title: Combined radiological-endoscopic management of difficult bile duct stones: 18-year single center experience.
abstract: OBJECTIVE
  Clinical evidence regarding radiological-endoscopic management of intrahepatic bile duct stones is currently lacking. Our aim is to report our 18-year experience in combined radiological-endoscopic management of intrahepatic difficult bile duct stones.
  
  
  METHODS
  From June 1994 to June 2012, 299 symptomatic patients with difficult bile duct stones were admitted to our institution. Percutaneous transhepatic cholangiography (PTC)/biliary drainage/s was performed, dilating the PTC track to 10 or 16 French within 3-7 days. Afterward we carried out percutaneous transhepatic cholangioscopy (PTCS) with electrohydraulic lithotripsy (EHL) and/or interventional radiology techniques. Follow up was made with clinical/laboratory tests and ultrasound (US). We retrospectively analyzed our radiological-endoscopic approach and reported our technical and clinical outcomes.
  
  
  RESULTS
  Complete stone clearance was achieved in 298 patients after a maximum of 4 consecutive sessions. Most patients (64.6%) were treated with PTCS/EHL alone, while the remaining with radiological techniques alone (26%) or a combination of both techniques (13.3%). Recurrence of stones occurred in 45 cases (15%, Tsunoda class III and class IV) within 2 years and were successfully retreated. Major adverse events were: 5 (1.6%) cases of massive bleeding that required embolisation, 2 (0.66%) perforations of the common bile duct and 31 cases (10.3%) of acute cholangitis managed with medical therapy or intervention.
  
  
  CONCLUSIONS
  After 18 years of experience we demonstrated that our combined radiological-endoscopic approach to 'difficult bile duct stones' may result in both immediate and long-term clearance of stones with a low rate of adverse events.
authors.affiliation: Vascular and Interventional Radiology Unit, Department of Radiological Sciences, Sapienza University of Rome, Rome, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Cannavale
authors.affiliation: Vascular and Interventional Radiology Unit, Department of Radiological Sciences, Sapienza University of Rome, Rome, Italy.
authors.forename: Mario
authors.initials: M
authors.lastname: Bezzi
authors.affiliation: Department of General Surgery Paride Stefanini, Interventional Endoscopy Unit, Sapienza University of Rome, Rome, Italy.
authors.forename: Fabrizio
authors.initials: F
authors.lastname: Cereatti
authors.affiliation: Vascular and Interventional Radiology Unit, Department of Radiological Sciences, Sapienza University of Rome, Rome, Italy.
authors.forename: Pierleone
authors.initials: P
authors.lastname: Lucatelli
authors.affiliation: Department of General Surgery Paride Stefanini, Interventional Endoscopy Unit, Sapienza University of Rome, Rome, Italy.
authors.forename: Gianfranco
authors.initials: G
authors.lastname: Fanello
authors.affiliation: Vascular and Interventional Radiology Unit, Department of Radiological Sciences, Sapienza University of Rome, Rome, Italy.
authors.forename: Filippo Maria
authors.initials: FM
authors.lastname: Salvatori
authors.affiliation: Vascular and Interventional Radiology Unit, Department of Radiological Sciences, Sapienza University of Rome, Rome, Italy.
authors.forename: Fabrizio
authors.initials: F
authors.lastname: Fanelli
authors.affiliation: Department of General Surgery Paride Stefanini, Interventional Endoscopy Unit, Sapienza University of Rome, Rome, Italy.
authors.forename: Fausto
authors.initials: F
authors.lastname: Fiocca
authors.affiliation: Department of General Surgery Paride Stefanini, Interventional Endoscopy Unit, Sapienza University of Rome, 324, Viale Regina Elena, 00161 Rome, Italy.
authors.forename: Gianfranco
authors.initials: G
authors.lastname: Donatelli
keywords: bile ducts; biliary stones; cholangiography; endoscopy; lithotripsy