Indications for the choledochoscopic removal of intrahepatic stones based on the biliary anatomy

Choledochoscopic treatment has been used primarily to remove intrahepatic stones. However, failure in removing such stones can occasionally occur, resulting in the need for additional surgery. The aim of this study was to clarify the clinical indications and limitations of choledocoscopic treatment for the removal of intrahepatic stones.

A review of the records of 86 patients treated for intrahepatic stones between April 1974 and December 1993 formed the basis of this study. These patients were evaluated based on their bile-duct findings (no strictures, mild strictures, or severe strictures), the site of the stones (left hepatic lobe, right hepatic lobe, and the bilateral lobes), and the presence of variations in the posterior segmental bile-duct drainage.

Complete removal of stones was achieved in 59 patients (69%). Further, choledochoscopic removal was mainly successful in patients with no strictures or, to a lesser degree, with mild strictures; whereas stone removal was impossible in all patients (19) with severe strictures (P < 0.0001). As for the site of the stones, no statistical differences were seen among the three groups. Regarding the presence of drainage variations of the segmental bile duct, removal of the stones was more difficult in patients with variations than in those without variations (P < 0.01). With respect to long-term clinical outcomes, of the 59 successful patients, only 2 (3%) developed recurring stones.

Based on these findings, choledochoscopic treatment should be indicated for patients who have no, or only mild, bile-duct strictures and who mainifest normal segmental bile-duct drainage.