The role of lithotripsy in the treatment of common bile duct calculi

Lithotrity is aimed at breaking up the calculi in the main bile duct in order to facilitate their extraction, especially after endoscopic sphincterotomy (5% of cases). Extracorporeal lithotrity is effective in 90% of cases, but it requires repeated sessions. Intracorporeal lithotrity is advantageous in that it can be performed immediately after endoscopic sphincterotomy, but the material used may cause injuries to the wall of the biliary tract and requires a sophisticated biliary endoscopic system for visual control. Intrahepatic calculi also represent an excellent application of intracorporeal lithotrity, either during surgery or during transhepatic percutaneous drainage.     

Multidisciplinary Conservative Treatment of Difficult Bile Duct Stones: A Real Alternative to Surgery

56 patients with large CBD or intrahepatic stones underwent endoscopic and/or percutaneous treatment followed by extracorporeal shock wave lithotripsy. Percutaneous access to the biliary tract was chosen when an endoscopic approach was not possible (hepaticojejunostomy in 5 patients, 1 juxtapapillary diverticulum and I inflammatory bile duct stricture). Visualization of stones was achieved radiologically in 32 patients and by ultrasound in 24. The procedure was successful in 47 of 56 treated patients (83.9%). Clearance of the biliary tract was obtained in 25 cases (53%), whereas in 22 cases (47%) complete clearing of biliary tract was obtained only after endoscopic extraction of fragments (17 cases) or percutaneous (5 cases). The median number of shock waves in each session was 1725 (range 300–3166), which were applied during one (n=30), two (n=22) or three sessions (n=4). The only complications were 1 case of symptomatic hyperamylasemia and 3 cases of macrohematuria. In conclusion, extracorporeal lithotripsy combined with endoscopic and/or percutaneous treatment is a real alternative to surgery for difficult stones.     

肝移植术后胆道并发症的内镜治疗

目的:探讨内镜下逆行胰胆管造影术(ERCP)在治疗肝移植术后胆道并发症方面的临床疗效.方法:回顾性分析2002年8月-2012年12月采用ERCP治疗8例肝移植术后胆道并发症患者的临床资料,其中胆道狭窄5例(吻合口狭窄4例,肝内型胆道狭窄1例),胆瘘1例,胆石和胆泥形成2例.8例患者共行ERCP治疗21次,对胆道狭窄患者行括约肌切开、胆管扩张、鼻胆管引流和内支架置放术等治疗;对胆瘘患者行鼻胆管引流及塑料内支架置放术等治疗;对结石患者行括约肌切开、鼻胆管冲洗引流术及取石网篮取石等治疗.结果:ERCP手术成功率为100％ (21/21);4例吻合口狭窄、1例胆瘘和2例结石患者均治愈,1例肝内型胆道狭窄治疗未成功,建议再次肝移植;术后胆道感染的发生率为14.3％(3/21),胰腺炎发生率为19.0％ (4/21),经对症治疗后均痊愈.结论:ERCP是治疗肝移植术后胆道并发症微创、安全和有效的方法.     

经内镜乳头括约肌小口切开并放置塑料支架分期治疗巨大或多发胆总管结石

【摘要】目的探讨经内镜逆行胰胆管造影术（ERCP）Ⅰ期先行乳头括约肌小口切开并放置塑料支架解除梗阻,一月后再Ⅱ期取石,分期治疗巨大或多发胆总管结石的临床应用的安全性及有效性。方法回顾性分析2010年1月至2015年12月在我科住院首次行ERCP治疗的72例直径≥20mm或结石数量≥3粒的胆总管结石患者,分为观察组（一期ERCP放置支架,1月后二期取石,n=36）;对照组（一期治疗组,n=36）。观察和比较两组病例术后结石清除率,ERCP后胰腺炎（PEP）、重症胰腺炎发生,术后出血、胆道感染发生情况。结果在术后结石清除率方面观察组34例（94.4%）与对照组31例（91.2%）,比较差异无统计学意义（P>0.05）;观察组ERCP术后胰腺炎1例,对照组有8例（P<0.05）;观察组无重症胰腺炎发生,对照组发生2例;观察组1例发生术后出血,对照组则有6例发生（P<0.05）;观察组没有发生术后胆道感染,对照组发生5例（P<0.05）。结论内镜下乳头括约肌小切开并放置塑料支架分期取石术治疗巨大或多发胆总管结石是安全、有效、可行的。     

胆总管巨大结石胆道塑料内支架"搅动溶石"作用临床研究

目的 评价胆道塑料内支架置入对胆总管巨大结石的搅动溶石作用.方法 常规方法行ERCP,对45例胆总管巨大结石病人(8例结石伴下端胆管狭窄、5例结石伴乳头过小),在导丝引导下放置8.5 Fr胆道塑料内支架治疗.结果 3个月后第2次ERCP检查时发现,10例结石消失;22例结石直径变小1/2以上或成碎片状经网篮或气囊扩张顺利取出;13例结石无明显变化,行更换塑料内支架治疗并每月腹部B型超声随访,一旦发现结石明显变小,即再次行ERCP+取石.经平均2.4次内镜下联合治疗,95.6%(43/45)病人结石取净.期间未发生与ERCP或放置胆道塑料内支架相关的严重并发症.结论 放置胆道塑料内支架是治疗胆总管巨大结石简便、有效方法,尤其适用于高危老年胆总管结石病人.     

Experience with percutaneous transhepatic fiberoptic choledochoscopy for retained stones in the biliary tract

Summary Residual choledochal stones in 11 patients and stones in the intrahepatic bile ducts in 5 patients were successfully removed by the use of the fiberoptic choledochoscope (FCH-6T), introduced percutaneously into the intrahepatic biliary tract. The reasons for the use of percutaneous transhepatic extraction were: (1) unsuccessful endoscopic papillotomy; (2) unsuccessful choledochoscopic removal via the T-tube tract; (3) high surgical risk; (4) the presence of percutaneous transhepatic biliary drainage for acute cholangitis and acute pancreatitis. All stones were extracted through the liver or the papilla of Vater after crushing them. All minor complications such as pain, vomiting, or fever resolved without further therapy. Percutaneous transhepatic choledochoscopy proved safe and effective for the removal of retained choledochal stones and was essential for the treatment of stones in the intrahepatic bile ducts.     

Endoscopic diagnosis and management of biliary and pancreatic disease

The diagnosis and management of pancreatic and biliary tract disease require the closely coordinated efforts of the surgeon, radiologist, gastroenterologist, endoscopist and pathologist. Modern surgery needs a precise data base to meet the demands for speed, accuracy and a successful outcome. The sequential approach to the differential diagnosis of jaundice, with its emphasis on “noninvasive” diagnostic tests⁶² and lengthy evaluation⁶³ has been preempted by precise positive diagnostic studies. Our approach to the patient suspected of pancreatic or biliary tract disease has been revolutionized by developments in fiberoptic endoscopy and radiology, culminating in the techniques of ERCP, endoscopic biliary surgery, PTC and the removal of common duct stones through the T-tube tract. The therapeutic value of endoscopic biliary surgery and T-tube tract extraction of retained common duct stones as alternatives to secondary biliary tract surgery is clearly established. We are aware of the potential for dissolving cholesterol gallstones with oral medication or direct injection of solvents into the biliary tree. These advances will be clinically available shortly.Preoperative diagnosis of periampullary cancer permits the patient's referral to a specialized center that promises a lower operative mortality and the best chance for cure.⁶⁴ The frustrations and disappointments of operations for pancreatic cancer can be reduced by accurate preoperative diagnosis and palliative bypass surgery.^{[65.] and [66.]}The influence on surgical options of endoscopic biliary surgery and extraction or dissolution of stones through the T-tube tract is not yet clear. The pressure on the surgeon to clear the biliary tree at operation is lessened, since the mortality increase caused by adding common duct exploration (2.4%)⁶⁷ to elective cholecystectomy (0.6%) in the difficult case is greater than the hazard of endoscopic biliary surgery for choledocholithiasis (1.1%).⁶⁶ In patients with acute cholecystitis, preoperative definition of cystic duct patency and anatomy may reduce the hazard of cholecystectomy alone (2.4%) and allow the surgeon to exercise options that reduce the risk of the added common duct exploration (8%).⁶⁷ Cholangiographic studies performed by PTC or ERCP techniques may obviate the need for some common duct explorations. Initial endoscopic surgery can be used to control cholangitis by removing common duct stones and establishing biliary drainage or to facilitate clearing the biliary tree at operation. Alternatively, in the difficult operation, biliary drainage may be established by placing a T-tube in the common bile duct and extraction or dissolution techniques may be used postoperatively, when the patient is stable.^{[68.] and [69.]}These new concepts, therapies and techniques force us to reevaluate the indications for “exploratory laparotomy”, particularly in the elderly.^{[68.] and [72.]} More important, they herald a new era in surgery of the biliary tract and pancreas, when preoperative appreciation of pathologic anatomy and normal variants, with use of endoscopic and radiologic techniques, will produce the consistent yield of excellence desired by all.     

逆行胰胆管造影在肝移植中的应用

目的探讨经内镜逆行胰胆管造影(ERCP)在诊断和治疗肝移植术后胆道并发症中的应用。方法对本院肝移植术后出现胆道并发症的16例患者进行ERCP检查,并根据情况分别行鼻胆管引流(ENBD)和/或内镜下乳头切开取石(EST)等治疗。结果ERCP确诊16例肝移植术后胆道并发症,发生率为9.47%,其中胆道结石6例,胆道狭窄3例,吻合口漏2例,胆道结石伴左肝管狭窄1例,吻合口胆漏伴胆道结石3例,1例示供受体胆管比例不一致,供体胆管相对狭窄,所有患者都得到有效治疗。结论内镜下ERCP是诊断和治疗肝移植术后胆道并发症的一种安全而有效的手段,可作为非手术治疗中的首选。     

经内镜逆行胰胆管造影联合腹腔镜胆囊切除术后胆囊结石合并胆总管结石复发的危险因素分析

目的探讨经内镜逆行胰胆管造影（ERCP）联合腹腔镜胆囊切除术（LC）治疗胆囊结石合并胆总管结石复发的危险因素。 方法回顾性分析2012年1月至2015年3月沭阳县人民医院诊断为胆囊结石合并胆总管结石患者87例,均行ERCP联合LC术治疗。根据患者术后结石复发情况分为复发组与非复发组,对比两组患者一般情况、术者经验、胆道情况、结石情况。单因素分析以及多因素Logistic回归分析术后结石复发的危险因素。 结果87例患者术后随访32~60个月,中位随访时间为48个月,未复发组66例,复发组21例,中位复发时间15.0（95% CI=12.5~20.0）个月,术后1、2、3年复发率分别为8.0%、23.0%、24.1%,复发主要集中于术后2年内。单因素分析显示,胆道感染、胆道狭窄、胆总管夹角、结石数量、结石大小、乳头旁憩室情况影响胆囊结石合并胆总管结石复发（均P<0.05）。多因素分析显示,胆总管夹角（OR=0.196,95% CI=0.044~0.877）、胆道感染（OR=6.894,95% CI=1.698~27.984）、乳头旁憩室（OR=10.554,95% CI=2.134~52.197）、胆道口括约肌切开（OR=17.803,95% CI=3.342~94.845）是胆囊并胆总管结石术后复发的独立危险因素。 结论合并胆总管夹角过小、胆道感染、乳头旁憩室及术中括约肌切开的患者,ERCP联合LC术后结石更容易复发,对临床的预防和治疗有一定借鉴意义。     

中国病人内镜取石后胆总管结石复发相关危险因素的Meta分析

目的用循证医学的方法探讨中国病人内镜取石后胆总管结石复发的相关危险因素,为预测和预防结石复发提供理论依据。方法检索中国知网、维普和万方等数据库,收集自建库至2016年12月期间公开发表的有关内镜取石后胆总管结石复发危险因素的相关文献,运用固定或随机模型对各个因素进行合并分析。结果共纳入11项研究,6 137例内镜治疗病人。Meta分析结果显示,复发组中有胆道手术史的病人比例高于未复发组(OR=8.70,95%CI:5.22~14.50;P0.01);复发组中有乳头旁憩室的病人比例高于未复发组中的病人(OR=3.14,95%CI:2.32~4.25;P0.01);复发组中多发结石的病人比例高于未复发组(OR=1.57,95%CI:1.11~2.22;P0.05);复发组中结石直径10 mm的病人比例高于未复发组(OR=7.12,95%CI:4.98~10.19;P0.01);复发组中碎石的病人比例高于未复发组(OR=2.03,95%CI:1.66~2.49;P0.01)。结论既往有胆道手术史、合并乳头旁憩室、多发结石、结石直径10 mm和机械碎石是内镜治疗后胆总管结石复发的危险因素。     

NMR cholangiography in the diagnostic algorithm of candidates to video laparocholecystectomy

BACKGROUND: High resolution magnetic resonance cholangiopancreatography (MRCP) is a non invasive imaging modality for depicting the pancreatobiliary tree. It can demonstrate dilation, stenosis and intraductal filling defects of both the biliary and the pancreatic duct. The imaging quality of high resolution MRCP is excellent. MRCP appears to be more effective and less invasive than endoscopic retrograde cholangiopancreatography (ERCP) to evaluate many pancreatic and biliary diseases as choledocholithiasis, malignant obstruction, incomplete or failed ERCP, postsurgical alterations of the biliary tract (as biliary-enteric anastomoses), sclerosing cholangitis, chronic pancreatitis, and congenital anomalies of the biliary and pancreatic duct. METHODS: MRCP was performed in 21 non selected patients with suspected choledocholithiasis and demonstrated the presence of stones in the biliary tract in 5 of them. In these 5 patients sequential endoscopic-laparoscopic treatment was performed and confirmed in all cases the presence of stones in the biliary tree. Laparoscopic cholecystectomy (VLC) and transcystic cholangiography was attempted in the restant 16 patients. RESULTS: Laparoscopic transcystic cholangiography confirmed in all cases the response of MRCP. CONCLUSIONS: MRCP has the potential to replace ERCP in the management of patients candidate to VLC with suspected choledocholithiasis.     

腹腔镜、内镜在Mirizzi综合征I型患者中的应用(附11例报告)

目的探讨腹腔镜、内镜等微创技术在Mirizzi综合征(MS)Csendes I型患者"个体化诊疗"中的应用。 方法纳入成都中医药大学附属医院2013年11月至2015年12月施行腹腔镜胆囊切除术(LC)的患者900余例,进行回顾性分析。对病史中有黄疸、生化检查提示血胆红素升高和超声检查提示胆囊结石且肝总管或胆总管直径大于0.8 cm的患者,术前全部进行MRCP及ERCP,发现符合MS的患者24例,占同期LC患者的2.7%(24/900)。将其中Csendes I型11例纳入本研究,分析其临床特征及诊治特点。 结果11例Csendes I型患者中,Csendes Ia型6例,3例合并继发性胆总管结石,其中2例发生急性胆管炎;Csendes Ib型5例,2例合并继发性胆总管结石,其中1例发生急性胆管炎。所有患者行ERCP时一并清除胆总管内取石,留置ENBD管引流胆道,以改善肝功能。11例患者在ERCP后3～7 d成功施行了LC,仅1例Ia型患者胆囊管结石嵌顿,于LC中中转开腹,经胆囊管行胆道镜下的碎石取石。 结论怀疑MS的患者应行MRCP和ERCP,采用Csendes(1989,2008)标准进行准确分型,以便对肝外胆道的受损程度进行评估、合理抉择治疗策略。Csendes Ia型和Ib型患者均可行LC,但术中应利用胆道镜进行胆囊管探查及碎石取石,尽可能避免胆道探查,以防止医源性胆管狭窄。     

Common bile duct lithiasis. Reflections apropos of 1000 cases

One thousand case reports of patients treated in eleven French surgical departments for stones in the common bile duct between 1975 and 1982 were analyzed. One in three cases were asymptomatic and detected by peroperative radiology during treatment of a simple or complicated gallstone, most forms were painful, with jaundice in 9 p. cent, an angiocholitis in 12 p. cent, and biliary pancreatitis in 2 p. cent. The most reliable exploratory procedure for gallstones is ultrasound imaging, as positive results were obtained in 90 p. cent of cases, but it enabled the diagnosis of choledocholithiasis in only one out of five patients. Intravenous cholangiography is a useful diagnostic tod for painful forms (60 p. cent). The failure of these two methods to establish the diagnosis in forms complicated by jaundice, pancreatitis, or angiocholitis has to be compared with the good results (85 p. cent) observed with endoscopic retrograde cholangiography. Treatment was surgical in 99 p. cent of patients, peroperative radiology being performed in 95 p. cent of these cases and endoscopy in 30 p. cent. In one out of two cases a single large stone was present while multiple stones were present in 8 p. cent. A "ideal" choledochotomy was carried out in 77 patients (7,7 p. cent) without mortality. External biliary drainage in 702 cases resulted in a 1.7 p. cent mortality rate, this increasing to 8 p. cent after 192 biliodigestive shunt operations, and 7 p. cent after 146 sphincterotomies, including 18 under endoscopic control. Unrecognized lithiasis, detected during follow-up radiography two weeks after external biliary drainage, accounted for 2-8 p. cent of cases. Of the 30 patients with residual stones and open biliary pathways, 6 were treated by mechanical removal, 6 by endoscopic sphincterotomy, and the others by repeat surgery.(ABSTRACT TRUNCATED AT 250 WORDS)     

内镜在肝移植术后胆道并发症处理中的应用价值

目的探讨经内镜逆行胆胰管造影术(ERCP)在诊断和治疗肝移植术后胆道并发症中的应用价值。方法对2001年4月至2004年12月经ERCP诊治的33例肝移植术后出现胆管并发症病人的临床资料进行回顾性分析。结果33例肝移植术后出现胆道并发症的病人共行ERCP46例次,明确诊断31例(93.9%),其中胆漏4例,胆管狭窄18例,胆管狭窄伴胆泥淤积或结石6例,单纯胆泥淤积或结石2例,Oddi括约肌功能失调1例。针对不同的诊断结果,采取了不同的治疗方式,治疗成功27例(81.8%),发生并发症5例次(10.9%)。结论内镜处理肝移植术后胆道并发症是一种安全、有效的方法,应该作为首选方法在临床上推广应用。     

Percutaneous video choledochoscopic treatment of retained biliary stones via dilated T-tube tract

Background: Retained biliary stones is a common clinical problem in patients after surgery for complicated gallstone disease. When postoperative endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy are unsuccessful, several percutaneous procedures for stone removal can be applied as alternatives to relaparotomy. These procedures are performed either under fluoroscopic control or with the use of choledochoscopy, but it is also possible to combine these methods. Methods: Since 1994, we have used the percutaneous video choledochoscopic technique for the removal of difficult retained biliary stones via dilated T-tube tract in 17 patients, applying the technique of percutaneous stone extraction used in urology. While waiting for the T-tube tract to mature and after the removal of the T-tube, the dilatation of its tract was 26--30 Fr. Stone removal was carried out using a flexible video choledochoscope and a rigid renoscope under fluoroscopic control, with the aid of Dormia baskets, rigid forceps, and high-pressure irrigation. Results: We performed 23 operative procedures, and the clearance of the biliary ducts was successful in all cases. There were no major complications or deaths. Conclusion: Percutaneous video choledochoscopic--assisted removal of large retained biliary stones via the T-tube tract is a highly effective and safe procedure. Its advantages over other procedures include the ability to visualize the stones and noncalculous filling defects; it also guarantees that the stones can be removed under visual video endoscopic control. It has no problems related to tract or stone size. apd: 21 December 2000     

Results of the use of endoprostheses in the treatment of retained common bile duct stones

BACKGROUND: The value of endoprostheses for long term management of bile duct stones has not been formally established. A retrospective evaluation of results and complications of the insertion of biliary endoprostheses was performed in patients with endoscopic irretrievable bile duct stones. METHODS: From January 1990 to September 1999, 52 patients (19 men and 33 women; average age 76 years), underwent endoscopic biliary stenting for endoscopically irretrievable bile duct stones. RESULTS: Successful biliary drainage was achieved in 50/52 (96.1%) patients. Early complications occurred in 11.5% of cases. Over the long term follow-up (average follow-up = 39.5 months) late complications occurred in 40.8% of cases, with 3 cases of biliary-related death. CONCLUSIONS: For immediate bile duct drainage, endoprostheses proved a safe and effective alternative for treatment of patients with endoscopically irretrievable bile duct stones. Because of the risk of subsequent complications, its use as a definitive treatment should be confirmed to highly selected cases.     

Electrohydraulic lithotripsy (EHL) for the treatment of large retained common duct stones

Retained biliary stones may be too large for extraction through the existing T-tube tract. It may be necessary to dilate the tract, crush the stones or use endoscopic papillotomy. There are reports of stones and the extracting basket becoming stuck in the T-tube tract and tract ruptures caused by extracting large stones. In this study electrohydraulic lithotripsy (EHL) is used in combination with T-tube tract choledochoscopy for the fragmentation of large stones prior to basket extraction. T-tube choledochoscopy was performed under IV sedation and sterile conditions no sooner than one month following common bile duct exploration. The Olympus 4.9-mm choledochoscope was passed through the T-tube tract to visualize the stone. A #5 Fr EHL probe was passed through the endoscope and advanced to within 1 mm of the surface of the stone. EHL discharge was started at a low energy level being increased until the spark discharges caused stone fragmentation. The resultant stone fragments were basket extracted under direct vision. The procedure was used in twelve patients with removal of all stones in eleven patients. Eight patients were treated with one endoscopic session. Because of multiple stones, two patients required two sessions and one patient four sessions. In one patient stone position prevented adequate fragmentation and endoscopic papillotomy also failed. Repeat choledochoscopy and EHL were successful. There were no complications of EHL or choledochoscopy in any of the patients. EHL was both effective and safe for fragmentation of large common duct stones when performed under direct vision using a choledochoscope.     

The effect of indwelling endoprosthesis on stone size or fragmentation after long-term treatment with biliary stenting for large stones

BACKGROUND: Endoscopic biliary stenting is often used for large or difficult common bile duct (CBD) stones, but the effect of indwelling endoprosthesis on size or fragmentation of stones after long-term treatment with biliary stenting has not been formally established. We compared the stone size or fragmentation of common bile duct stones after a long period of biliary stenting. METHODS: Endoscopic biliary endoprosthesis was performed for 49 high-risk patients with CBD stones too large or difficult to be extracted by conventional endoscopic means. Bile duct drainage was established in all the patients without complications. Of the patients, 24 died with endoprosthesis in situ all from causes unrelated to biliar disease; 22 underwent a second and three patients a third attempt at stone extraction. The largest stone diameter was >12 mm in all patients. RESULTS: In 11 of 25 patients (44%) the endoprosthesis allowed resolution of the problem of unextractable common bile duct stones. Four patients showed no existence of stent, and ERCP complete stone clearance from the CBD on programmized appointment after endoprosthesis insertion. Reduced size or fragmentation of stones was obtained in seven patients, and the stones could be removed endoscopically. The remaining 14 patients demonstrated no significant change in the size or fragmentation of their stones, and endoprostheses were replaced. CONCLUSIONS: These results suggest that endoscopic endoprosthesis for large or difficult CBD stones is an effective method to clear the duct in selected cases, as well as an important definitive treatment in high-risk patients.     

Laser lithotripsy for the management of retained stones.

The morbidity of reoperation for retained biliary stones is not significant. Many techniques have been developed to avoid reoperation. This study analyzes T-tube tract choledochoscopy and lithotripsy using a 504-nm pulsed dye laser for treatment of retained stones. A flexible choledochoscope is passed into the biliary tract and laser energy is delivered under endoscopic visualization after passing a 320-microns laser fiber through the instrument channel. Eight patients were treated in nine sessions. The mean number of pulses was 1512.33, delivered at 3 to 5 Hz with an energy of 100 to 120 mJ. In all patients, the biliary tract was cleared. A single patient's treatment was complicated by transient bacteremia. Mean follow-up was 10 months. Choledochoscopic laser lithotripsy is a safe, effective technique that may also play a major role in laparoscopic common duct surgery.     

External biliary fistulas selectively managed by endoscopic retrograde cholangiography with sphincterotomy and/or stent placement

External bile duct fistulas are inherent postoperative complications that usually appear after biliary tract surgery, traumatic bile duct injuries and liver surgery for hepatic hydatid disease or liver transplant. The management is highly individualized, while the success and long-term results of endoscopic and surgical techniques are conflicting. The study included 32 cases with external bile duct fistulas managed by endoscopic retrograde cholangiography (ERC) with sphincterotomy and/or stent placement, including "rendez-vous" procedures in 2 cases. The causes of the external fistula were represented by cholecystectomy with/without retained common bile duct stones or strictures (22 cases), cholecystectomy and drainage of a subphrenic abscess caused by severe acute pancreatitis (1 case) and surgical interventions for hepatic hydatid disease (9 cases). Due to the prospective protocol of the study we were able to apply an individualized endoscopic treatment: sphincterotomy with proper relief of the bile duct obstruction (stone extraction) or sphincterotomy with large-size (10 Fr) stent placement for large-sized bile duct defects. The results consisted in closure of the fistula in 3.5 +/- 1.7 days for the subgroup of patients with sphincterotomy alone. Among the patients with stent insertion, fistulas healed slower in 14 +/- 3.5 days. There were no complications after endoscopic treatment; however the stent could not be passed in one patient that required subsequent surgery. In conclusion, endoscopic intervention is the treatment of choice for small external biliary fistulas complicating biliary tract surgery or liver surgery for hepatic hydatid disease. When the fistula is large, the placement of a 10 Fr endoprosthesis becomes necessary, while failure of endoscopic treatment leads to surgery with hepatico-jejunal anastomosis.