often Roux-en-Y anastomosis, can be combined with hepatectomy to relieve biliary stricture or decrease the risk of cholangitis.
通常採用 Roux-en-Y 吻合術，可與肝切除術合併進行，以緩解膽道狹窄或降低膽管炎的風險。

Liver transplantation is another option for managing intrahepatic stones, particularly in cases of biliary cirrhosis or failure, diffusely distributed stones refractory of treatment, or coexisting cholangiocarcinoma (77). However, biliary cast syndrome, characterized by casts or debris in the intra- or extra-hepatic bile ducts and presenting with jaundice or cholangitis, can occur in 3-25% of transplanted livers (78).
肝臟移植是治療肝內結石的另一種選擇，尤其是在膽汁性肝硬化或肝衰竭、瀰漫性分佈且難以治療的結石，或合併膽管癌的情況下（77）。然而，3%-25%的移植肝患者可能會出現膽管管型綜合徵，其特徵是肝內或肝外膽管內出現管型或碎片，並伴隨黃疸或膽管炎（78）。

Intrahepatic stones are associated with increased all-cause mortality, with predictors including older age at initial diagnosis, prolonged jaundice lasting more than one week, and coexisting cholangiocarcinoma or biliary cirrhosis (79). The presence of cholangiocarcinoma or liver cirrhosis can decrease the 10-year life expectancy of intrahepatic stones from $92.7\mathrm{\%}$$92.7\mathrm{\%}$92.7%92.7 \% to $42.7\mathrm{\%}$$42.7\mathrm{\%}$42.7%42.7 \%. If complete stone clearance cannot be achieved, the sequence of intrahepatic stones-liver atrophy-cholangiocarcinoma may occur. Additionally, intraductal papillary neoplasia, a precancerous lesion can be found in $30\mathrm{\%}$$30\mathrm{\%}$30%30 \% of patients with intrahepatic stones, along with the risk of developing cholangiocarcinoma (80).
肝內結石與全因死亡率增加有關，預測因子包括初診時年齡較大、黃疸持續超過一週以及合併膽管癌或膽汁性肝硬化 (79)。膽管癌或肝硬化可使肝內結石的10年預期壽命從 $92.7\mathrm{\%}$$92.7\mathrm{\%}$92.7%92.7 \% 縮短至 $42.7\mathrm{\%}$$42.7\mathrm{\%}$42.7%42.7 \% 。如果無法完全清除結石，則可能出現肝內結石-肝臟萎縮-膽管癌的惡性循環。此外， $30\mathrm{\%}$$30\mathrm{\%}$30%30 \% 肝內結石患者可發現癌前病變－導管內乳頭狀腫瘤，並有膽管癌的風險 (80)。

Although there are no official guidelines for the interval to survey patients with intrahepatic stones, it is crucial to detect and manage retained stones, liver atrophy, and mass-forming lesions early to prevent biliary sepsis, secondary biliary cirrhosis, and cholangiocarcinoma. US is the preferred method for surveillance, but its detection rate for cholangiocarcinoma is only about $78\mathrm{\%}$$78\mathrm{\%}$78%78 \% due to the poor demarcation of the tumor (81). CT has a sensitivity of $93\mathrm{\%}$$93\mathrm{\%}$93%93 \%, while MRI has a sensitivity of $88\mathrm{\%}$$88\mathrm{\%}$88%88 \% for detecting cholangiocarcinoma (81). In cases where cholangiocarcinoma is suspected, the presence of elevated carbohydrate antigen 19 9 or carcinoembryonic antigen may raise concerns. However, it is important to note that elevated tumor
雖然目前尚無官方指引規定肝內結石患者檢查間隔時間，但及早發現和處理殘留結石、肝萎縮和腫塊形成性病變對於預防膽道膿毒症、繼發性膽汁性肝硬化和膽管癌至關重要。超音波是首選的監測方法，但由於腫瘤邊界不清，其對膽管癌的檢出率僅為 $78\mathrm{\%}$$78\mathrm{\%}$78%78 \% 左右(81)。 CT 檢查的敏感度為 $93\mathrm{\%}$$93\mathrm{\%}$93%93 \% ，而 MRI 檢查的敏感度為 $88\mathrm{\%}$$88\mathrm{\%}$88%88 \% (81)。在懷疑膽管癌的情況下，如果出現碳水化合物抗原 199 或癌胚抗原升高，則可能引起關注。然而，需要注意的是，腫瘤
markers can also be present in cases of biliary obstruction or cholangitis.
在膽道阻塞或膽管炎的情況下也可能出現標記。

Long-term follow-up is essential for intrahepatic stones, as the risk of stone recurrence, cholangitis, secondary biliary cirrhosis, and cholangiocarcinoma is high. Complete stone clearance is mandatory to reduce the risk of these long-term complications. Although there are no official guidelines for surveillance, regular monitoring is suggested to prevent these sequelae from developing. A multi-disciplinary approach is warranted for the management and follow-up of intrahepatic stones. Gastroenterologists should be responsible for regular surveillance and per-oral endoscopic management, while radiologists should handle interventional radiology procedures. Surgeons should perform operations combined with per-cutaneous endoscopic management.
肝內結石的長期追蹤至關重要，因為結石復發、膽管炎、繼發性膽汁性肝硬化和膽管癌的風險很高。必須徹底清除結石，以降低這些長期併發症的風險。雖然目前尚無官方的監測指南，但建議定期監測以防止這些後遺症的發生。肝內結石的治療和追蹤需要多學科協作。胃腸科醫師應負責定期監測和經皮內視鏡治療，而放射科醫師應負責介入放射學檢查。外科醫師應進行手術合併經皮內視鏡治療。

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