Does bile spillage during an operation present a risk for peritoneal metastasis in bile duct carcinoma?

Whether bile spillage during operation presents a risk for peritoneal metastasis in the treatment of bile duct carcinoma was studied in 15 patients (12 with bile duct cancer, 3 with cancer of the papilla of Vater) who had all undergone a pancreatoduodenectomy. Preoperative bile was sampled through a percutaneous transhepatic biliary drainage catheter. Nine patients with bile duct cancer and one with cancer of the papilla of Vater showed positive bile cytology. The operative bile was obtained at the hepatic duct stump after a resection of the tumor-bearing bile duct. The operative bile in 10 patients with positive preoperative bile was found to be positive, while that in the five patients with negative preoperative bile was negative. Thus, the specificity of operative bile was identified as 100%. Moreover, in five patients with preoperative positive bile, saline irrigation of intrahepatic bile duct after a full recovery of hepatic bile revealed cancer cells to remain in the intrahepatic biliary trees. The viability of preoperative bile was 61%–97% with 10⁴–2.4×10⁵ tumor cells, whereas there was a 41%–97% viability with 7.6×10⁴–10.4×10⁵ tumor cells in the operative or irrigated bile. Accordingly, the patients with preoperative positive bile are thus suggested to be at high risk of inducing peritoneal metastasis due to the inadvertent spillage of hepatic bile at the time of resection of a bile duct tumor.     

Villous tumor of the papilla of Vater presenting with hypopotassemia

We report a case of villous tumor of the papilla of Vater associated with hypopotassemia. The patient was a 73-year-old woman who presented with jaundice and fever. She had a history of diabetes mellitus and liver dysfunction. Laboratory studies revealed that levels of total bilirubin, alkaline phosphatase, and C-reactive protein, and the white blood cell count were elevated (suggestive of cholangitis) and that the serum potassium level was markedly reduced, to 1.9 mEq/l (normal value 3.5–5.0 mEq/l). Duodenoscopy showed a villous tumor arising in the papilla of Vater. Percutaneous transhepatic biliary drainage was performed. Approximately 700–1500 ml of bile with viscous mucoid fluid was drained daily. Percutaneous transhepatic cholangioscopy showed a papillary lesion in the distal common bile duct. Biopsied specimens from both percutaneous transhepatic cholangioscopy and duodenoscopy disclosed tubulovillous adenoma. Endoscopic ultrasonography showed that the tumor had spread to the main pancreatic duct as well as to the common bile duct. The patient underwent pylorus-preserving pancreaticoduodenectomy. Pathology examination disclosed well differentiated adenocarcinoma, carcinoma in situ, in tubulovillous adenoma. The cancer cells were observed at the bottom of the tumor spreading in the common bile duct. This is a rare case of a patient presenting with hypopotassemia associated with a tubulovillous tumor of the papilla of Vater that secreted mucoid material.     

Association of peripapillary fistula with common bile duct stones and cholangitis

Background: Peripapillary choledochoduodenal fistula (PCDF) is occasionally detected during endoscopic retrograde cholangiopancreatography. Cholelithiasis and biliary bougienage are two suspected causes of PCDF. Methods: The medical records for 841 patients who underwent endoscopic retrograde cholangiopancreatography between 1993 and 2002 were reviewed for evaluation of PCDF. Results: A total of 327 patients had common bile duct stones, and 16 of these had a PCDF at the papilla of Vater. None of the 16 patients had a history of pancreatitis, duodenal ulcer, or had undergone endoscopic retrograde cholangiopancreatography previously. Seven of the 16 had not undergone biliary surgery. Conclusions: This study indicates that PCDF is a relatively common complication of common bile duct stones and cholangitis. According to the present results, PCDF is more frequently associated with common bile duct stones than with biliary surgery and bougienage.     

Biliary tract cancer treatment: results from the Biliary Tract Cancer Statistics Registry in Japan

Background/Purpose: A registry project for cancers of the biliary tract accumulated a total of 11 030 cases for 10 years. In the present study, registered cases were analyzed for information bearing on problems with the treatment of cancer of the biliary tract. The Japanese classification of lymph nodes was also considered on the basis of the results of this study. Methods: In 11 030 cases, the site of cancer was the gallbladder in 4774, the bile duct in 4833, and the papilla of Vater in 1423. Those cases were analyzed with regard to patient survival according to the stage of disease and the extent of lymph node metastasis. Results: More than 11 000 cases of cancer of the biliary tract have been registered to date from 158 member institutions of the Japanese Society of Biliary Surgery. While the 5-year survival rates for stage I gallbladder cancer and cancer of the papilla were 77% and 75%, respectively, those for stage I hilar or upper bile duct cancer and middle or lower bile duct cancer were 47% and 54%. For stage II and stage III disease, the 5-year survival rates were about 50% for gallbladder cancer and 30% or higher for cancer of the papilla, while survival was only 20% to 30% for bile duct cancer, regardless of specific site. For stage IV, the 5-year survival rate was unexpectedly high, being about 10% or higher for cancers at all sites, with 19% for cancer of the papillary region being the highest. Thus, there still seem to remain surgical indications for stage IV cancers. The lymph node metastasis rate was about 40% for cancers at all sites. Changes in surgical procedures to improve the 5-year survival rate in patients with n2 metastasis or less will be needed. Noncurative resection occurred frequently for cancers at all sites, particularly in cancers of the hilar or upper bile duct, accounting for 60% of cases or more. We have to recognize that measures to reduce inadvertent noncurative resection are fundamental to the treatment of cancer. Conclusions: Considering the survival results according to specific lymph nodes involved, we concluded that the Japanese classification of lymph nodes, particularly hepatoduodenal ligament lymph nodes, should be reexamined, while another procedure to remove such lymph nodes completely should be developed. Received: July 13, 2001 / Accepted: February 8, 2002 Acknowledgments. The authors thank the many doctors at 158 institutes for their cooperation in this registry, and thank Miho Suzuki for secretarial assistance. Offprint requests to: T. Nagakawa     

Parapapillary choledochoduodenal fistula associated with cholangiocarcinoma

Parapapillary choledochoduodenal fistula is a rare disorder. We herein report a case of parapapillary choledochoduodenal fistula associated with cholangiocarcinoma. A 61-year-old woman was admitted to our hospital for further examination of a liver tumor. She had no clinical symptoms, but computed tomography scans showed an irregularly contoured liver tumor which was histologically confirmed to be adenocarcinoma, by a needle biopsy examination. Duodenal fiberscopy revealed a fistula orifice 1.0cm proximal to the orifice of the papilla of Vater, and endoscopic retrograde cholangiography through the fistula showed a communication to the common bile duct. Hypotonic duodenography demonstrated reflux of contrast material into the choledochoduodenal fistula. The bile sample collected from the common bile duct showed extremely high levels of pancreatic enzymes, including amylase, phospholipase-A2, and elastase-I. Furthermore, Helicobacter DNA was detected in bile by polymerase chain reaction (PCR) analysis. This experience suggests to us that parapapillary choledochoduodenal fistula may be a risk factor for biliary tract carcinoma, and surgical management is the treatment of choice for this rare condition, even when the patient has no significant clinical symptoms.     

A small-bowel segment as a total extrahepatic bile duct replacement.

The effect of a small-bowel segment as a total extrahepatic bile duct replacement, with preservation of the bile passage through the papilla of Vater, was examined in 12 pigs followed up for 420 days. No complications during or after surgery were observed in any of the animals. The laboratory parameters were within normal range during the entire observation period. No anastomotic stenosis was evident on percutaneous transhepatic cholangiography in animals examined 2, 6, or 12 months after surgery. The intrahepatic biliary tract was not dilated. There was obvious peristalsis of the grafted small-bowel toward the papilla of Vater. Autopsies showed that the grafts had healed without any sign of irritation. Histologically, the structure of the graft remained undisturbed. There was a clear distinction between the mucosa of the bile duct and that of the small bowel, with no sign of chronic infection. In the graft as well as in the vascular pedicle, the nerve fibers were intact. Liver biopsy showed no pathologic changes. In light of the results of these experiments, the small-bowel segment appears to be a very promising substitute for the injured extrahepatic biliary duct.     

27例胆道手术后胆漏的原因及治疗

目的 探讨胆道术后发生胆漏的原因及其预防措施与治疗方法。方法 对1991-2000年间3786例胆道术后发生胆漏的27例临床资料作回顾性分析,结果 27例术后发生胆漏的原因为肝床毛细胆管或细小副肝管损伤8例,胆总管癌切开探查后胆漏1例,胆囊管或胆囊颈部残端漏7例,T管早期滑脱或拔T管后胆漏10例,T管引流术后护理不当1例,本组保守治疗21例（78%）,再手术治疗6例（22%）;除1例胆管癌晚期自动出院外,其余均痊愈出院。结论 胆漏多发生于胆囊切除术及拔T管后,主要原因为与肝床毛细胆管或细小副肝管损伤,局部炎症和操作不当等有关,胆漏发生后应根据腹膜炎的轻重,胆道有无梗阻以及腹腔引流是否通畅等选择保守治疗与再手术治疗。     

Premalignant lesions of the pappilla of Vater and the common bile duct

Two patients with benign adenomatous papilloma of the papilla of Vater and the common bile duct are presented. Both patients had symptoms from the upper gastrointestinal tract and biliary system. The clinical and roentgenological aspects are discussed and the importance of the correct preoperative and/or peroperative diagnosis and the value of radical surgery is emphasized.     

Bile peritonitis due to a spontaneous perforation of the common bile duct: Report of a case

Spontaneous perforation of the extrahepatic bile duct is rare. We herein report the case of an 80-year-old woman who underwent emergency laparotomy for bile peritonitis due to a spontaneous perforation of the common bile duct. A 2-mm perforation was found in the posterior wall of the choledochus, and its wall was paper-thin. Three stones, 2 mm in diameter, were removed from the common bile duct. She underwent T-tube decompression with intraoperative cholangiography demonstrating a swollen papilla of Vater. The swelling of the papilla disappeared 4 weeks after the operation. Her postoperative course was uneventful. It seems likely that the elevated intraductal pressure due to the swollen papilla following stone impaction caused the perforation in this patient. Furthermore, the excessive friability of the common bile duct of unknown etiology may also have contributed to the perforation. This experience along with a review of the literature indicate that biliary decompression is the treatment of choice for this condition.     

Experience with percutaneous transhepatic fiberoptic choledochoscopy for retained stones in the biliary tract

Summary Residual choledochal stones in 11 patients and stones in the intrahepatic bile ducts in 5 patients were successfully removed by the use of the fiberoptic choledochoscope (FCH-6T), introduced percutaneously into the intrahepatic biliary tract. The reasons for the use of percutaneous transhepatic extraction were: (1) unsuccessful endoscopic papillotomy; (2) unsuccessful choledochoscopic removal via the T-tube tract; (3) high surgical risk; (4) the presence of percutaneous transhepatic biliary drainage for acute cholangitis and acute pancreatitis. All stones were extracted through the liver or the papilla of Vater after crushing them. All minor complications such as pain, vomiting, or fever resolved without further therapy. Percutaneous transhepatic choledochoscopy proved safe and effective for the removal of retained choledochal stones and was essential for the treatment of stones in the intrahepatic bile ducts.     

Ampullectomy for adenoma of the papilla and ampulla of Vater

Introduction: The frequency of malignant adenomas of the papilla figures between 15 and 30%. Villous adenoma is considered to be a premalignant lesion. Treatment: Resection of the papilla is indicated in large tubular and small tubulovillous adenoma. Ampullectomy, however, is mandatory in villous adenoma with severe dysplasia and large villous or tubulovillous adenoma. If villous adenoma with a low-risk pT1 N0 M0 G1/2-cancer is treated by ampullectomy, local lymph dissection should also be performed. Ampullectomy includes extirpation of the ampulla of Vater and reinsertion of the common bile duct and the pancreatic main duct into the duodenal wall. Results: Hospital mortality after ampullectomy is less than 0.4%, and surgical morbidity, e.g., cholangitis, below 10%. Received: 2 March 1998     

Biliary tract cancer treatment: 5,584 results from the Biliary Tract Cancer Statistics Registry from 1998 to 2004 in Japan

Background/Purpose  The results from the Japanese Biliary Tract Cancer Statistics Registry from 1988 to 1998 were reported in 2002. In the present study, we report here selectively summarized data as an overview of the 2006 follow-up survey of the registered cases from 1998 to 2004 for information bearing on problems with the treatment of cancer of the biliary tract. Methods  A total of 5,584 patients were registered from 1998 to 2004. The site of cancer was the bile duct in 2,732 patients, the gallbladder in 2,067, and the papilla of Vater in 785. Those cases were analyzed with regard to patient survival according to the extent of tumor invasion (pT), the extent of lymph node metastasis (pN) and the stage. Results  The five-year survival rate after surgical resection was 33.1% for bile duct cancer, 41.6% for gallbladder cancer, and 52.8% for cancer of the papilla of Vater. For hilar or superior bile duct cancer, the 5-year survival rate was lower with an increase in the pT, pN and f stage, except pT3 vs. pT4, pN1 vs. pN2 and stage III vs. stage IVa. For middle or distal bile duct cancer, the 5-year survival rate was lower with increase in pT, pN and f stage, except pT2 vs. pT3, pN2 vs. pN3, stage II vs. stage III and stage III vs. stage IVa. For gallbladder cancer, the 5-year survival rate was lower with increase in pT, pN and f stage. For cancer of the papilla of Vater, the 5-year survival rate was lower with increase in pT, pN and f stage, except pT1 vs. pT2, pN1 vs. pN2, and stage III vs. stage IVa. Conclusions  In the present study, the outcomes of surgical treatment were better than that of the previous report from Japan and foreign countries. The pT, pN and stage of gallbladder cancer are well defined. However, there were no significant differences in some groups of those of bile duct cancer and cancer of the papilla of Vater.     

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目的　探讨胆道手术后发生胆漏的原因及其预防与治疗方法。方法　对浙江省平湖市中医院 1994~2003年间胆道术后发生胆漏的 28例临床资料作回顾性分析。结果　术后发生胆漏的原因为肝床毛细胆管或细小副肝管损伤 15例,胆总管癌切开探查后胆漏 1例,胆囊管残端漏 1例,T管早期滑脱或拔T管后胆漏 10例,T管引流术后护理不当 1例。保守治疗 21例(75% ),再手术 7例 (25% ),除 1例胆管癌晚期自动出院外其余均痊愈出院。结论　胆漏多发生于胆囊切除术、胆道手术及拔T管后,主要原因与肝床毛细胆管或细小副肝管损伤、局部炎症和操作不当等有关。胆漏发生后应根据腹膜炎的轻重,有无胆道梗阻以及腹腔引流是否通畅等选择保守治疗或再手术治疗。     

Clinical problems in the surgical treatment of pancreaticobiliary maljunction

The results of surgical treatment of pancreaticobiliary maljunction at our department are described. The 67 patients who underwent surgery for this disease were divided by age into an adult group (45 patients, aged 16 years and over) and a pediatric group (22 patients, aged less than 16 years). The incidence of concomitant carcinoma before surgery and the incidence and severity of postoperative cholangitis were compared between these two groups. In addition, the cell proliferating activity of the biliary tract epithelium in cancer-free patients was compared between the two groups, using the proliferating cell nuclear antigen labeling index (PCNA LI). Ten patients (all adults) were diagnosed with cancer (gallbladder carcinoma in 7 and bile duct carcinoma in 3) before surgery. The surgical techniques used for reconstruction in the cancer-free patients were: in the adult group, hepaticoduodenostomy in 9 patients, Roux-en-Y hepaticojejunostomy in 17, jejunal interposition in 8, and another technique in 1. In the pediatric group, hepatico-duodenostomy was performed in 17 patients. Roux-en-Y hepaticojejunostomy in 3, and jejunal interposition in 2. Postoperative cholangitis occurred in 6 adults (including 2 with severe form) and 1 child (mild case). The PCNA LI of the biliary tract epithelium was high compared to control findings in the biliary tract epithelium of 10 adult patients without pancreaticobiliary maljunction. In the adult group with dilated extrahepatic bile ducts (n=10 examined) this index was 11.4% for the bile duct epithelium (control, 1.5%) and 12.7% for the gallbladder epithelium (control, 1.4%). In the adult group with non-dilated extrahepatic bile ducts (n=5 examined) it was 5.9% for the bile duct epithelium and 13.1% for the gallbladder epithelium. In the pediatric group (n=10 with extrahepatic bile duct dilatation) it was 7.5% for the bile duct and 9.7% for the gallbladder epithelium. (Differences from control values were all significant.) These results suggest that surgery for this disease should be performed as early as possible and that extrahepatic bile duct excision and biliary reconstruction should be performed whether or not extrahepatic bile ducts are dilated.     

Transduodenal resection of ampullary tumors

Objective: Whether the treatment of benign ampullary tumors should be performed as transduodenal surgical excision or endoscopic ampullectomy depends on the size and spread of the tumor. In this videopaper we report technical hints on the surgical resection.Indications: Surgical resection is indicated for benign ampullary lesions if endoscopic resection is not possible. In addition, local resection can be performed in cases with high risk of malignancy or in a palliative intention.Procedure: The duodenum is mobilized by the Kocher maneuver. It is recommendable to perform a cholecystectomy to introduce a flexible catheter antegrade into the common bile duct through the cystic duct for identification of the papilla of Vater by digital palpation. An anterolateral oblique duodenotomy is made and thereby the tumor of the papilla is exposed, followed by a submucosal injection of epinephrine to elevate the tumor. Afterwards a 5-10 mm margin is scored circumferentially in the mucosa around the adenoma. The extent of the excision is based on the preoperative and intraoperative assessment; a submucosal or full thickness (for transmural lesions) excision can be performed. After submucosal excision the mucosa of the ampulla is approximated to the mucosa of the duodenum. In cases with full thickness ampullectomy the borders of the pancreatic and bile duct are approximated and then the entire complex is sutured to the full wall of the duodenum. Furthermore in some cases with extensive resection a separate reconstruction of the pancreatic and bile duct may be required. A terminal assessment of the ductal patency is imperative. The duodenectomy is closed and a paraduodenal drain is placed.Conclusion: Transduodenal resection of periampullary tumors can be technically demanding, but provides a stage-adapted treatment modality for benign and premalignant lesions of the papilla of Vater.     

A histopathologic study of the region of the ampulla of vater in congenital biliary atresia

A histopathologic investigation of the duodenal wall and adjacent tissues in the vicinity of the papilla of Vater was performed in 37 autopsied cases of congenital biliary atresia which were treated in the Department of Pediatric Surgery of the Juntendo University Hospital during the past 11 years. A high incidence of the association of a congentially abnormal junction of the common bile duct and pancreatic duct, that is, a long common channel and a poorly developed sphincter musculature, were found in congenital biliary atresia. This suggests the possibility that reflux of pancreatic juice into the biliary system, followed by nonsuppurative chronic inflammation of bile ducts, may ultimately lead to the obstructive cholangiopathy seen in biliary atresia.     

Pathophysiologic mechanisms in patients with cholangitis or obstructive jaundice: Results of a cholangiographic study

Bacterial reflux from the biliary tract to the systemic circulation is considered to be the primary etiologic factor in bacteremia and the development of sepsis. However, as the pathophysiologic features of the biliary tract that may promote such a reflux of biliary bacteria remain unclear, we investigated, using direct cholangiography, the pathophysiologic relationship between the intrahepatic bile ducts and biliary reflux into the systemic circulation after the percutaneous infusion of a contrast material containing indocyanine green (ICG) into the circulating blood. The subjects were 19 patients who underwent percutaneous transhepatic cholangiography with drainage to treat either a biliary infection or obstructive jaundice, an 8 post-T-tube control patients with normal biliary drainage. The relationship between the biliary tract pressure and ICG reflux during cholangiography was also analyzed. An ICG reflux was observed in all 19 patients who had undergone percutaneous transhepatic cholangiography with drainage and in 2 of the 8 control patients. In all patients who showed positive ICG reflux, this occurred when the biliary pressure increased to 25cm H₂O. An ICG reflux was seen in the 16 patients with a positive bile culture, and in 7 of 13 patients with a negative bile culture. When we analyzed ICG reflux in relation to the morphology of the intrahepatic bile duct, we found that all 4 patients who had cholangitic hepatic abscesses also exhibited higher ICG reflux concentrations and the clinical symptoms of cholangitis. Radiologically, all 7 patients with cholangitis demonstrated many small intrahepatic branches, and they exhibited moderate ICG refluxes, whereas the 6 patients who had obstructive jaundice but no cholangitis had fewer ICG refluxes and no clinical symptoms. This study demonstrated two possible pathophysiological routes for biliary reflux: (1) via cholangitic hepatic abscesses, with entry of the bacteria directly into the circulating blood, or (2) via the small intrahepatic biliary branches, in which entry of bacteria into the systemic circulation occurs through the cholangioles.     

吲哚菁绿荧光显像技术在腹腔镜再次胆道手术中的应用

背景和目的：相比于术中胆道造影,吲哚菁绿（ICG）荧光影像技术具有操作方便、术中胆管显像更加清晰优势。国外研究已证实ICG荧光影像技术的可行性及安全性。目前国内关于ICG荧光显像技术应用于腹腔镜下再次胆道手术却鲜有报道。因此,本文报告笔者在腹腔镜再次胆道手术中应用ICG荧光影像技术的初步经验,以评估其临床应用价值。方法 按照纳入与排除标准回顾性收集2020年1月—2022年6月昆明医科大学第二附属医院肝胆胰外科收治的择期行腹腔镜再次胆道手术患者临床资料。将术中采用ICG荧光显像技术的患者作为观察组,术中未采用该技术的患者作为对照组。观察组患者于手术开始前60 min,经肘静脉注射2 mL（总剂量5 mg）ICG注射液,术中利用近红外光三维显像胆管。结果 共纳入184例患者,其中观察组80例,对照组104。观察组胆道ICG荧光影像系统成功率为93.75%（75/80）。观察组的术中平均胆道识别时间明显短于对照组（25 min vs. 39 min,P<0.05）,而两组间其他术中指标（手术方式、手术时间、术中出血量、中转开腹率）差异均无统计学意义（均P>0.05）。两组术后通气时间、胆汁漏发生率、术后并发症Clavein-Dindo分级、术后6个月结石复发率均无明显差异（均P>0.05）,但观察组术后平均住院时间明显短于对照组（7.13 d vs. 10.35 d,P=0.032）。结论 腹腔镜再次胆道手术中应用ICG荧光显像技术实现胆管系统的可视化,可以避免术中因对胆道系统识别不佳而导致的副损伤。这一技术的应用对再次胆道手术安全有保障,具有良好的应用前景。     

Intraduodenal Diverticulum Associated with a Double Common Bile Duct Causing Recurrent Pancreatitis and Cholangitis: Report of a Case

Intraduodenal diverticulum (IDD) is a rare congenital anomaly, arising at or near the papilla of Vater. Double common bile duct (DCBD) is another rare congenital anomaly of the biliary system. Recognition of these abnormalities is essential to prevent the development of lesions in the biliary system, as well as to avoid unnecessary surgical intervention. Although both conditions are often asymptomatic, severe clinical conditions may develop. Intraduodenal diverticulum should always be considered as a possible cause of pancreatitis of unknown etiology. We report a rare case of IDD with DCBD in a patient with Lemmel's syndrome, which consists of obstructive jaundice, acute pancreatitis, and suppurative cholangitis. The patient was treated successfully with a Roux-en-Y hepaticojejunostomy.     

Intervention radiologic treatments of the bile ducts as an alternative to reoperation

Balloon dilatation and diathermic cutting of the papilla of Vater through a T-drainage tube or a percutaneous transhepatic biliary drainage catheter were performed in 12 patients with jaundice, cholangitis, or acute pancreatitis due to retained common duct stones or benign papillary stenosis. Both methods are an alternative to reoperation and, in addition, there is a minor risk.