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Percutaneous stricture dilatation and cholangioscopic lithotomy has become a mainstay in the treatment of patients with recurrent hepatolithiasis associated with intrahepatic biliary strictures. In a consecutive series of 125 patients who underwent percutaneous management of recurrent hepatolithiasis from 1987 to 1999, there were 15 patients in whom the procedure failed to clear the stones. A second percutaneous transhepatic route was established for subsequent treatment. A reappraisal of its indications and efficacy was done. Treatment through a second route was helpful for patients with bilateral strictures, angulated duct, difficult strictures, large impacted stones, a subcutaneous jejunal limb, or hemobilia developing in the first route. Strictures remained impacted in 1 of the 15 patients (failure rate, 7%), with the remaining having complete clearance of stones. Cholangitis occurred in two patients; no other complications were encountered. A second percutaneous route is very helpful for the management of complicated hepatolithiasis and biliary stricture.

For recurrent hepatolithiasis coexisting with a complicated long-segment intrahepatic biliary stricture, repeated surgeries, balloon dilation of the stricture, and external-internal stenting may still fail to solve the problem. We tried using a Gianturco-Rosch metallic Z internal stent (Wilson-Cook Medical, Inc., Bloomington, IN, USA) with the aid of percutaneous transhepatic cholangioscopy (PTCS) to treat such patients. Eight patients had a Z stent placed through a percutaneous transhepatic biliary drainage tract. Immediately after stent placement, PTCS was inserted via the percutaneous transhepatic biliary drainage route and a part of the wire skirt not firmly anchored in one of the eight patients was detected. It was successfully repositioned using PTCS. Recurrent cholangitis developed in three patients 6, 7, and 30 months, respectively, after stent placement. PTCS was undertaken again through a reestablished percutaneous transhepatic biliary drainage route and revealed sludge in their stent lumens. We cleared it by PTCS. No further cases of cholangitis occurred in later follow-up. PTCS is useful in ensuring adequate stent position, diagnosing and treating the causes of recurrent cholangitis, and prolonging the function of stents.