Anatomic Hepatectomy As a Definitive Treatment for Hepatolithiasis: a Cohort Study

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provided by Elsevier - Publisher Connector DOI:10.1111/j.1477-2574.2012.00488.x HPB

ORIGINAL ARTICLE Anatomic hepatectomy as a definitive treatment for hepatolithiasis: a cohort study

Nicolás Jarufe, Eduardo Figueroa, César Muñoz, Fabrizio Moisan, Julian Varas, José R. Valbuena, Claudia Bambs, Jorge Martínez & Fernando Pimentel

Department of Digestive Surgery, Pontificia Universidad Católica de Chile (Pontifical Catholic University of Chile), Santiago, Chile

Abstracthpb_488 604..610 Background: Treatment requirements in hepatolithiasis may vary and may involve a multidisciplinary approach. Surgical resection has been proposed as a definitive treatment. Objectives: This study aimed to evaluate the clinical results of anatomic liver resection among Chilean patients with hepatolithiasis. Methods: An historical cohort study was conducted. Patients who underwent hepatectomy as a definitive treatment for hepatolithiasis from January 1990 to December 2010 were included. Patients with a preoperative diagnosis of cholangiocarcinoma were excluded. Preoperative, operative and postoperative variables were evaluated. Results: A total of 52 patients underwent hepatectomy for hepatolithiasis. The mean Ϯ standard deviation patient age was 49.8 Ϯ 11.8 years (range: 24–78 years); 65.4% of study subjects were female. A total of 75.0% of subjects had a history of previous cholecystectomy. The main presenting symptom was abdominal pain (82.7%). Hepatic involvement was noted in the left lobe in 57.7%, the right lobe in 34.6% and bilaterally in 7.7% of subjects. The rate of postoperative clearance of the biliary tree was 90.4%. Postoperative morbidity was 30.8% and there were no postoperative deaths. Three patients had recurrence of hepatolithiasis, which was associated with Caroli's disease in two of them. Overall 5-year survival was 94.5%. Conclusions: Anatomic liver resection is an effective treatment in selected patients with hepatolithiasis and is associated with low morbidity and no mortality. At longterm follow-up, anatomic hepatectomy in these patients was associated with a lower rate of recurrence.

Keywords hepatectomy, lithiasis, hepatolithiasis, liver resection, therapy

Received 3 January 2012; accepted 17 April 2012

Correspondence Nicolás Jarufe, Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Marcoleta 350, Santiago 8330033, Chile. Tel: + 56 2 354 3870. Fax: + 56 2 354 3870. E-mail: [email protected]

Introduction Among patients in occidental countries, intrahepatic stones usually occur secondary to bile stasis resulting from an extrahe- Hepatolithiasis has been defined as the occurrence of stones in any patic factor (such as common bile duct stones, or postoperative or intrahepatic bile duct proximal to the confluence of the right and inflammatory strictures of bile ducts), in congenital diseases (such left hepatic ducts, irrespective of the presence of stones in the as Caroli’s disease), and in relation to the tendencies of some main bile duct or the gallbladder.1 It is prevalent in Japan and ethnic groups towards lithogenic bile.6–8 Southeast Asia2 and uncommon in Western countries.3,4 Treatment options are diverse. The therapeutic purpose is to Hepatolithiasis is now more commonly detected with the obtain complete clearance of the stone and to avoid recurrent regular use of diagnostic imaging methods, of which the most episodes of cholangitis and subsequent hepatic fibrosis and sec- precise is cholangiographic assessment.5 ondary cholangiocarcinoma.1 Recently, non-surgical procedures,

such as percutaneous transhepatic or peroral cholangioscopic the affected segments, with or without liver abscesses. An ana- lithotripsy, have been applied to treat hepatolithiasis, but these tomic resection (with or without the Pringle manoeuvre) using non-surgical procedures are associated with recurrence rates of an open or laparoscopic approach was performed for all seg- 30–60%.9–11 ments affected by biliary stenosis and the affected bile duct Alternatively, liver resection has been proposed as a definitive drainage area. Hepaticojejunostomy was performed in patients treatment for segmental hepatolithiasis because it treats not only with common bile duct stenosis and in those considered to be at the stones, but also strictures and atrophic and inflammatory high risk for recurrence. At each exploration of the common bile changes.12 duct, routine cholangiography, with or without choledochoscopy, The aim of this study was to assess the factors associated with was performed to ensure clearing of the biliary system. When the hepatolithiasis in one centre and to evaluate the clinical results of biliary tract was not explored, cholangiography was achieved its treatment by anatomic liver resection. through the cystic duct and US was performed to detect residual stones. Drains were used routinely and removed postoperatively Materials and methods if there was no evidence of bile leakage or bleeding between postoperative days 2 and 5. All patients presenting from January 1990 to December 2010 at the Pontifical Catholic University of Chile Hospital were included Postoperative management in this study. Hepatolithiasis was defined as the presence of stones Routine nasogastric drainage was not employed. Re-feeding was in the intrahepatic bile duct proximal to the right and left hepatic initiated 24 h after surgery if the patient showed signs of gas- duct confluence. Hepatectomy involved any procedure in which trointestinal transit resumption and had no nausea. Antibiotic excision of a part of the liver was performed using anatomic prophylaxis was used for 24 h perioperatively. Standard doses of techniques according to Couinaud’s segmentation and Brisbane therapeutic antibiotics were used in patients with cholangitis or 13 2000 terminology. Recurrence was deemed to have occurred liver abscess. Routine liver tests were monitored after surgery on when clinical and imaging evidence of new lithiasis was detected days 1, 3 and 5, and as required according to the patient’s clinical in the intrahepatic biliary duct above the biliary confluence. status. Patients who were not candidates for hepatectomy and those with a preoperative diagnosis of cholangiocarcinoma were Follow-up excluded from analysis. Recurrence screening was conducted using liver function tests. Ultrasound or CT were performed every 6 months for the first Registered data 2 years postoperatively and then annually or when the patient had Demographic data as well as data on risk factors for hepa- symptoms of recurrence. To confirm the suspicion of recurrence, tolithiasis, comorbidities, previous surgical therapies, clinical endoscopic or percutaneous cholangiography was carried out; presentation, laboratory and imaging tests, perioperative data, from 2000 onwards MRCP was used. postoperative morbidity, mortality and postoperative stone recurrence were recorded for all subjects. The extent of disease was Statistical analysis assessed by imaging studies, including abdominal ultrasound Variables are presented using descriptive statistics with measures (US), computed tomography (CT) and/or magnetic resonance of central tendency and dispersion. Chi-squared and Fisher’s tests cholangiopancreatography (MRCP). Some patients also under- were used for univariate subgroup and categorical variable analy- went endoscopic retrograde cholangiopancreatography (ERCP) ses. Student’s t-test and analysis of variance (anova) were used or percutaneous transhepatic cholangiography (PTC). A multidis- for continuous variables. A binary logistic regression model was ciplinary team defined the type of liver resection based on generated for multivariate analysis. The Kaplan–Meier method imaging findings. was used for survival analysis. A P-value of <0.05 was considered Clinical results and patient outcomes were classified in short- to indicate statistical significance. All analyses were performed and longterm categories. Short-term results included postopera- using spss Version 18.0 (SPSS, Inc., Chicago, IL, USA). tive morbidity (any complication occurring within 30 days of surgery). Longterm results included any morbidity or sequel Report detected during follow-up (any complication occurring >30 days This manuscript was developed according to the STROBE after surgery), the rate of recurrence of stones and longterm (strengthening the reporting of observational studies in epidemi- 14 survival. ology) criteria for the reporting of cohort studies. Results Procedural details Hepatectomy was considered to be indicated in all patients with From 1990 to 2010, a total of 52 patients underwent anatomic symptomatic hepatolithiasis with hepatic or intrahepatic duct liver resection for treatment of hepatolithiasis. Twenty-six of these stenosis, or with recurrent pyogenic cholangitis and atrophy of operations (50.0%) were performed between 2004 and 2010.

Table 1 History of bile pathology or biliary surgery in the present Patients with right hepatic involvement (n = 17/18, 94.4%) were series (n = 52) significantly more likely to have a history of previous cholecystec- Bile pathology or biliary n % tomy compared with those with left (n = 19/30, 63.3%) or bilateral surgery (n = 2/4, 50.0%) liver involvement (P < 0.05) (Table 3). Patients with one or more record 42 80.8 Cholecystectomy 39 75.0 Choledocholithiasis 10 19.2 Caroli's disease Caroli's disease 8 15.4 Evidence of Caroli’s disease was significantly more frequent in Acute biliary pancreatitis 2 3.8 surgical biopsy specimens of patients with left (n = 15/30, 50.0%) Biliary bypass 1 3.8 or bilateral (n = 3/4, 75.0%) liver involvement than in specimens < Biliary resection 1 3.8 of patients with right lobe involvement (n = 3/18, 16.7%) (P 0.05). Of 17 patients with prior cholecystectomy who developed hepatolithiasis in the right liver, only two had Caroli’s disease. Table 2 Clinical presentation in the present series (n = 52) Multivariate analysis considering the presence of Caroli’s disease, Clinical presentation n % sex, age and previous cholecystectomy showed that the latter was Abdominal pain 43 82.7 an independent risk factor for the development of right liver Cholangitis 18 34.6 hepatolithiasis (odds ratio = 6, 95% confidence interval 1.2–30.5; < Jaundice 17 32.7 P 0.05) compared with left or bilateral hepatolithiasis (Table 3). Fever 14 26.9 Choluria 11 21.2 Surgical treatment Pruritus 3 5.8 The most frequent procedure was left lateral sectionectomy, which Pancreatitis 3 5.8 was conducted in 42.3% of patients, three of whom underwent a Nausea 2 3.8 laparoscopic procedure. This was followed by right posterior sec- Acholia 2 3.8 tionectomy and left hepatectomy, conducted in 17.5% and 15.4% Fatigue 2 3.8 of patients, respectively (Table 4). Intraoperative US was performed for anatomic delineation in 32 (61.5%) patients. This rate increased to 78.1% from the year The mean Ϯ standard deviation (SD) age of patients was 49.8 2000. Ϯ 11.8 years (range: 24–78 years). Overall, 34 (65.4%) patients Cholecystectomy was performed as an additional surgical pro- were female, 39 (75.0%) had a prior history of cholecystectomy cedure in 13 (25.0%) patients, choledochostomy in 16 (30.8%) and 20 (38.5%) had associated comorbidities (Table 1). The main patients (13 patients prior to 2000) and hepaticojejunostomy in presenting symptom was abdominal pain. Acute cholangitis was three (5.8%) patients. The mean Ϯ SD operative time was 229.7 Ϯ diagnosed in 18 (34.6%) patients (Table 2). 84.0 min (range: 110–450 min). Mean Ϯ SD intraoperative bleed- Diagnoses were obtained through US in 40 (76.9%) patients. ing amounted to 437 Ϯ 209 ml (range: 100–2000 ml). Hepatic Computed tomography was performed in 26 (50.0%) patients. pedicle clamping (Pringle manoeuvre) was performed in 48.1% of Twenty-eight (53.8%) patients had ERCP and 16 of these under- patients, with a mean clamping time of 32.0 Ϯ 14.5 min (range: went papillotomy. Thirty (57.7%) patients underwent MRCP; 10–100 min). after 2000, this diagnostic modality was used in all but one patient. Findings on MRCP indicated the presence of bile duct dilatation in 25 patients, associated choledocholithiasis in eight, liver abscess Short-term results in three, stenosis of the intrahepatic bile duct in 27 patients, and The mean hospital stay was 11.1 Ϯ 8.8 days (range: 3–55 days). liver segment atrophy in one patient. Complete clearance of the biliary system was achieved in 47 Hepatic involvement was noted in the left lobe in 30 patients (90.4%) patients. Early complications occurred in 16 (30.8%) (57.7%), the right lobe in 18 (34.6%) and bilaterally in four patients (Table 5), nine of whom had biliary complications. There (7.7%) patients. were no significant differences in the incidence of biliary complications according to type of surgery or segment affected. Three of Development of hepatolithiasis after cholecystectomy the five patients with bile leakage had Caroli’s disease that was Thirty-nine (75.0%) patients had a prior history of cholecystec- confirmed by histology. Three patients with bile leakage were tomy. The mean period between cholecystectomy and the presen- treated with drainage and the leakage resolved within 30 days of tation of hepatolithiasis was 17.8 Ϯ 10 years. No statistically surgery. Of the four patients with residual stones, two had post- significant differences emerged when this period was analysed operative cholangitis and were treated with ERCP, and the other according to which of the hepatic lobes were compromised. two were treated percutaneously with choledochal drainage. The

Table 3 Relationship between prior cholecystectomy, Caroli's disease and liver lobe involvement Liver lobe involvement P-value Right liver Left liver Bilateral Prior cholecystectomy 17 (94.4%) 19 (63.3%) 2 (50.0%) 0.035 Caroli's disease in biopsy specimen 3 (16.7%) 15 (50.0%) 3 (75.0%) 0.025

Table 4 Type of liver resection in hepatolithiasis (Brisbane Table 6 Late complications in patients who underwent hepatectomy Terminology)13 for hepatolithiasis (n = 12/52) Type of liver resection n % Type of complication n % Left lateral sectionectomy 22 42.3 Choledocholithiasis 3 25.0 Right posterior sectionectomy 9 17.5 Recurrent hepatolithiasis 3 25.0 Left hepatectomy 8 15.4 Remnant bile duct lithiasis 2 16.7 Right hepatectomy 6 11.5 Biliodigestive anastomosis stenosis 2 16.7 Right anterior sectionectomy 2 3.9 Bile leakage for >30 days 2 16.7 Extended right hepatectomy 1 1.9 Intestinal obstruction 1 8.3 Extended left hepatectomy 1 1.9 Incisional hernia 1 8.3 Left lateral sectionectomy + segmentectomy VII 1 1.9 Abdominal collection 1 8.3 Right posterior sectionectomy + segmentectomy V 1 1.9 Pulmonary embolism 1 8.3 Segmentectomy VIII 1 1.9 Hepatic infarction 1 8.3 Total 52 100

Late complications occurred in 12 (23.1%) patients and were of Table 5 Early complications in patients who underwent hepatec- biliary origin in nine (17.3%) (Table 6). Biliary complications tomy for hepatolithiasis (n = 16/52) included choledocholithiasis, hepatolithiasis and common hepatic Type of complication n % duct lithiasis in patients with biliodigestive anastomosis. One Wound infection 2 12.5 patient had choledocholithiasis plus hepatolithiasis. All patients Residual stones 4 25.0 with recurrence of lithiasis in the main biliary duct were success- Acute cholangitis 2 12.5 fully treated by endoscopic or percutaneous procedures. Intra-abdominal collection 3 18.8 Three patients developed recurrent hepatolithiasis. Two of Liver abscess 2 12.5 these patients have Caroli’s disease and are currently undergoing Atelectasis 3 18.8 treatment with ursodeoxycholic acid and have not developed Pleural effusion 2 12.5 complications from their disease. The remaining patient with Bile leakage 5 31.3 recurrent hepatolithiasis developed stenosis of the biliodigestive anastomosis, requiring multiple interventions. The patient is Acalculous obstructive jaundice 1 6.3 currently listed for liver transplantation because of diffuse Hepatic infarction 1 6.3 hepatolithiasis. In two of the five patients who developed bile leakage as an early final rate of clearance of the biliary tree was 98.1%. There was no complication, fistulae remained unresolved for >30 days. One of postoperative liver failure and no inpatient mortality (Table 5). these patients had a common bile duct stenosis, required a bilio- Surgical specimen evaluation digestive anastomosis and thereafter had recurrent stones in the (histopathological study) common hepatic duct and required endoscopic balloon dilatation Biopsy results showed that 21 (40.4%) patients had Caroli’s with percutaneous extraction of bile duct stones. Some patients disease. Biopsy findings also showed that 46 (88.4%) patients had more than one complication (Table 6). had bile duct dilatation and periductal fibrosis, 21 (40.4%) had Overall survival at 5 years was 94.5%. Of the two patients who chronic cholangiohepatitis, and nine (17.3%) had purulent cho- died within 5 years of surgery, one had developed cholangiocar- langitis. Liver atrophy was found in two patients, micronodular cinoma 6 months after surgery and the other demonstrated cirrhosis in another two patients, and intrahepatic bile duct chronic renal failure 53 months after surgery. Overall survival at tubular adenocarcinoma in one. 10 years was 90.5%; a third patient died of acute pneumonia within 10 years of surgery. Three other patients died after the Longterm results 10-year follow-up, all for reasons not attributable to surgery or The median follow-up was 63.7 months (range: 3–274 months). biliary stones.

Discussion 5.8%, which is lower than comparative rates reported in other studies using similar treatment.12,28 The higher rates of recurrence In the past 10 years, the introduction of new imaging technology probably reflect the development of biliary stenosis, which occurs in clinical practice has improved the diagnosis of hepatolithiasis. in 42–96% of patients with hepatolithiasis and is the main factor Magnetic resonance imaging (MRI) and MRCP are non-invasive in recurrence. Consequently, when treatment does not involve tests that not only allow the clear diagnosis of hepatolithiasis, but removing the stenotic bile duct, recurrence is likely to occur also facilitate the complete evaluation of the biliary system and the relatively soon.9,29–32 degree of liver atrophy. This allows for better planning of treat- In the present study, an analysis of causes associated with ment for patients and clarifies indications for surgery.7 In the hepatolithiasis revealed that 50.0% of patients showed evidence present series, US continued to play a leading role in the diagnosis of Caroli’s disease in biopsy specimens. Similar results have of hepatolithiasis, but since the advent of MRCP, almost all been reported by other authors in occidental countries,19,33 where patients have been evaluated using MRI or MRCP as the main patients have a different pathophysiology.34 diagnostic tool. The left liver lobe emerged as the most frequent location of There are many treatment modalities for intrahepatic stones. hepatolithiasis in the present series, which is consistent with find- The most frequently used are endoscopic and percutaneous treat- ings reported by other authors.1,6,7,35 This can be explained by the ments, with or without lithotripsy, by choledochoscopy and acute angle taken by the left hepatic duct when it reaches the surgery (hepatectomy or biliary bypass). Currently, there is no confluence, which results in more bile stasis when associated with consensus on which treatment best achieves adequate clearing of stenosis of the biliary system. However, the frequency of left hepa- the biliary tree and lower rates of residual stones, recurrence, tolithiasis in the present series (57.7%) was lower than those morbidity and mortality. The main objectives in the management reported by Chen et al.36 (77%) in a series of 103 patients and of this disease are to extract all intra- and extrahepatic stones, and Jiang et al.37 (72%) in 106 patients. This difference reflects the to remove any bile duct stenosis, affected bile duct drainage areas higher frequency of right hepatolithiasis in the present series and all atrophic segments. The chronic inflammatory process that (32.7%). This higher frequency of right side involvement, espe- causes stones in the intrahepatic bile ducts is a well-known risk cially in the posterior segments, may be explained by the presence factor for cholangiocarcinoma and the only treatment to elimi- of anatomic variations in which the posterior segment artery nate this bile duct pathology is liver resection.15 comes from the common hepatic artery or is divided so that a In the present series, the rate of stone clearance at 30 days prior branch passes through the gallbladder fossa, which can be injured to surgery was 91.4% and all failures occurred at an extrahepatic during cholecystectomy, resulting in ischaemia of the bile ducts in level. After percutaneous or endoscopic treatment, the clearance that area. It is the present authors’ belief that the history of pre- rate rose to 98.1% postoperatively. These results are comparable vious cholecystectomy in patients with iatrogenic vascular injuries with those in a series reported by Uenishi et al.,16 in which 86 during cholecystectomy is related to right side involvement; patients underwent hepatectomy for hepatolithiasis, achieving an however, further study is required to substantiate this effect. It is initial clearance rate of 88%, which increased after postoperative noteworthy that the average period between cholecystectomy and choledochoscopy with lithotripsy. These clearance rates are con- the diagnosis of hepatolithiasis was 18 years. Balandraud et al.38 siderably higher than those achieved by a single percutaneous found anatomic variations in 14 patients with right hepatolithi- treatment (44%) or single endoscopic treatment (57%) in a com- asis, whereby a cranial shift of the right sectorial ducts proximal to parative study by Cheon et al.17 Treatment with ERCP alone the hepatic confluence, present in six of the patients, was an inde- reported clearance rates that did not exceed 70%.18,19 The devel- pendent risk factor for hepatolithiasis and explained the occur- opment of more effective lithotripsy techniques, such as laser and rence of bile stasis and formation of hepatolithiasis. percutaneous electrohydraulic lithotripsy, have resulted in bile The surgical protocol used in the present institution favours duct clearance rates of 73–96%, but recurrence rates are high.9,20–24 anatomic over non-anatomic liver resection as the main approach. The present series recorded no postoperative mortality, but did This is supported by studies that have shown the former to have show high morbidity, most of which concerned infections. This benefit in terms of reducing the incidence of residual lithiasis, bile increased rate may reflect the high number of patients who under- leakage and recurrence.37,39 went surgery with recurrent cholangitis and/or medically treated In the present series, morbidity reached 30.8% and most com- episodes of acute cholangitis. The high rate of bile leakage after plications were mild and rapidly resolved; these results are com- elective hepatectomy is probably associated with the substantial parable with the international standard.40 No postoperative liver proportion (40.4%) of patients with Caroli’s disease, as similar failure occurred in the present series, although two patients had associations have been previously reported.25–27 liver cirrhosis. In the present study, the recurrence rate was 13.5% and the The treatment of patients with bilateral hepatolithiasis is con- median follow-up was 63.7 months. Recurrences occurred mainly troversial and patients with bilateral disease show higher rates of in the extrahepatic bile ducts and were successfully treated with recurrence. Therapeutic approaches range from hepatectomy to ERCP. The rate of recurrence in the intrahepatic bile ducts was complex bilioenteric anastomosis using a subcutaneous loop to

remove residual or recurrent lithiasis.41–43 In the present series, 2. Su HC, Wei HC, Liu QX, Li YB. (1991) Treatment of bilateral intrahepatic only four patients had bilateral hepatolithiasis, three of whom stones with high duct strictures through selective central hepatic resec- underwent hepatectomy for severe involvement in segments on tion. Surgery 110:8–12. both sides. The remaining patient underwent a left lateral section- 3. Herman P, Bacchella T, Pugliese V, Montagnini AL, Machado MA, da Cunha JE et al. (2005) Non-Oriental primary intrahepatic lithiasis: ectomy in addition to the extraction of the contralateral lithiasis experience with 48 cases. World J Surg 29:858–862. by intraoperative choledochoscopy. To date, none of these patients 4. Machado MA, Herman P, Rocha JR, Machado MC. 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(2008) Liver resection for primary intrahepatic stones: a single- went radical oncological surgery with lymph node dissection and centre experience. Arch Surg 143:570–573; discussion 574. achieved survival of 6 months. None of the patients in the present 7. Vetrone G, Ercolani G, Grazi GL, Ramacciato G, Ravaioli M, Cescon M et al. (2006) Surgical therapy for hepatolithiasis: a Western experience. series developed cholangiocarcinoma during follow-up. However, J Am Coll Surg 202:306–312. Chen et al.44 observed that 9% of patients with and 3% of those 8. Pimentel F. (2004) Enfermedad de Caroli. Rev Chil Cir 56:426–433. without residual stones developed cholangiocarcinoma. 9. Otani K, Shimizu S, Chijiiwa K, Ogawa T, Morisaki T, Sugitani A et al. The prevention of hepatolithiasis and bile stasis at an early stage (1999) Comparison of treatments for hepatolithiasis: hepatic resection avoids the end result of progressive liver failure and cirrhosis. versus cholangioscopic lithotomy. J Am Coll Surg 189:177–182. However, in patients with diffuse bilateral hepatolithiasis, disease 10. Huang MH, Chen CH, Yang JC, Yang CC, Yeh YH, Chou DA et al. (2003) recurrence can lead to repeated episodes of cholangitis, liver Longterm outcome of percutaneous transhepatic cholangioscopic litho- atrophy and biliary cirrhosis associated with portal hypertension tomy for hepatolithiasis. Am J Gastroenterol 98:2655–2662. and liver failure. Liver transplantation has become the best treat- 11. Pitt HA, Venbrux AC, Coleman J, Prescott CA, Johnson MS, Osterman FA ment option for patients with end-stage liver disease.45 Patients Jr et al. (1994) Intrahepatic stones. The transhepatic team approach. Ann with diffuse hepatolithiasis and secondary biliary cirrhosis should Surg 219:527–535; discussion 535–537. 12. Chen DW, Tung-Ping Poon R, Liu CL, Fan ST, Wong J. (2004) Immediate consider liver transplantation, which eliminates the possibility of and longterm outcomes of hepatectomy for hepatolithiasis. Surgery developing cholangiocarcinoma, as an alternative treatment. 135:386–393. The present authors believe that hepatectomy is the best treat- 13. Pang YY. (2000) The Brisbane 2000 terminology of liver anatomy and ment when hepatolithiasis is located in a segment or lobe associ- resections. HPB 2:333–339. ated with biliary stenosis or atrophy of a segment or liver lobe. 14. STROBE. (2008) STROBE statement – checklist of items that should be Hepatectomy should also be considered as the treatment of choice included in reports of observational studies (STROBE initiative). Int J when there is suspicion or certainty of cholangiocarcinoma. Public Health 53:3–4. Endoscopic or percutaneous treatment should be considered as a 15. Tyson GL, El-Serag HB. 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