A case of complex hepatolithiasis successfully treated with a systematic approach

A systematic approach is required to treat complex hepatolithiasis. A 45 ye ar-old female patient with hepatolithiasis had bilateral intrahepatic stone s, biliary strictures at the right hepatic duct and segment TV duct, cholan gitic abscess, and shrinkage of the right hepatic lobe. Six sessions of lit hotomy were carried out under the guidance of percutaneous transhepatic cho ledochoscopy using a dye-laser lithotriptor through the segment III duct. A lthough stones were eradicated from the common bile duct and segment III du ct, stones remained in other segments where cholangioscopic access was not feasible. Biliary bilirubin concentration increased and the liver abscess w as resolved. Thereafter, the patient underwent right hepatectomy and choled ochojejunostomy. After surgery, percutaneous transhepatic cholangio-drainag e and, balloon dilatation of the segment IV duct was performed. The patient underwent 11 more sessions of cholangioscopic lithotomy through 2 transhep atic routes and the bilioenteric bypass. Thereafter, the patient became alm ost stone-free. After discharge, biliary tracts were irrigated with saline through a subcutaneously placed reservoir. The patient is alive and well an d had been without stone recurrence for 3 years. This report shows the effi cacy of the vigorous combination therapy, including repeated cholangioscopi c lithotomy through multiple routes using laser lithotripsy, surgery, and l ong-term biliary irrigation.