[Non-surgical treatment of intrahepatic calculi]

It is obvious that the most favorable therapeutic results can be obtained by hepatic lobectomy in the patients with intrahepatic calculi. However the number of patients in which hepatic lobectomy can be indicated is limited because of localization of lesions and some others. Endoscopic stone-extraction technique is the only therapeutic tool available in those patients. In this paper, technical know-how of postoperative cholangioscopy (POCS) and percutaneous transhepatic cholangioscopy (PTCS) was introduced and their clinical significance for management of intrahepatic calculi were discussed. POC was safely carried out 3 weeks after surgery if the extra-ductal limb of T-tube, lager than 14 Fr size, in the common bile duct, was brought out through the abdominal wall as straight as possible to obviate a tortuous sinus tract. PTCS was carried out through the sinus tract dilated up to over 14 Fr size after percutaneous transhepatic biliary drainage. Advantages of these modalities are; 1) they can be safely and repeatedly carried out if the sinus tract is maintained open. 2) stones visible are readily removable with the use of basket forceps or stone-integrator under endoscopic guidance and 3) preoperative application of PTCS provides us the important informations necessary to decide an adequate surgical procedure by delineation of intrahepatic anatomy. For the period started from 1975 when we introduced the first model of cholangiofiberscope to the end of 1995, 134 cases with intrahepatic calculi have been encountered and stone extraction was successful in 119 cases, success rate being 88.8%. The prognosis of the patients in which stone-extraction was successful was generally good. Main causes of failure in 15 cases were attributable to difficult location of lesion to perform choplangioscopy and concomitant liver cirrhosis or pururent cholangitis. The 6 cases with concomitant liver cirrhosis and pururent cholangitis were passed away before stone-extraction was completed. Therefore it can be said that complete stone-extraction was POCS or PTCS is very important to obtain a better long term prognosis in the cases with intrahepatic calculi. The authors believe that therapeutic results of inrahepatic calculi will be improved with the use of POCS or PTCS.