Classification and management of hepatolithiasis: A high-volume, single-center's experience

Abstract

Hepatolithiasis is endemic to East Asia, but immigration from the region means that this rare but emerging disease will pose a therapeutic challenge to doctors in the West as well. Curative management of hepatolithiasis is difficult since its etiology has not been fully elucidated. Hepatectomy is the best approach to treating hepatolithiasis. Here, we propose a novel classification of hepatolithiasis and describe features of each type. We then relate our experience with various forms of hepatectomy to treat different types of hepatolithiasis. Surgery should be indicated for all cases of hepatolithiasis. The proposed classification will help to determine surgical strategies. Better selection of which patients should undergo a hepatectomy will lead to better outcomes.

Keywords: Hepatectomy; classification; hepatolithiasis.

Figure 1.

Type I hepatolithiasis. (A), Type Ia. Localized stone disease with stones located in only one lobe. In this case, stones were localized in the atrophic right anterior portion of the liver. Segmentectomy of S5 and S8 was performed; (B), Type Ib. Localized stone disease with stones located in both lobes. In this case, stones were localized in the atrophic right anterior portion and left lateral portion of the liver.

Figure 2.

Type II hepatolithiasis. (A), Type IIa. Diffuse stone disease without segmental atrophy or stricture; (B), Type IIb. Diffuse stone disease with segmental atrophy and/or stricture. In this case, stones were located in every liver segment and there was atrophy or biliary stricture of S2, S3, S6, and S7; (C), Type IIc. Diffuse stone disease with secondary biliary cirrhosis. In this case, stones were located in every liver segment and there was biliary cirrhosis and portal hypertension. A liver transplant is needed.

Figure 3.

Additional type E hepatolithiasis. Hepatolithiasis with extrahepatic stones. Hepatolithiasis with extrahepatic stones (E) is divided into three subtypes based on functioning of the sphincter of Oddi. Normal function of the sphincter of Oddi is designated “Ea”, relaxation of the sphincter of Oddi is designated “Eb”, and stricture of the sphincter of Oddi is designated “Ec”.

Figure 4.

Typical selection of the procedure to treat type I hepatolithiasis. (A), In this case, anatomic left lobectomy was performed to treat type I hepatolithiasis; (B), In this case, segmentectomy of S8 was performed; (C), In this case, a right posterior sectionectomy was performed.

Figure 5.

A specific form of bilateral lobectomy excluding the caudate lobe to treat hepatolithiasis. (A), CT images and overall findings; (B), Separation and dissection of liver segments S2–S8, with only segment S1 remaining in the patient.