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Original Article |

Indication and Procedure for Treatment of Hepatolithiasis FREE

Kazuhisa Uchiyama, MD; Hironobu Onishi, MD; Masaji Tani, MD; Hiroyuki Kinoshita, MD; Masaki Ueno, MD; Hiroki Yamaue, MD
[+] Author Affiliations

From the Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan.


Arch Surg. 2002;137(2):149-153. doi:10.1001/archsurg.137.2.149.
Text Size: A A A
Published online

Hypothesis  Because of its complicated clinicopathologic features, hepatolithiasis is difficult to treat, and there is no established method of treating patients with intrahepatic stones.

Design  Retrospective case-control study.

Setting  Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan (January 1, 1971-December 31, 2000).

Patients  Eighty-nine patients treated for hepatolithiasis (43 male; median age, 56.9 years).

Main Outcome Measures  The rate of residual stones and complications after the treatments of hepatolithiasis.

Results  Between 1971 and 1985, 17 patients (41%) had stones located in the left or right intrahepatic duct, and 25 patients (60%) had stones located in the bilateral intrahepatic duct. From 1986 through 2000, 32 patients (68%) had stones located in the left or right intrahepatic duct, and 15 patients (32%) had stones located in the bilateral intrahepatic duct (P = .009). The rate of residual stones after surgical and nonsurgical treatment was 41% (17 of 42 patients) in 1971 through 1985, but decreased to 11% (5 of 47 patients) in 1986 through 2000 (P = .001). The rate of residual stones after cholangioenterostomy or T-tube insertion was 43.8% (21 of 48 patients), but the rate of residual stones after hepatectomy or percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) was 2.4% (1 of 41 patients, P<.001). In cases treated by PTCSL, we used a holmium (Ho):YAG laser in 3 cases since 1999. To our knowledge, there have been no reports describing the use of Ho:YAG lasers to treat hepatolithiasis. Also, board-shaped stones can be sufficiently pulverized without inducing hemorrhage from the bile duct wall.

Conclusions  According to the current therapeutic strategy for hepatolithiasis, hepatectomy seems to be the most effective treatment for selected patients with isolated left hepatolithiasis if other surgical procedures cannot remove all the related lesions. In addition, PTCSL seems to be performed first in isolated right hepatolithiasis and bilateral lobe type hepatolithiasis. In PTCSL procedures, favorable results have been obtained using the Ho:YAG laser for fracturing intrahepatic stones.

Figures in this Article

HEPATOLITHIASIS is a common disease in Southeast Asia, and the relative incidence of hepatolithiasis is 20% in China and Taiwan.1,2 However, our study3 in Japan investigated 105 062 patients with cholelithiasis between 1989 and 1992 and found that 2353 of these patients (2.2%) had hepatolithiasis. In Japan, the number of patients with hepatolithiasis also is lower compared with previous nationwide statistics.3 This decrease could be attributable to the fact that as the number of patients undergoing laparoscopic cholecystectomy increased, the size of the patient pool increased, thus lowering the relative incidence of choledocholithiasis and hepatolithiasis.4

As ultrasonography and computed tomography have come into wider use, it has become possible to not only identify the location of hepatic stones but also assess these stones qualitatively. With magnetic resonance cholangiopancreatography or helical computed tomography, the 3-dimensional structure of the bile duct can now be described; thus, the accuracy in diagnosing hepatolithiasis has been greatly improved.1 Recent advances in medical technology have been marked, and the results of surgical procedures, such as hepatectomy, have improved.2 Furthermore, noninvasive treatments, such as percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) and extracorporeal shock wave lithotripsy (ESWL), have been established.3 However, postoperative residual and recurrent stones occur in 20% of treated patients.1 To decrease residual and recurrence rates, it will be necessary to accurately diagnose the complex pathologic features of hepatolithiasis and select the most effective treatment for each type of hepatolithiasis. In the present study, we clarify the indication of invasive and noninvasive treatments and procedures for patients with hepatolithiasis.

Between January 1, 1971, and December 31, 2000, 2104 patients with cholelithiasis were admitted to Wakayama Medical University Hospital, Wakayama, Japan. Cholecystolithiasis accounted for 78% of the cases, whereas hepatolithiasis accounted for 4% (43 men and 46 women). Patients ranged in age from 20 to 72 years, with a mean age of 56.9 years. Sixty-eight patients (54%) had previously undergone 1 or more biliary procedures. We classified the 89 patients with hepatolithiasis by pathologic types. Based on the location of stones in the hepatic bile duct, patients were grouped into the following types: intrahepatic (type I), extrahepatic (type E), and both (type IE). Based on the lobe localization of hepatolithiasis, patients were grouped into the following types: left lobe (L type), right lobe (R type), and bilateral lobe (LR type).

All patients underwent surgical or nonsurgical intervention, and the presence of hepatolithiasis was confirmed. In terms of the treatment procedures, 34 patients (38%) underwent hepatectomy; 36 (40%), cholangioenterostomy (choledochojejunostomy or cholangioduodenostomy); 12 (13%), T-tube insertion; and 7 (8%), PTCSL. Intraoperative cholangioscopy (external diameter, 4.9 mm; CHF-P20; Olympus, Tokyo, Japan) was routinely used instead of intraoperative cholangiography for visualizing the residual stones, ductal strictures, and tumors. Postoperative cholangiography and cholangioscopy were routinely performed to detect residual stones. In cases treated by PTCSL, a cholangioscope was inserted through the percutaneous transhepatic choloangiodrainage (PTCD) fistula orifice, where grasping forceps could be inserted through the cholangioscope to remove any stones. Giant and impacted stones were fragmented by introducing an electrohydraulic shock wave lithotripter probe or pulsed dye laser before 1997, but were fragmented by introducing holmium (Ho):YAG lasers after 1998. We established the following treatment conditions: 0.8 J, 20 Hz, and 16 W. Under these conditions, 1-cm stones can be pulverized in 10 seconds. Also, board-shaped stones can be sufficiently pulverized without inducing hemorrhage from the bile duct wall.

In combination with other treatments such as PTCSL, ESWL is performed on patients with intractable hepatolithiasis, such as IE and LR types, in whom hepatectomy would not be sufficient for complete remission. We used a lithotriptor (Lithostar 2-plus lithotriptor; Siemens Inc, Erlangen, Germany). Under imaging guidance via PTCD or an endoscopic nasal bile draining tube, we established the maximum voltage and shot count as 19 kV and 4000 times, respectively, and we performed irradiation 1 to 10 times. The lithotriptor is equipped with ultrasonography and x-ray modes. Although ultrasonography is affected by gastrointestinal gas, pneumobilia, and subcutaneous fat thickness, tests can be performed using the lithotriptor regardless of these conditions. We analyzed chronological changes in treatment methods for patients with hepatolithiasis and investigated the most appropriate treatments for each disease type.

All data are expressed as mean ± SD. Statistical analysis was performed with the χ2 test and t test. Probability differences of .05 or less were considered significant.

Patients with hepatolithiasis were older (mean age, 56.9 years) than patients with cholecystolithiasis (P<.001), but were younger than those with choledocholithiasis (P<.001). There were no differences among the 3 disease entities in terms of age or sex (Table 1). Comparing data from 1971 through 1985 with those from 1986 through 2000, the number of patients with cholecystolithiasis increased, whereas there was no change observed in the number of those with choledocholithiasis and hepatolithiasis (P<.05).

Table Graphic Jump LocationTable 1. Clinical Data of Patients With Cholelithiasis

There were chronological changes in the prevalence of various hepatolithiasis types. The L or R type comprised 17 cases (13 L type and 4 R type), whereas the LR type comprised 25 cases in 1971 through 1985; however, in 1986 through 2000, the L or R type increased to 32 cases (22 L type and 10 R type) and the LR type decreased to 15 (P = .009). When hepatolithiasis was classified according to IE typing, IE type accounted for 30 cases (71%) in 1971 through 1985 and 26 cases (55%) in 1986 through 2000, and I type accounted for 12 cases in 1971 through 1985 and 21 cases in 1986 through 2000. When hepatolithiasis was classified according to LR typing, the patients with LR type hepatolithiasis accounted for 25 cases (60%) in the first 15-year period, but this decreased to 15 cases (32%) in the second 15-year period (P<.01).

There were chronological changes in treatment procedures for hepatolithiasis (Table 2). Before 1985, cholangioenterostomy (cholangiojejunostomy or cholangioduodenostomy) was performed more frequently than hepatectomy (9 vs 25); after 1986, hepatectomy was performed more frequently than cholangioenterostomy (25 vs 14, P = .001). The rates of residual stones after treatment were higher in 1971 through 1985 (41%, 17 of 42 patients) than in 1986 through 2000 (11%, 5 of 47 patients, P = .01). Compared with cholangioenterostomy, hepatectomy demonstrated a lower rate of residual stones (0% vs 50%, P<.001). However, after 1986, noninvasive treatments such as PTCSL have been performed more often (7 cases). In the past, PTCSL was performed using mechanical or electrohydraulic forces or pulsed dye laser, but after 1999, PTCSL has been performed using Ho:YAG lasers (3 cases). Consequently, the rate of residual stones decreased to 0 after PTCSL procedures.

Table Graphic Jump LocationTable 2. Treatment Procedures for Hepatolithiasis*

Table 3 gives a breakdown of treatments for the 3 different LR types. Hepatectomy was performed more frequently on patients with L type hepatolithiasis than other types (29 vs 5). Hepatectomy was performed on patients with R or LR type hepatolithiasis when the absence of residual stones was ensured by such a procedure. Cholangioenterostomy or PTCSL was performed more frequently for R or LR type hepatolithiasis than L type hepatolithiasis (40 vs 4). Thus, the incidence of residual stones was lower in the L type than in the LR type (0.03% vs 42.5%, P = .001) or in the R type (0.03% vs 28.6%, P = .02).

Table Graphic Jump LocationTable 3. Treatment for Hepatolithiasis According to the Location of Stones*

All lateral segmentectomies (n = 18) were performed on patients with L type hepatolithiasis, and left lobectomy was performed on those with L (10 patients) or LR (3 patients) type hepatolithiasis. Right lobectomy (n = 2) was performed on patients with R type hepatolithiasis. In addition, an extended left lobectomy was performed on 1 patient with L type hepatolithiasis.

There were no surgical deaths among the 89 patients. The surgical procedure duration was longer for hepatectomy (256 ± 102 minutes) than for cholangioenterostomy (236 ± 146 minutes) or T-tube insertion (186 ± 90 minutes). The intraoperative blood loss for hepatectomy (962 ± 364 mL) was greater than for cholangioenterostomy (542 ± 182 mL) or T-tube insertion (486 ± 144 mL, P<.001), whereas the durations of hospitalization were similar for hepatectomy (29 ± 22 days), cholangioenterostomy (38 ± 28 days), and T-tube insertion (36 ± 30 days). Table 4 gives the type and incidence of postoperative complications. Common complications included disturbance of liver function (n = 10), bile leakage (n = 7), and wound infection (n = 7). There were no deaths after surgery. Moreover, the incidence of mortality was similar among these groups.

Table Graphic Jump LocationTable 4. Morbidity and Mortality After Surgery for Hepatolithiasis

The biggest advantage associated with performing hepatectomy to treat hepatolithiasis is that all hepatic stones can be removed together with the pathologic bile ducts (including carcinomatous bile ducts), thus reducing the risk of recurrent intrahepatic stones.5 Hepatectomy is most often indicated for the treatment of L type hepatolithiasis,6 and lateral segment resection or left lobe resection is performed to remove intrahepatic stones and pathologic bile ducts.2 The incidence of I and L type hepatolithiasis is increasing in Japan, and hepatectomy now accounts for more than half of the surgical treatments performed for I and L type hepatolithiasis.3

The indications for hepatectomy are as follows: (1) hepatolithiasis is localized in the unilateral lobe, (2) the hepatic bile duct containing stones is markedly constricted or dilated, (3) combination with intrahepatic bile duct carcinoma, or (4) hepatolithiasis is accompanied by hepatic lesions including hepatic abscess or atrophy.7 Thus, hepatectomy is usually performed on patients with L type hepatolithiasis and rarely on patients with R type hepatolithiasis. Our data showed that left hepatic resection was performed more frequently than right hepatic lobectomy (32 vs 3).

When hepatectomy is not indicated, choledochojejunostomy is often performed to treat hepatolithiasis. There are 2 problems with choledochojejunostomy. First, choledochojejunostomy is indicated when the bile duct below the hepatic portal is constricted, but contraindicated when the intrahepatic bile duct is constricted.6 Intrahepatic bile duct constriction could lead to severe postoperative intrahepatic cholangitis, and careful postoperative care is needed.6 Second, choledochojejunostomy is indicated when intrahepatic stones are seen in both lobes and residual stones are expected to remain even though extensive lithotripsy has been performed.4 To facilitate postoperative natural stone elimination, the T tube is placed in the common bile duct, or a retrograde transhepatic biliary drainage tube is inserted into an area of the bile duct where residual stones are found.3

Therapeutic planning for hepatolithiasis begins with accurate diagnosis. An attempt should be made to perform PTCSL before other procedures to ascertain the condition of the intrahepatic biliary tract, the location of stones, and the location and severity of biliary stricture or dilatation.6 One of the reasons that multiple surgical procedures for hepatolithiasis are often performed is that the initial treatment is not appropriate, thus further complicating the condition due to residual or recurrent stones. In addition, PTCSL is performed for patients with intractable hepatolithiasis (ie, LR or R types where hepatectomy is not indicated).8

Residual stones are the most troublesome problem after treatment for hepatolithiasis.9 The incidence of residual stones has markedly decreased from 19.8% to 62.3%3,10 without cholangioscopy to 10.0% to 30.2% with intraoperative and postoperative cholangioscopy.110 In our study, the residual stone rate after PTCSL for hepatolithiasis is 14.3%. Cholangiojejunostomy was one of the major treatment procedures for hepatolithiasis before 1985, but the rate of residual stones was 56% (14/25) after this treatment. However, after 1986, hepatectomy and noninvasive treatments, including PTCSL, have been performed with greater frequency, and the rate of residual stones has decreased to 31% (1/32) after these treatments. Lee et al11 reported only a 4.2% recurrent stone rate after hepatectomy. Jan et al1 reported that recurrent stone rates after complete stone clearance for hepatolithiasis by hepatectomy and PTCSL were 9.5% and 36.4%. In another report of 19 patients who underwent complete lithotomy, calculi recurred in 4 (21%), 3 of which had disease recurrence less than 1 year after PTCSL.9 The rate of recurrent stones has been high after PTCSL, and the reason is that even when initial therapy is successful in completely eliminating stones, the structure of the bile duct remains unchanged.11

In the past, lithotripsy was performed mechanically or electrohydraulically using basket forceps.12 In recent years, favorable results have been obtained using lasers.13 At our institution, we have recently used the Ho:YAG laser in 3 cases, which has been used with increasing frequency in the field of urology in recent years.14 To our knowledge, there have not been any previous reports on the use of Ho:YAG lasers for the treatment of hepatolithiasis. The Ho:YAG laser fragments the components and achieves high stone-free success rates clinically.15 Extracorporeal shock wave lithotripsy is a noninvasive treatment technique for patients. The decision whether to perform ESWL is based on the type of stone and is indicated for the treatment of cholesterol stones.16 Also, stones can become trapped in the common bile duct during ESWL for hepatolithiasis, leading to severe acute suppurative cholangitis.16 Therefore, it is necessary to perform drainage procedures such as PTCD beforehand.17 Because 4% to 7% of patients with hepatolithiasis have intrahepatic bile duct carcinoma, it is necessary when performing PTCS or ESWL to perform a bile duct biopsy to ascertain the hardness and color of the bile duct wall and determine whether dilatation or constriction of the bile duct has resulted from inflammation or cancer.18

These findings suggest that cholangiojejunostomy or T-tube drainage is sufficient for the treatment of stacked intrahepatic stones secondary to choledocholiths when unaccompanied by hepatic atrophy or intrahepatic bile duct constriction. However, in the case of primary hepatolithiasis, ESWL should be performed first for cholesterol stones, hepatectomy should be performed first for L and R type bilirubin calcium stones, and PTCSL should be performed first for LR type and recurrent stones. In the case of secondary hepatolithiasis (following choledocholithiasis), if there is no liver atrophy and no stenosis of intrahepatic duct, cholangioenterostomy, T-tube drainage, or endoscopic sphincterotomy should be performed. In PTCSL, favorable results have been obtained using the Ho:YAG laser. Therefore, the use of hepatectomy should be considered when stones are localized in the unilateral lobe after PTCSL (Figure 1).

Place holder to copy figure label and caption

Decision tree for treatment of hepatolithiasis. In the case of primary hepatolithiasis, extracorporeal shock wave lithotripsy (ESWL) should be performed first for cholesterol stones, hepatectomy should be performed first for bilirubin calcium stones located in the left (L type) or right (R type) intrahepatic duct, and percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) should performed first for stones located in the bilateral intrahepatic duct (LR type) and recurrent stones. In the case of secondary hepatolithiasis (following choledocholithiasis), if there is no liver atrophy and no stenosis of intrahepatic duct, cholangioenterostomy, T-tube drainage, or endoscopic sphincterotomy should be performed.

Graphic Jump Location

Corresponding author and reprints: Hiroki Yamaue, MD, Second Department of Surgery, Wakayama Medical University, School of Medicine, 811-1 Kimiidera, Wakayama 641-8510, Japan (e-mail: yamaue-h@wakayama-med.ac.jp).

Jan  YYChen  MFWang  CS  et al.  Surgical treatment of hepatolithiasis: long-term results. Surgery. 1996;120509- 514
Link to Article
Sun  WBHan  BLCai  JX The surgical treatment of isolated left-sided hepatolithiasis: a 22-year experience. Surgery. 2000;127493- 497
Link to Article
Uchiyama  KTanimura  HIshimoto  K Hepatolithiasis in Japan. Nippon Geka Hokan. 1996;65145- 157
Kusano  TIsa  TTMuto  YOtsubo  MYasaka  TFurukawa  M Long-term results of hepaticojejunostomy for hepatolithiasis. Am Surg. 2001;67442- 446
Fan  STLai  ECSWong  J Hepatic resection for hepatolithiasis. Arch Surg. 1993;1281070- 1074
Link to Article
Sun  WBHan  BLCai  JXHe  ZPHung  ZQ Surgical treatment and long-term prognosis of localized left hepatolithiasis. Chin Med J. 1998;11182- 83
Chijiiwa  KYamashita  HYoshida  JKuroki  STanaka  M Current management and long-term prognosis of hepatolithiasis. Arch Surg. 1995;130194- 197
Link to Article
Lee  SKSeo  DWMyung  SJPark  ET Percutaneous transhepatic cholangioscopic treatment for hepatolithiasis: an evaluation of long-term results and risk factors for recurrence. Gastrointest Endosc. 2001;53318- 323
Link to Article
Yoshida  JChijiiwa  KShimizu  SSato  HTanaka  M Hepatolithiasis: outcome of cholangioscopic lithotomy and dilation of bile duct stricture. Surgery. 1998;123421- 426
Link to Article
Sato  TSuzuki  NTakahashi  WUematsu  I Surgical treatment of intrahepatic stones. Ann Surg. 1980;19228- 32
Link to Article
Lee  KTSheen  PCTsai  CCChen  JSKer  CG Long-term results of one hundred and seven hepatic resections for intrahepatic stones. Dig Surg. 1992;19298- 302
Link to Article
Binmoeller  KFBruckner  MThonke  F  et al.  Treatment of difficult bile duct stones using mechanical, electrohydraulic and extracorporeal shock wave lithotripsy. Endoscopy. 1993;25201- 206
Link to Article
Dawson  SLMueller  PRLee  MJSaini  SKelsey  PNishioka  NS Treatment of bile duct stones by laser lithotripsy: results in 12 patients. AJR Am J Roentgenol. 1992;1581007- 1009
Link to Article
Teichman  JMChan  KFCecconi  PP  et al.  Erbium:YAG versus holmium:YAG lithotripsy. J Urol. 2001;165876- 879
Link to Article
Vassar  GJChan  KFTeichman  JM  et al.  Holmium:YAG lithotripsy: photothermal mechanism. J Endourol. 1999;13181- 190
Link to Article
Uchiyama  KTanimura  HIshimoto  KMurakami  KNakai  T Extra-corporeal shock wave lithotripsy (ESWL) for biliary stones: a nation wide survey in Japan. Nippon Geka Hokan. 1994;63199- 207
Becker  CDFache  JSGibeny  MB  et al.  Choledocholithiasis: treatment with extracorporeal shock wave lithotripsy. Radiology. 1987;165407- 408
Chen  MFJan  YYHwang  TLJeng  LBYeh  TS Impact of concomitant hepatolithiasis on patients with peripheral cholangiocarcinoma. Dig Dis Sci. 2000;45312- 316
Link to Article

Figures

Place holder to copy figure label and caption

Decision tree for treatment of hepatolithiasis. In the case of primary hepatolithiasis, extracorporeal shock wave lithotripsy (ESWL) should be performed first for cholesterol stones, hepatectomy should be performed first for bilirubin calcium stones located in the left (L type) or right (R type) intrahepatic duct, and percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) should performed first for stones located in the bilateral intrahepatic duct (LR type) and recurrent stones. In the case of secondary hepatolithiasis (following choledocholithiasis), if there is no liver atrophy and no stenosis of intrahepatic duct, cholangioenterostomy, T-tube drainage, or endoscopic sphincterotomy should be performed.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Clinical Data of Patients With Cholelithiasis
Table Graphic Jump LocationTable 2. Treatment Procedures for Hepatolithiasis*
Table Graphic Jump LocationTable 3. Treatment for Hepatolithiasis According to the Location of Stones*
Table Graphic Jump LocationTable 4. Morbidity and Mortality After Surgery for Hepatolithiasis

References

Jan  YYChen  MFWang  CS  et al.  Surgical treatment of hepatolithiasis: long-term results. Surgery. 1996;120509- 514
Link to Article
Sun  WBHan  BLCai  JX The surgical treatment of isolated left-sided hepatolithiasis: a 22-year experience. Surgery. 2000;127493- 497
Link to Article
Uchiyama  KTanimura  HIshimoto  K Hepatolithiasis in Japan. Nippon Geka Hokan. 1996;65145- 157
Kusano  TIsa  TTMuto  YOtsubo  MYasaka  TFurukawa  M Long-term results of hepaticojejunostomy for hepatolithiasis. Am Surg. 2001;67442- 446
Fan  STLai  ECSWong  J Hepatic resection for hepatolithiasis. Arch Surg. 1993;1281070- 1074
Link to Article
Sun  WBHan  BLCai  JXHe  ZPHung  ZQ Surgical treatment and long-term prognosis of localized left hepatolithiasis. Chin Med J. 1998;11182- 83
Chijiiwa  KYamashita  HYoshida  JKuroki  STanaka  M Current management and long-term prognosis of hepatolithiasis. Arch Surg. 1995;130194- 197
Link to Article
Lee  SKSeo  DWMyung  SJPark  ET Percutaneous transhepatic cholangioscopic treatment for hepatolithiasis: an evaluation of long-term results and risk factors for recurrence. Gastrointest Endosc. 2001;53318- 323
Link to Article
Yoshida  JChijiiwa  KShimizu  SSato  HTanaka  M Hepatolithiasis: outcome of cholangioscopic lithotomy and dilation of bile duct stricture. Surgery. 1998;123421- 426
Link to Article
Sato  TSuzuki  NTakahashi  WUematsu  I Surgical treatment of intrahepatic stones. Ann Surg. 1980;19228- 32
Link to Article
Lee  KTSheen  PCTsai  CCChen  JSKer  CG Long-term results of one hundred and seven hepatic resections for intrahepatic stones. Dig Surg. 1992;19298- 302
Link to Article
Binmoeller  KFBruckner  MThonke  F  et al.  Treatment of difficult bile duct stones using mechanical, electrohydraulic and extracorporeal shock wave lithotripsy. Endoscopy. 1993;25201- 206
Link to Article
Dawson  SLMueller  PRLee  MJSaini  SKelsey  PNishioka  NS Treatment of bile duct stones by laser lithotripsy: results in 12 patients. AJR Am J Roentgenol. 1992;1581007- 1009
Link to Article
Teichman  JMChan  KFCecconi  PP  et al.  Erbium:YAG versus holmium:YAG lithotripsy. J Urol. 2001;165876- 879
Link to Article
Vassar  GJChan  KFTeichman  JM  et al.  Holmium:YAG lithotripsy: photothermal mechanism. J Endourol. 1999;13181- 190
Link to Article
Uchiyama  KTanimura  HIshimoto  KMurakami  KNakai  T Extra-corporeal shock wave lithotripsy (ESWL) for biliary stones: a nation wide survey in Japan. Nippon Geka Hokan. 1994;63199- 207
Becker  CDFache  JSGibeny  MB  et al.  Choledocholithiasis: treatment with extracorporeal shock wave lithotripsy. Radiology. 1987;165407- 408
Chen  MFJan  YYHwang  TLJeng  LBYeh  TS Impact of concomitant hepatolithiasis on patients with peripheral cholangiocarcinoma. Dig Dis Sci. 2000;45312- 316
Link to Article

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