Long-term follow-up of percutaneous transhepatic therapy (PTT) in patientswith definite benign anastomotic strictures after hepaticojejunostomy

Background and Study Aims: Percutaneous transhepatic therapy (PTT) is a pro mising minimally invasive procedure for benign stenosis of the anastomosis after hepaticojejunostomy. In this prospective study, the effectiveness and safety of this technique were investigated. Patients and Methods: Between October 1995 and May 2000 34 consecutive pati ents were referred for treatment of symptomatic cholestasis due to anastomo tic strictures after hepaticojejunostomy, In all patients percutaneous tran shepatic cholangioscopic (PTCS) drainage and bougienage of the stenosis up to 16 Fr were per formed. Associated bile duct stones were fractured using PTCS laser lithotripsy and removed into the jejunum, Afterwards, patients r eceived transhepatic drainage for 3 months initially. The tubes were replac ed in case of persistent strictures every 3 months up to 1 gear. Patients i n whom treatment failed underwent surgery or received biliary metal stents, depending on risk factors and individual anatomy. Results: The procedure was performed in 34 patients (mean age 57 +/- 15) wi th cholestasis (alkaline phosphatase 691 +/- 485 U/l, bilirubin level mean 3.2 +/-3.1 mg/dl), The transhepatic tube was successfully positioned into t he right hepatic bile duct (n = 25), into the left (n = 3), or into both (n = 3) after 4 +/-1 sessions, except in two patients in whom an external dra inage was used and another patient in whom the procedure had to be stopped due to a bleeding complication. In 14 patients bile duct stones were succes sfully treated by PTCS laser lithotripsy before the placement of a transhep atic tube, The 30-day morbidity and mortality rates were 23.5% and 0% respe ctively. In 23 patients, the transhepatic tube could be removed after 212 /- 122 days, with no evidence of cholestasis during a further follow-up of 736 +/- 479 days. Four patients received metal stents because of persistent strictures after transhepatic intubation, Surgery had to be performed in a total of five patients, because of recurrent bile duct stones or recurrent strictures, in one patient with previous implantation of a metal stent, an d in two patients with bile duct disconnection. Two patients died, one 1.5 years after surgery and one 427 days after metal stent implantation. None o f these cases was related to the procedure. In two patients, the transhepat ic tube is still in situ, Conclusions: Percutaneous transhepatic treatment of anastomotic strictures after hepaticojejunostomy is safe and highly effective in achieving interna l biliary drainage. Temporary transhepatic intubation seems to be a promisi ng minimally invasive alternative to surgery.