Choledocholithiasis occurs in 5 to 10% of patients
with gallstones and up to 18% of patients with gallstone pancreatitis. An
estimated 21 to 34% of stones migrate spontaneously from the bile duct, and up
to 25 to 36% are at risk of causing pancreatitis or cholangitis if obstructed.
Treatment algorithms have been considered, including endoscopic retrograde
cholangiopancreatography (ERCP) before cholecystectomy, intraoperative ERCP,
and postoperative ERCP. However, 5 to 10% of these procedures may fail due to
difficult access or inability to remove the stones. Stones considered difficult
include those larger than 15 mm that cannot be captured in a basket, stones
located in the intrahepatic biliary tract, stones associated with chronic
biliary tract stricture, stones present in patients undergoing surgeries that
modify the continuity of the proximal digestive tract (Billroth II gastrectomy
or gastric bypass), and stones in patients with Mirizzi syndrome. These
conditions drastically reduce the possibility of minimally invasive therapies.
For example, residual stones have been reported in 5 to 14% of cases treated
with laparoscopic biliary tract exploration [4-7]. Patients with
hepatolithiasis often have concomitant extrahepatic gallstones. Therefore, in
these cases, biliary exploration and stone extraction. Conventional
choledochotomy requires dissection of the common bile duct; however,
choledochotomy can be easily completed through the common bile duct stump [7].
Li R, [8] assert that biliary exploration through the
left bile duct (LHD) stump can be safely performed in left-sided
hepatolithiasis. Furthermore, the LHD approach was associated with comparable
intraoperative outcomes and shorter postoperative hospitalization compared with
the CBD approach, and did not increase the incidence of stone recurrence.
Therefore, hepatolithiasis refers to primary stones found above the confluence
of the left and right hepatic ducts, and its main part is brown bile pigment
stones. Hepatolithiasis is a disease with regional characteristics. Its
incidence in Asia is higher than in Europe and America. In recent years, Japanese
literature has reported a downward annual incidence of hepatolithiasis, but the
outlook in China is still not optimistic, where the incidence in the population
ranges between 2 and 25%. According to the literature, the incidence of
intrahepatic cholangiocarcinoma in patients with hepatolithiasis is 1 to 23%,
and that of liver cirrhosis in patients with hepatolithiasis is 4 to 14%.
Therefore, early diagnosis of hepatolithiasis and proper treatment methods for
intervention are useful in reducing the incidence of complications, improving
the prognosis, and improving the median survival of patients. Currently, there
is no exact explanation for the etiology of hepatolithiasis. National and
international studies suggest that it may be related to lifestyle, biliary
bacterial infection, biliary parasite infection (Clonorchis sinensis), biliary
anatomical variation, genetic mutation, and abnormal gene expression, among
others [9]. Treatment of hepatolithiasis consists of stone extraction plus
adjuvant drug therapy. Cholangitis usually coexists with hepatolithiasis;
therefore, antibiotic therapy is necessary. For nonsurgical stone extraction,
PTCL or ERCP is used. Although a noninvasive approach is a promising treatment,
the recurrence of hepatolithiasis is 20% and is not showed in all cases. For
example, when hepatolithiasis coexists with bile duct strictures, which occurs
in 40% of cases, the recurrence rate in these patients after PTCL or ERCP
reaches 51%. In contrast, the recurrence rate of hepatolithiasis after surgical
treatment ranges from 6% to 14%. In 93% of surgical cases, no residual stones
are still, and when the surgical procedure is combined with the noninvasive
method, the percentage of stone-free patient’s increases to 96%.
On the other hand, treatment has evolved, and a
conservative approach is trying to increase the use of endoscopic techniques
and decrease the number of hepatectomies. A 55-year-old male patient with a
history of multiple sclerosis was clinically asymptomatic but with elevated transaminase
levels. Ultrasound revealed hepatic steatosis with dilation of the intrahepatic
bile duct, with multiple hyperechoic images seen within the bile duct. An ERCP
was performed, which ruled out choledocholithiasis. A CT scan confirmed marked
dilation of the intrahepatic bile duct, on the right side. Lithiasis images
were seen in the branches of both lobes and in the proximal area of the common
hepatic duct, associated with periportal lymphadenopathy. Stones were extracted
from both proximal bile ducts using an endoscopic technique; a flexible
cystoscope was used, and stones were extracted from peripheral biliary
branches, some of them being fragmented with a Holmium laser. In this case, the
presence of bilateral lithiasis of different sizes in main and peripheral
branches of the biliary tree was observed, so hepatectomy should be avoided,
extracting the largest and most accessible stones manually, and leaving the
smallest and peripheral ones for destruction with the Holmium laser with a
satisfactory combined surgical result. Although the indications continue to be
varied, most author’s use this technique when there are single stones larger
than 2 cm, multiple, bilateral, impacted, or difficult to find, having
previously performed ERCP without success [10]. On the other hand, there are
various studies that try to help prevent the formation of stones in the body,
which include studies about alcohol intake, the usefulness of physical exercise
and changes in diet, the sitting position in order to prevent this serious
disease that although it is not very common, it is disabling and fatal [11-15].
