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.

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.

Shigella serogrouping antisera from six companies (Becton Dickinson, Denka, Difco, Murex, Roach, and Sanofi-Pasteur) intended for the slide agglutination test and those of the Wellcolex Colour Shigella latex agglutination test were evaluated to identify quality products for Shigella identification. Forty-six reference Shigella strains (one for each serotype and species), 50 clinical strains (21 S. flexneri, 21 S. sonnei, 4 S. dysenteriae, 4 S. boydii) representing the most prevalent species and serotypes encountered in Quebec, and 9 non-Shigella strains were tested according to the manufacturers' instructions. A 3؉ reaction (>75% agglutination) was considered positive for the slide agglutination tests. Sensitivity varied from 47% (Roach) to 94% (Difco). For the 105 strains tested, accuracy ranged from 53% (Roach) to 91% (Wellcolex). Specificity varied from 97 to 100% for group A antisera, from 96 to 100% for group B antisera, from 88 to 100% for group C antisera, and from 95 to 99% for group D antisera. The costs of reagents required to test one strain varied from $3.50 to $13.20 (in Canadian dollars). In conclusion, Roach reagents proved to be unsatisfactory for Shigella serogrouping. Among those from the remaining companies, the Denka, Difco, and Wellcolex reagents met a performance standard of 90% accuracy. Shigella species are primarily responsible for gastrointestinal tract infections ranging from bacillary dysentery to less acute infections and are spread worldwide (1, 9-11, 13, 14). They share common characteristics with members of the genus Escherichia, from which they cannot be differentiated by DNA-DNA hybridization. According to modern taxonomy, subdivision of the genus into species is irrelevant. Nonetheless, medical and epidemiological interests justify maintaining the genus with its four species: S. dysenteriae, S. flexneri, S. boydii, and S. sonnei, also known as groups A, B, C, and D, respectively. These are subdivided into serotypes, which are given numerical designations (5-7, 13). Laboratory diagnosis relies on the isolation of the organism from feces and its identification by means of cultural and biochemical characteristics. Serological identification is mandatory because of its close relatedness to Escherichia coli. It requires, for a start, that species be identified (serogrouping); this is followed by serotype determination (serotyping). Serogrouping is generally carried out in clinical laboratories, while serotyping is performed in central or reference laboratories (5, 6, 13). Serogrouping is based on the detection of somatic O antigens by an agglutination technique with polyclonal antisera specific to each of the four Shigella species. Unfortunately, there is no international consensus on the choice of Shigella strains for the production of the grouping antisera (6). These antisera are commercially available from various manufacturers, but the sensitivities and specificities of these products remain to be determined. A study conducted by the U.S. Centers for Disease Control in 1988 (4) s...

Combined endoscopic and fluoroscopic guidance is preferable to fluoroscopy alone. The technique is simple if the endoscope is inserted retrograde. Long-term results are satisfactory and we believe that incision should be the initial approach to strictures of uro-digestive anastomoses.