Editorials Daniel
Picus,
MD
Percutaneous
T
Gallbladder
first reports of percutaneous gallbladder intervention appeared in the radiology literature in the early 1980s (1,2). Widespread adoption of these techniques, however, was slowed by initial concerns with regard to bile peritonitis and life-threatening vagal reactions. Over the last 5 years, a large number of investigators have shown that these procedures are both safe and effective. As a result, percutaneous gallbladder interventions have become an active part of the practice of many interventional radiologists. Two articles in this issue of Radiology emphasize the role of the interventional radiologist in the treatment of gallbladder disease. These articles also illustrate that indications for percutaneous gallbladder intervention are still evolving. Currently, the most common indication for percutaneous gallbladder intervention is decompression of the acutely inflamed and obstructed gallbladder. In high-risk patients, such as the elderly and those with underlying cardiac disease, pulmonary disease, or both, percutaneous cholecystostomy can provide a significant temporizing benefit: that of often allowing delayed, elective cholecystectomy under more optimal circumstances (3-5). Percutaneous cholecystostomy is particularly beneficial in patients with acalculous cholecystitis in whom temporary drainage may allow resolution of cystic duct obstruction and eventual removal of the cholecystostomy tube without the need for cholecystectomy. HE
Index
terms:
ducts,
interventional
ducts,
stenosis
Bile
calculi,
procedure,
1
From
tional
1990;
the
Bile
#{149}
#{149} Editori-
#{149} Gallbladder, #{149} Interven-
1228
#{149} Jaundice
176:5-6
Section
Radiology,
diology,
762.289 762.
768.1228
#{149} Bile
764.289
procedures,
Radiology
76.289 76.1229
or obstruction,
interventional
tional
calculi,
procedure,
#{149} Gallbladder,
als
ducts,
of Vascular Mallinckrodt
Washington
and
Interven-
Institute
University
School
of Raof
Medicine, 510 S Kingshighway Blvd. St Louis, MO 631 10. Received April 9, 1990; accepted April 12. Address reprint requests to the author. RSNA, 1990 See
also
vanSonnenberg
the
articles (pp
by 15-18)
Cope in
(pp this
19-24) issue.
and
.
Intervention’
Percutaneous cholecystostomy also has been used to decompress the biliary tract in patients with obstruction of the distal common bile duct (2,3). Although transhepatic or endoscopic biliary drainage is usually a better alternative for patients with distal obstruction of the common bile duct, percutaneous cholecystostomy may be preferable in selected cases. In this issue of Radiology, vanSonnenberg et a! (6) further define the role of percutaneous cholecystostomy in such selected patients. They successfully established external drainage in i 1 carefully selected patients with obstructive jaundice. The primary indication for intervention in their Series was common bile duct obstruction associated with nondilated intrahepatic ducts. Their only complication occurred in one patient in whom the cholecystostomy catheter became dislodged and could not be replaced. Percutaneous cholecystostomy provided temporary decompression before definitive therapy in six of 1 1 patients and short-term palliation for obstruction secondary to pancreatitis in three of 11 patients. In only one of 1 1 patients was the procedure considered long-term palliative drainage. The main advantage of percutaneous cholecystostomy in patients with obstructive jaundice is the ease with which it can be performed. As anyone who has performed transhepatic biliary drainage knows, placing a needle into a large, distended gallbladder is much easier and quicker than placing a needie into a tiny, nondiiated intrahepatic duct. Although transhepatic biliary drainage is technically more difficult, the procedure usually is the first step in the overall treatment for an individual patient. Transhepatic access to the bile ducts allows stone removal, stricture dilation, and stent placement. For percutaneous cholecystostomy to be more widely applied in patients with obstructive jaundice, access to the common bile duct must be secured in a safe and easy fashion. VanSonnenberg et al successfully cannulated the cystic duct in only two of the five patients in whom the procedure was attempted. Although others have been somewhat more successful, cannulation of the cystic duct can be technically difficult. The ability to pass a guide wire through the cystic duct is often limited by the spiral
valves. We have found a Terumo guide wire (Medi-tech/Boston Scientific, Watertown, Mass) most helpful. After a guide wire has been passed through the cystic duct, subsequent placement of a catheter may also be difficult. Finally, manipulating guide wires and large catheters through the cystic duct is often painful for the patient. Future technical improvements in guide-wire and catheter design may improve our ability to cannulate the cystic duct. There is an additional drawback to the use of percutaneous cholecystostomy for definitive drainage in patients with malignant distal obstruction of the common bile duct. Frequently, both pancreatic carcinomas and cholangiocarcinomas eventually grow to obstruct the cystic duct origin. Such obstruction depends on the location of the cystic duct insertion into the common bile duct. Because of this potential pitfall, surgeons rarely perform a cholecystojejunostomy for palliative decompression, preferring a choledochojejunostomy instead. Despite these limitations, percutaneous cholecystostomy is useful for decompressing bile duct obstructions in highly selected patients. The procedure is most helpful for providing temporary decompression prior to more definitive therapy in acutely ill patients with cholangitis and distal obstruction of the common bile duct. We have found percutaneous cholecystostomy especially useful in patients with cholangitis following endoscopic manipulations. Percutaneous cholecystostomy in this select group of patients is a safer, easier alternative to transhepatic biliary drainage and extends the range of patients amenable to percutaneous intervention. The second article in this issue of Radiology dealing with percutaneous gallbladder intervention (by Cope et al [7]) takes percutaneous cholecystostomy one step further in an effort to more definitively treat patients with symptomatic gallbladder calculi. A number of investigators have explored ways of removing gallstones through a percutaneous tract with techniques of dissolution or fragmentation (ie, mechanical
Abbreviation: wave lithotripsy.
ESWL
extracorporeal
shock
fragmentation, electrohydraulic lithotripsy, or fragmentation with a laser) (8-10). Cope et al successfully performed percutaneous gallstone removal in 17 of 20 patients. Complications occurred in eight of 20 patients; one complication necessitated cholecystectomy. A careful review of the article by Cope et al reveals that the procedure is complex and technically demanding, with a steep learning curve. Percutaneous gallstone removal has several advantages over both cholecystectomy and other, nonsurgical treatments for symptomatic gallbladder calculi. Percutaneous removal of gallstones requires no general anesthesia. Therefore the procedure is a particularly promising alternative in elderly, debilitated patients with cardiac and/or pulmonary compromise who are at high risk for general anesthesia. No incision is needed, so recovery is much more rapid than in routine cholecystectomy. Unlike extracorporeal shock wave lithotripsy (ESWL) or dissolution therapy with methyl tert-butyl ether, the technique is not limited by the cornposition, size, or number of the gallstones. Also, the technique requires neither complex, expensive ESWL units nor potentially explosive, toxic solvents. Percutaneous removal of gallstones does, however, have the same drawbacks inherent in all nonsurgical techniques: It is tedious and time consuming, and at the conclusion of the procedure the gallbladder remains in place. The experience of Cope et al is similar to our own experience with percutaneous removal of gallstones. The procedure is extremely labor intensive, frequently requiring multiple sessions to render the patient stone free (7). Dissolution therapy is no faster. The average time necessary for gallstone dissolution with methyl tert-butyl ether, as reported by Thistle et al, was 12.5 hours (range, 3.8-30.8 hours), excluding the time required for initial catheter placement (10). Finally, biliary ESWL frequently requires multiple treatments, and stone clearance time is measured in months. More important, all current nonsurgical therapies leave the diseased gallbladder in place. It is well established that if the gallbladder is left in place, both gallstones, as well as the symptoms of biliary tract disease, will recur in 20%-50% of patients 2-5 years after treatment (11). Additionally, patients with chronically diseased gallbladders may be at higher risk for gallbladder carcinoma (12). In elderly, debilitated patients, gallstone recurrence and the development of gallbladder carcinoma are less important considerations. However, when younger patients are involved, the cost-benefit equation becomes more difficult to construct.
6
#{149} Radiology
Clearly, the ideal supplement to these nonsurgical procedures would be percutaneous gallbladder ablation (i3,i4). However, ablation has proved difficult because of the extensive regenerative capability of the gallbladder and cystic duct mucosa. Additionally, such an ablation technique must destroy all viable mucosa to prevent any risk of malignant transformation. The ultimate role of all nonsurgical approaches to gallbladder disease will need to be reevaluated in light of the newest “minimally invasive” technique: laparoscopic cholecystectomy. Although little has appeared in the science literature regarding this procedure, it is being actively evaluated at several centers (i5-i6). Laparoscopic cholecystectomy is an outgrowth of well-established techniques in gynecology. The procedure necessitates general anesthesia, and the patient is prepared for immediate laparotomy if the laparoscopic procedure is unsuccessful. After a pneumoperitoneurn is established, a 30-F (10-mm) sheath is placed through the umbilicus to allow insertion of the laparoscope. Two or three additional 15-F (5-mm) sheaths are placed subcostally in the right upper quadrant for the introduction of various instruments. The gallbladder, cystic duct, and cystic artery are dissected free under direct vision through the laparoscope. Clips are placed on the cystic duct and cystic artery, and the gallbladder is removed through the larger sheath in the urnbilicus. If necessary, intraoperative cholangiography can even be performed to evaluate the common bile duct. Few complications have been reported, and few patients have needed conversion to formal cholecystectomy. However, the procedure generally is being performed only in otherwise healthy patients. Most patients can be discharged the day after the procedure and are back to work in 5-7 days. Contraindications, while still evolving, indude previous upper abdominal surgery, bleeding diathesis, acute cholecystitis, severe general anesthesia risk, massive obesity, very large gallstones (>4 cm), and the known presence of common bile duct calculi. Bile duct calculi may be treated preoperatively with endoscopic techniques, if necessary. Advantages of laparoscopic cholecystectomy include a shorter hospital stay and reduced recovery time, because the largest incision is only 1 cm long. The cosmetic advantages appeal to most patients. Furthermore, the diseased organ is definitively removed. Disadvantages of the procedure are that it is not universally applicable, requires general anesthesia, and does not allow common bile duct exploration. However, the technique is still evolving, and some
predict that common bile duct exploration will be possible with flexible endoscopes. Percutaneous cholecystostomy for drainage of the acutely inflamed gallbladder, as well as for treatment of biliary tract obstruction in selected patients, is well established as a viable interventional radiologic technique. The future is less clear for percutaneous gallstone removal, dissolution therapy, and biliary ESWL. If laparoscopic cholecystectomy becomes widely available, percutaneous gallstone removal may be limited to the treatment of elderly, debilitated patients who are at high risk for general anesthesia. Additional mdications may include patients with extremely large stone burdens or those with previous upper abdominal surgery that caused extensive adhesions. The next 5-10 years will be an exciting time for interventional radiologists, as minimally invasive therapies such as those developed for the gallbladder are applied to a wide variety of pathologic processes. U References 1.
2.
3.
4.
5.
6.
7. 8.
9.
10.
1 1.
12.
13.
14.
15.
16.
Elyaderani M, Gabriele OF. Percutaneous cholecystostomy and cholangiography in patients with obstructive jaundice. Radiology 1979; 130:601-602. Shaver RW, Hawkins IF, Soong J. Percutaneous cholecystostomy. AJR 1982; 138:11331136. Vogelzang RL, Nemcek AA. Percutaneous cholecystostomy: diagnostic and therapeutic efficacy. Radiology 1988; 168:29-34. Teplick 5K. Diagnostic and therapeutic interventional gallbladder procedures. AJR 1989; 152:913-916. McGahan JP, Lindfors KK. Percutaneous cholecystostomy: an alternative to surgical cholecystostomy for acute cholecystitis? Radiology 1989; 173:481-485. van onnenberg E, D’Agostino HB, Casola G, Varney RR, Taggart SC, May S. Obstructive jaundice: percutaneous cholecystostomy for decompression in selected patients. Radiology 1990; 176:15-18. Cope C, Burke DR. Meranze SC. Percutaneous extraction of gallstones in 20 patients. Radiology 1990; 176:19-24. Picus D, Marx MV, Hicks ME, Lang EV, Edmundowicz SA. Percutaneous cholecystolithotomy: preliminary experience and technical considerations. Radiology 1989; 173:487-491. Hruby W, Stackl W, Urban M, Armbruster C, Marberger M. Percutaneous endoscopic cholecystolithotripsy: work in progress. Radiology 1989; 173:477-479. Thistle JL, May CR, Bender CE, et al. Dissolution of cholesterol gallbladder stones by methyl tert-butyl ether administered by percutaneous transhepatic catheter. N EngI Med 1989; 320:633-639. Gibney RG, Chow, K, So CB, Rowley VA, Coopernerg PL, Burhenne HJ. Gallstone recurrence after cholecystolithotomy. AJR 1989; 153:287-289. So CB, Gibney MB, Scudamore CH. Carcinoma of the gallbladder: a risk associated with gallbladder-preserving treatments for cholelithiasis. Radiology 1990; 174:127-130. Salomonowitz E, Frick MP, Simmons RL, et al. Obliteration of the gallbladder without formal cholecystectomy: a feasibility study. Arch Surg 1984; 119:725-729. Becker CD, Quenville NF, Burhenne HJ. Gallbladder ablation through radiologic intervention: an experimental alternative to cholecystectomy. Radiology 1989; 171:235-240. Reddick EJ, Olsen DO. Laparoscopic laser cholecystectomy: a comparison with mini-lap cholecystectomy. Surg Endosc 1989; 3:131-133. Dubois F, Icard P. Berthelot C, Levard H. Coelioscopic cholecystectomy: preliminary report of 36 cases. Ann Surg 1990; 211:60-62.
July
1990
Picus,
MD
Percutaneous
T
Gallbladder
first reports of percutaneous gallbladder intervention appeared in the radiology literature in the early 1980s (1,2). Widespread adoption of these techniques, however, was slowed by initial concerns with regard to bile peritonitis and life-threatening vagal reactions. Over the last 5 years, a large number of investigators have shown that these procedures are both safe and effective. As a result, percutaneous gallbladder interventions have become an active part of the practice of many interventional radiologists. Two articles in this issue of Radiology emphasize the role of the interventional radiologist in the treatment of gallbladder disease. These articles also illustrate that indications for percutaneous gallbladder intervention are still evolving. Currently, the most common indication for percutaneous gallbladder intervention is decompression of the acutely inflamed and obstructed gallbladder. In high-risk patients, such as the elderly and those with underlying cardiac disease, pulmonary disease, or both, percutaneous cholecystostomy can provide a significant temporizing benefit: that of often allowing delayed, elective cholecystectomy under more optimal circumstances (3-5). Percutaneous cholecystostomy is particularly beneficial in patients with acalculous cholecystitis in whom temporary drainage may allow resolution of cystic duct obstruction and eventual removal of the cholecystostomy tube without the need for cholecystectomy. HE
Index
terms:
ducts,
interventional
ducts,
stenosis
Bile
calculi,
procedure,
1
From
tional
1990;
the
Bile
#{149}
#{149} Editori-
#{149} Gallbladder, #{149} Interven-
1228
#{149} Jaundice
176:5-6
Section
Radiology,
diology,
762.289 762.
768.1228
#{149} Bile
764.289
procedures,
Radiology
76.289 76.1229
or obstruction,
interventional
tional
calculi,
procedure,
#{149} Gallbladder,
als
ducts,
of Vascular Mallinckrodt
Washington
and
Interven-
Institute
University
School
of Raof
Medicine, 510 S Kingshighway Blvd. St Louis, MO 631 10. Received April 9, 1990; accepted April 12. Address reprint requests to the author. RSNA, 1990 See
also
vanSonnenberg
the
articles (pp
by 15-18)
Cope in
(pp this
19-24) issue.
and
.
Intervention’
Percutaneous cholecystostomy also has been used to decompress the biliary tract in patients with obstruction of the distal common bile duct (2,3). Although transhepatic or endoscopic biliary drainage is usually a better alternative for patients with distal obstruction of the common bile duct, percutaneous cholecystostomy may be preferable in selected cases. In this issue of Radiology, vanSonnenberg et a! (6) further define the role of percutaneous cholecystostomy in such selected patients. They successfully established external drainage in i 1 carefully selected patients with obstructive jaundice. The primary indication for intervention in their Series was common bile duct obstruction associated with nondilated intrahepatic ducts. Their only complication occurred in one patient in whom the cholecystostomy catheter became dislodged and could not be replaced. Percutaneous cholecystostomy provided temporary decompression before definitive therapy in six of 1 1 patients and short-term palliation for obstruction secondary to pancreatitis in three of 11 patients. In only one of 1 1 patients was the procedure considered long-term palliative drainage. The main advantage of percutaneous cholecystostomy in patients with obstructive jaundice is the ease with which it can be performed. As anyone who has performed transhepatic biliary drainage knows, placing a needle into a large, distended gallbladder is much easier and quicker than placing a needie into a tiny, nondiiated intrahepatic duct. Although transhepatic biliary drainage is technically more difficult, the procedure usually is the first step in the overall treatment for an individual patient. Transhepatic access to the bile ducts allows stone removal, stricture dilation, and stent placement. For percutaneous cholecystostomy to be more widely applied in patients with obstructive jaundice, access to the common bile duct must be secured in a safe and easy fashion. VanSonnenberg et al successfully cannulated the cystic duct in only two of the five patients in whom the procedure was attempted. Although others have been somewhat more successful, cannulation of the cystic duct can be technically difficult. The ability to pass a guide wire through the cystic duct is often limited by the spiral
valves. We have found a Terumo guide wire (Medi-tech/Boston Scientific, Watertown, Mass) most helpful. After a guide wire has been passed through the cystic duct, subsequent placement of a catheter may also be difficult. Finally, manipulating guide wires and large catheters through the cystic duct is often painful for the patient. Future technical improvements in guide-wire and catheter design may improve our ability to cannulate the cystic duct. There is an additional drawback to the use of percutaneous cholecystostomy for definitive drainage in patients with malignant distal obstruction of the common bile duct. Frequently, both pancreatic carcinomas and cholangiocarcinomas eventually grow to obstruct the cystic duct origin. Such obstruction depends on the location of the cystic duct insertion into the common bile duct. Because of this potential pitfall, surgeons rarely perform a cholecystojejunostomy for palliative decompression, preferring a choledochojejunostomy instead. Despite these limitations, percutaneous cholecystostomy is useful for decompressing bile duct obstructions in highly selected patients. The procedure is most helpful for providing temporary decompression prior to more definitive therapy in acutely ill patients with cholangitis and distal obstruction of the common bile duct. We have found percutaneous cholecystostomy especially useful in patients with cholangitis following endoscopic manipulations. Percutaneous cholecystostomy in this select group of patients is a safer, easier alternative to transhepatic biliary drainage and extends the range of patients amenable to percutaneous intervention. The second article in this issue of Radiology dealing with percutaneous gallbladder intervention (by Cope et al [7]) takes percutaneous cholecystostomy one step further in an effort to more definitively treat patients with symptomatic gallbladder calculi. A number of investigators have explored ways of removing gallstones through a percutaneous tract with techniques of dissolution or fragmentation (ie, mechanical
Abbreviation: wave lithotripsy.
ESWL
extracorporeal
shock
fragmentation, electrohydraulic lithotripsy, or fragmentation with a laser) (8-10). Cope et al successfully performed percutaneous gallstone removal in 17 of 20 patients. Complications occurred in eight of 20 patients; one complication necessitated cholecystectomy. A careful review of the article by Cope et al reveals that the procedure is complex and technically demanding, with a steep learning curve. Percutaneous gallstone removal has several advantages over both cholecystectomy and other, nonsurgical treatments for symptomatic gallbladder calculi. Percutaneous removal of gallstones requires no general anesthesia. Therefore the procedure is a particularly promising alternative in elderly, debilitated patients with cardiac and/or pulmonary compromise who are at high risk for general anesthesia. No incision is needed, so recovery is much more rapid than in routine cholecystectomy. Unlike extracorporeal shock wave lithotripsy (ESWL) or dissolution therapy with methyl tert-butyl ether, the technique is not limited by the cornposition, size, or number of the gallstones. Also, the technique requires neither complex, expensive ESWL units nor potentially explosive, toxic solvents. Percutaneous removal of gallstones does, however, have the same drawbacks inherent in all nonsurgical techniques: It is tedious and time consuming, and at the conclusion of the procedure the gallbladder remains in place. The experience of Cope et al is similar to our own experience with percutaneous removal of gallstones. The procedure is extremely labor intensive, frequently requiring multiple sessions to render the patient stone free (7). Dissolution therapy is no faster. The average time necessary for gallstone dissolution with methyl tert-butyl ether, as reported by Thistle et al, was 12.5 hours (range, 3.8-30.8 hours), excluding the time required for initial catheter placement (10). Finally, biliary ESWL frequently requires multiple treatments, and stone clearance time is measured in months. More important, all current nonsurgical therapies leave the diseased gallbladder in place. It is well established that if the gallbladder is left in place, both gallstones, as well as the symptoms of biliary tract disease, will recur in 20%-50% of patients 2-5 years after treatment (11). Additionally, patients with chronically diseased gallbladders may be at higher risk for gallbladder carcinoma (12). In elderly, debilitated patients, gallstone recurrence and the development of gallbladder carcinoma are less important considerations. However, when younger patients are involved, the cost-benefit equation becomes more difficult to construct.
6
#{149} Radiology
Clearly, the ideal supplement to these nonsurgical procedures would be percutaneous gallbladder ablation (i3,i4). However, ablation has proved difficult because of the extensive regenerative capability of the gallbladder and cystic duct mucosa. Additionally, such an ablation technique must destroy all viable mucosa to prevent any risk of malignant transformation. The ultimate role of all nonsurgical approaches to gallbladder disease will need to be reevaluated in light of the newest “minimally invasive” technique: laparoscopic cholecystectomy. Although little has appeared in the science literature regarding this procedure, it is being actively evaluated at several centers (i5-i6). Laparoscopic cholecystectomy is an outgrowth of well-established techniques in gynecology. The procedure necessitates general anesthesia, and the patient is prepared for immediate laparotomy if the laparoscopic procedure is unsuccessful. After a pneumoperitoneurn is established, a 30-F (10-mm) sheath is placed through the umbilicus to allow insertion of the laparoscope. Two or three additional 15-F (5-mm) sheaths are placed subcostally in the right upper quadrant for the introduction of various instruments. The gallbladder, cystic duct, and cystic artery are dissected free under direct vision through the laparoscope. Clips are placed on the cystic duct and cystic artery, and the gallbladder is removed through the larger sheath in the urnbilicus. If necessary, intraoperative cholangiography can even be performed to evaluate the common bile duct. Few complications have been reported, and few patients have needed conversion to formal cholecystectomy. However, the procedure generally is being performed only in otherwise healthy patients. Most patients can be discharged the day after the procedure and are back to work in 5-7 days. Contraindications, while still evolving, indude previous upper abdominal surgery, bleeding diathesis, acute cholecystitis, severe general anesthesia risk, massive obesity, very large gallstones (>4 cm), and the known presence of common bile duct calculi. Bile duct calculi may be treated preoperatively with endoscopic techniques, if necessary. Advantages of laparoscopic cholecystectomy include a shorter hospital stay and reduced recovery time, because the largest incision is only 1 cm long. The cosmetic advantages appeal to most patients. Furthermore, the diseased organ is definitively removed. Disadvantages of the procedure are that it is not universally applicable, requires general anesthesia, and does not allow common bile duct exploration. However, the technique is still evolving, and some
predict that common bile duct exploration will be possible with flexible endoscopes. Percutaneous cholecystostomy for drainage of the acutely inflamed gallbladder, as well as for treatment of biliary tract obstruction in selected patients, is well established as a viable interventional radiologic technique. The future is less clear for percutaneous gallstone removal, dissolution therapy, and biliary ESWL. If laparoscopic cholecystectomy becomes widely available, percutaneous gallstone removal may be limited to the treatment of elderly, debilitated patients who are at high risk for general anesthesia. Additional mdications may include patients with extremely large stone burdens or those with previous upper abdominal surgery that caused extensive adhesions. The next 5-10 years will be an exciting time for interventional radiologists, as minimally invasive therapies such as those developed for the gallbladder are applied to a wide variety of pathologic processes. U References 1.
2.
3.
4.
5.
6.
7. 8.
9.
10.
1 1.
12.
13.
14.
15.
16.
Elyaderani M, Gabriele OF. Percutaneous cholecystostomy and cholangiography in patients with obstructive jaundice. Radiology 1979; 130:601-602. Shaver RW, Hawkins IF, Soong J. Percutaneous cholecystostomy. AJR 1982; 138:11331136. Vogelzang RL, Nemcek AA. Percutaneous cholecystostomy: diagnostic and therapeutic efficacy. Radiology 1988; 168:29-34. Teplick 5K. Diagnostic and therapeutic interventional gallbladder procedures. AJR 1989; 152:913-916. McGahan JP, Lindfors KK. Percutaneous cholecystostomy: an alternative to surgical cholecystostomy for acute cholecystitis? Radiology 1989; 173:481-485. van onnenberg E, D’Agostino HB, Casola G, Varney RR, Taggart SC, May S. Obstructive jaundice: percutaneous cholecystostomy for decompression in selected patients. Radiology 1990; 176:15-18. Cope C, Burke DR. Meranze SC. Percutaneous extraction of gallstones in 20 patients. Radiology 1990; 176:19-24. Picus D, Marx MV, Hicks ME, Lang EV, Edmundowicz SA. Percutaneous cholecystolithotomy: preliminary experience and technical considerations. Radiology 1989; 173:487-491. Hruby W, Stackl W, Urban M, Armbruster C, Marberger M. Percutaneous endoscopic cholecystolithotripsy: work in progress. Radiology 1989; 173:477-479. Thistle JL, May CR, Bender CE, et al. Dissolution of cholesterol gallbladder stones by methyl tert-butyl ether administered by percutaneous transhepatic catheter. N EngI Med 1989; 320:633-639. Gibney RG, Chow, K, So CB, Rowley VA, Coopernerg PL, Burhenne HJ. Gallstone recurrence after cholecystolithotomy. AJR 1989; 153:287-289. So CB, Gibney MB, Scudamore CH. Carcinoma of the gallbladder: a risk associated with gallbladder-preserving treatments for cholelithiasis. Radiology 1990; 174:127-130. Salomonowitz E, Frick MP, Simmons RL, et al. Obliteration of the gallbladder without formal cholecystectomy: a feasibility study. Arch Surg 1984; 119:725-729. Becker CD, Quenville NF, Burhenne HJ. Gallbladder ablation through radiologic intervention: an experimental alternative to cholecystectomy. Radiology 1989; 171:235-240. Reddick EJ, Olsen DO. Laparoscopic laser cholecystectomy: a comparison with mini-lap cholecystectomy. Surg Endosc 1989; 3:131-133. Dubois F, Icard P. Berthelot C, Levard H. Coelioscopic cholecystectomy: preliminary report of 36 cases. Ann Surg 1990; 211:60-62.
July
1990
