title: Multidisciplinary approach in the long-term management of intrahepatic stones: Indian experience.
abstract: BACKGROUND
  Intrahepatic stones, though common in East Asia, are uncommon in India. There is paucity of data from India regarding the treatment and long-term outcome of patients with intrahepatic stones.
  
  
  METHODS
  We retrospectively analyzed medical records of 35 patients with intrahepatic stones who had been treated surgically. Endoscopic biliary drainage had been used in patients who presented with acute cholangitis. Intraoperative stone clearance was confirmed by choledochoscopy and intraoperative cholangiography. Outcome of surgery, frequency and subsequent management of recurrent intrahepatic stones, and factors associated with stone recurrence and cholangitis were analyzed.
  
  
  RESULTS
  Twenty-one (60%) patients had bilobar disease. Eight patients underwent hepatectomy and 16 hepatico-jejunostomy with access loop; 12 of these were jejuno-duodenal anastomoses. Postoperative morbidity was observed in 10 patients (29%). Recurrence of stones occurred in 12 patients (34%) and cholangitis in 9 patients (26%). Presence of bilobar disease and associated biliary strictures were associated with recurrent cholangitis (p< 0.05). Two patients (6%) required re-operation for recurrent cholangitis. Complete removal of recurrent stones using conventional endoscope was possible through jejuno-duodenostomy in all 5 cases who had this type of access loop construction.
  
  
  CONCLUSIONS
  Surgical treatment for intrahepatic stones depends on the site of involvement. Construction of a jejuno-duodenal access loop in patients with bilobar disease and intrahepatic strictures is helpful in facilitating postoperative stone clearance. A multidisciplinary approach is beneficial especially when the disease is bilobar and recurrent in type.
authors.affiliation: Department of Gastrointestinal Surgery, Digestive Diseases Center, P V S Memorial Hospital, Cochin, Kerala, India.
authors.forename: K
authors.initials: K
authors.lastname: Prakash
authors.forename: H
authors.initials: H
authors.lastname: Ramesh
authors.forename: G
authors.initials: G
authors.lastname: Jacob
authors.forename: A
authors.initials: A
authors.lastname: Venugopal
authors.forename: V
authors.initials: V
authors.lastname: Lekha
authors.forename: D
authors.initials: D
authors.lastname: Varma
authors.forename: G N
authors.initials: GN
authors.lastname: Ramesh
authors.forename: P
authors.initials: P
authors.lastname: Augustine
mesh_terms: D000328:Adult; D002761:Cholangitis / Q000453:epidemiology; D002763:Cholecystectomy; D002769:Cholelithiasis / Q000601:surgery*; D004724:Endoscopy; D005260:Female; D006498:Hepatectomy; D006500:Hepatic Duct, Common; D006801:Humans; D007582:Jejunostomy; D008297:Male; D012008:Recurrence