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Percutaneous, transhepatic, intracorporeal, electrohydraulic shock wave lithotripsy was performed in 50 patients after failure of endoscopic treatment (n = 43) or directly in patients with a strictured hepaticojejunostomy (n = 7). Twenty-seven patients had common bile duct stones; 23, intrahepatic stones. Three steps were used: A transhepatic bilicutaneous fistula was created, a wide communication between the bile duct and the gut was established, and contact shock wave lithotripsy was performed under endoscopic guidance. Afterward, 46 patients were free of stones. In four patients with diffuse intrahepatic lithiasis, only 75% of stones could be cleared. Severe complications, seen in 11 patients (hemobilia necessitating transfusion [n = 6], bile duct perforation resulting in cholangitis [n = 3], acute pulmonary edema [n = 1], and hemothorax [n = 1]), were fatal in four patients; all occurred early in the study. The authors modified their technique by dilating the biliary tract in two sessions 3 days apart, waiting 6 days for the tract to mature, and then introducing the cholangioscope directly through the skin, significantly reducing complications and mortality (P less than .005).

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.

One hundred consecutive patients were prospectively studied to assess the clinical and biochemical features of symptomatic choledocholithiasis. Biochemical tests were performed during the three days following the onset of symptoms. Pain was the most frequent symptom of choledocholithiasis, observed in 75% of the patients, but rarely occurred alone (12%). Clinical symptoms were not different according to age. High serum gamma glutamyl transpeptidase and alkaline phosphatase were the most frequent biochemical abnormalities in patients with symptomatic choledocholithiasis: they were increased in 94 and 91% of cases, respectively. Only one patient had no biochemical abnormality. Serum transaminases could reach very high levels just as in hepatitis. Biochemical data did not differ regardless of whether the common bile duct was enlarged or not. Biochemical abnormalities had been studied over the first 10 days of spontaneous evolution in 25 patients while choledocholithiasis persisted: serum bilirubin and transaminases significantly decreased while serum gamma glutamyl transpeptidase, alkaline phosphatase, and amylase remained unchanged. These results indicate that, in patients with suggestive symptoms, choledocholithiasis is unlikely in the absence of biochemical abnormalities in the first three days following the onset of symptoms.

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