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This review recalls the clinical, anatomic, physiopathological and etiological features necessary in the management of patients with neoplastic bile duct obstruction and exposes the current practice concerning endoscopic and radiologic palliative drainage. Clinical practice according to the clinical situations is explained. This review exposes complications management for patients having undergone an endoscopic or percutaneous drainage of the biliary ducts, the particular case of periportal stenosis, the respective indications of endoscopic and transhepatic percutaneous drainage, usual immediate evolution according to the type of the stenosis and the technique used as well as the management in case of stent obstruction.

Purpose: To review the etiology, location, and morphology of pelvic collection as well as the technique and results of image guided drainage., Materials and Methods: From June 1996 to August 2002, we performed image guided drainage of pelvic fluid collections in 21 males and 21 females. In patients where a direct contact between the collection and the endocavitary probe was present, the drainage was performed either by transrectal or transvaginal approach using 10F, 12F, 14F or 16F catheters according to the viscosity of the fluid. When the patients were no longer septic, when drainage had stopped, the drains were removed at day 5. When a fistula was present, the drain was left in place until the fistula healed., Results: The most common location of pelvic collections was the cul-desac (43%). A total of 81% of pelvic abscesses were digestive in origin, either from the colon or appendix. Transrectal or transvaginal drainage was possible in 83% of cases. Mean follow-up was 41 months. No drainage related complication was recorded. In two patients with collections of clear fluid, a simple aspiration was performed without insertion of a drain. In the 40 other patients, a drainage catheter was inserted. Twenty-nine patients were cured after 15 days of drainage. Two patients had recurrent collections. Image guided drainage failed in five patients, and all underwent successful surgical management., Conclusion: Image guided drainage of pelvic collections is a safe and effective procedure. Failures were due to initially undiagnosed pathology requiring surgical treatment.

Aim: To present our experience with percutaneous intracorporeal electrohydrolic lithotripsy in the treatment of intrahepatic lithiasis., Subjects and Methods: From January 1989 to November 1998, 53 patients with intrahepatic lithiasis were treated with percutaneous intracorporeal electrohydrolic lithotripsy. Twenty-six patients had primary intrahepatic lithiasis. Intrahepatic stones were associated with intrahepatic duct abnormalities in 11 patients, 9 had strictures and 2 had cystic dilatations. Twenty-seven patients had secondary intrahepatic lithiasis formed a biliodigestive bypass in 20 patients. Intracorporeal electrohydrolic lithotripsy was performed under cholangioscopic guidance in all patients. The endoscope was introduced into the biliary ducts through a cutaneobiliary tract in 51 patients, through a cutaneocholecystic tract in one and through a cutaneojejunal tract in one. These tracts were created and gradually dilated in two sessions three days apart. In twenty-two patients stenosis or sharp angulation prevented adequate positioning of the scope which was only successful after balloon dilation or insertion of a stiff wire., Results: Complete clearance of stones was achieved in 49 patients (92%). Biliary or hepaticojejunostomy strictures were successfully dilated with an angioplasty balloon in all patients. Ten patients (19%) had early complications: four had bilomas treated by percutaneous drainage, three had resolutive onset of cholangitis, two had transient arterial hemobilia, and one had a pneumothorax. The mean duration of follow-up was five years. During this period, 5 patients (9%) had recurrent symptoms of biliary obstruction. Among these patients, three (5.7%) had recurrent symptomatic intrahepatic lithiasis, one had a recurrent biliary stricture and one had secondary sclerosing cholangitis. Treatment of recurrent stones was repeated intracorporeal electrohydrolic lithotripsy in two and left hepatectomy in one; recurrent biliary stricture was treated by hepaticojejunostomy and secondary sclerosing cholangitis by antibiotics., Conclusion: Intracorporeal electrohydrolic lithotripsy is effective and safe and should be proposed as the first line treatment of primary or secondary intrahepatic lithiasis.

Purpose: The endoscopic treatment of malignant hilar obstruction is followed in 70% of the case by infection of undrained biliary sectors. We report the influence of complete biliary drainage on post procedural cholangitis., Method: From January 1990 to January 1993 we treated 120 consecutive patients presenting with a malignant hilar obstruction. There were 61 women and 59 men, mean age 65 +/- 7.5 years. The level of stenosis was type II in 45 patients (37%), type III in 18 patients (13%) and above type III in 57 patients (48%). Complete biliary drainage with multiple biliary access was attempted in all patients. Long term internal drainage was achieved by metallic autoexpansive endoprosthesis., Results: Complete drainage was achieved in all patients with type II or type III biliary stenosis. Drainage was incomplete in all patients with biliary stenosis above type III. Early complications were observed in 35% of the patients. Persistent cholangitis, the most frequent complication (22%) was only observed in patients with above type III biliary stenosis. Mortality at 30 days was 17%. Recurrent biliary obstruction was observed in 22% of the patients after an average of 187 days. Median survival was 95 days., Conclusion: Complete biliary drainage prevents persistent cholangitis in patients with type II or III biliary stenosis without increasing other complications related to biliary drainage.

Certain stones need to be fragmented before being extracted via endoscopic sphincterotomy (ES). From April 1988 to December 1991, extracorporeal lithotripsy was used in this indication in 28 patients (22 females, 6 males) with a mean age of 77 +/- 20 years, using an ultrasound-guided electrohydraulic lithotriptor. Stone detection was performed after perfusion of the nasogastric tube and was easy in 20 cases (71%), difficult in 6 cases (22%) and impossible in 2 cases (7%), which could not be treated by this method. The patients had an average of 1.4 +/- 0.9 stones measuring 19.6 +/- 8 mm and received an average of 2.480 +/- 580 shock waves in a single session for 24 patients and in two sessions for 2 patients. Radiologically obvious fragmentation was achieved in 11 out of 26 cases (42%) and was found to be effective at a further extraction attempt in 4 other cases. Complete clearance of the common bile duct was achieved in 15 cases (57.7%). The size of the stones (> or < 20 mm) and the solitary or multiple nature of the stones did not significantly influence the fragmentation results. No complication related to the technique was observed apart from the constant development of cutaneous petechiae. An improvement in the power of the generator and the use of fluoroscopic rather than ultrasonographic guidance should allow an improvement of these results in the future. Because of its safety, this lithotripsy method can be proposed following failure of mechanical lithotripsy.

Between March 1982 and December 1987, 466 patients (256 women, 210 men, mean age 73 years) with tumor obstruction of the common bile duct were referred to our department. The causes of obstruction were carcinoma of the pancreas (298 patients), carcinoma of the ampulla of Vater (32 patients) and carcinoma of the common bile duct (136 patients). Endoscopical insertion of a biliary prosthesis was initially possible in 377 patients (81%). In case of failure, patients were referred to the radiologist for percutaneous drainage. Successful drainage was obtained in 58 patients with an overall success rate of 93% (435 patients). Endoscopic replacement was necessary in 170 cases for 114 patients and was successful in 155 (91%). Pruritus was relieved in 89% of the patients. Serum bilirubin levels decreased more than 75% after initial endoscopic endoprosthesis, repeated endoscopic endoprosthesis and percutaneous prosthesis insertion in 80%, 79%, and 62% of the patients, respectively. Short term complications of endoscopic endoprosthesis occurred in 28% of patients with a mortality rate of 8%. Percutaneous prosthesis complications occurred in 33% of patients with a mortality rate of 11%. In the long term, cholangitis was the main complication and occurred in 27% of patients with a delay of 103 +/- 105 days. Intestinal obstruction was observed in 7% of patients. The average life expectancy of endoscopic endoprosthesis and percutaneous prosthesis was 109 +/- 157 and 92 +/- 101 days, respectively. The average life expectancy of patients was 163 +/- 224 days.(ABSTRACT TRUNCATED AT 250 WORDS)

102 patients with suspected vasculogenic impotence were evaluated with color doppler sonography. Measurement of normal systolic and diastolic velocities were obtained from the cavernosal arteries of patients responding by a full erection after intra-cavernosal injection of 20 mg of Papaverine. A correlation with cavernosometry was obtained in 61 patients and with selective internal pudendal arteriography in 11. The 10 patients with abnormal arteriograms had a systolic velocity < 25 cm/sec. 13 out of the 15 patients with an end diastolic velocity > 5 cm/sec had a venous leak defined by a maintenance flow rate of erection during cavernosometry > 25 ml/mn. End diastolic velocity is an excellent index of the function of the veno-occlusive system, provided the systolic velocity remains at a normal value. In case of arterial insufficiency, a diastolic flow < 5 cm/sec is of no value and cavernometry is mandatory to detect a mixed arterio-venous impotence. The addition of color doppler sonography permitted a more rapid detection of vessels and an easily reproducible measurement of velocities which makes color doppler sonography an excellent screening test for examining patients with potential vasculogenic impotence.

Endoscopic retrograde cholangio-pancreatography (ERCP) confirms the diagnosis of obstructive jaundice and sometimes provides the histological proof that the stenosis is due to cancer. Palliative treatment of biliary and pancreatic cancers is indicated when the extension of the tumour is such that it precludes any oncologically satisfactory excision, in patients at high operative risk, when jaundice recurs after surgery and in cases of biliary metastases from distant cancers. Cancers located below the hilum are usually easily treated by endoscopic insertion of a biliary stent, whereas hilar cancers extending to the bifurcation often require combined endoscopic and percutaneous techniques to drain all liver segments. The most frequent of early complications of biliary stents is cholangitis, notably in hilar cancers. Late complications, notably obstruction of the stent, can be reduced by using expandable metal stents.

A new technique of electro-incision of ureteral stenoses and strictured uretero-enteric anastomoses is presented. Incision is performed with a papillotome, routinely used to achieve endoscopic retrograde sphincterotomy of the duodenal papilla. Group I: 7 ureteral stenoses were performed, on a dog model after surgical ligation of the lumbar ureter. Ten days later, through a percutaneous approach, the papillotome was placed through the stenosis, deflected, and cutting current was applied to incise the stenosis. The IVP performed one month later showed disappearance of the stenosis in 4 cases, a residual stenosis without obstacle in 2 cases and a residual stenosis with obstacle in one case. Group II: 7 strictured uretero-enteric anastomoses on 6 patients. After placement of a percutaneous nephrostomy, a wire guided papillotome was placed into the stenosis. Cutting current was then applied to cut the stenosis. A 18 F ureteral stent was subsequently placed for 8 weeks. Two patients have a patent anastomosis, 7 and 10 months after removal of the stent. One patient died from metastases of bladder tumor. The three remaining patients are still stented. An urinoma occurred in one patient the day following removal of the stent, and was surgically drained. This new technique which combines electro-incision and stenting with a large caliber stent may be proposed as an alternative to surgery or balloon dilatation for the treatment of strictured uretero-digestive anastomoses.

Out of 625 patients referred for stenting for a malignant stricture of the biliary tract, 97 (15.8%) had undergone previous surgery. Resection had been performed in 43 cases, by-pass in 15, surgical stenting in 11, laparotomy in 28. The stricture was located in the porta hepatis in 48 patients (49.5%) in the middle common bile duct (CBD) in 47 (48.5%) and juxtapapillary in 2 (2%). Endoscopic retrograde transhepatic stenting was successful in 51 patients (52.5%). Percutaneous transhepatic stenting was successful in 41 cases out of 46 (85%) and in 5 cases, only external drainage was possible. A 75% reduction in serum bilirubin was observed in 78 patients (81.5%) and normalization was observed in 66 (90%) who survived more than one month. The complication rate was 31.3% in the endoscopic group and 47.7% in the percutaneous transhepatic group, with a mortality related to early complications of 9.8% and 19.6% respectively. The higher complication rate of transhepatic stenting is at least partially related to an unfavourable selection of patients in this group: failures of endoscopic stenting, high frequency of hilar strictures. The mortality at D 30 was 24%, significantly higher in hilar strictures than in middle CBD strictures (p less than 0.02). A late obstruction of the stent occurred in 43 patients (58%) after an interval of 103 +/- 52 days, and endoscopic retreatment was possible in 65% of cases. The median survival was 153 days in subhilar strictures and 104 days in hilar strictures. These results justify considering the possibility of palliative stenting after failure of a surgical treatment especially in peri-ampullary and middle CBD strictures.

Unlabelled: 16 strictured uretero enteric anastomoses were dilated and stented for 4 months with a large size stent (18F in fifteen cases and 14F in one case). All the patients had undergone a radical cystoprostactectomy, had received radiotherapy prior to surgery. The length of the stenosis did not exceed 3 cm in all cases. All the stenoses occurred within 2 years following the removal all of the stent., Results: 6 cases (37%), have a patent anastomosis, 18 to 36 months following removal of the stent. Most of the recurrences occurred within six months following removal of the stent. We recommend a long term stenting with a large size stent to obtain long term patency of dilated anastomotic strictures.

The endoscopic treatment of calculi of the main biliary duct (CMBD) has been performed in France since 1974. One of us (Cl. L.) published his results with a series of 323 patients in 1979. The stones were extracted in 86.5% of all cases, the failures being caused by the impossibility to perform endoscopic sphincterotomy (ES) in 4.3% of cases or to extract the stones in 9.2%. Since that date, a number of factors helped improving the effectiveness of endoscopic treatment: the increasing experience of the surgeons, the improvement of endoscopes, especially more appropriate optics (wide angle and 15 degrees retrograde vision) and the endoscopic approach of the biliary tract, the use of intraoperative radiology allowing access to the biliary tract in all cases, and the development of extra- and intracorporeal lithotrity solving the problem of stones that cannot be extracted by conventional means. This work is aimed at demonstrating the current possibilities of the endoscopic treatment of lithiasis of the CMBD in a Hospital using plain radiology and lithotrity.

Instillation of Methyl tert-butyl ether in the gallbladder permits the dissolution of cholesterol stones. Percutaneous transhepatic puncture of the gallbladder is the currently used approach; but shortcomings of this procedure could make the transpapillary cannulation of the cystic duct preferable. The reproducibility of this procedure, however, is not established. "In situ" dissolution is useful in cases of multiples stones which are not amenable to treatment with extra corporeal shock wave lithotripsy (ESWL). It can also be complementary to standard ESWL by promoting rapid disappearance of stones fragments. Preliminary results obtained in 9 patients suggest the necessity of rigorous selection criterias particularly regarding the chemical nature of the stones.

A prospective study in 60 consecutive patients evaluated gain in quality of image using ECG servo-assistance during pulmonary digital subtraction angiography (PDSA). Two groups of 30 comparable patients were randomly allocated to examination with ECG servo-assistance or three images per second technique. Criteria for assessment of quality of image were defined and used to compare results. No significant difference were noted and ECG servo-assistance failed to improve images during PDSA.

A 94-year old woman presented with gallstone formation above a stenotic choledoco-duodenal anastomosis, responsible for episodes of cholangitis. After percutaneous biliary tract drainage, the anastomosis was dilated with an angioplasty catheter. As several stones persisted despite washing out, percutaneous cholangioscopy was performed. To introduce a small fibroscope into the biliary canals, transhepatic dilation up to 28 F was necessary. The last stones were pushed into the duodenum with the endoscope. Freedom of the biliary tract and patency of the anastomosis were ascertained.

Extracorporeal lithotripsy was performed in 5 patients whose stones in the main bile duct could not be extracted despite wide endoscopic sphincterotomy, conventional extraction techniques (basket and balloon catheter) and attempts at mechanical lithotripsy. Fragmentation of the stones was obtained in one session in 4 patients. The fragments were spontaneously expelled in 2 patients, while additional endoscopic manoeuvres (mechanical lithotripsy, extraction after installation of a temporary prosthesis) were necessary in the other 2 patients. Failure in the 5th patient was due to the impossibility to focus the point of convergence of the shock wave on the stones. No complication related to the technique was observed.

A 24-year-old man presented clinically confirmed Behcet's disease. He developed thoracic pain accompanied by hemoptyses as a result of thromboses and aneurysm formation in the pulmonary artery. The presence of these aneurysms was suggested by perihilar images on standard radiography, and confirmed by pulmonary arteriography findings and results of histological examination of the operative specimen. Radiological and anatomical evidence of the presence of bronchial endarteritis lesions was also obtained.

Seven cases of acute cholecystitis (4 women and 3 men, mean age 73 years) were observed in a series of 192 patients treated by endoprosthesis for cancerous obstruction of the bile ducts between october, 1984 and october, 1986. The suspected clinical diagnosis was confirmed by ultrasonography. Cholecystostomy was performed by percutaneous puncture under ultrasonic guidance. A catheter was positioned in the gallbladder by the Seldinger technique in 3 cases and by the trocar technique in 4 cases. Pain in the right hypochondrium was relieved in all patients immediately after emptying of the gallbladder. Five patients were cured. One patient developed purulent peritonitis which was treated by surgery. A female patient died of her pancreatic cancer 3 days after cholecystostomy. Provided a number of precautions are taken to prevent leakage of the infected bile into the peritoneal cavity, percutaneous cholecystostomy is the treatment of choice for acute cholecystitis consecutive to biliary endoprosthesis.

From October 1982 to October 1984, a percutaneous drainage under realtime ultrasound guidance was performed in 53 patients with abdominal abscesses. The location of the abscesses was subphrenic (23), retroperitoneal (16), and intrahepatic (14). A safe access route was found by using ultrasound and fluoroscopy in 53 out of 55 patients (96 p. 100). Percutaneous drainage failed in 8 patients and 3 of these patients died. The causes of death were: cerebral abscess (1), renal failure after surgery for correction of a duodenal fistula (1), and pancreatic abscess (1). The other five patients were cured by surgical drainage. Two complications were observed: one case each of pneumothorax and purulent peritonitis. Forty-five patients were healed by percutaneous drainage without operation. The duration of the catheter drainage was 14 days +/- 13 (m +/- 1 SD). Our results suggest that percutaneous drainage under realtime ultrasound guidance is an efficient and safe way to treat abdominal abscesses.

In order to evaluate the responsibility of pancreas divisum in the occurrence of pancreatitis, we studied retrospectively 1,808 endoscopic retrograde pancreatograms. Eighty-seven pancreas divisum (4.8 p. 100) were found in 50 males and 37 females, mean age 53.3 +/- 16.8 yrs. Acute pancreatitis was significantly more frequent (p less than 0.001) in this group (19.6 p. 100) than in the patients with fused pancreas (4.3 p. 100). The difference was also significant (p less than 0.01) for idiopathic recurrent acute pancreatitis. Histologic lesions in the dorsal pancreas were in favor of a retentional mechanism of pancreatitis. Sphincterotomy of the accessory papilla, proposed to improve the drainage of the dorsal pancreas, was performed in 11 patients (10 endoscopic, 1 surgical). This treatment, repeated in case of secondary stenosis of the accessory papilla, was successful in 5 out of 8 patients with acute pancreatitis followed up from 12 to 30 months. After reviewing the literature, secondary stenosis of accessory papilla was found significantly less frequently (p less than 0.05) after surgical sphincterotomy or sphincteroplasty (4 out of 46, 8.6 p. 100) than after endoscopic sphincterotomy (6 out of 22, 27.2 p. 100). Treatment, preferentially surgical, should be proposed only to patients with idiopathic recurrent pancreatitis before constitution of chronic non reversible pancreatitis.

Interventional radiology and operative endoscopy have considerably modified the diagnosis and treatment of neoplastic biliary obstruction. Ultrasound - or CT - guided needle biopsy provide a histological diagnosis without laparotomy. In almost every case, palliative treatment of jaundice can be performed by percutaneous stent insertion, due the combination of radiology and endoscopy. The major drawback of biliary drainage is the always possible distal obstruction of biliary stents.

From October 1983 to October 1985, 53 patients with malignant biliary obstruction were referred to our institution for a transhepatic biliary stent. One or two endoprostheses were inserted in 46 patients (87 p. 100). Stent insertion was usually performed in two sessions, after two or three days of external drainage. There were 23 men and 23 women. Their mean age was 70.6 years +/- 12 years (m +/- DS). Fourty-two patients (91 p. 100) were referred after failure of an endoscopic or surgical drainage procedure; fourty-four p. 100 of the patients had stage II or III high periportal obstruction. Five cases of severe early complications (11 p. 100) and 8 delayed complications requiring in-hospital treatment (17 p. 100) were observed. Among the latter, 7 were due to plugging of the endoprosthesis. All patients were unfit for surgery either because at a high operative risk or because of the extent of the cancer. Our results showed that percutaneous biliary drainage can be achieved in a high percentage of cases following failure of a surgical or endoscopic drainage procedure. The endoscopic transpapillary approach, which allows the insertion of 12 French endoprostheses in one session should be tried first. Percutaneous biliary drainage should be performed as a complementary procedure when endoscopic drainage has failed or in stage II or III high periportal obstruction associated with persistent jaundice or cholangitis.

The five patients presented with sudden lumbar pain, transient collapse, and a right hypochondrium palpable mass. The location and the type of the mass could be determined by ultrasonography which showed a septated heterogenous mass displacing the retroperitoneal fat anteriorly. Computed tomography showed in two cases tiny parietal calcifications and a spontaneous hyperdensity in one case. All the patients underwent surgery and no tumoral tissue could be found.

Nine patients with gallstones were treated by injection of methyl-tert-butyl-ether (MTBE) into the gallbladder. Complete or incomplete dissolution was observed in 5 of the 9 patients. The 4 failures were due to 2 main factors: poor selection of the patients (2 of them had pigment gallstones) and inadequate mixture with the solvent floating above the bile and gallstones. In addition, 4 complications were noted, all of them being resolved by medical treatment. A better selection of the patients and a more efficient technique of MTBE injection should improve these results.