Long-term follow-up after biliary stent placement for postcholecystectomy bile duct strictures: a multicenter study.

BACKGROUND AND STUDY AIMS: Endoscopic stenting is a recognized treatment of postcholecystectomy biliary strictures. Large multicenter reports of its long-term efficacy are lacking. Our aim was to analyze the long-term outcomes after stenting in this patient population, based on a large experience from several centers in France. METHODS: Members of the French Society of Digestive Endoscopy were asked to identify patients treated for a common bile duct postcholecystectomy stricture. Patients with successful stenting and follow-up after removal of stent(s) were subsequently included and analyzed. Main outcome measures were long-term success of endoscopic stenting and related predictors for recurrence (after one stenting period) or failure (at the end of follow-up). RESULTS: A total of 96 patients were eligible for inclusion. The mean number of stents inserted at the same time was 1.9±0.89 (range 1-4). Stent-related morbidity was 22.9% (n=22). The median duration of stenting was 12 months (range 2-96 months). After a mean follow-up of 6.4±3.8 years (range 0-20.3 years) the overall success rate was 66.7% (n=64) after one period of stenting and 82.3% (n=79) after additional treatments. The mean time to recurrence was 19.7±36.6 months. The most significant independent predictor of both recurrence and failure was a pathological cholangiography at the time of stent removal. CONCLUSION: Endoscopic stenting helps to avoid surgery in more than 80% of patients bearing postcholecystectomy common bile duct strictures. However, a persistent anomaly on cholangiography at the time of stent removal is a strong predictor of recurrence and may lead to consideration of surgery.

Laparoscopic approach as primary treatment of common bile duct stones in children.

BACKGROUND: Preoperative endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy (ES) are an effective strategy for choledocholithiasis, but complications such as pancreatitis and outcome in children are unknown. The laparoscopic cholecystectomy became the new gold standard in children for cholelithiasis. For the choledocholithiasis in children, the attitude is more controversial. We analyzed our series of laparoscopic approach for the management of choledocholithiasis in children to determine if it is an effective procedure. PATIENTS AND METHOD: Between 1996 and 2001, 126 children were treated for cholelithiasis in our institution; 13 children (10.3%) were managed for a choledocholithiasis. We reviewed age at symptom onset results of paraclinical examinations, the type of laparoscopic management, and postoperative outcome. RESULTS: The mean age at clinical signs was 9.9 years (range, 3 months-15.5 years). One child was excluded because he had a preoperative ES. Twelve children had a laparoscopic cholecystectomy and cholangiogram at the same time. A choledocholithiasis was found in 10 cases. A flush of the common bile duct (CBD) was performed in all cases with a 3F or 5F ureteral catheter; the stone was pushed into the duodenum in 3 cases and successfully extracted in 3 with a 4F Dormia or Fogarty catheter. One child needed a conversion to open surgery. Three times, an ES was necessary in postoperative course in each case for clinical and biologic signs of CBD obstruction or pancreatitis (30%). All children are symptom-free with an average follow-up of 28 months. CONCLUSION: Laparoscopic CBD exploration for choledocholithiasis can be performed safely in children at the time of cholecystectomy and can clear all of the stones in the CBD in two thirds of cases. If there is residual obstruction, a postoperative ES can be performed. We suggest primary treatment of choledocholithiasis by laparoscopic approach in children.

[Image guided drainage of pelvic fluid collections: results in 42 patients]. / Drainage radiologique des collections pelviennes: résultats chez 42 malades.

PURPOSE: To review the etiology, location, and morphology of pelvic collection as well as the technique and results of image guided drainage. MATERIALS AND METHODS: From June 1996 to August 2002, we performed image guided drainage of pelvic fluid collections in 21 males and 21 females. In patients where a direct contact between the collection and the endocavitary probe was present, the drainage was performed either by transrectal or transvaginal approach using 10F, 12F, 14F or 16F catheters according to the viscosity of the fluid. When the patients were no longer septic, when drainage had stopped, the drains were removed at day 5. When a fistula was present, the drain was left in place until the fistula healed. RESULTS: The most common location of pelvic collections was the cul-desac (43%). A total of 81% of pelvic abscesses were digestive in origin, either from the colon or appendix. Transrectal or transvaginal drainage was possible in 83% of cases. Mean follow-up was 41 months. No drainage related complication was recorded. In two patients with collections of clear fluid, a simple aspiration was performed without insertion of a drain. In the 40 other patients, a drainage catheter was inserted. Twenty-nine patients were cured after 15 days of drainage. Two patients had recurrent collections. Image guided drainage failed in five patients, and all underwent successful surgical management. CONCLUSION: Image guided drainage of pelvic collections is a safe and effective procedure. Failures were due to initially undiagnosed pathology requiring surgical treatment.

[Percutaneous treatment of intrahepatic lithiasis]. / Traitement percutané de la lithiase intra-hépatique.

AIM: To present our experience with percutaneous intracorporeal electrohydrolic lithotripsy in the treatment of intrahepatic lithiasis. SUBJECTS AND METHODS: From January 1989 to November 1998, 53 patients with intrahepatic lithiasis were treated with percutaneous intracorporeal electrohydrolic lithotripsy. Twenty-six patients had primary intrahepatic lithiasis. Intrahepatic stones were associated with intrahepatic duct abnormalities in 11 patients, 9 had strictures and 2 had cystic dilatations. Twenty-seven patients had secondary intrahepatic lithiasis formed a biliodigestive bypass in 20 patients. Intracorporeal electrohydrolic lithotripsy was performed under cholangioscopic guidance in all patients. The endoscope was introduced into the biliary ducts through a cutaneobiliary tract in 51 patients, through a cutaneocholecystic tract in one and through a cutaneojejunal tract in one. These tracts were created and gradually dilated in two sessions three days apart. In twenty-two patients stenosis or sharp angulation prevented adequate positioning of the scope which was only successful after balloon dilation or insertion of a stiff wire. RESULTS: Complete clearance of stones was achieved in 49 patients (92%). Biliary or hepaticojejunostomy strictures were successfully dilated with an angioplasty balloon in all patients. Ten patients (19%) had early complications: four had bilomas treated by percutaneous drainage, three had resolutive onset of cholangitis, two had transient arterial hemobilia, and one had a pneumothorax. The mean duration of follow-up was five years. During this period, 5 patients (9%) had recurrent symptoms of biliary obstruction. Among these patients, three (5.7%) had recurrent symptomatic intrahepatic lithiasis, one had a recurrent biliary stricture and one had secondary sclerosing cholangitis. Treatment of recurrent stones was repeated intracorporeal electrohydrolic lithotripsy in two and left hepatectomy in one; recurrent biliary stricture was treated by hepaticojejunostomy and secondary sclerosing cholangitis by antibiotics. CONCLUSION: Intracorporeal electrohydrolic lithotripsy is effective and safe and should be proposed as the first line treatment of primary or secondary intrahepatic lithiasis.

Placement of metallic stents for treatment of postoperative biliary strictures: long-term outcome in 25 patients.

OBJECTIVE: This study was undertaken to evaluate the results of our 7-year experience with Gianturco-Rosch metallic stents, used for the management of postoperative biliary strictures. SUBJECTS AND METHODS: From January 1989 to April 1995, self-expanding Gianturco-Rosch metallic stents were placed in 25 patients with postoperative bile duct stenosis. All patients had a history of bile duct injury during cholecystectomy. Twenty-four patients had a conventional open cholecystectomy and one patient had a laparoscopic cholecystectomy. Eight patients had stenosis at the level of the common bile duct. The other 17 patients, who had undergone surgical repair of the bile duct, had a stricture at the level of the hepaticojejunostomy. These anastomotic strictures recurred after simple cholangioplasty. Patients were monitored for 9-84 months (mean, 55 months). Treatment was considered successful if the initial stenosis did not recur. Treatment was considered a failure if the initial stenosis recurred within the stent. RESULTS: Two patients had early complications: one had bile pleural effusion, treated with percutaneous drainage, and the other had arterial hemobilia, treated with embolization. Eighteen (72%) of 25 patients had no recurrence of the initial strictures. Among these patients, 11 had no further symptoms of biliary obstruction and seven, all with strictured hepaticojejunostomies, had recurrent episodes of cholangitis caused by secondary sclerosing cholangitis or intrahepatic stone formation. Seven (28%) of 25 patients had recurrence of the initial stenoses, causing repeated episodes of cholangitis. Among these seven patients, six had common bile duct stenoses and one had an anastomotic stricture. Recurrent biliary obstruction was treated surgically or with percutaneous methods, despite the presence of the metallic stent. CONCLUSION: Gianturco-Rosch stent placement should be considered in patients with postoperative bile duct stenoses in whom another operation is not indicated and cholangioplasty has failed. The results are better in patients who have hepaticojejunostomy strictures rather than common bile duct strictures. Overall, a long-term recurrence rate of cholangitis of more than 50% of patients was seen because of recurrence of the original stenosis or intrahepatic bile duct obstruction.

Biliary symptoms and complications more than 8 years after endoscopic sphincterotomy for choledocholithiasis.

BACKGROUND & AIMS: Although long-term results of endoscopic sphincterotomy (ES) have been poorly estimated, extended indications of ES have been proposed, especially in young patients. The aim of this study was to assess late biliary complications of ES. METHODS: Between 1981 and 1986, 169 patients younger than age 70 (55+/-11.8 years; range, 24-70 years; male-female sex ration, 0.55) underwent ES for choledocholithiasis. One hundred fifteen patients (68%) underwent cholecystectomy. Long-term data were obtained retrospectively from the patients and general practitioners. RESULTS: Information was obtained for 156 patients, 2 of whom died within 1 month (one ES-related death). The mean follow-up for 154 patients was 9.6+/-3.3 years (range 8-13 years); 138 patients had no biliary symptoms. During follow-up, 16 patients experienced biliary symptoms; 2 of these patients underwent elective cholecystectomy, 3 had malignant strictures, 1 had a complicated cirrhosis, and 1 had a benign stricture related to the previous cholecystectomy. Nine patients developed potentially ES-related biliary symptoms. Second endoscopic exploration showed papillary stenosis in 3 patients (with stones in 2 patients) and recurrent bile duct stones in 3 others. Two patients had sine materia cholangitis, and 1 patient developed liver abscesses. CONCLUSIONS: Long-term ES-related complications seem to be rare, ES could reasonably be included in management strategies of choledocholithiasis, even in young patients.

Diagnosis and prognosis of AIDS-related cholangitis.

OBJECTIVE: To determine more precisely the clinical and biological characteristics of AIDS-related cholangitis, and to investigate prognostic variables of this disease. DESIGN: Retrospective clinical and prognostic study. SETTING: Biliary unit, Bicêtre Hospital, France. PATIENTS: HIV-positive patients (n = 52) referred to the unit between December 1986 and June 1993 for biliary symptoms leading to the suspicion of AIDS-related cholangitis, (42 men; 10 women; mean age, 37 +/- 8 years). INTERVENTION: Endoscopic retrograde cholangiopancreatography (ERCP) was performed in order to determine the cause of the biliary symptoms. MAIN OUTCOME MEASURE: Clinical features and evolution of the cholangitis. RESULTS: Among the 52 patients, 45 met the ERCP criteria of AIDS-related cholangitis (36 men; nine women). The diagnosis of cholangitis was strongly suggested by abdominal ultrasonography in 47% of the cases. ERCP showed papillary stenosis, diffuse cholangitis, extrahepatic cholangitis alone, and intrahepatic cholangitis alone in 60, 67, 7 and 27%, respectively. Endoscopic sphincterotomy was performed in 28 patients. Pain was relieved by sphincterotomy in nine patients, but the other clinical or biological features were not influenced. One-year and 2-year survival rates were 41 +/- 7% and 8 +/- 4%, respectively. Multidimensional analysis using a Cox model showed that a lymphocyte count > 500 x 10(6)/l was the only independent predictive factor of better survival. CONCLUSION: AIDS-related cholangitis is a disease which leads preferentially to papillary stenosis or diffuse abnormalities of the biliary tract. Prognostic factors depend on the stage of the HIV infection. Another diagnosis of cholestasis was found in approximately 15% of the patients who showed biliary symptoms.

[Percutaneous treatment of malignant stenoses of the hilum]. / Traitement percutané des sténoses malignes du hile.

PURPOSE: The endoscopic treatment of malignant hilar obstruction is followed in 70% of the case by infection of undrained biliary sectors. We report the influence of complete biliary drainage on post procedural cholangitis. METHOD: From January 1990 to January 1993 we treated 120 consecutive patients presenting with a malignant hilar obstruction. There were 61 women and 59 men, mean age 65 +/- 7.5 years. The level of stenosis was type II in 45 patients (37%), type III in 18 patients (13%) and above type III in 57 patients (48%). Complete biliary drainage with multiple biliary access was attempted in all patients. Long term internal drainage was achieved by metallic autoexpansive endoprosthesis. RESULTS: Complete drainage was achieved in all patients with type II or type III biliary stenosis. Drainage was incomplete in all patients with biliary stenosis above type III. Early complications were observed in 35% of the patients. Persistent cholangitis, the most frequent complication (22%) was only observed in patients with above type III biliary stenosis. Mortality at 30 days was 17%. Recurrent biliary obstruction was observed in 22% of the patients after an average of 187 days. Median survival was 95 days. CONCLUSION: Complete biliary drainage prevents persistent cholangitis in patients with type II or III biliary stenosis without increasing other complications related to biliary drainage.

Retrograde pancreatography. Technical tips and spectrum of pathology.

ERP is an important technique in the diagnosis of diseases involving the pancreatic ducts, in determining therapeutic strategy, and in assessing the results of surgical bypass procedures. ERP facilitates the diagnosis of the majority of pancreatic tumors at a stage when they normally present to the clinician. It assists the diagnosis of small tumors in the ampullary region at an early stage when other tests are negative. In cases of obscure recurrent pancreatitis, ERP may identify a mechanical cause (e.g., stone, stricture). ERP is useful in the diagnosis of CCP only in the precalcified stage. If histologic confirmation already has been obtained at surgery, ERCP is not required. Compared with noninvasive techniques, ERP provides additional information: It enables a concomitant examination of the gastroduodenal tract and opacification of the bile ducts; additional procedures may be performed, such as intraductal cytologic brushings, biochemical and cytologic analysis of pancreatic juice, endoscopic manometry, and pancreatoscopy. The diagnostic yield is increased if these procedures are performed during ERCP. Because ERP outlines the ductal anatomy, it is of great value in assessing therapeutic strategy. In cases of acute recurrent pancreatitis or chronic pancreatitis, ERP provides an important baseline for performing procedures such as ductal drainage and therefore reduces the inappropriate use of exploratory laparotomy. In cases of necrotic pancreatitis or pancreatic trauma, ERP enables accurate localization of a pancreatic fistula and facilitates any subsequent surgical procedure. Finally, ERP is the method of choice when assessing the patency of pancreatic-digestive anastomosis.

Management of clinically relevant bleeding following endoscopic sphincterotomy.

We report here on our experience of clinically relevant bleeding after endoscopic sphincterotomy (ES). Relevant bleeding was defined by the occurrence of (a) hematemesis or melena and (b) at least a two-point drop in hemoglobin, with no other bleeding source on endoscopy. These two criteria were met in 16 patients between 1983 and 1992. They represented 0.65% of all ES procedures performed during this period. Bleeding occurred immediately after ES in five cases, and was delayed in 11 cases from one to eight days (mean two days). Patients were retrospectively classified into three groups according to the severity of bleeding and subsequent clinical management. In six cases (group 1), bleeding developed slowly without shock and stopped spontaneously. In five cases (group 2), bleeding developed rapidly with melena and a drop in hemoglobin, but without shock. These patients were successfully managed with sclerotherapy without any further complications. The five patients in Group 3 had brisk bleeding with hematemesis and shock. Endoscopic hemostasis could not be performed; emergency arteriography disclosed active bleeding in four patients, and embolization of the gastroduodenal artery was performed. Bleeding stopped in all patients. Billroth II anastomosis appeared to be the only factor associated with an increased risk of clinically relevant bleeding. It was possible to control bleeding following ES using endoscopic or angiographic hemostasis, surgery being avoided in all cases.

[Large calculi of the common bile duct. Value of lithotripsy]. / Calculs volumineux de la voie biliaire principale. Intérêt de la lithotritie.

Certain stones need to be fragmented before being extracted via endoscopic sphincterotomy (ES). From April 1988 to December 1991, extracorporeal lithotripsy was used in this indication in 28 patients (22 females, 6 males) with a mean age of 77 +/- 20 years, using an ultrasound-guided electrohydraulic lithotriptor. Stone detection was performed after perfusion of the nasogastric tube and was easy in 20 cases (71%), difficult in 6 cases (22%) and impossible in 2 cases (7%), which could not be treated by this method. The patients had an average of 1.4 +/- 0.9 stones measuring 19.6 +/- 8 mm and received an average of 2.480 +/- 580 shock waves in a single session for 24 patients and in two sessions for 2 patients. Radiologically obvious fragmentation was achieved in 11 out of 26 cases (42%) and was found to be effective at a further extraction attempt in 4 other cases. Complete clearance of the common bile duct was achieved in 15 cases (57.7%). The size of the stones (> or < 20 mm) and the solitary or multiple nature of the stones did not significantly influence the fragmentation results. No complication related to the technique was observed apart from the constant development of cutaneous petechiae. An improvement in the power of the generator and the use of fluoroscopic rather than ultrasonographic guidance should allow an improvement of these results in the future. Because of its safety, this lithotripsy method can be proposed following failure of mechanical lithotripsy.

[Palliative treatment by endoprosthesis of icterus caused by distal biliary tumoral obstruction]. / Traitement palliatif par endoprothèse des ictères par obstacle tumoral biliaire sous-hilaire.

Between March 1982 and December 1987, 466 patients (256 women, 210 men, mean age 73 years) with tumor obstruction of the common bile duct were referred to our department. The causes of obstruction were carcinoma of the pancreas (298 patients), carcinoma of the ampulla of Vater (32 patients) and carcinoma of the common bile duct (136 patients). Endoscopical insertion of a biliary prosthesis was initially possible in 377 patients (81%). In case of failure, patients were referred to the radiologist for percutaneous drainage. Successful drainage was obtained in 58 patients with an overall success rate of 93% (435 patients). Endoscopic replacement was necessary in 170 cases for 114 patients and was successful in 155 (91%). Pruritus was relieved in 89% of the patients. Serum bilirubin levels decreased more than 75% after initial endoscopic endoprosthesis, repeated endoscopic endoprosthesis and percutaneous prosthesis insertion in 80%, 79%, and 62% of the patients, respectively. Short term complications of endoscopic endoprosthesis occurred in 28% of patients with a mortality rate of 8%. Percutaneous prosthesis complications occurred in 33% of patients with a mortality rate of 11%. In the long term, cholangitis was the main complication and occurred in 27% of patients with a delay of 103 +/- 105 days. Intestinal obstruction was observed in 7% of patients. The average life expectancy of endoscopic endoprosthesis and percutaneous prosthesis was 109 +/- 157 and 92 +/- 101 days, respectively. The average life expectancy of patients was 163 +/- 224 days.(ABSTRACT TRUNCATED AT 250 WORDS)

[Current results of endoscopic sphincterotomy for lithiasis of the common bile duct]. / Résultats actuels de la sphinctérotomie endoscopique pour lithiase de la voie biliaire principale.

Between January 1989 and June 1990, endoscopic sphincterotomy was performed in 308 consecutive patients with common bile duct stones (mean age: 74 years). Complete clearance of common bile duct was achieved at the first attempt in 65% of cases. This rate was significantly related to the size and the number of biliary stones. The success rate reached 97 percent after repeated endoscopic sessions (127 patients), mechanical lithotripsy (20 patients), extracorporeal or intracorporeal lithotripsy (18 and 11 patients, respectively). During the month following the endoscopic sphincterotomy, 39 patients (13%) developed one or more complications and 11 patients (3.7%) died. The complication rate was related to the time elapsed between biliary opacification and endoscopic sphincterotomy (P = 0.04) and between endoscopic sphincterotomy and total common bile duct clearance (P = 0.0007). No patient younger than 75 years died, but death occurred in 4.5% of the patients older than 75 years. Thirty patients (10%) developed endoscopic sphincterotomy-related complications. Cholangitis and bleeding were the most frequent complications (4 and 2%, respectively). Cholangitis occurred more frequently among the patients older than 75 (P < 0.05) or when transhepatic guided endoscopic sphincterotomy or intracorporeal lithotripsy was used (P < 0.005). Cholangitis led to death in 2 patients, 86 and 87 years old (0.7%). Endoscopic sphincterotomy related complications developed within 48 hours in all but 4 patients (2 patients with pancreatitis and 2 patients with cholecystitis).

[Septicemias after endoscopic retrograde cholangiopancreatography. Risk factors and antibiotic prophylaxis]. / Scepticémies après cholangiopancréatographie rétrograde endoscopique. Facteurs de risque et antibioprophylaxie.

The infection following endoscopic retrograde cholangiopancreatography (ERCP) is one of the most severe complications. The aim of the present study was to assess the prevalence and the prognosis of this complication, to look for the risk factors and to define bacterial ecology in order to put forward the most appropriate antibiotherapy. Two thousand and ten patients were included in this study. Among these, 51 (2.5%) had a septic complication following ERCP. Endoscopy biliary drainage was complete in 24 cases, incomplete in 19 and lacking in 8. Transhepatic biliary drainage was carried out in 17 cases. Sixteen patients (31%) with tumor obstructions died within 30 days after ERCP. Four risk factors were isolated when comparing infected patients with other patients: the completeness of biliary obstruction (90 vs 48%, P < 0.001); multiple cannulation attempts (1.76 +/- 1.12 vs 1.25 +/- 0.70, P < 0.001); the malignant nature of the obstruction (80 vs 23%, P < 0.002) and the lack of satisfactory drainage following endoscopy (53 vs 23%, P = 0.009). Pseudomonas aeruginosa was the most frequently isolated species, both from blood cultures (30%) and bile samples (23%). The preventive therapy of septic complications following ERCP must include strict rules concerning the disinfection of endoscopic material.(ABSTRACT TRUNCATED AT 250 WORDS)

[Endoscopic drainage of pseudocysts of the pancreas. Study of 26 cases]. / Drainage endoscopique des pseudo-kystes du pancréas. Etude de 26 cas.

Endoscopic drainage of pancreatic pseudocysts has been proposed for several years as an alternative to surgical treatment. We report the results of 26 endoscopic cystostomies of pancreatic pseudocysts (13 cystoduodenostomies, 13 cystogastrostomies) performed in two specialized centres, from 1985 to 1991. The patients were divided into 3 groups (I, II, III) according to the pseudocysts' clinical presentation. The opening of the collection into digestive lumen was achieved in 22 cases; there were 3 puncture failures and 1 cystostomy was not performed because of a prior haemorrhagic puncture. Pain relief was obtained rapidly after cystodigestive drainage in 13 out of the 14 symptomatic patients. Three complications required surgery: 1 bleeding after cystoduodenostomy, 1 perforation and 1 peritonitis after cystogastrostomies. Two of them occurred after recutting a cystostomy. Two pseudocyst surinfections healed with antibiotic therapy. No deaths occurred due to the procedure. Among the 18 long-term followed-up patients (average = 33 months), 4 required surgery for persistence or relapse of pseudocysts. The results were excellent for the 14 other patients without any difference between cystoduodenostomies and cystogastrostomies, neither between the I, II and III groups. Each of the 5 cases with a digestive lumen-pseudocyst cavity thickness above 1 cm (measured on 20 CT scans) failed: 1 puncture failure, 3 complications, 1 relapse.

Association of juxtapapillary diverticula with choledocholithiasis but not with cholecystolithiasis.

Juxtapapillary diverticula are often associated with biliary lithiasis. The aim of this study was to compare the prevalence of juxtapapillary diverticula in choledocholithiasis and in cholecystolithiasis without common bile duct stones. The results of 520 consecutive retrograde cholangiographies were retrospectively analysed. The prevalence of juxtapapillary diverticula was higher in patients with biliary lithiasis than in patients without: 26.0% vs 10.5% (p less than 0.001). However, juxtapapillary diverticula were more frequently encountered in patients with choledocholithiasis than in those with gallbladder lithiasis or previous cholecystectomy and a stone-free common bile duct: 40.0% vs 10.2% (p less than 0.001). There was no significant difference between the patients with cholecystolithiasis alone and those without biliary lithiasis. Among the patients with previous cholecystectomy or with gallbladder lithiasis, common bile duct stones were more frequently found in patients with juxtapapillary diverticula than in those without: 80.3% vs 40.6% (p less than 0.001). These data suggest that juxtapapillary diverticula are associated only with choledocholithiasis and not with gallbladder lithiasis.

Management of malignant hilar biliary obstruction by endoscopy. Results and prognostic factors.

Between January 1983 and December 1987, 103 patients who had hilar biliary obstruction (59 men, 44 women, median age 73 years) were referred to our institution. The causes of hilar biliary obstruction were carcinoma of the bile ducts (55), hepatic metastases or hepatocellular carcinoma (30), and carcinoma of the gallbladder (18). When endoscopic retrograde cholangiography was performed, the stricture was classified as type I in 28%, type II in 41%, and type III in 31% of the patients. In 92 patients, we tried to insert endoscopically a 10, 11, or 12 F Amsterdam type prosthesis; it proved possible in 66 (74%), and the prosthesis proved functional without further procedure in 49 cases (53%); no combined percutaneous and endoscopic method was used. At death or discharge, 45 patients (49%) had a successful drainage. Cholangitis was the main procedure-related complication and occurred in 25 patients. The 30-day mortality was 43%. Results varied according to type of stenosis: successful drainage was performed in 15% of the patients with type III stenosis, compared with 86% when the stenosis was of type I. Under a multivariate analysis the independent prognostic factors of 30-day mortality were: (1) development of infectious complications after endoscopic attempt at drainage (P less than 0.0001), and (2) absence of successful drainage (P less than 0.0001). In conclusion, endoscopic endoprosthesis placement allows a sufficient drainage in 53% of the cases. In type III stenosis, the high rate of 30-day mortality leads us the conclusion that endoscopic drainage must be avoided.

[Extracorporeal lithotripsy in the treatment of common bile duct calculi]. / La lithotritie extracorporelle dans le traitement de la lithiase de la voie biliare principale.

Thirty-three patients with common bile duct stones which could not be extracted by routine endoscopic measures were treated with extracorporeal lithotripsy. Two electrohydraulic lithotripters were used: Dornier HM3 and Technomed Sonolith 3000 using fluoroscopy and ultrasonography, respectively, for stone localisation. Twenty-nine patients were treated with only one session and four patients in two sessions. Fragmentation of stones was obtained in 29 patients (88 p. 100) and complete bile duct clearence in 26 patients (79 p. 100). The fragments passes spontaneously through the papilla in 7 cases; in 19 cases complete removal of fragments was achieved with a Dormia basket (16 cases) or after mechanical lithotripsy (3 cases). There were no significant differences in successful fragmentation rates between the two lithotriters. No serious adverse effects or mortality were observed within the 30 days following treatment. In conclusion, extracorporeal lithotripsy is an effective and safe method for the treatment of bile duct stones when, after sphincterotomy, routine endoscopic measures have failed.