Long-term results of hepaticojejunostomy for hepatolithiasis

The results of a hepaticojejunostomy as a biliary-enteric bypass for benign disease are usually excellent. On the other hand, hepatolithiasis features a high rate of residual and recurrent stones with cholangitis after surgery. This study aims to evaluate the long-term results of a hepaticojejunostomy for hepatolithiasis regarding both the degree of the occurrence of postoperative cholangitis and the outcome. The clinical records of 159 patients with hepatolithiasis who underwent surgical treatment over a 23-year period were also retrospectively reviewed. Ninety-four of 159 patients underwent a hepatecetomy and 65 patients were subjected to liver-preserving surgery by means of intra- and postoperative endoscopic lithotripsy. In addition 72 patients underwent a hepaticojejunostomy. The rate of residual or recurrent stones was 31.4 per cent after complete stone removal. Twenty-two (30.6%) of the 72 patients developed some kind of cholangitis. This rate was significantly higher than that (three of 87 patients) of the non-biliary-enteric anastomosis group regarding the occurrence of biliary complications. We conclude that the use of a hepaticojejunostomy for patients with possible residual stones or intrahepatic bile duct lesions remains controversial.     

Rendezvous Technique Using Double Balloon Endoscope for Removal of Multiple Intrahepatic Bile Duct Stones in Hepaticojejunostomy After Living Donor Liver Transplant: A Case Report

Cholangitis is a major complication following transplantation. We report a living donor liver transplant (LDLT) patient with cholangitis due to multiple stones in the intrahepatic bile duct during hepaticojejunostomy anastomosis, who was successfully treated with the rendezvous technique using double balloon endoscope. A 64-year-old woman underwent LDLT with right lobe graft and hepaticojejunostomy for Wilson disease. There was bile leakage with biliary peritonitis, which was treated conservatively after transplant. Two years after surgery, she developed reiterated cholangitis due to stenosis of hepaticojejunostomy anastomosis and multiple stones in the intrahepatic bile ducts.Percutaneous transhepatic biliary drainage was performed. The size of the drainage tube was increased, and the anastomotic area was dilated in a stepwise manner using a balloon catheter. The stones were crushed and lithotomy was performed using electronic hydraulic lithotripsy through cholangioscopy. Finally, lithotomy was performed for the remaining stones through endoscopic retrograde cholangiography with the rendezvous technique using the double balloon endoscope.Rendezvous approach with percutaneous transhepatic biliary drainage and double balloon endoscopic retrograde cholangiography was an effective treatment for the multiple intrahepatic stones in hepaticojejunostomy following LDLT with right lobe graft.     

Management of complex biliary tract calculi with a holmium laser

The difficulty in managing complex biliary tract calculi is exemplified in patients with primary intrahepatic calculi. Standard surgical and endoscopic approaches often fail to clear calculi in these patients who have recurrent episodes of cholangitis. The success of the holmium laser for urologic calculi led us to adapt treatment strategies for primary and secondary biliary tract calculi where standard treatments had been unsuccessful. Our goals were to remove all calculi, prevent recurrent sepsis, and preserve hepatic parenchyma. Thirty-six patients with complex biliary calculi were treated. After sepsis was controlled and the extent of calculi was evaluated, appropriate access to and drainage of the biliary tract was achieved. Holmium laser lithotripsy was performed under video guidance using flexible choledochoscopes and a 200 μ laser fiber generating 0.6 to 1.0 joules at frequencies of 6 to 10 Hz. Lithotripsy procedures were repeated until cholangiography and cholangioscopy confirmed the clearance of calculi. Twenty-two patients of Asian descent with primary intrahepatic calculi and 14 patients with secondary intrahepatic calculi were treated. Access to the biliary tract could be accomplished through percutaneous catheter tracts, T-tube tracts, or the cystic duct during laparoscopic cholecystectomy. Biliary drainage was by biliary enteric anastomosis or endoscopic sphincterotomy. Complete stone clearance required an average of 3.9 procedures (range 1 to 15) for patients with primary intrahepatic calculi and 2.6 procedures (range 1 to 10) for patients with secondary intrahepatic calculi regardless of stone composition. No patient required hepatic resection and no complications or deaths were attributed to the holmium laser. Clearance of calculi can reliably and safely be achieved with a holmium laser regardless of stone composition or location while preserving hepatic parenchyma and preventing recurrent sepsis. Presented at the Fourth Americas Hepato-Pancreato-Biliary Association Congress, Miami Beach, Florida, February 27-March 2, 2003.     

A new biliary access technique for the long-term endoscopic management of intrahepatic stones

Intrahepatic stone disease poses a difficult postoperative management problem due to frequent stone recurrence. Most of the methods proposed for long-term access to the intrahepatic biliary tree require multiple sessions of additional, usually invasive, procedures. An alternative method for endoscopic long-term access to the intrahepatic ducts, represented by a side-to-side anastomosis between the isolated Roux-en-Y jejunal limb of the bilioenteric bypass and the duodenum (duodenojejunostomy), was used in eight patients with retained and/or recurrent stones after surgical treatment of intrahepatic stone disease. There were no short- or long-term complications or mortality associated with the duodenojejunostomy. Postoperative endoscopic access to the intrahepatic ducts was successfully achieved in five of six patients: one with stone recurrence, one with a left hepatic duct stricture and stone recurrence and one with known retained postoperative stones. In two patients, no stones were found at endoscopy. Side-to-side duodenojejunostomy may be useful in the long-term endoscopic management of recurrent intrahepatic biliary stone disease and should be indicated whenever a bilioenteric anastomosis is performed for the treatment of bilateral intrahepatic stone disease. Introduction Received: August 16, 2001 / Accepted: February 8, 2002     

Management of gallstone cholangitis in the era of laparoscopic cholecystectomy

HYPOTHESIS: The combined endoscopic and laparoscopic approach is safe and effective in managing gallstone cholangitis in the era of laparoscopic cholecystectomy (LC). DESIGN: Retrospective case series. SETTING: University teaching hospital. PATIENTS: One hundred eighty-four consecutive patients with gallstone cholangitis treated between January 1995 and December 1998. INTERVENTIONS: The main treatments were endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) followed by interval LC. Open or laparoscopic common bile duct exploration (OCBDE or LCBDE) was used when ERCP or ES failed. MAIN OUTCOME MEASURES: Success of various interventions, morbidity and mortality, and long-term incidence of recurrent biliary symptoms. RESULTS: Endoscopic retrograde cholangiopancreatography was successful in 175 patients (95%), with bile duct stones found in 147 (84%). Endoscopic stone clearance by ES was achieved in 132 patients (90%). Morbidity rate after ERCP or ES was 4.0% (n = 7), and overall mortality rate from cholangitis was 1.6% (n = 3). After bile duct stone clearance, 82 patients underwent LC with a conversion rate of 9.8% (n = 8) and a morbidity rate of 3.6% (n = 3). Eighteen patients underwent OCBDE with a morbidity rate of 33% (n = 6), and 3 underwent LCBDE with 1 conversion and no morbidity. There was no operative mortality. Seventy-eight patients were managed conservatively after endoscopic clearance of bile duct stones. Follow-up data were available in 101 patients with cholecystectomy and 73 patients with gallbladder in situ. During a median follow-up of 24 months, recurrent biliary symptoms occurred in 5.9% (n = 6) and 25% (n = 18), respectively (P =.001). In both groups, the most common recurrent symptom was cholangitis (n = 5 and n = 14, respectively). Gallbladder in situ (risk ratio, 4.16; 95% confidence interval, 1.39-12.50; P =.01) and small-size papillotomy (risk ratio, 2.94; 95% confidence interval, 1. 07-8.10; P =.04) were significant risk factors for recurrent biliary symptoms. CONCLUSIONS: Endoscopic sphincterotomy for biliary drainage and stone removal, followed by interval LC, is a safe and effective approach for managing gallstone cholangitis. Patients with gallbladder left in situ after ES have an increased risk of recurrent biliary symptoms. Laparoscopic cholecystectomy should be recommended after endoscopic management of cholangitis except in patients with prohibitive surgical risk.33333333333333333333333     

A study of endoscopic sphincterotomy in recurrent pyogenic cholangitis

Recurrent pyogenic cholangitis is a condition prevalent in Asia. Surgery has been the only form of treatment when extrahepatic and/or intrahepatic biliary dilatation, irregularity, debris and calculi are present. Endoscopic sphincterotomy was attempted in 134 such patients, the majority of whom had calculi confined to the common bile duct, and in whom 85.8 per cent were over 60 years old, 61.2 per cent had previous biliary surgery, and 36.6 per cent had an associated major medical illness. Sphincterotomy was successful in 88 per cent of patients, good results were obtained in 81.3 per cent, and stone removal was achieved in 91.7 per cent of those with demonstrable biliary calculi. Major complications occurred in 7.5 per cent, resulting in emergency surgery in 3 per cent and death in 1.5 per cent. The mortality of surgical sphincteroplasty in 143 patients with this condition who were over 60 years old was known to be 7 per cent. Five of 109 patients without residual calculi after endoscopic sphincterotomy developed mild to moderate symptoms after a follow-up period of 6 months to 6 years (median 2.3 years). Endoscopic sphincterotomy is a safe and effective form of treatment in patients with recurrent pyogenic cholangitis whose calculi are confined to the common bile duct.     

Postoperative flexible choledochoscopy for residual primary intrahepatic stones.

Postoperative flexible choledochoscopy was carried out in 103 patients with residual biliary calculi. Forty-one patients had residual stones in the common duct, and 63 patients had residual stones in the intrahepatic ducts with or without stones in the common duct. The majority of the intrahepatic stones were primary stones. Postoperative choledochoscopy was very effective in removing residual common duct stones (95% removed, no morbidity). For intrahepatic stones, removal was more difficult and was associated with a higher morbidity (11.2%). Stone extraction through the stenotic intrahepatic ducts was made possible by the balloon dilatation of the ducts. Repeated endoscopic access to the biliary system was made easier by the construction of a hepatico-cutaneous-jejunostomy, which also provides a route to the biliary tree for future stone removal if stone reformation occurs. Complimented by these procedures, postoperative choledochoscopy was successful in removing the residual intrahepatic stones in 82.3% of the patients. At a median follow-up of 17 months, the majority of the patients who had all the stones removed as well as those who had stones left behind were symptom free.     

Efficacy of percutaneous treatment of biliary tract calculi using the holmium:YAG laser

Background Few Western studies have focused on percutaneous techniques using percutaneous transhepatic choledochoscopy (PTHC) and holmium:yttrium–aluminum–garnet (YAG) laser to ablate biliary calculi in patients unable or unwilling to undergo endoscopic or surgical removal of the calculi. The authors report the efficacy of the holmium:YAG laser in clearing complex biliary calculi using percutaneous access techniques. Methods This study retrospectively reviewed 13 non-Asian patients with complex secondary biliary calculi treated percutaneously using holmium:YAG laser. Percutaneous access was accomplished via left, right, or bilateral hepatic ducts and upsized for passage of a 7-Fr video choledochoscope. Lithotripsy was performed under choledochoscopic vision using a holmium:YAG laser with 200- or 365-μm fibers generating 0.6 to 1.0 joules at 8 to 15 Hz. Patients underwent treatment until stone clearance was confirmed by PTHC. Downsizing and subsequent removal of percutaneous catheters completed the treatment course. Results Seven men and six women with an average age of 69 years underwent treatment. All the patients had their biliary tract stones cleared successfully. Of the 13 patients, 3 were treated solely as outpatients. The average length of percutaneous access was 108 days. At this writing, one patient still has a catheter in place. The average number of holmium:YAG laser treatments required for stone clearance was 1.6, with no patients requiring more than 3 treatments. Of the 13 patients, 8 underwent a single holmium:YAG laser treatment to clear their calculi. Prior unsuccessful attempts at endoscopic removal of the calculi had been experienced by 7 of the 13 patients. Five patients underwent percutaneous access and subsequent stone removal as their sole therapy for biliary stones. Five patients were cleared of their calculi after percutaneous laser ablation of large stones and percutaneous basket retrieval of the remaining stone fragments. There was one complication of pain requiring admission, and no deaths. Conclusions The use of PTHC with holmium:YAG laser ablation is safe and efficacious, but requires prolonged biliary access and often multiple procedures to ensure clearance of all calculi.     

Reoperative surgery in cholelithiasis

From 1965 to 1980, reoperations for residual or recurrent stones were performed on 78 out of 962 Japanese patients with cholelithiasis. The majority of patients who required reoperation had intrahepatic stones. Most of the causes of reoperation were residual stones due to incomplete removal or the non-detection of intrahepatic stones at the previous surgery. Very careful examination of the intrahepatic biliary trees should be done in patients with biliary tract diseases, because in many, the first operation was done during their youth. To remove the intrahepatic calculi completely, hepatic lobectomy should be considered as a final procedure. The causes of reoperation of common duct stones were residual in 60 per cent and recurrent in 40 per cent. Definitive surgery should be done at the first or at least the second operation to avoid irreversible hepatic disorders which have untoward effects on the prognosis. It is important not only to remove the stones but also to relieve the bile stasis in the biliary tract.     

Treatment of bilateral intrahepatic stones with high duct strictures through selective central hepatic resection

Bilateral intrahepatic duct stones with strictures, more common in the Orient than elsewhere, are difficult to access surgically. The results of surgical procedures have not been generally successful and are attended by a high postoperative complication and recurrence rate. We report the treatment of 30 patients with intrahepatic calculi and high duct strictures by means of selective central hepatic resection without dissection of the major vessels at the hilum. Central hepatic resection provided satisfactory access to the primary and secondary confluences of the intrahepatic ducts, allowed removal of residual stones and ascariasis, and permitted correction of multiple strictures. Twenty-nine patients so treated were followed for a mean of 32 months after operation. No patients developed recurrent fever, biliary colic, or jaundice after the operation. The technique is therefore recommended as an effective alternative to extensive hepatic lobectomy in the treatment of the intrahepatic calculi with multiple strictures.     

Recurrence of intrahepatic stones after an end-to-side choledochojejunostomy

The risk factors for the recurrence of intrahepatic stones after an end-to-side choledochojejunostomy were investigated, along with the outcome following the treatment of such stones. Thirty-two patients with intrahepatic stones underwent an end-to-side choledochojejunostomy, and a complete lithotomy was achieved in 26 of them. The follow-up which ranged from 5-19 years after surgery revealed that eight patients developed a recurrence of intrahepatic stones, and their clinical and cholangiographic findings were thus reviewed. Recurrent stones were associated with onset of symptoms at a younger age and were predominantly located in the intrahepatic bile ducts. Recurrence was also associated with severe intrahepatic bile duct dilatation. Six of the eight patients developed recurrent stones more than 5 years after a complete lithotomy. One of these patients died of liver cirrhosis while two died of acute obstructive suppurative cholangitis. Five patients underwent cholangioscopic lithotomy through the jejunostomy for their recurrent stones, and a complete lithotomy was accomplished in three of them. These findings indicate the necessity of performing a hepatectomy in such patients whenever possible, and also emphasize the need for a long-term follow-up after a complete lithotomy with an end-to-side choledochojejunostomy. In addition, any recurrent stones should be treated promptly by a cholangioscopic lithotomy through a jejunostomy.     

腹腔镜胆囊切除术后再疼痛的原因分析

目的 :探讨腹腔镜胆囊切除术后再疼痛的原因。方法 :回顾分析 2 786例腹腔镜胆囊切除术术后 35例再疼痛的临床资料。结果 :诊断为右肝管狭窄肝内胆管局灶性扩张 4例 ,残株胆囊炎和 (或 )胆囊管残余结石 6例 ,胆管炎胆道残余结石 2例 ,胆道运动障碍 4例 ,膈神经损伤 3例 ,肝下间隙积液感染 5例 ,上腹部切口硬结 ,肋弓部损伤性疼痛 1 1例 ,多数病例术后疼痛与操作有关。 34例行保守治疗 ,1例行EST ,症状缓解或痊愈。结论 :对腹腔镜胆囊切除术因操作引起的术后再疼痛 ,应予以高度重视 ,只要仔细手术 ,术后疼痛是可以避免的     

Acute biliary pancreatitis. Therapeutic trends

BACKGROUND: Treatment of biliary pancreatitis includes suppression of the biliary cause by cholecystectomy and common bile duct clearance. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy for eradication of biliary stones and laparoscopic cholecystectomy (L.C.) for residual gallbladder stones would be ideal but were once considered to be contraindicated by most surgeons. The timing of definitive biliary tract surgery and the role of ERCP have been the focus of discussion in recent years. METHODS: During a two-year study period 51 patients with acute biliary pancreatitis were studied. Seven patients (14%) underwent emergency laparotomy, necrosectomy, cholecystectomy, exploration of the common bile duct and T-tube insertion, because unstable clinical conditions, with evidence of pancreatic and peripancreatic necrosis on CT-scan. Elective open cholecystectomy and CBD exploration were performed in 7 patients after the resolution of acute pancreatitis during the same hospital admission. RESULTS: Early ERCP and L.C. were associated with favourable outcomes. 33 patients underwent ERCP preoperatively: 17 within 72 hours of admission and 16 after signs of clinical improvement. Laparoscopic cholecystectomy performed 3-25 days after admission was successful in 27 of 29 patients. Postsphincterectomy bleeding occurred in one patient and was treated successfully by endoscopic epinephrine injection. For median hospital stay and recurrence there were statistical differences between early and delayed ERCP. CONCLUSIONS: ERCP and sphincterectomy have a certain role in conjunction with laparoscopic cholecystectomy in the management of patients with acute biliary pancreatitis, particularly in institutions where there is easy access to expert interventional endoscopic techniques. This policy should reduce the risk of cholangitis and recurrent pancreatitis.     

109例成人型胆管囊肿的诊治经验

目的 探讨成人型胆管囊肿的临床特点和手术方式,总结胆管囊肿的诊治经验.方法 回顾性分析1984-2007年北京协和医院收治的109例成人型胆管囊肿的病例,总结病例特点.109例中男女之比为1:3.8.平均年龄32.8岁.Ⅰ型78例,Ⅳa型26例,Ⅴ型5例,没有Ⅱ、Ⅲ型病例.结果 成人型胆管囊肿临床表现以右上腹不适或疼痛占大多数,共100例(91.7%),其次为寒战、发热等发作性胆管炎症状.30例(27.5%)有过胆道系统手术史,26例初次手术在2000年前施行.B超结合MRCP是确诊的主要手段.94例行囊肿切除、肝管空肠Roux-Y吻合重建术,4例因肝内病变局限于左肝加做左肝外侧段切除术.4例囊肿恶变.无手术死亡病例.手术近期并发症有胰瘘、膈下脓肿.后期并发症主要是发作性胆管炎、吻合口狭窄和肝内胆管结石.结论 成人型胆管囊肿的临床表现不典型,以右上腹痛或不适最为多见.B超是初查的主要手段,为明确诊断、了解胆管囊肿分型和累及范围可首选MRCP.胆管囊肿理想的手术方式是囊肿切除、肝管空肠Roux-Y吻合重建术.     

Primary intrahepatic lithiasis: report of a case treated by laparoscopic bilioenteric anastomosis

Recent advances in videolaparoscopic surgery have made this method the treatment of choice for many biliary diseases. However, it has not been used in certain cases, such as primary intrahepatic lithiasis. The authors report a case of a 62-year-old woman with a history of several episodes of cholangitis. Investigation revealed dilated intra- and extrahepatic bile ducts with intrahepatic stones. The patient underwent laparoscopy, and intraoperative cholangiography disclosed an enlarged common duct with absence of stones and the presence of multiple calculi in the intrahepatic biliary tree. A choledochotomy followed by choledochoscopy was performed, which revealed several intrahepatic pigmented stones that were completely retrieved, followed by a laterolateral choledochoduodenostomy to decompress the biliary tree and to allow the migration of residual or recurrent stones. The patient had an uneventful recovery and was discharged on the fourth postoperative day. After 15 months of follow-up the patient is asymptomatic with normal results of liver function tests. Late postoperative upper digestive endoscopy showed a patent choledochoduodenostomy.     

Right Hepatic Segmentectomy for the Treatment of Intrahepatic Biliary Stones due to Ascaris lumbricoides: Report of a Case

We report herein the case of a 46-year-old woman investigated for recurrent acute cholangitis. Ultrasound, endoscopic retrograde cholangiopancreatography, and computed tomography scan revealed dilatation and multiple images suggestive of intrahepatic biliary stones in the ducts that drained segments V and VI of the liver. Endoscopic treatment was attempted unsuccessfully, and based on the severity of the last crisis of cholangitis a laparotomy was performed. A right hepatic lobectomy including segments V and VI was carried out without any complications, resulting in complete relief of symptoms. Pathological examination of the liver demonstrated the presence of worm nests in the liver parenchyma with chronic granulomatous lesions. Received: September 28, 2000 / Accepted: May 15, 2001     

Clinical significance of intrahepatic biliary stricture in efficacy of hepatic resection for intrahepatic stones

In the Far East, hepatic resection is the definitive treatment for complicated intrahepatic stones (IHS). However, many investigators have reported that the associated intrahepatic biliary stricture is the main cause of treatment failure. A retrospective comparative study was undertaken to clarify the long-term efficacy of hepatic resection for treatment of IHS and to investigate the clinical significance of intrahepatic biliary stricture in treatment failure after hepatic resection performed in 44 patients with symptomatic IHS. The patients were divided into two study groups: group A, with intrahepatic biliary stricture (n = 28) and group B, without stricture (n = 16). Residual or recurrent stones, recurrence of intrahepatic biliary stricture, late cholangitis, and final outcomes were analyzed and compared statistically between the two groups. The patients were followed up for a median duration of 65 months after hepatectomy. The overall incidence of residual or recurrent stones was 36% and 11%, respectively, in groups A and B. The initial treatment failure rate was 50% in group A and 31% in group B. Intrahepatic biliary stricture recurred in 46% of patients in group A, while none of the group B patients had biliary stricture recurrence (P = 0.001). More than two-thirds of the restrictures in group A were identified at the primary site. The incidence of late cholangitis was higher in group A (54%) than in group B (6%) (P = 0.002). Three-quarters of the patients with cholangitis in group A had severe cholangitis, that was recurrent, and related to stones and strictures (n = 11). They and 2 asymptomatic patients in group B required secondary procedures done at a median of 12 months after hepatectomy. Final outcomes after hepatectomy with or without secondary management were good in 80%, fair in 16%, and poor in 4% of our 44 patients. Most recurrent cholangitis after hepatectomy in patients with IHS was related to recurrent intrahepatic ductal strictures. Therefore, to be effective, hepatic resection should include the strictured duct. However, with hepatectomy alone it is difficult to clear the IHS or relieve the ductal strictures completely, particularly in patients with bilateral IHS, so perioperative team approaches that include both radiologic and cholangioscopic interventions should be combined for the effective management of IHS. Received for publication on Oct. 15, 1997; accepted on Feb. 2, 1998     

Peroral tunable-dye laser lithotripsy of intrahepatic stones in Oriental cholangitis

Summary This case report details the use of a pulsed tunable-dye laser lithotripter in the endoscopic management of recurrent intrahepatic stones in a patient with Oriental cholangitis. A 42-year-old Chinese man had a cholecystectomy and choledochoduodenostomy in 1980. Subsequently he had three episodes of recurrent cholangitis which responded to medical treatment. The patient presented in April 1989 with a fourth attack of cholangitis. Endoscopic retrograde cholangiopancreatography (ERCP) and ultrasound demonstrated a large mass of stones in the right intrahepatic ductal system. A flexible upper gastrointestinal endoscope was passed into the right hepatic duct via the choledochoduodenostomy. The stones were fragmented with a tunable-dye laser and the residual fragments were removed endoscopically.     

Are expandable metallic stents better than conventional methods for treating difficult intrahepatic biliary strictures with recurrent hepatolithiasis?

BACKGROUND: Conventional methods for treating patients with recurrent hepatolithiasis associated with complicated intrahepatic biliary strictures include balloon dilatation of the intrahepatic biliary strictures, lithotripsy, and the clearance of difficult stones as completely as possible, with the placement of an external-internal stent for at least 6 months. After these modalities are used, symptomatic refractory strictures remain. Recently we used internal Gianturco-Rosch metallic Z stents to treat patients who had refractory strictures. OBJECTIVE: To compare therapeutic results and complications of an internal expandable metallic Z stent with those of repeated external-internal stent placement. STUDY DESIGN: Case-control study. SETTING: A referral center. PATIENTS: From January 1992 to December 1996, 18 patients with recurrent hepatolithiasis and complicated intrahepatic biliary strictures underwent percutaneous dilatation of stricture and transhepatic percutaneous cholangioscopic lithotomy for recurrent stones. After their stones were completely cleared, their biliary strictures failed to dilate satisfactorily. The patients were randomly enrolled into 2 groups: group A (7 patients), who received an expandable metallic Z stent, and group B (11 patients), who had repeated placement of external-internal stents. INTERVENTIONS: Percutaneous stricture dilatation, electrohydraulic lithotripsy, balloon dilatation, percutaneous transhepatic cholangioscopic lithotomy, and biliary stenting by a Silastic external-internal catheter or a modified Gianturco-Rosch expandable metallic Z stent (for an internal stent). MAIN OUTCOME MEASURES: The number of procedures, days in hospital, procedure-related complications, incidents of stone recurrence and recurrence of cholangitis, readmissions to the hospital, treatment sessions required, and mortality rate. Patients' limitations in ordinary activities were also compared. RESULTS: The follow-up period ranged from 28 to 60 (40.7+/-12.7 [mean +/- SD]) months in group A and from 28 to 49 (36.0+/-7.2) months in group B. Fewer group A patients (3 [43%]) than group B patients (8 [73%]) tended to have recurrent cholangitis and to require readmission to the hospital, but this was not statistically significant (P = .33). When their cumulative probability of a first episode of cholangitis during follow-up was compared, however, it was significantly lower in patients treated with a metallic stent (P = .04). Compared with group B patients, group A patients had less frequent recurrence of stones (0% vs 64%; P = .01), fewer procedures for the clearance of biliary stones or sludge (1.7+/-2.2 vs 6.4+/-4.3; P = .03), and shorter hospital stays (8.0+/-11.5 days vs 17.0+/-12.0 days; P = .07). No patients in group A experienced limitation in ordinary activities, whereas 7 patients in group B did (P<.02). CONCLUSIONS: Compared with the repeated placement of external-internal stents, the use of a metallic internal stent effectively decreases stone recurrence, simplifies further procedures, and is more convenient. Its use is suggested as an alternative choice in the treatment of recurrent hepatolithiasis with refractory intrahepatic biliary strictures.     

Liver transplantation in patients with Caroli's disease and recurrent cholangitis

Caroli's disease is an uncommon congenital disorder of the intrahepatic biliary tree. It is characterized by multiple and segmental dilatations of the bile ducts. The clinical course of Caroli's disease is often complicated by recurrent episodes of bacterial cholangitis that seriously impair the patient's quality of life. Despite wide spectrum antimicrobial agents, medical treatment of cholangitis is frequently unsuccessful in patients with Caroli's disease due to the persistence of bacteria in dilatated bile ducts. Other therapies, including internal or external biliary drainages and various surgical or endoscopic procedures, have been used in the treatment of Caroli's disease, with poor results. There are no previous reports in the literature of liver transplantation for recurrent cholangitis in patients with Caroli's disease. We present two such cases, in which cholangitis is resolved. Received: 16 July 1996 Received after revision: 4 February 1997 Accepted: 5 February 1997