A case of complex hepatolithiasis successfully treated with a systematic approach

A systematic approach is required to treat complex hepatolithiasis. A 45 year-old female patient with hepatolithiasis had bilateral intrahepatic stones, biliary strictures at the right hepatic duct and segment IV duct, cholangitic abscess, and shrinkage of the right hepatic lobe. Six sessions of lithotomy were carried out under the guidance of percutaneous transhepatic choledochoscopy using a dye-laser lithotriptor through the segment III duct. Although stones were eradicated from the common bile duct and segment III duct, stones remained in other segments where cholangioscopic access was not feasible. Biliary bilirubin concentration increased and the liver abscess was resolved. Thereafter, the patient underwent right hepatectomy and choledochojejunostomy. After surgery, percutaneous transhepatic cholangio-drainage and balloon dilatation of the segment IV duct was performed. The patient underwent 11 more sessions of cholangioscopic lithotomy through 2 transhepatic routes and the bilioenteric bypass. Thereafter, the patient became almost stone-free. After discharge, biliary tracts were irrigated with saline through a subcutaneously placed reservoir. The patient is alive and well and had been without stone recurrence for 3 years. This report shows the efficacy of the vigorous combination therapy, including repeated cholangioscopic lithotomy through multiple routes using laser lithotripsy, surgery, and long-term biliary irrigation.