Hepatic Resection for Primary Hepatolithiasis: A Single-Center Western Experience Parissa Tabrizian, MD, Ghalib Jibara, MD, MPH, Brian Shrager, MD, Myron E Schwartz, MD, FACS, Sasan Roayaie, MD, FACS BACKGROUND: The incidence (0.6% to 1.3%) of primary hepatolithiasis (PHL), also known as Oriental cholan- giohepatitis, is increasing in Western countries and the treatment remains challenging. We analyzed the outcomes of patients undergoing hepatic resection (HR) for PHL at a single Western center. STUDY DESIGN: The records of all patients undergoing HR for PHL between August 1998 and January 2012 were reviewed. Patients were required to have preserved liver function (Child-Pugh class A) with no evidence of portal hypertension. Diagnosis of disease recurrence was based on radiographic and clinical findings. RESULTS: Of the 30 patients who underwent HR, 63.3% presented with earlier failed therapeutic strategies. The majority of the patients were female (63.3%), presented with cholangitis (66.6%), left-sided (66.6%), and unilateral (90.0%) disease, and underwent left-sided hepatic resection (76.6%). Pre- viously created choledochoduodenostomies (13.3%) were all revised into Roux-en-Y hepaticojeju- nostomy anastomoses in conjunction with the HR. The incidence of concomitant cholangiocarci- noma was 23.3%, with a mean tumor size of 4.2 cm. Perioperative morbidity and mortality rates were 6.6% and 0%, respectively. At a median follow-up of 35 months, all patients had complete intrahepatic stone clearance. One patient required postoperative ERCP. Of the 7 patients with cholangiocarcinoma, 2 had cancer recurrence within the first year of the HR. The remaining patients are disease-free at a median follow-up of 21 months. CONCLUSIONS: Hepatic resection is a safe and definitive treatment option in the management of PHL. It achieves excellent short- and long-term results. The high incidence of concomitant cholangio- carcinoma makes a compelling argument for resection of all involved hepatic segments, when possible. (J Am Coll Surg 2012;215:622–626. © 2012 by the American College of Surgeons) Hepatolithiasis (HL), also known as Oriental cholangio- hepatitis, defined as the presence of intrahepatic duct stones, is a common disease in Asia, with a reported inci- dence up to 20%. 1,2 Although rare in the West, with a reported incidence of 0.6% to 1.3%, 1,2 the disease has be- come more common due to increased immigration from endemic areas. In Western patients, it is distinguished from secondary HL, which is caused by extrahepatic factors, such as conditions resulting in stricturing of the biliary tree or stasis. 3,4 Primary hepatolithiasis (PHL) is caused by de novo formation of stones originating at the level of single or multiple cystic dilations of the intrahepatic biliary tree (Figs. 1 and 2). 1 The disease can affect one or multiple hepatic segments. The pathogenesis of this condition is not completely understood. The disease can result from a pri- mary abnormality of the wall of the biliary tree or chemical components of bile. With improved diagnostic modalities, accuracy in diagnosing hepatolithiasis has increased. 1 Morbid- ity is associated with repeated cholangitis, which can lead to progressive biliary strictures, abscess, cirrhosis, atrophy of the affected liver, and even cholangiocarcinoma. 5 The optimal treatment for patients with hepatolithiasis remains unclear. Management should be directed toward complete removal of stones and elimination of bile stasis, infection, and prevention of progression to cholangiocar- cinoma. A variety of noninvasive procedures, such as per- cutaneous transhepatic cholangioscopic lithotripsy and ex- tracorporal shock wave lithotripsy have been described. 6-9 However, the incidence of residual and recurrent stones remains high and is reported in 20% to 50% of patients treated with these therapies. 6-9 Resection has been pro- posed as the preferred treatment option, as it offers defin- itive management for existing stones and removes the stric- tured ducts, preventing recurrent hepatolithiasis. However, Disclosure Information: Nothing to disclose. Received April 9, 2012; Revised July 12, 2012; Accepted July 16, 2012. From the Mount Sinai Liver Cancer Program, Mount Sinai School of Med- icine, New York, NY. Correspondence address: Sasan Roayaie, MD, FACS, Mount Sinai Liver Cancer Program, Box 1104, Mount Sinai School of Medicine, New York, NY 10029. email: sasan.roayaie@mountsinai.org 622 © 2012 by the American College of Surgeons ISSN 1072-7515/12/$36.00 Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jamcollsurg.2012.07.005