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.

No abstract

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.

We performed a retrospective computer-aided statistical study of 228 patients who received treatment for malignant biliary obstruction to compare survival rates after surgical or radiological biliary decompression. To adjust for the selection bias produced by the clinical choice of surgical vs. catheter drainage, we examined differences in survival rates after controlling for various clinical and laboratory factors, which are predictive of short and long-term survival. These factors were selected by multivariate analysis. Short-term survival was significantly correlated with preoperative metabolic status as reflected in serum albumin, and blood urea nitrogen (BUN) levels. Elevated serum bilirubin values had no additional negative effect on survival. Long-term survival was influenced mainly by the extent of the primary cancer and the preoperative presence of leukocytosis. Although there was a difference in the raw data for hospital mortality between patients who underwent surgical drainage (11%) and those who underwent radiological drainage (30%), we found no real effect produced by the form of therapy after controlling for prognosis variables, i.e., eliminating selection bias. We propose a simple statistical model to predict short-term hospital survival. The application of objective risk factor analysis according to accepted statistical methods should permit the assessment of new radiologic therapeutic techniques with greater clinical validity.