It has been suggested that there may be many differences between Korean and Western cholelithiasis by late Professor Ludlow (1930) of Severance Union Medical College. Following the years clinical and pathological investigation had confirmed the Ludlow's statement and furthermore it is suggested that a high incidence of intrahepatic calculi may be the other factor contributing to the different clinical picture of Korean cholelithiasis.
However, no document studies of the intraheoatic claculi of Korean are available yet.
85 cases of surgically proved intrahepatic calculi were observed among the 462 cases of the gall stone patients encountered at the Dept. of Surgery Yonsei University Medical College(1958, Jan-1967, June, 68 cases) and Korea General
Hospital (1968. Nov.-1971. April, 17 cases) for the last 12 years.
Clinical incidence, symptomatology, location of the stones, the classification for the selection of the method of treatment, and the change of operative method for the last 12 years were reviewed and evaluated.
Incidence of the intrahepatic calculi to the all gall stone patients is about 18.4%.
Peak incidence was noted at the 4th decade and youngest patient was 17 years old and oldest patient was 74 years old.
There is no significant sex differences.
The most prominent symptoms and signs are pain (89%) and tenderesis(93%) in the fight upper quardrant and epigastric region.
Two third of all intrahepatic calculi harbored stones in the common hepatic or bileduct and one third of them were combined with gall bladder stones.
The calculi were found in the left intrahepatic duct in 76(89.4%) cases, in the right intrahepatic duct in 55(64.7%) cases. In 6 cases (7.1%). calculi were limited only in the left intrahepatic duct but in no case right intrahepatic calculi was
seen without combinations.
The classification of the intrahepatic calculi based upon our clinical experiences is as follows;
A type: Simple intrahepatic calculi
B type: complicated intrahepatic calculi
Ⅰ-: Intrahepatic calculi with stenosis at bifureation of both intrahepatic duct
Ⅱ-: Intrahepatic calculi with stenosis in the left intrahepatic duct with or without contralateral intrahepatic calculi
Ⅲ-: Intrahepatic calculi with stenosis in the right intrahepatic duct withor without contralateral intrahepatic calculi
Ⅳ-: Intrahepatic calculi with multiole stenosis in the both intrahepatic ducts
Most of the intrahepatic calculi is Simple type (34.8%) but Complicated B-Ⅳ type is the next most common (28.9%).
First period of early 5 years (1958. Jan.-1962. Dec.) 22 out of 25 cases had no by-pass procedures and recurrent rate of biliary colic and the other symptoms were 81.8% (18 out of 22) and the most of them had to undergo another operations.
At the second period (1963. Jan.-1967. June) 21 out of 43 had by-pass operation and the rest of 43(22 cases) had no by-pass operation with recurrent rate of 72.7%.
During 3rd period from 1968. Nov. to 1971. April. 11 (64.7%) out of 17 cases had by-pass procedures without recurrency, and only 6 (35.3%) out of 11 had no by-pass procedure with 2 (33.3%) cases of recurrency.
Throughout the three period of observations, there is increased tendency of indication of by-pass procedures at the time of primary surgery.
The following surgical procedures for each type of intrahepatic calculi is considered as a choice of proper approach to conouer the problems of the intrahepatic calculi.
A Type: Simple by-pass procedure(preferably Roux-en-Y type)
B-Ⅰ Type: Templeton-Dodd's procedure with Roux-en-Y type
B-Ⅱ Type: Longmire's procedure
B-Ⅲ Type: Roux-en-Y choledocho-jejunostomy and right intrahepatico-jejunostomy
B-Ⅳ Type: No definite treatment but simple by-pass procedure may be helpful