The new DEAL--a novel technique using a double-entry access loop to facilitate bilateral intrahepatic biliary access for complex intrahepatic stones.

SAJS The management of patients with primary intrahepatic stones may be complex as the natural history is frequently complicated by further episodes of cholangitis after initial treatment because of residual or recurrent intrahepatic stones or strictures. Curative segmental or lobar hepatic resection of atrophic segments and diseased ducts is possible in only the 20% of patients with localised stones or strictures. Complete stone removal by resection is therefore not feasible in the majority of patients with bilateral lobar stones and strictures. Patients who subsequently develop cholangitis pose a major operative risk if secondary biliary cirrhosis, portal hypertension or the atrophy-hypertrophy complex has occurred. Treatment of recurrent stones and strictures via the percutaneous transhepatic biliary route is successful in only 70% of patients. In order to avoid these hazards, to reduce the incidence of incomplete operative stone removal and to facilitate extraction of recurrent intrahepatic stones, we have used a multidisciplinary approach in complex hepatolithiasis, combining resection of atrophic liver segments with a modified hepaticojejunostomy incorporating permanent access for interventional radiological procedures via a jejunal access loop. A single percutaneous entry site may limit optimal access to all intrahepatic ducts in both right and left lobes, especially if the intrahepatic segmental duct orifices are angulated, stenotic or obstructed. An access loop may also be difficult to enter after repeated percutaneous punctures because of fibrosis or peri-jejunal adhesions at the site of attachment to the anterior or lateral abdominal wall, especially following repeated manipulation and low-grade sepsis. We describe a new double-entry access loop (DEAL) technique as a modification of the subparietal single-entry access loop to enhance percutaneous radiological entry and facilitate intrahepatic biliary intervention.