Methods, Indications, and Results of Percutaneous Choledochoscopy

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Abstract
Nonsurgical methods for evaluation and treatment of the biliary tree are usually done under fluoroscopic guidance. Direct visualization of the bile ducts, that is, choledochoscopy, could provide a more precise method with which to perform these maneuvers. The methods, indications, and results of percutaneous choledochoscopy are discussed from a series of 161 procedures performed in 123 consecutive patients. Ninety-six patients had transhepatic drains and 27 had T-tubes implanted. Biopsy of bile duct stenosis was conducted in 52 cases. The sensitivity for the diagnosis of malignancy was 78%, and the authors recommended this method in case of nonsurgical treatment of stenosis. Gallstone extraction was performed in 75 cases (35 intrahepatic). Lithotripsy was necessary for 64 patients and complete gallstone clearance was obtained for 69 patients (92%). The rate of stone recurrence was 18.1% (median follow-up, 32 months), prompting the authors to reconsider surgery for the treatment of underlying disease. Laser photocoagulation was used successfully for two of three patients to ablate an intraductal adenoma. In eight cases of cholangiocarcinoma, the laser effect was too short to satisfactorily relieve obstruction of the intrahepatic bile ducts. Morbidity dramatically decreased from 53.7% to 5% when progressive dilation of the tract, aseptic conditions, and general anesthesia were applied systematically. Percutaneous choledochoscopy can be used routinely, provided that strict techniques are adhered to. This procedure should be reserved for only a small subset of biliary diseases.