Expression of nitric oxide synthase in normal and preeclamptic placental tissue and effects of glyceryl trinitrate and shear stress on placental blood flow

Large and multiple common bile duct stones may defy extraction despite an adequate endoscopic papillotomy. We treated 65 patients with symptomatic bile duct stones with endoscopic stents after failed attempts at stone extraction. Of the 65 patients, bile duct stones were extracted in eight at a second attempt, 29 underwent elective surgery and 28 patients were followed with the stent in situ for 21-52 months (median 42 months). During follow up, two patients had recurrent pain and two required surgery. The remaining 24 patients remained asymptomatic. Biliary stenting is a safe and effective mode of treatment for common bile duct stones in patients who have failed stone extraction after endoscopic papillotomy.     

Laparoscopic cholecystectomy and lithiasis of the common bile duct: prospective study on the importance of preoperative endoscopic ultrasonography and endoscopic retrograde cholangiography

OBJECTIVES: Laparoscopic cholecystectomy is the standard treatment of symptomatic gallstones. At present, no consensus has been reached on the diagnostic and therapeutic methods of concomitant common bile duct stones. Systematic preoperative endoscopic ultrasonography followed, if necessary, by endoscopic retrograde cholangiography and sphincterotomy during the same anesthetic procedure could be a diagnostic and therapeutic alternative for common bile duct stones making possible a laparoscopic cholecystectomy without intraoperative investigation of the common bile duct. METHODS: One hundred and twenty-five patients underwent a prospective endoscopic ultrasonographic evaluation prior to laparoscopic cholecystectomy for symptomatic gallstones. Fourty-four patients (35%) had at least one predictive factor for common bile duct stones. Endoscopic ultrasonography and cholecystectomy were performed on the same day. Endoscopic ultrasonography was followed by endoscopic retrograde cholangiography and sphincterotomy by the same endoscopist in case of common bile duct stones on endoscopic ultrasonography. Patients were routinely followed up between 3 and 6 months and one year after cholecystectomy. RESULTS: Endoscopic ultrasonography suggested common bile duct stones in 21 patients (17%). Endoscopic ultrasonography identified a stone in 17 of 44 patients (38.6%) with predictor of common bile duct stones and only in 4 of 81 patients (4.9%) without predictor of common bile duct stone. Among these 21 patients, one patient was not investigated with endoscopic retrograde cholangiography because of the high risk of sphincterotomy, 19 patients had a stone removed after sphincterotomy, one patient had no visible stone neither on endoscopic retrograde cholangiography, nor on exploration of the common bile duct after sphincterotomy. Endoscopic ultrasonography was normal in 104 patients (83%). However, two patients in this group were investigated with endoscopic retrograde cholangiography because endoscopic ultrasonography was incomplete in one case and because endoscopic ultrasonography was normal in the second case but a stone in the left hepatic duct was detected by ultrasonography. A stone was removed after endoscopic sphincterotomy in these two patients. In the group of 102 patients without stone, 91 out of 92, continued to be asymptomatic during a median follow-up of 8.5 months. One patient with symptoms one month after cholecystectomy underwent endoscopic sphincterotomy but no stone was found. CONCLUSIONS: Systematic preoperative endoscopic ultrasonography followed, if necessary with endoscopic retrograde cholangiography and sphincterotomy is a diagnostic and therapeutic alternative for common bile duct stones making possible a laparoscopic cholecystectomy without intraoperative investigation of the common bile duct for all patients. This alternative is only justifiable in patients with predictor of common bile duct stones.     

Postsurgical bile leaks: endoscopic obliteration of the transpapillary pressure gradient is enough

OBJECTIVES: Bile leaks are a well documented complication of biliary surgery, occurring more frequently with laparoscopic procedures. Endoscopic therapy with a long biliary endoprosthesis traversing the site of the leak is effective. We have evaluated the hypothesis that equalizing biliary and duodenal pressures with a short transpapillary stent is an equally effective therapy for bile leaks. METHODS: Thirty one consecutive patients presenting over a 52-month period with postsurgical bile leaks were evaluated. Patients had been treated with long endoprostheses (stents or nasobiliary tubes), sphincterotomy, or short transpapillary stents. The success, complication rate, need for additional therapy, and hospitalization time of each therapeutic approach were determined. RESULTS: Endoscopic therapy was successful in all 25 patients in whom a bile leak could be documented. The clinical success, need for radiological drainage, length of hospitalization, and incidence of pancreatitis were similar for all methods of treatment. CONCLUSIONS: These results confirm that endoscopic therapy is highly successful in the treatment of postoperative bile leaks and suggest that the mechanism of healing is the equalization of bile duct and duodenal pressures, allowing flow of bile into the duodenum. The endoscopic placement of short transpapillary stents without sphincterotomy is a temporary, effective, and technically simple method of pressure equalization. This should be considered as the primary therapy for most postoperative bile leaks.     

Outcome of mechanical lithotripsy of bile duct stones in an unselected series of 704 patients

BACKGROUND/AIMS: This paper evaluates the potential benefit of non mechanical bile duct stone lithotripsy techniques. The efficacy, limitations and risks of mechanical lithotripsy as first choice procedure were studied. MATERIAL AND METHODS: Endoscopic sphincterotomy was performed by Erlangen-type papillotomes, stone extraction by Olympus baskets and mechanical lithotripsy by the Wurbs-system. In an unselected series of 704 patients, everyone with common bile and hepatic duct stones (independent of size, number, location and stone consistency) was included in the study. RESULTS: Complete stone clearance by endoscopic sphincterotomy and basket extraction was possible in 87.6%. Additional mechanical lithotripsy led to a success rate of 98.4% and in combination with ESWL of 98.5%. In 11 patients without possibility of endoscopic stone removal (1.6%), 4 had no access transpapillary (B-II-situs or duodenal diverticulum), 5 anatomical problems (S-shaped common bile duct, intrahepatic stones or impacted stones in cystic duct orifice), and 2 refused further endoscopic interventions. Complication rate was 1.4% (thereof 1.1% successful treatment by endoscopic or surgical means), lethality rate 0.3%. CONCLUSIONS: A very high rate of stone clearance by standard endoscopic procedures is possible. In those patients where mechanical lithotripsy is not successful, other non-surgical lithotriptic procedures either cannot be applied because of anatomical reasons or if performed, the improvement in success rate is marginal.     

Efficacy of endoscopic diagnosis and treatment for postoperative biliary leak

BACKGROUND/AIMS: The purpose of this study was to evaluate the efficacy of endoscopic approaches for the diagnosis and treatment of postoperative biliary leak. METHODOLOGY: Endoscopic retrograde cholangiopancreatography (ERCP) was performed in eight patients with postoperative biliary leak. Of 8 cases, 6 had biliary leak alone (4 cases with a cystic duct leak and 2 cases with a bile duct leak) and 2 cases with a bile duct leak were associated with a bile duct stricture. Endoscopic sphincterotomy (ES) and endoscopic biliary stenting (EBS) were employed in 5 patients and nasobiliary tube drainage (NBD) without ES was performed in 3 patients. RESULTS: In all the patients, ERCP was successfully performed and could demonstrate exact nature and site of postoperative bile duct injuries. In 2 patients with a concomitant bile duct stricture, repetitive endoprosthesis placements were required. The remaining six patients with biliary leak alone were successfully treated by temporary stenting, i.e., ES and EBS (n = 3), and NBD (n = 3). CONCLUSIONS: The patients with postoperative biliary leaks can be successfully diagnosed by ERCP and treated by temporary endoscopic methods. Among various endoscopic treatments, NBD alone appears to be preferable in treating patients with small bile leaks. However, cases with a concomitant bile duct stricture were intractable and required longer period of stenting.     

Endoscopic management of acute calculous cholangitis

Acute cholangitis is associated with significant morbidity and mortality. Endoscopic drainage procedures have been shown to be a safe and effective mode of treatment in acute cholangitis. As there is paucity of large series on endoscopic management of acute cholangitis, a study was performed to evaluate safety and efficiency of endoscopic biliary decompression in acute cholangitis. The study included 89 consecutive patients (mean age 55+/-15 years; range 35-70 years; 50 males) with acute cholangitis requiring biliary drainage. Main presenting features were upper abdominal pain (84%), fever with chills (90%) and jaundice (74%). Altered sensorium, hypotension, features of peritonitis and acute renal failure were present in 15, 11, 18 and 5%, respectively. Endoscopic procedures performed were endoscopic sphincterotomy (ES) with stone extraction (n=40); ES with endoscopic nasobiliary drainage (ENBD; n=30); ENBD without ES (n=8); and ES with stent placement (n=11). Of the 89 patients, 85 (95%) responded within 48-72 h. Endoscopic common duct clearance could be achieved in 58 of 78 (74%) patients, whereas in 11 patients undergoing stent placement, stone extraction was not attempted. Complications included post-sphincterotomy bleed (n=2), retroduodenal perforation (n=1) and acute pancreatitis (n=1) with an overall complication rate of 4.4%. All the complications were seen in patients undergoing ES with stone extraction. Mortality was 3.3%. In conclusion, endoscopic biliary drainage is a safe and effective mode of treatment for acute cholangitis. Endoscopic nasobiliary drainage or stent placement is safer than ES in acute cholangitis as an initial step.     

Comparison of routine and selective endoscopic retrograde cholangiography before laparoscopic cholecystectomy

To evaluate the role of endoscopic retrograde cholangiography (ERC) before laparoscopic cholecystectomy, we compared the frequency of concomitant common bile duct stones, their clinical outcome, and the frequency of bile duct injury between a group of 128 patients with routine preoperative ERC (group A) and 1010 patients with selective ERC (group B). Overall, 48 patients (4.2%) had duct stones, but the predictive signs were absent in six of them (12.5%). The stones were demonstrated by ERC and removed by sphincterotomy in all 11 patients in group A. Of 37 patients in group B, 22 were diagnosed by selective ERC and underwent endoscopic removal. Of four patients whose stones were found by operative cholangiography, one had immediate open surgery, another passed a stone spontaneously, and the other two underwent postoperative sphincterotomy, which failed in one. The stones were not recognized until pain recurred in the remaining 11 patients. Sphincterotomy was successful in nine patients but failed in the other two. Thus postoperative sphincterotomy failed in 3 of 13 patients (23%), necessitating open surgery. Forty-two patients overall (3.7%) had aberrant biliary tract anatomy, which did not lead to bile duct injury in any of the patients. Morbidity of routine ERC (3.1%) was lower than that of selective ERC (7.4%) (p < 0.05). It should be noted that a certain proportion of duct stones may be missed by selective ERC, necessitating laparotomy when sphincterotomy fails. The routine use of preoperative ERC may be justified at institutions where the expertise is available, at least until laparoscopic lithotomy becomes easy.     

Expandable metallic biliary stents

Eighteen expandable metallic biliary stents were inserted in patients with malignant (16 patients) or benign (two patients) biliary strictures. Four were the Gianturco-Rosch biliary Z-stents and the remaining 14 were the Wallstent. The stents were delivered through either the endoscopic transpapillary (10 patients), percutaneous transhepatic (five patients) or combined percutaneous-endoscopic (three patients) route. No failure in implantation was encountered. Bile drainage was successful in all patients. Stent occlusions were observed in four patients with hilar obstruction due to tumour overgrowth above the stents at 30-67 days (mean 47.75 days) after insertion. The occlusions were drained percutaneously (two patients) or endoscopically (two patients). Migration of stent did not occur. After a median follow-up period of 170.5 days (range 57-731 days), 11 patients were still alive and free of jaundice. The median patency period of the stents for common bile duct and hilar obstruction was 288.5 days (range 117-731 days) and 61.5 days (range 30-188 days), respectively. The overall median patency period was 165 days. It is concluded that expandable metallic biliary stent is a useful adjunct to the treatment of malignant biliary obstructions with a better result in distal obstruction.     

Current results of endoscopic sphincterotomy for lithiasis of the common bile duct

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).     

Prediction of recurrent choledocholithiasis by quantitative cholescintigraphy in patients after endoscopic sphincterotomy

BACKGROUND: Endoscopic sphincterotomy (EST) is widely used for the removal of stones from the bile duct, but stones recur in about one fifth of patients. AIMS: To investigate hepatic clearance by quantitative cholescintigraphy (QC) in patients after EST and to discern the relationship between biliary emptying and stone recurrence. METHODS: One hundred and forty nine patients who had EST and clearance of the bile duct for choledocholithiasis were selected. All patients were confirmed to have complete EST by sphincter of Oddi manometry and underwent QC soon after normalisation of liver function. Regular clinical follow up was performed for each patient. RESULTS: During a mean 36 month follow up, 22 (14.8%) patients developed recurrent stones in the bile duct. Irrespective of the status of the gall bladder, patients with recurrent stones had a slower hepatic clearance of radioisotope during QC compared with patients without stone recurrence, but only the differences in cholecystectomised patients had statistical significance. After carrying out multivariate analysis, one parameter of QC, percentage clearance of maximal count at 45 minutes, was found to be the only significant factor for stone recurrence. All recurrent stones in the common bile duct were successfully removed at endoscopy. CONCLUSION: Slower hepatic clearance as shown by QC is an important factor responsible for stone recurrence after sphincter ablation.     

Mass screening of colorectal cancer: where are we up to?

BACKGROUND AND STUDY AIMS: Conventionally, acute cholangitis is managed by placing a nasobiliary drainage catheter. We have attempted to place a biliary endoprosthesis in such patients as an alternative to using nasobiliary catheter drainage. PATIENTS AND METHODS: Twenty-seven patients with acute cholangitis were managed by placement of 7-Fr straight biliary endoprostheses instead of using nasobiliary drainage catheters to decompress the biliary system. The procedure was carried out without sphincterotomy and without image intensification. RESULTS: Biliary endoprosthesis placement was successfully carried out in all the patients. Definitive treatment was then provided to all but four patients, who either had inoperable cancer or were at high risk for surgery. Early stent occlusion occurred in one patient, and in another patient the Dormia basket became entrapped while stones were being removed from the common bile duct. There were no mortalities. CONCLUSIONS: Biliary endoprosthesis placement is safe, easy to perform, and is a cheaper alternative to endoscopic nasobiliary drainage.     

Treatment of postoperative bile fistulas after laparoscopic cholecystectomy by ERCP, EPT and bile duct drainage

BACKGROUND: Bile leakage as a complication following cholecystectomy can be found more frequently after laparoscopic cholecystectomy (LC) than after open cholecystectomy. The present study planned to find out the importance of ERCP, sphincterotomy and temporary drainage of the bile duct system in the treatment of bile leakage. PATIENTS AND METHODS: From July 1992 to October 1996 15 consecutive patients presenting with bile leakage following LC underwent endoscopic therapy by CBD-drainage with sphincterotomy (n = 11), CBD-drainage without sphincterotomy (n = 1) and sphincterotomy alone (n = 3). RESULTS: Closure of the bile leakage could be achieved in all cases, biliary secretion stopped after 2.1 days (1-7 days). One dislocation of the drainage into the CBD was found and could be treated endoscopically. Endoscopy-related mortality was 0%. CONCLUSIONS: Endoscopic therapy offers a safe, effective and minimal invasive method in the treatment of bile leakage following LC.     

Harmonic imaging of porcine intraovarian arteries using sonographic contrast medium: initial findings

BACKGROUND AND STUDY AIMS: The role of the needle knife at endoscopic retrograde cholangiopancreatography (ERCP) remains controversial, with conflicting views being held on the value and safety of this device. The aim of the present study was to assess prospectively the value and safety of suprapapillary fistulosphincterotomy (FS) in the endoscopic management of biliary disease. PATIENTS AND METHODS: Suprapapillary fistulosphincterotomy was performed when biliary cannulation had failed after attempting to opacify the bile duct for 30 minutes, initially with a standard diagnostic cannula and then by further attempts with a tapered cannula. The second indication for suprapapillary fistulosphincterotomy was inability to obtain satisfactory cannulation with the sphincterotome in patients in whom cholangiopancreatography showed pathology requiring endoscopic sphincterotomy. Using this technique, an opening was created into the intraduodenal segment of the common bile duct at a point on the vertical axis 3-5 mm proximal to the papillary orifice. The opening was then cannulated, and extended as required to facilitate clearance of stones or stent insertion. RESULTS: Of 531 consecutive patients, 83 (16%) underwent suprapapillary fistulosphincterotomy, and biliary cannulation was achieved in 74 of the 83 (89%). If suprapapillary fistulosphincterotomy had not been used, the diagnostic success rate would have fallen from 513 out of 531 (97%) to 451 out of 531 (85%) (P = 0.0001); the clearance rate for duct stones would have fallen from 150 out of 156 (96%) to 130 out of 156 (83%) (P = 0.0003); and successful stent insertion would have fallen from 52 out of 59 (88%) to 38 out of 59 (64%) (P = 0.0044). There were no fatalities following suprapapillary fistulosphincterotomy. Complications occurred in five of the 83 patients (6%) who underwent fistulosphincterotomy, compared with five of the 448 patients (1%) who did not undergo the procedure (P = 0.01). CONCLUSIONS: Our results suggest that suprapapillary fistulosphincterotomy is a valuable adjunct in the management of biliary disease at ERCP, but, in view of the increased risk of complications, it should be reserved for patients in whom the index of suspicion for biliary disease is high and further endoscopic treatment is likely.     

Laparo-endoscopic "rendezvous": a new technique in the choledocholithiasis treatment

BACKGROUND/AIMS: Endoscopic sphincterotomy for common bile duct stone clearance during laparoscopic cholecystectomy may fail due to difficulties in cannulating the papilla major. In this study we propose a new technique that facilitates the cannulation of the papilla and the common bile duct stone clearance during a standard laparoscopic cholecystectomy. Its clearance percentage, complication rate and post-operative stay have been evaluated and compared with standardized procedures such as open surgery and endoscopic sphincterotomy before laparoscopic cholecystectomy. METHODOLOGY: In a group of 16 patients presenting with cholelithiasis and common bile duct stones or papillitis, the sphincterotome was driven across the papilla into the choledochus by a Dormia basket passed in the duodenum through the cystic duct during laparoscopic cholecystectomy. Measures of outcome were clearance rate, mortality, morbidity and hospital stay. Furthermore, data obtained from this sample of patients were compared with those from another two groups of 16 patients in which choledocholithiasis was managed either by endoscopic sphincterotomy performed before laparoscopic cholecystectomy or by open cholecystectomy and trans-duodenal sphincterotomy. RESULTS: The rate of cannulation of the papilla and of the common bile duct stone clearance was 100% when the combined endo-laparoscopic approach was used in 15 patients with endoscopic sphincterotomy (93,7%) and in 15 patients with open sphincterotomy (93,7%), cholecystectomy was successful in every case. The groups were statistically similar with regard to complications; none of the patients required blood transfusion. The mean post operative stay was 95.2 hours (range 48-240) for the first group, 350.1 hours (range 192-1680) for the second and 69.7 hours (range 24-132) for the third. CONCLUSION: The laparo-endoscopic rendezvous, though still in evolution, is an efficacious method which can be used during the laparoscopic strategy of common bile duct clearance.     

Laparoscopic transcystic choledochoscopy

Preoperative prediction of common bile duct stones (CBDS) is imprecise. Cholangiography during laparoscopic cholecystectomy (LC) is the best method for detection of CBDS. Treatment of most stones detected at LC can be safely accomplished using transcystic choledochoscopy and stone extraction. This technique is applicable in nearly 90% of patients with CBD calculi. It may be preferable to endoscopic sphincterotomy (ES) in younger patients and is probably equivalent to ES in patients over 65 years of age.     

Endoscopic therapy for patients with a post-operative biliary leak

Twenty-three patients with a post-operative biliary leak were treated by various endoscopic methods and results were analyzed. Leaks occurred at the cystic duct in 13 patients, at the common duct in 6 patients, and at an anomalous branch of the right hepatic duct in 4 patients. Treatments included sphincterotomy alone (4 patients), stent alone (6 patients), sphincterotomy and stent (12 patients), and sphincterotomy and nasobiliary drainage catheter (1 patient). Five patients also had supplemental percutaneous catheter drainage of a biloma. All treatments were completed successfully in the absence of major morbidity, and permanent closure of the leak occurred in 100% of cases. Endoscopic therapy for patients with a post-operative biliary leak is safe and effective and should be recommended before surgical re-exploration.     

Control of the mutagenicity of arylamines by protein kinases and phosphatases: II. Lack of response of rat liver N-acetyl transferases to phosphorylation modulators

OBJECTIVES: Endoscopic sphincterotomy has become a generally accepted method for extracting common bile duct stones in high risk or cholecystectomized patients. However, stone extraction is impossible by the usual methods in 5 to 10% of cases. The purpose of this study was to evaluate the effect of a recently developed solvent system in patients with large bile duct stones. METHODS: Forty four patients (15 men and 29 women, median age of years) underwent contact dissolution after unsuccessful Dormia extraction. Solvents were administered via a nasobiliary catheter in 41 patients following papillotomy and through a T-tube in 3 patients. Solvent mixtures (26 mM ethylene diamine tetraacetic acid, 40 mM sodium deoxycholate and 30% dimethyl sulfoxide in an alkaline aqueous solution; and a 70/30 dimethyl sulfoxide/methyl tert-butyl ether mixture) were infused continuously and alternatively for 2 hours. RESULTS: Bile duct stones disappeared in 13-24 hours of infusion in 11 patients. In 29 patients, a clear reduction in stone volume occurred, allowing complete endoscopic extraction of the fragments. In 4 patients, the size of the stone did not change. Only mild and transient side-effects including abdominal pain (68%), nausea (72%), vomiting (52%), diarrhea and sleepiness (50%) were observed. CONCLUSION: Direct dissolution therapy could be an effective method for the non-surgical management of large bile duct stones in selected patients when intra- or extracorporeal lithotripsy is unsuccessful.     

Characterization and specificity of B-cell responses in lupus induced by Mycobacterium bovis in NOD/Lt mice

BACKGROUND: Endoscopic treatment of postoperative benign bile duct strictures (BBDS) is technically challenging, and the long-term outcome after stricture dilation remains poorly defined. METHODS: Forty-eight cases of postoperative BBDS with attempted endoscopic treatment (either transient plastic stenting or definitive metal stent insertion) were reviewed. RESULTS: Endoscopic stricture dilation succeeded in 47 of 48 cases (98%). No procedure-related mortality was observed; 16 (33%) procedure-related or stent-associated complications were observed during treatment. Endoscopic treatment was interrupted in five patients. Stricture relapse occurred in 6 of 6 (100%) and 7 of 36 (19%) patients after metal stent insertion and plastic stent removal, respectively (p < 0.001) (mean follow-up periods 50+/-12 and 44+/-34 months, respectively). After plastic stent removal, stricture relapses were more frequent among patients with strictures related to liver transplantation as opposed to other surgical procedures (p < 0.05); these recurrent strictures were successfully treated by repeated insertion of plastic stents on a temporary basis. At the end of follow-up, all but one patient treated with plastic stents had normal serum alkaline phosphatase values. CONCLUSION: Metal stents proved to be inadequate for treating postoperative BBDS. Temporary insertion of a plastic stent (possibly repeated) provided long-term results equal or superior to those reported for surgical biliary drainage. Repeated insertion of plastic stents was more frequently indicated for strictures related to liver transplantation compared with other surgical procedures.     

Benign biliary strictures associated with recurrent pyogenic cholangitis: treatment with expandable metallic stents

OBJECTIVE: The purpose of this study was to determine the long-term effectiveness of expandable metallic stents in benign biliary strictures associated with recurrent pyogenic cholangitis and the differences in primary patency of the various types of stents deployed. SUBJECTS AND METHODS: During a 20-month period, 26 metallic stents (19 Gianturco-Rosch Z stents and seven Strecker stents) were used to treat benign biliary strictures associated with recurrent pyogenic cholangitis in 23 patients (11 men and 12 women; mean age, 42 years; range, 30-78 years). Insertion routes were percutaneous transhepatic biliary drainage tracts for 16 stents, T-tube tracts for seven stents, and retrograde endoscopic routes for three stents. The deployed locations were common hepatic or common bile ducts for 11 stents, right or left hepatic ducts for 10 stents, and segmental ducts for five stents. RESULTS: The initial technical success rate was 100%. Two stents in one patient migrated spontaneously. Primary stent patency for the remaining 24 stents was 34 months (range, 3-58 months). Primary stent patency of the Gianturco-Rosch Z and Strecker stents was 50 and 10 months, respectively (p < .05). Primary stent patency for the intrahepatic and extrahepatic ducts was 50 and 18 months, respectively (p = .05). Primary patency rates for all stents at 6, 12, 24, and 36 months were 92%, 75%, 67%, and 46%, respectively. The causes of stent obstruction were recurrent stone or sludge in eight stents and epithelial hyperplasia in five stents. CONCLUSION: We believe that metallic stent placement is not an effective long-term treatment technique for benign biliary stricture associated with recurrent pyogenic cholangitis.     

Intraoperative cholangiography as a routine method? A prospective, controlled, randomized study

A prospective, controlled, randomized trial was conducted in 275 patients with symptomatic gall stone disease, whose history, laboratory data or sonographical findings did not suggest common bile duct stones. Of these patients, 137 did not undergo intraoperative fluoroscopic cholangiography (IOC), but in the remaining 138 patients IOC was attempted. In 111 cases (80.4%) the biliary system was sufficiently visualized. In 3 patients (2.7%) calculi in the cystic or common bile duct were diagnosed, which would have been overlooked without IOC. IOC was false-positive in one case. One year after the operation the patients were asked to return for a follow-up examination. Three patients in the group without IOC had had symptomatic passage of a stone, and one had a common bile duct stone removed by endoscopic papillotomy. A retained stone was discussed as etiology for a pancreatitis in a fifth patient in this group. No patient sustained long-term sequelae from the retained common bile duct stones. None of the patients in the IOC group had evidence of cholangiolithiasis at follow-up. There was no difference between the study groups concerning the incidence of post-operative complications. The operations with IOC lasted significantly longer (92 +/- 31 min vs 77 +/- 28 min). According to our data and those published earlier, the additional financial and logistic expenditure associated with routine IOC is not justified. Patients with the preoperative suspicion of a common bile duct stone should have endoscopic bile duct clearance (ERCP and EPT) prior to cholecystectomy.