Reprints Available Directly from the Publisher Photocopying Permitted by License Only 1990 Harwood Academic Publishers Gmbh Case Report Liver Resection for Intrahepatic Stones

Intrahepatic stones are difficult to manage, especially when they are associated with bile duct stricture, cholangitis and destruction of liver parenchyma. Suggested modes of treatment include surgical bile duct exploration, endoscopic procedures, transhepatic cholangiolithotomy and liver resection. This paper reports 2 patients in whom liver resection was performed because of intrahepatic ductal stones, bile duct strictures and repeated episodes ofcholangitis. Liver resection was uncomplicated and long-term results were satisfactory. Our results support the view that liver resection is indicated in rare instances of intrahepatic bile duct stones associated with bile duct strictures.


INTRODUCTION
Patients with intrahepatic calculi are difficult to treat especially when they have associated bile duct stricture(s), repeated episodes ofcholangitis and sepsis and destruction of liver parenchyma. Procedures that have been tried in the past include proximal 13 134 extended bile duct exploration -, cholangiolithotomy by liver split and partial hepatectomy5-8. New instruments and techniques like flexible choledochoscopy9, the Fogarty balloon 3 and the Dormia basket l have been tried and will certainly help to improve our future handling of patients with intrahepatic stones. Experience from hepatic resection for intrahepatic ductal stones comes mainly from Asia and is based on a limited number of patients (about a hundred)2'6-8. Liver resection has been reported to be the preferred method of treatment when one or more of the following conditions are met: localized involvement, intrahepatic bile duct strictures and extensive liver tissue destruction6. This paper reports the management and outcome ofliver resection in two patients with multiple hepatic stones and multiple bile duct strictures. ERCP also demonstrated a choledochal duct stone, which was removed with a Dormia basket after sphincterotomy. Control ERCP confirmed the presence of intrahepatic stones but did not show any extrahepatic stones. As before, catheters or wires could not be forced to pass the stricture. Three weeks later, the patient underwent resection of the dorsocaudal segment of the right liver lobe with removal of 120 intrahepatic stones. Microscopic examination of the resected specimen revealed extensive inflammatory and fibrotic changes. A postoperative bilio-cutaneous fistula closed after 3 weeks. The patient has not had biliary tract symptoms during the 6 years that have passed since the liver resection despite the fact that ERCP, performed 5 months after surgery, disclosed 4-5 residual stones at the confluence of the dorsocaudal and the ventrocranial segmental ducts. We have refrained from further diagnostic and therapeutic procedures because the patient suffers from symptomatic cerebrovascular disease.

DISCUSSION
Multiple, intrahepatic stones are more common in Asia than in Sweden or other parts ofthe Western world. Usually, the pathogenesis is obscure, although the high incidence of bilirubin containing stones in Asia suggests that dietary factors, and possibly worm 6,11 infestations, are causative in this part of the world Intrahepatic stones may also form because of iatrogenic stricture of the bile ducts with stasis hemolytic disease, sclerosing cholangitis, choledochal cysts or Caroli's disease. As in our, and other non-Asian, patients, intrahepatic stones usually appear in the absence of these conditions, which suggests that most intrahepatic stones have migrated from the gallbladder.
Although most stones pass unnoticed, a few may cause intrahepatic obstruction by mass or by erosion with infection and stricturing. A vicious circle is then established.
Reported results for liver resection of intrahepatic stones are good both with respect to ooerative mortality and the incidence of residual stones and postoperative cholan-gitis2'5'6'8. The low operative mortality, like the 2% reported by Choi et al6, is explained by the fact that limited resections, usually a left lateral segmentectomy, are sufficient for most patients. In addition, resection is performed in a fibrotic segment of the liver with diminished blood supply in a patient with normal clotting capacity.
It is concluded that liver resection is indicated for multiple intrahepatic stones when they are associated with irreversibly strictured, undilatable and unpassable, intrahepatic ducts.