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DOI: 10.1055/s-2001-14264
© Georg Thieme Verlag Stuttgart · New York
Long-Term Follow-Up of Percutaneous Transhepatic Therapy (PTT) in Patients with Definite Benign Anastomotic Strictures after Hepaticojejunostomy
B. Schumacher, M.D.
Dept. of Internal Medicine
Evangelisches Krankenhaus
Kirchfeldstr. 40
40217 Düsseldorf
Germany
Fax: Fax:+ 49-211-919-3960
Email: E-mail:BrgSchumacher@aol.com
Publication History
Publication Date:
31 December 2001 (online)
Background and Study Aims: Percutaneous transhepatic therapy (PTT) is a promising minimally invasive procedure for benign stenosis of the anastomosis after hepaticojejunostomy. In this prospective study, the effectiveness and safety of this technique were investigated.
Patients and Methods: Between October 1995 and May 2000 34 consecutive patients were referred for treatment of symptomatic cholestasis due to anastomotic strictures after hepaticojejunostomy. In all patients percutaneous transhepatic cholangioscopic (PTCS) drainage and bougienage of the stenosis up to 16 Fr were performed. Associated bile duct stones were fractured using PTCS laser lithotripsy and removed into the jejunum. Afterwards, patients received transhepatic drainage for 3 months initially. The tubes were replaced in case of persistent strictures every 3 months up to 1 year. Patients in whom treatment failed underwent surgery or received biliary metal stents, depending on risk factors and individual anatomy.
Results: The procedure was performed in 34 patients (mean age 57 ± 15) with cholestasis (alkaline phosphatase 691 ± 485 U/l, bilirubin level mean 3.2 ± 3.1 mg/dl). The transhepatic tube was successfully positioned into the right hepatic bile duct (n = 25), into the left (n = 3), or into both (n = 3) after 4 ± 1 sessions, except in two patients in whom an external drainage was used and another patient in whom the procedure had to be stopped due to a bleeding complication. In 14 patients bile duct stones were successfully treated by PTCS laser lithotripsy before the placement of a transhepatic tube. The 30-day morbidity and mortality rates were 23.5 % and 0 % respectively. In 23 patients, the transhepatic tube could be removed after 212 ± 122 days, with no evidence of cholestasis during a further follow-up of 736 ± 479 days. Four patients received metal stents because of persistent strictures after transhepatic intubation. Surgery had to be performed in a total of five patients, because of recurrent bile duct stones or recurrent strictures, in one patient with previous implantation of a metal stent, and in two patients with bile duct disconnection. Two patients died, one 1.5 years after surgery and one 427 days after metal stent implantation. None of these cases was related to the procedure. In two patients, the transhepatic tube is still in situ.
Conclusions: Percutaneous transhepatic treatment of anastomotic strictures after hepaticojejunostomy is safe and highly effective in achieving internal biliary drainage. Temporary transhepatic intubation seems to be a promising minimally invasive alternative to surgery.
#Introduction
Benign postoperative anastomotic strictures after hepaticojejunostomy present a difficult management problem. If they remain untreated, jaundice, cholangitis, and biliary cirrhosis may result. Surgical treatment carries a morbidity of approximately 25 % [1] [2] [3] [4] [5] and a mortality of 2-13 % [2] [3] [4] [5] . Recurrences requiring further treatment occur in about 20 - 25 % of cases [5] [6] within a 7-year follow-up period.
Percutaneous transhepatic stenting of benign postoperative strictures has achieved success rates of approximately 80 % in patients with short-term follow-up [7] [8] [9] .
We prospectively studied the efficacy and safety of temporary transhepatic intubation as a treatment for benign postoperative anastomotic strictures after hepaticojejunostomy, with long-term follow-up after removal of the tubes.
#Patients and Methods
#Patients
A total of 34 patients (12 men, 22 women; mean age 57 ± 15) with symptomatic cholestasis were referred for percutaneous transhepatic therapy (PTT) of presumed anastomotic strictures after hepaticojejunostomy between October 1995 and May 2000 (Table [1]). In two patients, further diagnosis showed that internal biliary drainage would not be successful, because of a total bile duct disruption. These patients were included in the study with the intent to treat with an external biliary drainage.
| n | 34 | ||||
| Age, y | 57 ± 15 | ||||
| Sex | 22 women, 12 men | ||||
| Clinical manifestations | |||||
| Elevated serum | |||||
| Bilirubin | 61.8 % | ||||
| Alkaline phosphatase | 82.4 % | ||||
| Jaundice | 47.1 % | ||||
| Pain | 32.4 % | ||||
| Itching | 14.7 % | ||||
| Cholangitis | 44.1 % | ||||
| Serum biochemistry prior to biliary drainage* | |||||
| Total bilirubin, mg/dl | 3.2 (0.3 - 10) | ||||
| Alkaline phosphatase, U/l | 691 (53 - 1 962) | ||||
| γ-glutamyltransferase, U/l | 297 (41 - 865) | ||||
| * Mean (range) | |||||
Of 34 patients, 20 had undergone hepaticojejunostomy because of an intraoperative injury of the bile duct during a cholecystectomy (nine laparoscopic, nine conventional, two converted); 14 patients had hepaticojejunostomies for other reasons (Whipple resection in five, surgery for choledochocele in three, and surgery for traumatic injury other than intraoperative injury in six). The indication for Whipple resection in the five patients had been chronic pancreatitis. In none of the patients malignant disease was detectable.
A total of 25 patients had undergone an end-to-side anastomosis of the common hepatic duct with a Roux-en-Y jejunal loop, three patients an anastomosis of the left hepatic duct, and three patients a separated anastomosis of the right and left hepatic ducts. Seven of the 34 patients had undergone more than one hepaticojejunostomy (two procedures in five patients and three procedures in two). The mean interval between the last surgery and our subsequent percutaneous biliary drainage was 4.9 years. Clinical manifestations in the 34 patients were elevated serum bilirubin (61.8 %) and alkaline phosphatase levels (82.4 %), jaundice (47.1 %), pain (32.4 %), pruritus (14.7 %), and cholangitis (44.1 %). Mean serum bilirubin was 3.2 ± 3.1 mg/dl (median 1.9 mg/dl), mean serum alkaline phosphatase was 691 ± 485 units/l and mean serum γ-glutamyltransferase was 297 ± 226 units/l.
#Methods
All transhepatic maneuvers were performed under intravenous sedation with 2.5 - 7.5 mg midazolam and analgesia with 25 - 100 mg pethidine. The patients received antibiotics (Mezlocillin and metronidazole) before and after interventions.
After PTC drainage had been performed as previously reported [10], a 10-Fr pigtail catheter was passed through the anastomotic stricture into the jejunum via the right or left hepatic duct, depending on the individual anatomy. The transhepatic tract was sequentially dilated by exchange of transhepatic catheters with an increasing diameter up to 16-18 Fr. The time interval between the single sessions and the number of dilation procedures depended on the rigidity of the stenoses and the course of the transhepatic tract. A stable cutaneobiliary fistula could usually be established within 7 - 10 days. PTCS (CHFX-P20, Olympus, Tokyo, Japan) and laser lithotripsy (Baasel, Lithognost, Munich, Germany) was performed in patients with associated bile duct stones. Stone fragments were flushed or pushed with the tip of the cholangioscope into the jejunum as previously described [11]. Transhepatic tubes with sideholes (Yamakawa type; Nippon Zeon Co. Ltd., Tokyo, Japan) with an outer diameter of 16 - 18 Fr were left in situ in all patients, for 3 months initially, to reduce the risk of anastomotic restenosis (Figures [1] [2] [3] [4] [5] [6] ). They were blocked at the skin level and flushed with saline solution once or twice a week. After this period the tubes were removed and PTC was performed by injection of contrast media through the transhepatic tract. The tubes were replaced and left for another 3 months when cholangiography indicated a persistent stricture and incomplete spontaneous drainage of contrast within approximately 5 minutes. This routine exchange of catheters was repeated up to three times at intervals of 3 months. All patients were contacted by one of the authors every 3 months after the first treatment. After discharge patients were questioned by telephone call. For objective information, i. e. laboratory results, the patient’s family doctor was contacted. Persistent strictures after this period or intolerance of the tubes by the patients were regarded as failures of long-term transhepatic intubation.
Figure 1A transhepatic tube (Yamakawa prosthesis) 40 cm in length
Figure 2PTC showing an anastomotic stricture after hepaticojejunostomy. Various guide wires could not be passed under fluoroscopic control.
Figure 3Cannulation of the stricture with an 0.035-inch guide wire inserted through the instrumentation channel of the cholangioscope after creation of a cutaneobiliary fistula
Figure 4Dilation of the stenosis and implantation of the Yamakawa prosthesis
Figure 5After 6 months the transhepatic tube could be removed. The cholangiogram, by injection of contrast media, demonstrates a sufficient spontaneous drainage through the anastomosis
Figure 6 a This patient with jaundice underwent a hepaticojejunostomy after an injury of the common bile duct during cholecystectomy. A percutaneous transhepatic cholangiogram shows a complete stenosis of the anastomosis with multiple large stones impacted in the intrahepatic system. b Completed bile duct clearance after laser lithotripsy was performed through the miniscope
The option of a repeated surgical approach was discussed in all of these patients. Percutaneous transhepatic implantation of metal stents was only preferred in candidates at high risk for surgery or when patients refused surgery.
#Statistics
Statistical analysis was carried out using the software Sigma Stat for Windows 1.0 (Jandel Corporation 1994, San Rafael, California, United States). The Mann-Whitney rank sum test was used, and P < 0.05 was considered statistically significant.
#Results
The procedure was performed in 34 patients. In 32 patients, an anastomotic stricture after hepaticojejunostomy was diagnosed. In two patients a total disconnection of the hepatic bile duct was found. A 12-16-Fr Yamakawa prosthesis was successfully positioned into the right hepatic bile duct (n = 25), into the left (n = 3), or into both (n = 3) after 4 ± 1.0 sessions. Internal biliary drainage was successful in 91.2 % of patients. The patients with disconnected hepatic ducts received an external drainage and were than referred to elective surgery. In another patient the procedure had to be stopped because of a bleeding complication. This patient developed a subcapsular liver hematoma which was managed by conservative treatment. In 14 patients, bile duct stones were treated by PTCS laser lithotripsy before placement of transhepatic tubes. In these patients laser lithotripsy allowed complete clearance of stones in 1.5 ± 0.7 sessions. The 30-day morbidity and mortality rates were 23.5 % and 0 %, respectively. The early complications included temporary cholangitis in four patients, and sepsis in one. Bleeding occurred in two patients due to biliovenous fistulas. Hemostasis was achieved by placement of transhepatic tubes with no sideholes at the site of the fistula. During a mean hospitalization of 16.5 ± 6.7 days, the median bilirubin level decreased significantly from 1.9 to 0.9 mg/dl (P = 0.0176). The decrease in serum levels of alkaline phosphatase and γ-glutamyltransferase was not statistically significant.
#Long-Term Results
In 23 patients, the transhepatic tubes could be removed after 212 ± 122 days without evidence of cholestasis during the follow-up of 736 ± 479 days (Figure [7]). In two patients the prostheses are still in situ at the time of writing.
Figure 7Longterm results of PTT after hepaticojejunostomy
Surgery had to be performed in five patients. In one of these patients bile duct stones recurred in a blind sac of the stump of the common hepatic duct with a side-to-side anastomosis. Two patients could not be treated by PTCS drainage because of a disconnection of the hepatic duct. Two patients underwent surgery for reanastomosis of hepaticojejunostomy because of a recurrent stricture. One of these patients died 1.5 years after surgery due to peritonitis after recurrent pancreatitis. Four patients received metal stents after 3 and 6 months for permanent treatment of the anastomotic stenosis, with a mean follow-up of 591 ± 413 days. In all these high-risk patients implantation of the metal stents was because of nonacceptance of the plastic tubes and refusal of surgery. One patient showed an occluded Wallstent after 289 days and received a Yamakawa prosthesis. One of these patients died 427 days after metal stent implantation due to a tumor of the urogenital tract.
#Discussion
Benign stricture of the common bile duct is a serious complication of biliary surgery, leading, if untreated, to repeated cholangitis, biliary cirrhosis, hepatic failure, or death [12] [13] [14] . Many patients have undergone one or more operations for the same condition before admission to specialized centers [13] [15] . For the past 10 to 15 years, hepaticojejunostomy has been the standard procedure in these patients. Surgical results showed excellent early success rates [5] [6] [12] [13] but recurrent strictures developed in up to 25 % of patients over 6 - 7 years [5] [6] . Few direct comparisons between long-term results of surgery and interventional techniques have been made to date. Some surgical studies demonstrate superior results (88 % success rate vs. 55 %) for surgery at a mean follow-up of 57 and 59 months [15], other authors found identical success rates of 83 % [16]. Better results have been reported in an uncontrolled series for percutaneous treatment, with a 93 % success rate, at a mean follow-up of 38 months, for balloon dilation [17]. It is obviously necessary that new interventional and minimally invasive techniques like percutaneous transhepatic therapy be compared with surgical results after reintervention. The goal of the percutaneous treatment of anastomotic strictures after hepaticojejunostomy is to establish internal biliary drainage to prevent cholestasis, cholangitis, sludge or stone formation, and further stricture. If we define the success of the treatment as absence of symptoms or biochemical cholestasis without a prosthesis or stent, we can report a success of 74.2 % after a long-term follow-up of 862 ± 482 days.
All of the therapeutic procedures aim at an improvement of bile flow after dilation of the anastomotic stricture. It is difficult to give guidelines on when the plastic tube can be removed and there is no objective information about time of removal. The transhepatic tube should not be left in place longer than 3 months. After this time the tube should be replaced in case of persistent stricture every 3 months up to 1 year.
Our data show that after an initial percutaneous transhepatic drainage, a tube removal after a mean of 7 months and a mean long-term follow-up of 24 months, 74.2 % (n = 23) of the patients were asymptomatic and without evidence of cholestasis. Only two patients needed repeat surgery because of recurrent bile duct stones and recurrent stricture of the anastomosis. Two needed surgery because of a complete disconnection of the hepatic bile duct, and one because of nonacceptance of the transhepatic tube.
Four high-risk patients received self-expanding metal stents with a mean primary patency of 694 days. In one other patient, the metal stent was occluded after 289 days. This patient received surgical therapy because of nonacceptance of a new transhepatic tube.
In recent years, metallic stents have been used extensively for palliative treatment of malignant biliary obstruction [18] [19] [20] [21] . However, little experience has been gained in the use of Wallstents for treatment of benign biliary lesions. The overall reocclusion rate in benign strictures treated with the Gianturco-Rösch Z stent has been reported to be 7 % [22]. Other authors have reported a 3-year patency rate of 68.7 % [23]. In another study, metal stents were inserted in 37 patients after liver transplantation with biliary strictures. Occlusion rates after 3 and 5 years were 56 % and 100 % respectively [22]. These data show that it is not advisable at this time to treat benign biliary lesions with a metal stent. In selected cases, metal stent implantation may be performed to avoid further complications and additional surgical procedures. In 14 patients intrahepatic stones were diagnosed due to anastomotic stricture. The stone-free success rate was 100 % without any complications using a laser lithotriptor. Comparable high success rates of 83-100 % were reported with the practice of different techniques of lithotripsy under cholangioscopic control [10] [11] [24] [25] [26] .
With the use of laser lithotripsy, no complications such as perforations or hemobilia occurred. In comparison, in other studies where electrohydraulic shock waves produced by a 3-Fr lithotripsy probe were used, bile duct perforations and severe hemobilia were observed in up to 23 % [24] [27] .
In our study, we report a 30-day morbidity of 23.5 % and a mortality of 0 %. There was severe sepsis in one patient and temporary mild cholangitis in five patients. We observed only two cases of serious bleeding, which is the most frequent complication in other studies [20] [24] . We show that PTCS drainage and dilation is a low-risk procedure used in conjunction with bouginage intervals of twice a week. Arterial lesions are created by the puncture and are probably enlarged by dilation of the tract and introduction of a sheath. In our study one patient had an arterial lesion of a side branch of the proper hepatic artery. In this patient a catheter was advanced selectively in the damaged arterial branch. Therapeutic embolization was achieved and bleeding stopped immediately after embolization.
Long-term success defined as no further stricture and no reccurence of cholangitis is the vital issue for patients with benign biliary strictures. Direct comparison of results between surgery and interventional techniques is difficult because data have rarely been published. The success rate of primary operation is about 80 % and after 6 - 7 years varies between 75 % and 90 % [6] [14] [15] [28] . In comparison with these data we had a primary success rate of 91.2 %, and 74.2 % of patients were asymptomatic after percutaneous therapy after a long-term follow-up of 826 ± 482 days.
There are no data on how for long a plastic tube should remain in place. From our experience we conclude that plastic stents should be placed for up to 1 year. A stricture remaining after this length of treatment should be operated upon again, because it is unlikely that a conservative treatment would be successful.
In conclusion, our data show that percutaneous therapy is an effective and low-risk procedure for treatment of patients with benign anastomotic stenosis after hepaticojejunostomy. The long-term results of temporary transhepatic intubation promise an alternative to surgery.
#References
- 1 Kalman P G, Taylor B R, Langer B. Iatrogenic benign bile duct strictures. Can J Surg. 1982; 25 321-324
- 2 Warren K W, Jefferson M F. Prevention and repair of strictures of the intrahepatic ducts. Surg Clin N Am. 1973; 53 1169-1190
- 3 Way L W, Bernhoft R A, Thomas M J. Biliary strictures. Surg Clin N Am. 1981; 61 963-972
- 4 Genest J F, Nanos E, Grundfest-Broniatowski S, et al. Benign biliary strictures: an analytic review (1970-1984). Surgery. 1986; 99 409-412
- 5 Tocchi A, Costa G, Lepre L, et al. The long-term outcome of hepaticojejunostomy in the treatment of benign bile duct strictures. Ann Surg. 1996; 224 162-167
- 6 Röthlin M, Löpfe M, Schlumpf R, Largiader F. Long-term results of hepaticojejunostomy for benign lesions of the bile ducts. Am J Surg. 1998; 175 22-26
- 7 Gallacher D J, Kadir S, Kaufmann S L, et al. Nonoperative management of benign postoperative strictures. Radiology. 1985; 156 625-629
- 8 Martin E C, Fankuchen K, Laffey J, et al. Percutaneous management of benign biliary disease. Gastrointest Radiol. 1984; 9 207-210
- 9 Hausegger K, Kugler C, Uggowitzer M, et al. Benign biliary obstruction: is treatment with the Wallstent advisable?. Radiology. 1996; 200 437-441
- 10 Neuhaus H, Hoffmann W, Classen M. Nutzen und Risiken der perkutanen transhepatischen Cholangioskopie. Dtsch Med Wochenschr. 1993; 118 574-581
- 11 Neuhaus H, Hoffmann W, Gottlieb K, Classen M. Endoscopic lithotripsy of bile duct stones using a new laser with automatic stone recognition. Gastrointest Endosc. 1994; 40 708-715
- 12 Warren K W, Mountanin J C, Midell A I. Management of strictures of the biliary tract. Surg Clin N Am. 1971; 51 711-751
- 13 Pellegrini C A, Thomas M J, Way L W. Recurrent biliary stricture. Patterns of recurrence and outcome of surgical therapy. Am J Surg. 1984; 147 175-179
- 14 Csendes A, Diaz C, Burdiles P. Indications and results of hepaticojejunostomy in benign strictures of the biliary tract. Hepatogastroenterology. 1992; 39 333-336
- 15 Pitt H A, Kaufmann S L, Coleman R N. Benign postoperative biliary strictures. Operate or dilate?. Ann Surg. 1989; 210 417-425
- 16 Davids P HP, Tanka A KF, Rauws E AJ. Benign biliary strictures: surgery or endoscopy?. Ann Surg. 1993; 217 237-243
- 17 Lee M J, Müller P R, Saini S. Percutaneous dilatation of benign biliary strictures: single session therapy with general anesthesia. AJR Am J Roentgenol. 1991; 157 1263-1266
- 18 Lameris J S, Stocker J, Zonderland H M. Malignant biliary obstruction: percutaneous use of self-expandable stents. Radiology. 1991; 179 703-707
- 19 Men S, Hekimoglu B, Kaderoglu H. Palliation of malignant obstructive jaundice. Use of self expandable metal stents. Acta Radiol. 1996; 37 259-266
- 20 Bonnel D, Liguory L, Lefebvre J F, Corund F. Percutaneous treatment of malignant stenoses of the hilum. Gastroenterol Clin Biol. 1995; 19 564-571
- 21 Adam A, Chetty N, Roddie M. Self-expandable stainless steel endoprotheses for treatment of malignant bile duct obstruction. AJR Am J Roentgenol. 1991; 156 321-325
- 22 Culp W C, McCowan T C, Liebeman R P. Biliary strictures in liver transplant recipients: treatment with metal stents. Radiology. 1996; 199 339-46
- 23 Maccioni F, Rossi M, Salvatori F M, et al. Metallic stents in benign biliary strictures: three-year follow-up. Cardiovasc Intervent Radiol. 1992; 15 360-366
- 24 Bonnel D, Liguory C, Chornud F, Lefebvre F. Common bile duct and intrahepatic stones. Results of transhepatic electrohydraulic lithotripsy in 50 patients. Radiology. 1991; 180 345-348
- 25 Mo L, Hwang M, Yneh S, et al. Percutaneous transhepatic choledochoscopic electrohydraulic lithotripsy (PTCS-EHL) of common bile duct stones. Gastrointest Endosc. 1988; 34 122-125
- 26 Ponchon T, Gagnon P, Valette P, et al. Pulsed dye laser lithotripsy of bile duct stones. Gastroenterology. 1991; 100 1730-1736
- 27 Chen M, Jan Y. Percutaneous transhepatic cholangioscopic lithotripsy. Br J Surg. 1990; 77 530-532
- 28 Lillemore K D, Pitt H A, Cameron J L, et al. Current management of benign bile duct strictures. Adv Surg. 1992; 25 119-174
B. Schumacher, M.D.
Dept. of Internal Medicine
Evangelisches Krankenhaus
Kirchfeldstr. 40
40217 Düsseldorf
Germany
Fax: Fax:+ 49-211-919-3960
Email: E-mail:BrgSchumacher@aol.com
References
- 1 Kalman P G, Taylor B R, Langer B. Iatrogenic benign bile duct strictures. Can J Surg. 1982; 25 321-324
- 2 Warren K W, Jefferson M F. Prevention and repair of strictures of the intrahepatic ducts. Surg Clin N Am. 1973; 53 1169-1190
- 3 Way L W, Bernhoft R A, Thomas M J. Biliary strictures. Surg Clin N Am. 1981; 61 963-972
- 4 Genest J F, Nanos E, Grundfest-Broniatowski S, et al. Benign biliary strictures: an analytic review (1970-1984). Surgery. 1986; 99 409-412
- 5 Tocchi A, Costa G, Lepre L, et al. The long-term outcome of hepaticojejunostomy in the treatment of benign bile duct strictures. Ann Surg. 1996; 224 162-167
- 6 Röthlin M, Löpfe M, Schlumpf R, Largiader F. Long-term results of hepaticojejunostomy for benign lesions of the bile ducts. Am J Surg. 1998; 175 22-26
- 7 Gallacher D J, Kadir S, Kaufmann S L, et al. Nonoperative management of benign postoperative strictures. Radiology. 1985; 156 625-629
- 8 Martin E C, Fankuchen K, Laffey J, et al. Percutaneous management of benign biliary disease. Gastrointest Radiol. 1984; 9 207-210
- 9 Hausegger K, Kugler C, Uggowitzer M, et al. Benign biliary obstruction: is treatment with the Wallstent advisable?. Radiology. 1996; 200 437-441
- 10 Neuhaus H, Hoffmann W, Classen M. Nutzen und Risiken der perkutanen transhepatischen Cholangioskopie. Dtsch Med Wochenschr. 1993; 118 574-581
- 11 Neuhaus H, Hoffmann W, Gottlieb K, Classen M. Endoscopic lithotripsy of bile duct stones using a new laser with automatic stone recognition. Gastrointest Endosc. 1994; 40 708-715
- 12 Warren K W, Mountanin J C, Midell A I. Management of strictures of the biliary tract. Surg Clin N Am. 1971; 51 711-751
- 13 Pellegrini C A, Thomas M J, Way L W. Recurrent biliary stricture. Patterns of recurrence and outcome of surgical therapy. Am J Surg. 1984; 147 175-179
- 14 Csendes A, Diaz C, Burdiles P. Indications and results of hepaticojejunostomy in benign strictures of the biliary tract. Hepatogastroenterology. 1992; 39 333-336
- 15 Pitt H A, Kaufmann S L, Coleman R N. Benign postoperative biliary strictures. Operate or dilate?. Ann Surg. 1989; 210 417-425
- 16 Davids P HP, Tanka A KF, Rauws E AJ. Benign biliary strictures: surgery or endoscopy?. Ann Surg. 1993; 217 237-243
- 17 Lee M J, Müller P R, Saini S. Percutaneous dilatation of benign biliary strictures: single session therapy with general anesthesia. AJR Am J Roentgenol. 1991; 157 1263-1266
- 18 Lameris J S, Stocker J, Zonderland H M. Malignant biliary obstruction: percutaneous use of self-expandable stents. Radiology. 1991; 179 703-707
- 19 Men S, Hekimoglu B, Kaderoglu H. Palliation of malignant obstructive jaundice. Use of self expandable metal stents. Acta Radiol. 1996; 37 259-266
- 20 Bonnel D, Liguory L, Lefebvre J F, Corund F. Percutaneous treatment of malignant stenoses of the hilum. Gastroenterol Clin Biol. 1995; 19 564-571
- 21 Adam A, Chetty N, Roddie M. Self-expandable stainless steel endoprotheses for treatment of malignant bile duct obstruction. AJR Am J Roentgenol. 1991; 156 321-325
- 22 Culp W C, McCowan T C, Liebeman R P. Biliary strictures in liver transplant recipients: treatment with metal stents. Radiology. 1996; 199 339-46
- 23 Maccioni F, Rossi M, Salvatori F M, et al. Metallic stents in benign biliary strictures: three-year follow-up. Cardiovasc Intervent Radiol. 1992; 15 360-366
- 24 Bonnel D, Liguory C, Chornud F, Lefebvre F. Common bile duct and intrahepatic stones. Results of transhepatic electrohydraulic lithotripsy in 50 patients. Radiology. 1991; 180 345-348
- 25 Mo L, Hwang M, Yneh S, et al. Percutaneous transhepatic choledochoscopic electrohydraulic lithotripsy (PTCS-EHL) of common bile duct stones. Gastrointest Endosc. 1988; 34 122-125
- 26 Ponchon T, Gagnon P, Valette P, et al. Pulsed dye laser lithotripsy of bile duct stones. Gastroenterology. 1991; 100 1730-1736
- 27 Chen M, Jan Y. Percutaneous transhepatic cholangioscopic lithotripsy. Br J Surg. 1990; 77 530-532
- 28 Lillemore K D, Pitt H A, Cameron J L, et al. Current management of benign bile duct strictures. Adv Surg. 1992; 25 119-174
B. Schumacher, M.D.
Dept. of Internal Medicine
Evangelisches Krankenhaus
Kirchfeldstr. 40
40217 Düsseldorf
Germany
Fax: Fax:+ 49-211-919-3960
Email: E-mail:BrgSchumacher@aol.com
Figure 1A transhepatic tube (Yamakawa prosthesis) 40 cm in length
Figure 2PTC showing an anastomotic stricture after hepaticojejunostomy. Various guide wires could not be passed under fluoroscopic control.
Figure 3Cannulation of the stricture with an 0.035-inch guide wire inserted through the instrumentation channel of the cholangioscope after creation of a cutaneobiliary fistula
Figure 4Dilation of the stenosis and implantation of the Yamakawa prosthesis
Figure 5After 6 months the transhepatic tube could be removed. The cholangiogram, by injection of contrast media, demonstrates a sufficient spontaneous drainage through the anastomosis
Figure 6 a This patient with jaundice underwent a hepaticojejunostomy after an injury of the common bile duct during cholecystectomy. A percutaneous transhepatic cholangiogram shows a complete stenosis of the anastomosis with multiple large stones impacted in the intrahepatic system. b Completed bile duct clearance after laser lithotripsy was performed through the miniscope
Figure 7Longterm results of PTT after hepaticojejunostomy