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PURPOSE: To evaluate the efficacy of percutaneous transhepatic biliary drainage in the treatment of biliary leaks. MATERIALS AND METHODS: Sixteen patients with a biliary leak involving either the common bile duct (n = 12), the biliary confluence (n = 2), or a hepaticojejunal anastomosis (n = 2) were treated by means of percutaneous transhepatic biliary drainage. The biliary leak was due to severe acute necrotizing pancreatitis in six patients, while 10 patients had postoperative leak. Percutaneous transhepatic biliary drainage was performed with a 12-F catheter, with two series of side holes positioned on both sides of the extravasation to divert bile flow away from the defect. RESULTS: In 13 patients, the biliary leak healed after drainage (mean duration, 78 days). In four of these patients, a slight residual narrowing of the bile duct was treated by means of either balloon dilation (n = 2) or balloon dilation followed by insertion of a metallic stent (n = 2). All 13 patients remained cured (mean follow-up, 38 months). Two patients with severe acute necrotizing pancreatitis died of complications unrelated to the biliary leak. Vascular complications occurred in two patients, one of whom died after surgical drainage of a subcapsular hematoma. CONCLUSION: Biliary leaks can be treated successfully by means of percutaneous transhepatic biliary drainage. The procedure is particularly useful when surgical or endoscopic management has failed.

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OBJECTIVE: The purpose of our study was to assess the efficacy of transcatheter arterial chemoembolization in the treatment of hepatocellular carcinoma using two different infusion schedules. MATERIALS AND METHODS: Chemoembolization with lipiodol-mediated injection of doxorubicin was performed in 160 patients. In the first group of 80 patients, conventional chemoembolization was initially planned to be repeated at least three times at 2-month intervals. In the second group of 80 patients, chemoembolization was used selectively and repeated only when necessary on the basis of follow-up CT or MR imaging. According to the Okuda classification, 72 patients were stage 1, 33 belonging to group 1 (subgroup 1, Okuda 1) and 39 belonging to group 2 (subgroup 2, Okuda 1). Eighty-eight patients were stage 2, 47 belonging to group 1 (subgroup 1, Okuda 2) and 41 belonging to group 2 (subgroup 2, Okuda 2). RESULTS: Complications of transcatheter arterial chemoembolization occurred in 19 patients from group 1 and six patients from group 2 (p < .001). The mean time between the first and the third courses was significantly different between group 1 (4 months) and group 2 (14 months) (p < .001). The 1-year, 2-year, and 3-year survival rates were significantly different between subgroup 1, Okuda 1, (58%, 28%, 11%) and subgroup 2, Okuda 1 (89%, 68%, 39%) (p <. 001), and between subgroup 1, Okuda 2 (19%, 0%, 0%), and subgroup 2, Okuda 2 (48%, 31%, 15%) (p < .001). CONCLUSION: The efficacy and tolerability of chemoembolization increase when it is used selectively and repeated only when necessary. Such technical considerations might explain some of the discrepancies of the results of chemoembolization in published data.

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A 15-month-old girl, who presented with biliary cirrhosis secondary to cystic fibrosis with refractory ascites and recurrent intestinal bleeding, underwent percutaneous transjugular intrahepatic portosystemic shunting. Immediately following the procedure the ascites disappeared and no further bleeding occurred. The stent shunt was patent on Doppler ultrasound until the 22nd day. The patient died on day 22 because of liver failure due to a low-flow syndrome with severe hepatic ischaemia, but with no recurrence of bleeding or ascites.

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The results of percutaneous transhepatic endoprosthesis in the treatment of biliary stenosis are discussed on the basis of the reports of the literature and a personal experience of more than 400 patients treated for about 15 years. Advantages and disadvantages of conventional stents as compared with metal endoprosthesis are discussed, the latter being now preferred by most authors. However they do not prove to be more efficient than conventional stents which are suitable for those patients who have a relatively short life expectancy. Percutaneous treatment of benign biliary stenosis has grown as well but the choice of the best procedure remains difficult. Metal endoprostheses are controversial because the risk of delayed obstruction has not yet been clearly evaluated. However it might become an interesting therapeutic procedure in the future.

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PURPOSE: To report on the frequency and treatment of arterial complications due to percutaneous transhepatic biliary drainage (PTBD). MATERIALS: Lesions of the intrahepatic artery were encountered in 10 of 525 patients treated by PTBD (2%). Hemobilia followed in 9 patients and subcapsular hematoma in 1. Seven patients had a benign biliary stenosis and 3 had a malignant stenosis. RESULTS: The bleeding resolved spontaneously in 3 patients. In 7 it required arterial embolization, which was successfully achieved either through the percutaneous catheter (n = 3) or by arteriography (n = 4). CONCLUSION: Arterial bleeding is a relatively rare complication of PTBD that can easily be treated by selective arterial embolization when it does not resolve spontaneously. In this series its frequency was much higher (16%) when the stenosis was benign than when it was malignant (0.6%).

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During a 7-year period, bleeding esophageal varices were treated by means of percutaneous transhepatic embolization in 400 cirrhotic patients, including 258 patients with Child's class C cirrhosis (65%) and 142 patients with Child's class B cirrhosis (35%). Embolization was performed either with bucrylate or with absolute ethanol and stainless-steel coils. Variceal hemorrhage was controlled in 245 (83%) of the 297 patients in whom percutaneous transhepatic embolization was performed as an emergency treatment. The 10-day survival rate in the series was 76%, with 97 deaths occurring shortly after the procedure as a result of recurrent bleeding or liver failure. The actuarial rate of recurrent bleeding was 55% at 6 months (38% Child's class B, 70% Child's class C) and 81% at 2 years (71% Child's class B, 90% Child's class C). One-half the cases of recurrent bleeding were easily controlled by medical treatment; 56% of these patients were still alive at 6 months (79% Child's class B, 42% Child's class C), 48% were alive at 1 year, and 26% were alive at 5 years. Results indicated that the survival rate was significantly higher (p less than .01) in Child's class B patients than in Child's class C patients during the 5-year follow-up period. The overall technical failure and complication rates were 9% and 7%, respectively, but these rates declined progressively as we gained more experience with the procedure. In this large series, transhepatic embolization was a safe, easy-to-perform, and effective treatment for the control of variceal bleeding and was somewhat more efficacious than previously reported.

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Seventy three patients with malignant obstruction of the extrahepatic bile ducts were submitted to palliative drainage through percutaneous transhepatic endoprosthesis (P.T.E.). Complications occurred within the first month following the procedure in 13 patients (18%) and 8 of them died (10%). Cholangitis was the main complication resulting, from dysfunction of the endoprosthesis due to an incorrect placement of the stent in most cases. On the other hand, not any significant vascular complication such as previously reported following P.T.E., was encountered in our series. Late complications are mainly due to endoprosthesis obstruction (5 cases) or dislodgement (2 cases). The mortality rate within the first month following P.T.E. is 19%, resulting from either a complication of the procedure (11%) or the underlying disease (8%). The mean survival of these 73 patients, is 4, 7 months. When considering only the 59 patients who are alive one month following the procedure, the mean survival (post-operative deaths excluded) is 6 months. According to our experience P.T.E. remains a valuable palliative procedure when other endoscopic or surgical methods either have failed or cannot be resorted to provided a correct placement of the stent allowing for a good bile drainage can be achieved. Thus P.T.E. is able to provide in many cases the same long-term survival as palliative surgery, allowing the patients to resume their normal daily activity.

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PIP: A 34 year old woman, on oral contraception (OC) for 10 years, was hospitalized for an acute and painful abdominal syndrome. Radiological examinations showed an anomaly in the jejunoileal intestine, later diagnosed as ischemia. After treatment with vibramycine and after interruption of OC the ischemic syndrome regressed completely in 3 weeks. A review of the published literature on the subject reveals 25 such cases, usually evolving toward intestinal infarction.^ieng

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