Surgical Treatment of Hepatolithiasis: Our Experience in Bangabandhu Sheikh Mujib Medical University.

: Recurrent cholangitis and sepsis are common complications after surgical treatment for hepatolithiasis as total clearance is not always possible. This retrospective study is designed to see the effect of our treatment for hepatolithiasis on stone clearance and post operative complications. We have treated 60 patients with hepatolithiasis surgically from September 2010 to September 2016 in the Department of Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh. Various operative procedures were applied on the basis of location of stone and status of biliary tree. Choledocoscopic examination was performed during surgery for checking and cleaning of intrahepatic duct. Regular follow up was given and outcome was assessed. The chronological changes of treatment methods for patients with hepatolithiasis were analyzed for appropriate treatments for particular type. There were 22 males and 38 females with age ranges from 15 to 60 years. The stone were located in left duct (56.6%), right duct (10%) and both duct (33.4%). The most commonly performed operation was extended choledocholithotomy and hepatolithotomy and it was performed in 28 patients (46.7%). Segmentectomy and lobectomy was performed in 17 patients (28.3%). Common bile duct (CBD) excision, hepatolithotomy and hepaticojejunostomy with or without segmentectomy, lobectomy and Houston access loop formation was performed in rest of the patients. Stones could be removed completely in all patients who underwent lobectomy or segmentectomy. In contrast stone clearance was possible only in 57.2% and 55.5% who underwent extended choledocholithotomy and hepatolithotomy, and excision of CBD, hepatolithiasis with hepaticojejunostomy for unilateral or bilateral hepatolithiasis respectively. Houston's access loop to stomach was made in 2 patients for future endoscopic removal of stone. There was no mortality in the present series but morbidity occurred in 18 patients; wound infection (n=15, 25%), bile leakage (n=1, 1.7%), and renal dysfunction (n=1, 1.7%), septicemia (n=1, 1.7%). Patients who underwent lobectomy or segmentectomy did not develop cholangitis or sepsis on 1 to 3 years follow up. In contrast who underwent extended choledocholithotomy and hepatolithotomy, 70.8% patients developed cholangitis and sepsis, and the patients who underwent excision of CBD, hepatolithotomy with hepaticojejunostomy 50% developed cholangitis and sepsis within 1 to 3 years of follow up, required re-operations or conservative treatment. The difference of developing postoperative cholangitis and sepsis is significant (p<0.05) between patient who underwent extended choledocolithotomy and hepatolithotomy, and who underwent excision of CBD, hepatolithotomy and Roux-en-Y hepaticojejunostomy. In conclusion, lobectomy or segmentectomy is the best option for hepatolithiasis if the stones are limited to a lobe or segment. Excision of CBD, hepatolithotomy with hepaticojejunostomy is better than extended choledocholithotomy and hepatolithotomy for bilateral hepatolithiasis. Huston's access loop formation associated with other procedures may be considered for bilateral hepatolithiasis for future minimal invasive stone retrieval procedure as residual stones and recurrent stone formation is common.