patients got CBD exploration who received
choledochoscopic FREDDY laser lithotripsy
therapy.
• Laser pulses of 1.2 μs were applied at a
repetition rate of 10-15 Hz (wavelengths of
532 nm and 1064 nm as a double pulse was
applied with pulse energy of 120 mJ)

29. Methods
• 12 patients received hepatectomy
• Indication hepatectomy
– Severely narrowed intrahepatic bile duct is not
successful insert the scope
– Atrophy of liver lobe
– Clinically suspected cholangiocarcinoma

30. Methods
• Routinely T-tube placed in CBD post op
• Removed 2 Mth post op when no stone left
(T-tube cholangiography)
• Residual stone: detected IHD stone in 3 mth
post op

31. Statistic Analysis
• Chi-square test and Student's t test, using
SPSS software for Windows (Statistical Product
and Service Solutions, version 18.0, SPSS
Inc., Chicago, IL., USA).

32. Results
• 45 patients in laser group
– 42 complete stone fragmentation with IHD
clearance (93.3%)
– 3 failed (impacted stone in both lobes, bile duct
stricture and biliary cirrhosis)
– 5 segmental hepatectomy of the right liver
– 7 left lateral hepatectomy
– 1 cholangiocarcinoma with negative margins,

33. Results

34. Results
• 48 patients in conventional group
– 41 complete stone fragmentation with IHD
clearance (85.4%)
– 6 segmental hepatectomy of the right liver
– 12 left lateral hepatectomy
– 1 cholangiocarcinoma with negative margins,

35. Complications
• 45 patients in laser group
– 2 Hemobilia
– 3 Acute cholangitis
• 48 patients in conventional group
–
–
–
–
3 Intraop hemorrhage
1 Leakage (placed drain)
6 Acute cholangitis
1 Died (liver failure from cirrhosis)

36. Results

37. Discussion
• High rate of treatment failure & recurrence in
IHD stone
• Removed all stone, correct stricture to
promote adequate drainage
• The percutaneous approach of Nd:YAG laser
lithotripsy is difficult to resolve hepatolithiasis
completely when it occurs in both liver lobes

38. Discussion
• Bilateral intrahepatic stones + absence of
intrahepatic bile duct stricture + absence liver
atrophy >> choledochoscopic FREDDY laser
lithotripsy.
• In cases with stricture and atrophy >> still
need Ix

39. Prognosis
• 6.6% High overall recurrence rate
– 5.3% Hepatectomy
– 8.3% Choledochojejunostomy
– 6.4% Choledochotomy followed by
cholangioscopic lithotomy
– 9.6% PTCS
Blumgart's Surgery of the Liver, Pancreas and Biliary Tract (5th Edition)

40. Thank You
For
Your good attentions