Treatment of Leaks Following Sleeve Gastrectomy by Endoscopic Internal Drainage (EID).

BACKGROUND: Leaks are considered one of the major complications of laparoscopic sleeve gastrectomy (LSG) with a reported rate up to 7 %. Drainage of the collection coupled with SEMS deployment is the most frequent treatment. Its success is variable and burdened by high morbidity and not irrelevant mortality. The aim of this paper is to suggest and establish a new approach by endoscopic internal drainage (EID) for the management of leaks. METHODS: Since March 2013, 67 patients presenting leak following LSG were treated with deployment of double pigtail plastic stents across orifice leak, positioning one end inside the collection and the other end in remnant stomach. The aim of EID is to internally drain the collection and at the same time promote leak healing. RESULTS: Double pigtails stent were successfully delivered in 66 out of 67 patients (98.5 %). Fifty patients were cured by EID after a mean time of 57.5 days and an average of 3.14 endoscopic sessions. Two died for event not related to EID. Nine are still under treatment; five failure had been registered. Six patients developed late stenosis treated endoscopically. CONCLUSIONS: EID proved to be a valid, curative, and safe mini-invasive approach for treatment of leaks following SG. EID achieves complete drainage of perigastric collections and stimulates mucosal growth over the stent. EID is well tolerated, allows early re-alimentation, and it is burdened by fewer complications than others technique. Long-term follow-up confirms good outcomes with no motility or feeding alterations.

Nonsurgical treatment of staple line leaks after laparoscopic sleeve gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is gaining popularity as a "per se" bariatric procedure due to its effectiveness on weight loss and comorbidity resolution. The most feared and life-threatening complication after LSG is the staple line leak and its management is still a debated issue. Aim of this paper is to analyze the incidence of leak and the treatment solutions adopted in a consecutive series of 200 LSG. METHODS: From October 2002 to November 2008, 200 patients underwent LSG. Nineteen patients (9.5%) had a body mass index (BMI) of >60 kg/m(2). A 48-Fr bougie is used to obtain an 80-120-ml gastric pouch. An oversewing running suture to reinforce the staple line was performed in the last 100 cases. The technique adopted to reinforce the staple line is a running suture taken through and through the complete stomach wall. RESULTS: Staple line leaks occurred in six patients (mean BMI 52.5; mean age 41.6 years). Leak presentation was early in three cases (first, second, and third postoperative (PO) day), late in the remaining three cases (11th, 22nd, and 30th PO day). The most common leak location was at the esophagogastric junction (five cases). Mortality was nihil. Nonoperative management (total parenteral nutrition, proton pump inhibitor, and antibiotics) was adopted in all cases. Percutaneous abdominal drainage was placed in five patients. In one case, a small fistula was successfully treated by endoscopic injection of fibrin glue only. Self-expandable covered stent was used in three cases. Complete healing of leaks was obtained in all patients (mean healing time 71 days). CONCLUSION: Nonoperative treatment (percutaneous drainage, endoscopy, stent) is feasible, safe, and effective for staple line leaks in patients undergoing LSG; furthermore, it may avoid more mutilating procedures such as total gastrectomy.

ERCP in total situs viscerum inversus.

A 69-year-old cholecystectomized female with known total situs viscerum inversus presented recurrent colicky pain in the left upper abdominal quadrant and jaundice. Laboratory parameters showed increased neutrophils and coniugated bilirubin of 5.53 mg/dl. US and MRCP confirmed total situs viscerum inversus and a dilatation of the intra- and extrahepatic ducts with a peripapillary 13 mm stone. ERCP, sphincterotomy and successful common bile duct stone extraction were performed in the conventional way. ERCP was carried out successfully despite situs inversus maintaining the patient in the prone position with the endoscopist on the right side of the table. Some authors have reported similar cases in whom ERCP was performed in other positions, while this report shows that an experienced endoscopist can achieve the same results in the conventional way as it is possible when anatomical changes, Billroth II or Roux-en-Y, or different positions of the patient, supine or on the left side, are present.

Anaesthetic management in a case of Huntington's chorea.

There are only a few case reports regarding the anaesthetic management of a patient with Huntington's chorea and the best anaesthetic technique is yet to be established for those patients which are at higher risk of perioperative complications. We describe the successful management of a 30-year-old patient suffering from Huntington's chorea admitted for urgent appendectomy. To minimize the risk of aspiration, the trachea was intubated using a fiberscope with the patient sedated and spontaneously breathing. Anaesthesia was maintained with isoflurane and fentanyl and the recovery was rapid and uneventful as the postoperative course.

Palliative treatment for malignant jaundice: endoscopic vs surgical approach.

In this retrospective, comparative study a total of 107 patients, presenting with malignant inoperable strictures of common bile duct, due to a pancreatico-biliary malignancy, underwent palliative treatments. In a group, consisting of 82 patients (76.64%), endoscopic stenting procedures were performed; polyethylene stents or self-expanding metal stents were applied in 37 and 45 patients, respectively. The prerequisites for a successful endoscopic stenting were a) accuracy of diagnosis and b) exclusion of patients presenting with tumors potentially treatable by a curative resection. In the other group, consisting of 25 patients (23.36%), biliary-enteric bypass procedures were performed. Endoscopic treatment was successful in 97.5% of the cases (80/82); complication rate was 7.3% (6 patients on 82), and mortality rate was 3.6% (3 patients on 82). Median hospital stay was 13.4 and 7.3 days in patients treated with plastic stents and metallic stents, respectively. Bypass surgery was successful in 99% of the cases (24/25); complication rate was 24% (6 patients on 25), and mortality rate was 16% (4 patients on 25). Median hospital stay was 26 days. For the patients in whom a curative resection could not be performed, both the above mentioned methods resulted in a high rate of immediate technical and therapeutic success. However, the surgical approach showed a significantly higher rate in procedure-related mortality and morbidity; in addition, the hospital stay lasted longer in surgically treated patients. The patients who are definitely unsuitable for curative resection are better managed by positioning a stent. The use of metal stents should be preferred in those less serious patients who may supposedly survive longer.

Outcome of endoscopic sphincterotomy in post cholecystectomy patients with sphincter of Oddi dysfunction as predicted by manometry and quantitative choledochoscintigraphy.

BACKGROUND: Sphincter of Oddi dysfunction is diagnosed at manometry and, after cholecystectomy, non-invasively at quantitative choledochoscintigraphy. Patients may benefit from endoscopic sphincterotomy. AIMS: The aim of this study was to assess the usefulness of choledochoscintigraphy compared with manometry in predicting outcome of sphincterotomy in post cholecystectomy patients with sphincter of Oddi dysfunction. PATIENTS AND METHODS: Thirty patients with biliary-type pain complying with the Rome diagnostic criteria of sphincter of Oddi dysfunction and belonging to biliary group I and II were subjected to clinical evaluation, choledochoscintigraphic assessment of the hepatic hilum-duodenum transit time, endoscopic retrograde cholangiopancreatography, and perendoscopic manometry. Twenty two biliary group I and II patients with prolonged hepatic hilum-duodenum transit times were invited to undergo sphincterotomy. Fourteen patients underwent sphincterotomy; eight refused. Clinical and scintigraphic assessments were performed at follow up. RESULTS: Hepatic hilum-duodenum transit time was delayed in all patients with manometric evidence of sphincter of Oddi dysfunction, in all biliary group I patients and in 64% of biliary group II patients. At follow up, all patients who underwent sphincterotomy were symptom free and hepatic hilum-duodenum transit time had either normalised or significantly improved. A favourable post sphincterotomy outcome was predicted in 93% of cases at choledochoscintigraphy and in 57% at manometry. CONCLUSIONS: Quantitative choledochoscintigraphy is a useful and non-invasive test to diagnose sphincter of Oddi dysfunction as well as a reliable predictor of sphincterotomy outcome in post cholecystectomy biliary group I and II patients, irrespective of clinical classification and manometric findings.

ERCP and acute pancreatitis.

Acute biliary pancreatitis (ABP) is a serious complication of biliary stones disease and is associated with significant morbidity and mortality. The role of ERCP in the management of ABP has been the focus of discussion in recent years. In this report, we evaluated a protocol of emergency Endoscopic retrograde Cholangiopancreatography (ERCP) (within 24 hours) and early ERCP (within 72 hours). From July 1997 to July 2000, were observed 45 patients (19 man and 26 women) with acute biliary pancreatitis. Mean age of patients was 63.4 years (range 21-87 years). Diagnosis of ABP was based on anamnesis and clinical assessment and was confirmed by specific laboratory data (hyperamylasemia, hyperlipasemia, total and fractionated bilirubinemia, gamma-GT, transaminase, alkaline phosphatase, hypocalcemia, hyperglycemia, leukocytosis). Ultrasound scanning within 24 h of admission was performed in 45 patients (100%) and it revealed gallbladder stones and muddy bile in 39 patients (87%). Computed tomography (CT) performed in all patients, showed a severe acute pancreatitis in the second or subsequent week following admission. The severity of acute pancreatitis was established by Glasgow's criteria and by clinical details of patients. ERCP and Endoscopic Sphinterotomy (ES) was performed in all 45 patients with acute biliary pancreatitis. Twenty-six patients (57%) were classified as having a severe attack (> 4) 19 as having a mild attack by Glasgow's criteria. ERCP associated with ES was performed within 24 hours in 22 patients (49%), 11 (50%) showed a severe attack and 11 (50%) showed a mild attack. A total of 2 complications (4%) occurred and the mortality was of 2 patients (4%). In 23 patients (51%) ERCP and ES was performed within 72 hours after conservative therapy, 8 (35%) showed a mild attack and 15 (65%) showed a severe attack. A total of 5 complications (9%) occurred and the mortality was of 3 patients (6%). Our study showed that ERCP with endoscopic sphincterotomy can be performed safely by skilled endoscopist, without adverse consequences soon after the onset of acute biliary pancreatitis even within the first 24 hours and it showed that is better than ERCP within 72 hours after conservative therapy.

Increased sphincter of Oddi basal pressure in patients affected by gall stone disease: a role for biliary stasis and colicky pain?

BACKGROUND AND AIMS: Even if the motor activity of the gall bladder and sphincter of Oddi (SO) are integrated, it is not known if the presence of stones in the gall bladder affects SO function. The aim of the study was to compare SO motor activity in patients with and without gall stones. PATIENTS AND METHODS: In a series of 155 patients consecutively submitted to endoscopic retrograde cholangiopancreatography and SO manometry for suspected biliary or pancreatic disease, 23 gall stone patients had recurrent episodes of biliary or pancreatic pain (colicky group); 52 patients had non-biliary/pancreatic-type abdominal pain/discomfort, and of these, 15 had gall stones (non-colicky group), 25 were free of stones (controls), and 12 had undergone cholecystectomy. RESULTS: SO basal pressure in gall stone patients in the colicky or non-colicky group was significantly higher than in controls (p<0.001). SO basal pressure recorded in postcholecystectomy patients did not differ from controls. SO phasic activity did not differ between the patient groups. SO dysfunction was detected in more than 40% of gall stone patients irrespective of associated biliary/pancreatic pain but in none of the control subjects (p<0.001). CONCLUSIONS: Gall stones are frequently associated with increased SO tone which may obstruct bile flow thus acting to facilitate gall bladder stasis, and may play a role as a cofactor in biliary/pancreatic pain.

Conservative approach in the treatment of the biliary tract's iatrogenic lesions.

Iatrogenic lesions of the biliary tract have always represented a problem of real actuality in the abdominal surgery. The incidence of post-cholecystectomy complications is from 0.1% to 0.25% and it's increased to 0.3-0.6% for laparoscopic surgery. Potential predisposing factors to iatrogenic biliary lesions are anatomic anomalies, acute and chronic phlogosis and technical mistakes. Anatomic anomalies are present in 6-25% of all cases according to different statistics; an incomplete knowledge of the biliary tract can predispose to a mistake legating or dissecting a wrong branch. This paper present a caseload of 27 patients admitted to our Service of Digestive Endoscopy owing to post laparoscopic cholecystectomy complications. Patients have been recruited in a period from two days to six months to the intervention. Detected complicances have been divided in "major", which comprehended biliary lesions (7 cases) and biliary stenosis (8 cases), and in "minor" which included biliary leakages (12 cases). CPRE, PTC, Ultrasound, CT and cholangio-MR were used to diagnose the biliary damage. Conservative approach has been resolutive in all patients with minor biliary lesions and in three cases of major lesions; in seven cases of biliary stenosis endoscopic-radiologic combined treatment has been successfully performed, in the other patients surgical operation was obliged choice. Comparing our results with literature we can affirm that conservative treatment represents the first choice in case of minor lesions (100% of successes), whereas in case of major biliary lesions it constitutes a valid alternative to the reparative surgery; when surgical option results impossible to defer, it can help the surgeon identifying the damage and draining the biliary tract.

Laparoscopic cholecystectomy and intraoperative endoscopic sphincterotomy in the treatment of cholecysto-choledocholithiasis.

BACKGROUND: A single-stage minimally invasive procedure would be optimal for management of cholecysto-choledocholithiasis. Two alternative strategies are available: management by laparoscopy alone or a combined laparoscopic-endoscopic approach. This study evaluates the results of the latter procedure. METHODS: From June 1993 to September 1997, 1400 patients with symptomatic biliary stone disease were evaluated for laparoscopic cholecystectomy. Intraoperative cholangiography was performed on the basis of a preoperative suspicion of bile duct stones; bile duct stone treatment was by intraoperative endoscopic retrograde sphincterotomy. RESULTS: Intraoperative cholangiography was performed because of a preoperative suspicion of a bile duct abnormality in 141 of 1400 patients (10%) undergoing laparoscopic cholecystectomy because of biliary stone disease. Of those 141 patients, 54 (38.3%) presented with pathologic findings (bile duct stone [52] and papillary stenosis [2]); all 54 underwent intraoperative endoscopic sphincterotomy. Complete clearance of the ductal stones was achieved in 43 patients (82.7%) by intraoperative sphincterotomy, and in 9 patients by an additional postoperative endoscopic procedure. Laparoscopic cholecystectomy was carried out in all cases. There were no conversions to an open operation. Postoperative course in the uncomplicated cases was comparable to that for laparoscopic cholecystectomy alone. The postoperative complication rate was 5.6% and mortality 1.8%. Mean hospital stay was 3.3 days (range 2 to 16). At a mean 38 months follow-up, no complications related to the laparoscopic-endoscopic procedure were observed. CONCLUSION: The intraoperative combined laparoscopic-endoscopic approach seems to be a feasible and effective management of cholecysto-choledocholithiasis, saving patients a subsequent invasive procedure.

Improvement of intestinal metaplasia six month after misoprostol treatment.

PURPOSE: To establish whether misoprostol (a synthetic prostanoid) is effective in improving intestinal metaplasia of dyspeptic patients. PATIENTS: Of the 206 dyspeptic patients without Helicobacter pylori, 18 (7.1%) had histological evidence of intestinal metaplasia (2 presented mild metaplasia, 9 moderate and 7 severe). They were treated with misoprostol 200 mg twice daily for six months and, after stopping the treatment, they all underwent endoscopic control. RESULTS: There was a statistical significant improvement of intestinal metaplasia (p < 0.001) and of the activity of antral gastritis (p = 0.03). There were no significant changes in antral and body specimens during follow-up. DISCUSSION: Though the small number of the patients and the lack of control group, our results suggest that misoprostol allows regression and/or improvement of histological IM (p < 0.001). It has proved to be effective in prevention of both gastric and duodenal ulcers induced by NSAID therapy, probably related largely to replacement of endogenous prostaglandins inhibited by the use of NSAID and it may also exerts its protective effects through inhibition of gastric acid secretion. Moreover, misoprostol showed to increase the rate of gastric blood flow, inducing a mucosal protective effect against the factors damaging gastric mucosa. It has been also documented that misoprostol regulates inflammatory cytokines and prolonged the survival of transplants, reflecting both its immunosuppressive and anti-inflammatory effect. In conclusion, since intestinal metaplasia increases the risk of gastric cancer, the use of misoprostol, in this pathology, would be of some interest.

MR cholangiography (MRC) in the evaluation of CBD stones before laparoscopic cholecystectomy.

BACKGROUND: The aim of our work was to evaluate the predictive value of MR cholangiography (MRC) in detecting CBD stones before laparoscopic surgical treatment. METHODS: MRC was performed as a unique preoperative imaging modality in 45 selected patients (16 male; 29 female; age range: 28-72; mean age: 54.4) before laparoscopic cholecystectomy. MRC imaging was obtained with a 3D Turbo Spin-Echo sequence (TR = 3000 ms, TE = 700 ms, Echo Train Length--128) with an acquisition time of 5 min 48 s. Diagnostic confirmation was obtained in all the cases at i.o. cholangiography. When a stone was detected it was removed by transcystic or transcholedochal approach. RESULTS: Eighteen of the 45 patients (40%) had CBD stones. MRC correctly evaluated 16 out of 18 stones, with a resulting sensitivity of 88.9%, specificity 100%, positive predictive value 100%, negative predictive value 90%, and accuracy 95.6%. CONCLUSIONS: Despite the good results of MRC, it cannot be proposed as a screening technique to be performed in all patients submitted to laparoscopic cholecystectomy due to high cost and the limited amount of MR equipment. In conclusion, only selected patients should be submitted to MRC before laparoscopic cholecystectomy.

Magnetic resonance-cholangiopancreatography in the diagnosis of biliopancreatic diseases.

BACKGROUND: Magnetic resonance cholangiopancreatography (MRCP) is a new, noninvasive imaging technique for the visualization of the biliary ducts with cholangiographic images similar to those obtained with endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography. No contrast medium injection is used. The aim of this study was to assess the feasibility of MRCP versus ERCP in the diagnosis of biliary tract and pancreatic diseases. PATIENTS AND METHODS: One hundred and thirty-six patients were submitted to MRCP. They were referred to MR study according to four inclusion criteria: (1) evidence or suspicion of choledocholithiasis, (2) benign or malignant bile ducts stenosis, (3) follow-up of patients submitted to biliary-enteric anastomosis, and (4) chronic pancreatitis with Wirsung duct dilatation. The MRCP was performed with a 0.5T superconducting magnet (Philips Gyroscan T5). When neoplastic disease was detected, additional images on axial planes were acquired. MRCP allowed images of diagnostic value to be obtained in all the cases. RESULTS: In choledocholithiasis, MRCP showed 91.6% sensitivity, 100% specificity, and overall diagnostic accuracy 96.8%. Of 48 patients with stenotic lesions, 16 were correctly characterized as benign and 30 as malignant. Two cases of focal chronic pancreatitis were misdiagnosed as pancreatic head carcinoma. In the patients submitted to biliary-enteric anastomosis, MCRP was able to detect the dilatation of the intrahepatic ducts, the stenosis, and associated stones in all 8 positive cases. In the remaining 7 patients with mild signs of cholangitis, MCRP showed irregular aspects of the biliary tree in the main ducts. In the 11 patients with chronic pancreatitis, MCRP was able to depict the dilated Wirsung duct and the stenotic tract, although the fine details of the secondary ducts were not evaluated due to the low spatial resolution as compared with conventional films. CONCLUSIONS: MRCP can be considered a technique able to completely replace diagnostic ERCP. Further studies are necessary for a better evaluation of the potential advantages and disadvantages of this technique.

ESWL experience in the therapy of difficult bile duct stones.

In recent years, alternatives to surgery for difficult bile duct stones have been developed. Routine endoscopy fails in about 10% of patients. To verify the role of extracorporeal shock wave lithotripsy in residual CBD stones, we treated 32 patients by HM4 or MPL 9000 Dornier lithotripters. Ten (34.4%) patients needed two extracorporeal shock wave lithotripsy sessions, and 3 (10.3%) patients three. Complete clearance was achieved in 29 patients (90.6%) after one or more sessions either by endoscopic (20 pts) or percutaneous (9 pts) extraction of the debris; of the remaining 3 patients, in 2 a bilioduodenal stent was placed and in 1 electrohydraulic lithotripsy was performed. Eighteen and seven-tenths percent transient mild hemobilia, 12.5% microhematuria, and no mortality were observed. It is possible to state that in site- or size-related difficult biliary stones, extracorporeal shock wave lithotripsy is a rapid, safe, and highly effective treatment as an additional nonoperative option to resolve the failure of routine endoscopic measures.

Sequential endoscopic-laparoscopic treatment of cholecystocholedocholithiasis.

Preoperative common bile duct (CBD) clearance with endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) is routinely performed in many centers where laparoscopic cholecystectomy (LC) is the procedure of choice for the treatment of cholelithiasis. The purpose of this study was to evaluate prospectively the results of the sequential endoscopic-laparoscopic management in patients with gallstones and suspected CBD stones. From November 1990 to May 1993, 700 consecutive patients were evaluated for LC. Preoperative workup included clinical history and physical examination; serum levels of bilirubin, alkaline phosphatase, and amylase; and ultrasonography. Preoperative ERCP was indicated in cases with previous or present jaundice or acute pancreatitis, altered liver or pancreatic blood tests, dilated CBD (> 6 mm) and CBD stones at ultrasonography. If CDB pathology was confirmed, ES was performed and treatment attempted. All patients were assigned to undergo LC within 48 h. Morbidity, mortality, hospital stay, and disability were recorded. Of 700 patients, 49 (7%) underwent ERCP. In 26 patients (54.2%), CBD stones were identified; ES was performed and stone extraction succeeded in 22 patients (84.6%). Two patients with intrahepatic stones were successfully treated with a percutaneous transhepatic approach and then underwent surgery. Two patients with cholecystocholedochal fistula underwent open surgery. In two cases ERCP showed a papillary stenosis, which was treated with ES. Of 44 patients, 35 (79.5%) underwent LC within 48 h. The overall morbidity (ERCP/ES plus LC) was 10.4%. No mortality occurred. The mean hospital stay was 4.5 days. Return to normal activities occurred within 11 days after LC. This sequential approach resulted in a safe and effective treatment of cholecystocholedocholithiasis and a decrease in the overall costs.

Non-invasive evaluation of the biliary tree with magnetic resonance cholangiopancreatography: initial clinical experience.

Magnetic resonance cholangiopancreatography is a new, non-invasive imaging technique for visualization of the biliary ducts. Magnetic resonance cholangiopancreatography was performed on 136 patients (20-87 years old) with a superconductive magnet at 0.5T (Philips Gyroscan T5). Volumetric images on coronal planes were acquired; a T2 weighted turbo spin echo sequence (TR = 3000; TE = 700; number of excitations = 8; echo train length = 128; Acquisition time = 5'48") with respiratory compensation was performed. Images were reconstructed on coronal planes rotated at different angles using the MIP algorithm. When neoplastic disease was detected additional images on axial planes (SE Tlw: TR/TE 300/10 and turbo spin echo T2w: TR/TE 3000/120) were acquired. Magnetic resonance cholangiopancreatography allowed images of diagnostic value to be obtained in all cases. In choledocholithiasis, the technique had a sensitivity of 91.6%, specificity of 100% and overall diagnostic accuracy of 96.8%. Of the 48 patients with stenotic lesions, 16 cases were correctly characterized as benign and 30 as malignant. Two cases of focal chronic pancreatitis were misdiagnosed as pancreatic head carcinoma. In patients submitted to bilioenteric anastomosis, the technique was able to detect dilation of intrahepatic ducts, stenosis and associated stones in the 8 positive cases. In all 11 patients with chronic pancreatitis, dilated Wirsung duct and the stenotic tracts were revealed. In conclusion, magnetic resonance cholangiopancreatography can be considered as a technique able to completely replace diagnostic endoscopic retrograde cholangiopancreatography. However, further studies are necessary for a better evaluation of potential advantage and disadvantages.

Minimally invasive approach in Mirizzi's syndrome.

During a 4-year period (November 1990-September 1994), 1152 patients underwent laparoscopic cholecystectomy (LC). In five (0.4%) patients a cholecysto-choledochal fistula (Mirizzi's syndrome type II) was diagnosed and a minimally invasive treatment (endoscopy-laparoscopy-interventional radiology) was attempted. The first two cases were converted to open surgery probably because of severe anatomical distortion and inadequate confidence in performing a laparoscopic choledochal repair. The last three patients were successfully treated by minimally invasive procedures. These data indicate that a minimally invasive treatment can be safely attempted through a multi-disciplinary approach in Mirizzi's syndrome.

Complications after laparoscopic cholecystectomy. Coordinated radiologic, endoscopic, and surgical treatment.

The diagnostic and therapeutic approaches used for patients referred for bile duct injuries and other major complications after laparoscopic cholecystectomy (LC) were reviewed and the results of a coordinated radiologic, endoscopic, and surgical approach were assessed. From April 1991 to October 1993, 23 patients were observed. Seven patients had biliary strictures, five had biliary lesions, five presented with retained common bile duct (CBD) stones, and one had a minor cystic duct leak. Five patients had miscellaneous abdominal fluid collections; in addition, biloma or bile ascites were present in 10/23 cases. Correct definition of iatrogenic lesions was mainly made by endoscopic retrograde cholangiography (ERCP) (n = 15), associated in six cases also with percutaneous cholangiography (PTC). "Minimally invasive" treatment included the full range of endoscopic and interventional radiological procedures. Six patients with biliary strictures, one patient with a biliary lesion, all five patients with residual CBD stones, and four patients with abdominal collections were treated by "minimally invasive" techniques: Therefore, laparotomy was avoided in 70% of cases (16/23 patients). Open surgery was necessary in 7/23 patients (30%), because of ductal lesion (n = 4), ductal stricture by endoloop (n = 1), iliac artery injury (n = 1), and phlegmon of gallbladder bed (n = 1). It appears that careful assessment of complications after LC is mandatory and often requires the combined use of ERCP/PTC and cross-sectional imaging.(ABSTRACT TRUNCATED AT 250 WORDS)