Stent endoprosthesis has been advocated as an alternative to internal-external catheter drainage for decompression of biliary obstruction, but drawbacks have never been specifically analyzed, to our knowledge. A retrospective review of 118 biliary stent endoprostheses placed in 113 patients assessed the frequency, nature, and treatability of significant complications. Complications were categorized as early (morbidity or mortality within the first 30 days) or late (after 30 days). The early complication rate was 17% (19/113); the late complication rate, 31% (32/102). Early complications were most often due to unstable stent positioning in technically difficult procedures involving periportal obstruction (4/8), while the most common late problems were lumen occlusion (23/102 [23%]), migrations (6/102 [6%]), and tumor overgrowth of the stent (3/102 [3%]). Neither the histologic features nor the location of the primary tumor correlated with the potential for long-term stent dysfunction. Specific treatment of complications was carried out in 17 of 102 patients (17%) and almost invariably required readmission and remanipulation or de novo biliary drainage.

Transhepatic cholangiography (THC) was performed in 107 patients who had nondilated intrahepatic bile ducts on computed tomography (CT) or ultrasound. The cholangiogram was diagnostic in 72 patients (67%). Thirty-one (43%) of the 72 diagnostic studies were abnormal and showed poor emptying, stones, or strictures. Twenty-three (21%) complications occurred, including two deaths. Sixteen patients experienced acute pain, requiring additional narcotics. There was one case of peritonitis and pancreatitis, and two of bacteremia. We compared our success and complication rates to those of endoscopic retrograde cholangiography (ERC) reported in the literature. We conclude that when a bile duct abnormality is clinically suspected, the incidence of pathology is sufficiently high to warrant direct visualization of the ducts in order to make an anatomic diagnosis, even if the intrahepatic ducts are not dilated. However, ERC has a better success rate and fewer complications than THC and it should be the initial invasive procedure.

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Sixteen critically ill patients underwent percutaneous cholecystostomy because of suspected acute cholecystitis. The procedure was technically successful, although 11 of 16 patients died subsequently because of various complications of their underlying primary disorders. We reviewed this series to reassess the value of percutaneous cholecystostomy. Four of 11 patients with definite acute cholecystitis (group 1) were cured by this technique, but three required surgery because of gallbladder wall necrosis. Two of these were among four cases which had demonstrated pericholecystic fluid collections on computed tomography (CT) or ultrasound of the abdomen. There were also five patients (group 2) in whom acute cholecystitis or its relationship to patients' symptoms were not fully determined, and four of them did not improve after percutaneous cholecystostomy. We conclude that this technique has a lower success rate in critically ill patients than reported previously.

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