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Background: Percutaneous transhepatic biliary drainage (PTBD) allows ductal material to be collected for cyto-histologic examination. We evaluated the data from a large series of patients with a PTBD in whom endobiliary cyto-histologic sampling techniques were employed in order to define a strategy for their use in the diagnostic work-up., Patients and Methods: Ductal samples for cyto-histologic examination were obtained from 409 consecutive patients with a PTBD for stenosing lesions of the biliary tree. Bile aspirate cytology was performed for all patients and ductal biopsy specimens were obtained, generally after negative cytology, from 49 of them (11.9%), all candidates for a therapeutic procedure. The cyto-histologic results of intraductal sampling were compared with pathologic surgical data in 210 patients and with clinical-radiologic follow-up in 199., Results: Overall, 22 out of the 409 patients had a final diagnosis of benign stenosis and 177 had samples positive for neoplastic disease. The sensitivity of bile cytology was 43.8% while ductal biopsies showed a sensitivity of 60.4%. The combination of the two sampling techniques achieved a sensitivity of 65.1%. For both sampling methods the specificity was 100%. Hilar metastases from neoplastic lesions of the GI tract and primary lesions of the biliary ducts showed the highest sensitivity., Conclusion: Cyto-histologic assessment of stenosing lesions of the biliary ducts is mandatory when highly sophisticated interventions (e.g. wide hepatic resection or liver transplantation) or non-surgical treatments are envisaged. The collection of cyto-histologic samples from bile ducts, in patients with a percutaneous bile drainage, is an easy, safe and valuable method to obtain the diagnosis. In view of the absence of false positive results in our series and in others, intraductal biopsy serves no purpose when positive exfoliative cytology is positive for malignancy. In the presence of negative cytology it is felt that an intraductal biopsy should be mandatory when the choice of a therapeutic program depends on the result of the cyto-histologic diagnosis.

The authors report on the use of a safety catheter when removing the T-tube in the patients with choledocho-choledochal biliary reconstruction after liver transplantation. After T-tube removal, bile may leak into the peritoneal cavity through the catheter insertion site in the biliary wall. Biliary peritonitis, bilomas, subhepatic collections may develop, which are difficult to treat in immunodepressed patients. The safety catheter is used to allow the external drainage of the biliary outflow, if present, and to prevent the complications due to bile collecting in the peritoneal cavity. Moreover, the catheter allows cholangiography and interventional procedures to be performed when necessary. A soft guidewire is inserted into the distal bile duct through the T-tube and pushed into the duodenum. After removing the T-tube, an 8.3-F all-purpose catheter (APD) is placed on the guidewire with the tip just outside the biliary wall. The APD is then connected to a drainage bag allowing the amount of bile eliminated daily to be checked. This maneuver was performed in 24 transplant recipients and the safety catheter correctly positioned in 22 of them (91.6%). The APD was removed 48 hours after insertion in 15 patients with no biliary leakage. In the remaining 7 patients the catheter was left in situ up to 8 days, since biliary leakage was observed (range: 50-400 ml/day). No early or late complications related to this technique were observed.

Self-expanding metal stents have been recently used for the treatment of neoplastic esophageal stenoses. In our series, nitinol Strecker stents were implanted in ten patients with malignant esophageal intrinsic or extrinsic strictures, as a definitive palliation. Thirteen stents in all were used: two stents were positioned in three patients to recanalize the esophagus. The prostheses could always be inserted in the treated patients and in all of them swallowing was markedly improved. No major early complications were observed after stent insertion. All the stents but one were patent until the patient's death. Two patients are alive and bearing well-functioning stents. Self-expanding metal stents are to be preferred to plastic endoscopic tubes because their caliber is smaller at the time of insertion and they do not require general anesthesia, as endoscopic tubes sometimes require. Moreover, their complication rate is lower for both early and late complications. Tumor ingrowth through the stent mesh with stent occlusion is the major pitfall of these prostheses, together with the impossibility to use them when esophageal fistulas are present: these limitations will be soon overcome when silicone-coated expandable stents are on the market.

The clinical value of two digital fluoroscopy systems not connected to a PACS was investigated and compared with that of conventional radiology. Some critical variables were considered: image intensifier diameter, image definition, examination time, acquisition speed, patient exposure and finally film consumption. The main problems in the use of the digital techniques consisted in the limited size of the examination fields, which was not big enough to demonstrate the whole colon during double contrast enema, and in the difficult representation of the actual size on the image printed on the laser films. Definition was considered as sufficient for GI examinations. The main advantages consisted in acquisition speed, allowing detailed examinations of cervical esophagus, cardias and fistulous tracts, reduced patient dose and finally the real time visualization of the acquired image on the TV monitor.