Liver metastasis of rectal cancer with intraluminal growth in the extrahepatic bile duct

Metastatic liver tumors are considered to have a tendency for expansive growth and rarely invade the bile duct. We recently encountered a resected case of liver metastasis from rectal cancer with intraluminal growth in the extrahepatic bile duct with a successful left trisegmentectomy of the liver. A 54-year-old woman underwent a posterior total pelvic exenteration for advanced rectal cancer. Ultrasonography and computed tomography four months after the first operation demonstrated a solitary occupied lesion in the liver with dilation of the left hepatic duct. Endoscopic retrograde cholangiopancreatography disclosed a filling defect in the intra- to extrahepatic bile duct. Liver metastasis from rectal cancer with intraluminal growth in the bile duct was suspected despite a consideration of primary bile duct cancer. A left trisegmentectomy of the liver and resection of the extrahepatic bile duct with a right hepatojejunostomy were performed. The tumor had invaded the intrahepatic bile duct and had developed intraluminally in the extrahepatic bile duct. Tumor thrombi were microscopically found in the bile duct of the left caudal lobe. Liver metastasis arising from colorectal cancer with intraluminal growth in the bile duct is rare, however we encountered such a case with a successful resection involving a left trisegmentectomy of the liver.     

Rapid increase of bile salt secretion is associated with bile duct injury after human liver transplantation

BACKGROUND/AIMS: Biliary strictures are a serious cause of morbidity after liver transplantation. We have studied the role of altered bile composition as a mechanism of bile duct injury after human liver transplantation. METHODS: In 28 liver transplant recipients, bile samples were collected daily posttransplantation for determination of bile composition. Hepatic expression of bile transporters was studied before and after transplantation. Histopathological criteria as well as biliary concentrations of alkaline phosphatase (ALP) and gamma-glutamyltransferase (gamma-GT) were used to quantify bile duct injury. RESULTS: Early after transplantation, bile salt secretion increased more rapidly than phospholipid secretion, resulting in high biliary bile salt/phospholipid ratio (BA/PL). In parallel with this, mRNA levels of the bile salt transporters NTCP and BSEP increased significantly after transplantation, whereas phospholipid translocator MDR3 mRNA levels remained unchanged. Bile duct injury correlated significantly with bile salt secretion and was associated with a high biliary BA/PL ratio. CONCLUSIONS: Bile salt secretion after human liver transplantation recovers more rapidly than phospholipid secretion. This results in cytotoxic bile formation and correlates with bile duct injury. These findings suggest that endogenous bile salts have a role in the pathogenesis of bile duct injury after liver transplantation.     

Bile duct hamartomas （von Mayenburg complexes） mimicking liver metastases from bile duct cancer： MRC findings

We present a case of a 72-year-old man with a common bile duct cancer, who was initially believed to have multiple liver metastases based on computed tomography findings, and in whom magnetic resonance cholangiography (MRC) revealed a diagnosis of bile duct hamartomas. At exploration for pancreaticoduodenectomy, liver palpation revealed disseminated nodules at the surface of the liver. These nodules showed gray-white nodular lesions of about 0.5 cm in diameter scattered on the surface of both liver lobes, which were looked like multiple liver metastases from bile duct cancer. Frozen section of the liver biopsy disclosed multiple bile ducts with slightly dilated lumens embedded in the collagenous stroma characteristics of multiple bile duct hamartomas (BDHs). Only two reports have described the MRC features of bile duct hamartomas. Of all imaging procedures, MRC provides the most relevant features for the imaging diagnosis of bile duct hamartomas.     

Isolation of small polarized bile duct units.

Fragments of small interlobular bile ducts averaging 20 microns in diameter can be isolated from rat liver. These isolated bile duct units form luminal spaces that are impermeant to dextran-40 and expand in size when cultured in 10 microM forskolin for 24-48 hr. Secretion is Cl- and HCO3- dependent and is stimulated by forskolin > dibutyryl cAMP > secretion but not by dideoxyforskolin, as assessed by video imaging techniques. Secretin stimulates Cl-/HCO3- exchange activity, and intraluminal pH increases after forskolin administration. These studies establish that small polarized physiologically intact interlobular bile ducts can be isolated from rat liver. These isolated bile duct units should be useful preparations for assessing the transport properties of small bile duct segments, which are the primary site of injury in cholestatic liver disorders, known as "vanishing bile duct syndromes."     

Transcatheter cooling of intrahepatic bile duct during microwave coagulation therapy: A procedure to prevent bile duct injury

Microwave coagulation therapy (MCT) is a widely used and effective minimal invasive therapy for liver tumor. Bile duct injury, however, is a major obstacle to complete tumor necrosis. To facilitate the use of MCT for a liver tumor adjacent to the major bile duct, we developed a method for transcatheter cooling of the major intrahepatic bile duct. The procedure for this technique is: (1) an angular catheter is inserted into the designated bile duct via the cystic duct after cholecystectomy, and a small longitudinal cut is made in the common bile duct for drainage of the cooling liquid; (2) cool saline is continuously infused into the bile duct via the inserted catheter during MCT; (3) after the MCT, the small opening in the common bile duct is simply closed with two or three sutures, and a C-tube is inserted to prevent stenosis of the common hepatic duct. MCT with this newly developed surgical technique enabled complete tumor necrosis and bile duct preservation, and the technique is strongly recommended for treatment of liver tumor adjacent to the major bile duct.     

Involvement of the biliary system in autoimmune pancreatitis: a follow-up study.

BACKGROUND & AIMS: The aim of this study was to define the bile duct changes associated with autoimmune pancreatitis. METHODS: Eight patients with autoimmune pancreatitis were followed for a mean of 4 years. The clinical features of these patients, including extrapancreatic bile duct changes, were examined by using biochemical parameters and several imaging modalities. Pathologic features of the pancreas and liver were examined by using the biopsy specimens of 7 patients. RESULTS: Diffuse or focal narrowing of the main pancreatic duct was observed in all patients. Histologic examination of the pancreas showed lymphoplasmacyte infiltration with severe fibrosis and acinar cell depletion. In 6 patients extrapancreatic bile duct changes such as stricture of the bile duct at hilus or intrahepatic area were observed. In 2 patients abnormalities in the bile duct and pancreas were detected simultaneously at diagnosis, and changes in the bile duct were observed later in 4 patients. Lymphoplasmacyte infiltration and fibrosis were observed in the portal area of all 7 liver biopsy samples. Five of the patients with bile duct changes received steroid therapy, and the pathological changes improved. CONCLUSIONS: Extrapancreatic bile duct changes are frequently associated with autoimmune pancreatitis. Similar pathogenic mechanism might produce the biliary tract and pancreatic abnormalities in autoimmune pancreatitis resulting in a similar histopathology in the liver and pancreas and response to steroid therapy.     

Human ontogeny of the bile duct to portal space ratio

Paucity of interlobular bile ducts is a common feature of cholestatic liver disease in premature infants. Whereas a bile duct to portal space ratio of 0.9 to 1.8 is cited by Alagille as the norm for children, there are no data regarding the normal bile duct to portal space ratio in preterm infants. In this study, by examining liver tissue obtained from autopsied fetuses and infants, we have determined that the bile duct to portal space ratio increases as a function of postconceptional age. After 38 weeks postconception, a ratio equal to or greater than 0.9 was seen in eight of nine subjects. Therefore, in evaluating premature infants for duct paucity, liver biopsies should be obtained only after 38 weeks. Prior to 38 weeks postconception, a bile duct to portal space ratio less than 0.9 may be physiologic.     

Intrahepatic bile duct changes in human hepatosplenic schistosomiasis mansoni

Wedge liver biopsies of 132 patients with hepatosplenic mansonian schistosomiasis were studied and divided in two groups according to the presence (Group I - 69 cases) or absence (Group II - 63 cases) of markers of the actual presence of the parasite in the liver tissue. Histological variables indicating bile duct injury were analysed in each case: periductal fibrosis, hyperplasia of the bile duct epithelium, bile duct degeneration, and marginal ductular proliferation. The presence of one or more of these variables defined two sub-groups: A - bile duct lesions present (73 cases), and B - bile duct lesions absent (59 cases). The variables "bile duct degeneration" and "ductular proliferation" were related to the actual presence of the parasite in the host. In 55.3% of all cases of human mansonian schistosomiasis a spectrum of injuries to the bile ducts was present. Epithelial hyperplasia alone or associated with patterns of mucopolysaccharide production was observed in 87.6% cases of the Sub-group A. The bile ducts changes in mansonian schistosomiasis are close to those described in liver fluke infestations such as clonorchiasis, fascioliasis and opistorchiasis. Statistical analysis revealed that high mucopolysaccharide production was associated with epithelial hyperplasia. The pathogenesis of the bile duct changes in human mansonian schistosomiasis and its relation to the parasitic infestations and their antigens is discussed.     

Pathology and pathogenesis of intrahepatic bile duct loss

In recent years, the pathology and pathogenesis of bile duct loss have been extensively studied, and a num‐ber of hepatobiliary diseases have been added to the list of ductopenic diseases. In addition, the biology of biliary epithelial cells is now being studied with respect to bile duct loss, as well as biliary epithelial neoplasia. In this review, recent advances in pathogenetic and pathological studies of intrahepatic bile duct loss are described, with an emphasis on immune‐mediated cholangiopathies. The bile duct loss, an acquired and pathologic process that occurs in the biliary tree, is recognizable as an absence of bile duct in an individual portad tract, and also as such absence in the vicinity of parallel running hepatic arterial branches that constitute the portal triad. Immunostaining with biliary cytokeratin and other carbohydrate materials is useful for the identification of biliary elements in the inflamed portal tracts or fibrous septa. The underlying processes responsible for bile duct loss include immunological, ischemic, infectious, metabolic, and toxic processes. Bile duct loss in primary biliary cirrhosis and primary sclerosing cholangitis is immune‐mediated, that in interventional radiology using hepatic arterial branches is related to biliary ischemia, while that in hepatic allograft rejection is related to both immunological and ischemic insults. Bacterial and viral cholangitis with bile duct loss is an example of infectious cholangitis. The biliary tree maintains its homeostasis by renewal and dropout, and bile duct loss occurs mainly via biliary apoptosis. In some patients with bile duct loss, such as occurs in drug‐induced injuries, the bile ducts regenerate and finally redistribute in the liver, while in other types of bile duct loss, the loss is progressive and is followed by vanishing bile duct syndrome, leading to biliary cirrhosis or liver transplantation. More analysis of the biology of biliary epithelial cells is mandatory for the evaluation of the pathobiology of bile duct loss, as well as for the effective restoration of biliary epithelial cells, in ductopenic liver diseases.     

Use of ultrasound tomography in the control of endoscopic retrograde bile duct drainage

The sonography of three patients with a transpapillar catheter within the bile duct shows typically findings as the picture of catheter as a tubular structure with high level reflectivity, reduction of bile duct calibers and air in the bile ducts. The diminuation of the bile duct calibers is an argument for normal transpapillary bile flow and occurs before the change of laboratory parameters. In case of jaundice the differentiation between metastatic tumours of the liver and occlusion of the catheter is possible on the basis of ultrasound. After the diminuation of calibers of the bile ducts a metastatic tumours of liver are better to be seen.     

Successful treatment of complex cholangiolithiasis following orthotopic liver transplantation with interventional radiology

Bile duct stones are a serious and the third most common complication of the biliary system that can occur following liver transplantation.The incidence rate of bile duct stones after liver transplantation is1.8%-18%.The management of biliary stones is usually performed with endoscopic techniques;however,the technique may prove to be challenging in the treatment of the intrahepatic bile duct stones.We herein reporta case of a 40-year-old man with rare,complex bile duct stones that were successfully eliminated with percutaneous interventional techniques.The complex bile duct stones were defined as a large number of bile stones filling the intra-and extrahepatic bile tracts,resulting in a cast formation within the biliary tree.Common complications such as hemobilia and acute pancreatitis were not present during the perioperative period.The follow-up period was 20 mo long.During the postoperative period,the patient maintained normal temperature,and normal total bilirubin and direct bilirubin levels.The patient is now living a high quality life.This case report highlights the safety and efficacy of the percutaneous interventional approach in the removal of complex bile duct stones following liver transplantation.     

对肝内胆管结石外科治疗的再认识

肝内胆管结石系原发性胆管结石范畴,尽管其发病率有所下降,但因地区不同仍有差别。早期肝内胆管结石采用微创外科技术施行肝切除术治疗是正确选择,应保护Oddi括约肌的功能;但对复杂性肝内胆管结石所致的终末期肝病的外科治疗仍存在诸多问题。应提倡多学科合作医疗模式,进行综合性治疗,并加强肝内胆管结石预防、病因和发病机制等研究,为治疗肝内胆管结石努力探索。     

Portal vein thrombosis associated with hilar bile duct carcinoma and liver abscess

As most portal vein occlusion in hilar bile duct carcinoma is caused by tumor invasion to the portal vein, other mechanisms of its occlusion are very rare. We report the case of a 69-year-old man who underwent surgical resection for an advanced hilar bile duct carcinoma associated with unusual portal vein occlusion. Preoperative diagnosis was advanced hilar bile duct carcinoma with liver abscess and right portal vein occlusion due to tumor invasion. Extended right hepatectomy combined with resection of caudate lobe was performed. Intraoperatively, tumor invasion to the portal vein was not evident and resected margin of the right portal vein showed thrombosis and no evidence of malignancy histologically. To our knowledge, this is the first reported case of a patient with a combination of portal vein thrombosis and liver abscess in hilar bile duct carcinoma. Although portal vein occlusion due to thrombosis is an unusual complication in hilar bile duct carcinoma, the presence of liver abscess may be a useful diagnostic implication of this occlusion.     

Bile duct hamartomas--the von Meyenburg complex

Hamartomas of the bile duct (von Meyenburg complex) are benign neoplasms of the liver, constituted histologically cystic dilatations of the bile duct, encompassed by fibrous stroma. We report a 42-year-old female patient with symptomatic cholecystitis, whose gross and ultrasonic appearance suggestive of multiple liver metastases. Magnetic resonance imaging and liver biopsy are the gold standards for diagnosis of this rare hepatobiliary condition.     

Role of interventional therapy in hepatic artery stenosis and non-anastomosis bile duct stricture after orthotopic liver transplantation

AIM: To analyze the clinical manifestations and the effectiveness of therapy in patients with orthotopic liver transplantation (OLT)-associated hepatic artery stenosis (HAS) and non-anastomosis bile duct stricture. METHODS: Nine cases were diagnosed as HAS and non-anastomosis bile duct stricture. Percutaneous transluminal angioplasty (PTA) was performed in four HAS cases, and expectant treatment in other fi ve HAS cases; percutaneous transhepatic bile drainage, balloon dilation, stent placement were performed in all nine cases. RESULTS: Diffuse intra-and extra-bile duct stricture was observed in nine cases, which was associated with bile mud siltation and biliary infection. Obstruction of the bile duct was improved obviously or removed. Life span/ follow-up period was 13-30 mo after PTA of four HAS cases, 6-23 mo without PTA of other fi ve cases. CONCLUSION: Progressive, non-anastomosis, and diffuse bile duct stricture are the characteristic manifestations of HAS and non-anastomosis bile duct stricture after OLT. These are often associated with bile mud siltation, biliary infection, and ultimate liver failure. Interventional therapy is signifi cantly benefi cial.     

Synthetic capacity and cell metabolites of bile duct obstructed rat livers. Effect of free and conjugated dihydroxy bile acids.

Morphologic alterations in liver cells after bile duct ligation are well known and documented in numerous reports. Biochemical studies concerning metabolic changes in cholestatic liver are rare. Therefore, in this study, liver cell metabolites and the capacity of the perfused cholestatic rat liver to produce glucose, urea and ketone bodies were measured. In addition the influence of dihydroxy bile acids on normal and bile duct ligated rat livers was studied. Concentrations of adenine nucleotides, lactate, pyruvate, 3-hydroxybutyrate, acetoacetate, glucose and UDP-glucose were found to be identical in cholestatic and normal livers. Glycogen content, however, was significantly lowered in cholestatic livers. Gluconeogenesis from lactate and urea production from ammonium chloride were only slightly reduced in bile duct obstructed rat livers. Dihydroxy bile acids did not affect the metabolism of normal or cholestatic livers. Ketone body production from oleate was reduced to 66% in bile duct obstructed livers, taurochenodeoxycholate further reduced this value to the normal value. In contrast to earlier reports (Fisher and co-workers, 1971 Lab. Invest. 21; 88-91; Gastroenterology 60: 742) chenodeoxycholate induced neither cholestasis nor a marked fall in ATP content or rat liver in our experiments with female Wistar rats. In conclusion, dihydroxy bile salts did exert toxic short term effects on rat livers.     

One hundred and eleven liver resections for hilar bile duct cancer

A positive correlation between absence of residual tumor at resection margins and long‐term survival in the treatment of hilar bile duct carcinoma has encouraged some surgeons to use a more radical approach, including liver/portal vein resection and combined pancreatoduodenectomy. However, if liver resection is associated with significant morbidity and mortality, it may not produce any overall benefit. This review was undertaken in an attempt to determine whether liver resection is a safe procedure and whether if has any beneficial effect over that of local bile duct excision alone, in terms of achieving curative resection and long‐term survival. The records of 151 patients with hilar bile duct carcinoma surgically treated between June 1989 and December 1997 at the Asan Medical Center, Seoul, were retrospectively analyzed. Surgical resection was possible in 128 patients. The remaining 23 patients had surgical palliative drainage. Local bile duct excision alone was performed in 17 patients. Liver resection for tumor extending to secondary bile ducts or hepatic parenchyma was performed in 111 patients; portal vein resection was necessary in 29 of these 111 patients (26.1%) and pancreatoduodenectomy was combined in 18 patients (16.2%). Seven patients died during hospitalization after liver resection, an operative mortality of 6.3%. Margins of bile duct resection were free of tumor on histologic examination in 4 of the 17 local bile duct excisions, but in 86 of the 111 liver resections. The cumulative survival rate after local bile duct excision was 85.7% at 1 year, 42.9% at 2 years, 21.4% at 3 years, and 0% at 4 years. However, the survival rate after liver resection (excluding operative mortality) was 97.1% at 1 year, 72.8% at 2 years, 55.3% at 3 years, and 24.0% at 5 years. Survival and the percentage of patients with tumor‐free resection margins after liver resection were superior to those after local bile duct excision. Resection of hilar bile duct carcinoma offers long‐term survival only when surgery is aggressive and includes liver resection.     

Long-term culture of cholangiocytes from liver fibro-granulomatous lesions

Background  

Extensive bile duct proliferation is a key feature of the tissue reaction to clinical and experimental forms of liver injury. Experimental infection of mice by Schistosoma mansoni is a well-studied model of liver fibrosis with bile duct hyperplasia. However, the regulatory mechanisms of bile duct changes are not well understood. In this study we report the reproducible isolation of long-term cultures of cholangiocytes from mice livers with schistosomal fibrosis.     

Biliary cystadenocarcinoma with superficial spread to the extrahepatic bile duct.

We report a case of biliary cystadenocarcinoma of the liver with superficial spread to the extrahepatic bile duct. Preoperative endoscopic retrograde cholangiography revealed communication between a 4.5-cm cyst in segment 4 of the liver and the bile duct. From the findings obtained by peroral cholangioscopy and intraoperative cholangioscopy, the granular mucosa in the bile duct was diagnosed as superficially spreading cancer. The right posterior segmental bile duct and the right anterior segmental bile duct were resected at the point where the spread of cancer was no longer traceable and left lobectomy plus caudate lobectomy was carried out. This achieved radical resection, leaving the resected margin of the bile duct free from cancer. Histopathologically, well-differentiated papillary adenocarcinoma was found on the inner surface of the cyst, and the cancer had superficially spread from the cyst to the extrahepatic bile duct via the 2.5-mm diameter communication between the cyst and bile duct. The cancer was limited only to the mucosal layer all over the lesion. When performing radical surgery for biliary cystadenocarcinoma, it is recommended that cholangioscopy be performed to examine whether the cancer has superficial spread to the extrahepatic bile duct or not. Bile duct resection should be carried out, depending on the extent of the superficial spread, so that the resected margin of the bile duct is free from cancer.     

Experimental and clinical studies on liver tissue blood flow in obstructive jaundice

To clarify some pathologic aspects of obstructive jaundice before and after bile duct drainage, changes in liver tissue blood flow were observed using an electrolytic historheometer, in combination with the FITC-dextran method, during experimental bile duct obstruction and after its elimination. Clinical investigations were based on histologic findings in liver tissue specimens collected by wedge biopsy at the time of laparotomy following bile duct drainage. Rats with bile duct obstruction showed significantly (P less than 0.01) lower values for liver tissue blood flow, with sinusoid dilation, in comparison to control rats, at 2 and 4 weeks following the initiation of experimental bile duct obstruction. Liver tissue blood flow disturbance subsided 3 days after eliminating the obstruction, at 2 weeks following its initiation, while no improvement occurred even following elimination of obstruction after 4 weeks. Clinically, in cases with a high degree of sinusoid dilation the effect of postoperative bile duct drainage was poor, with a high incidence of postoperative complication. These findings suggest that liver tissue blood flow disturbance might causatively affect the pre- and postoperative course of obstructive jaundice.