Multiple bile duct cancers presenting 3 years after resection of early gallbladder cancer: Case report

A 76-year-old woman underwent combined resection of the gallbladder plus partial hepatectomy for early gallbladder cancer. From the pathology results, the surgical treatment was deemed to have been curative. However, 3 years later, the patient was readmitted to the hospital with an elevated carbohydrate antigen (CA) 19-9 level. Percutaneous transhepatic cholangiography demonstrated irregularity of the common hepatic duct and the left intrahepatic bile duct, and percutaneous transhepatic cholangioscopy revealed two separate papillary tumors at these sites. A diagnosis of multiple carcinomas of the bile duct was made and left hepatic lobectomy and resection of the extrahepatic bile duct was performed; reconstruction was carried out with a right hepatico-jejunostomy with Roux-en-Y anastomosis. Microscopic study revealed that both of the lesions were papillary adenocarcinomas, and normal biliary mucosa was confirmed to exist between them.     

Amputation neuroma mimics common hepatic duct carcinoma

Most amputation neuromas of the biliary tract occur in the cystic duct stump after cholecystectomy and are asymptomatic. However, when they arise in the main hepatic duct and are associated with obstructive jaundice, it is difficult to distinguish them from carcinoma. We describe a case in which preoperative differential diagnosis was difficult. A 60-year-old man was admitted to the Institute of Clinical Medicine, University of Tsukuba, with a chief complaint of jaundice. Cholangiography showed an irregularly elevated nodular lesion on the lateral wall of the common hepatic duct and multiple floating stones in the choledochus. Ultrasonography and computed tomography revealed one-sided regional thickening of the common hepatic duct associated with dilatation of the intrahepatic and extrahepatic bile ducts. Carbohydrate antigen 19-9 level was markedly elevated to 11,200 IU/mL in the bile juice, but was only 38 IU/mL in the serum, below the limit of abnormality. Cholangioscopy showed papillary tumor with coarse granular surface mimicking papillary carcinoma, but biopsy revealed no malignancy. The patient underwent hepaticocholedochus resection. Although the macroscopic finding from the surgical specimens was papillary carcinoma of the common hepatic duct penetrating to the hepatoduodenal ligament, histopathological examination revealed an amputation neuroma consisting of hypertrophic nerve tissues and giant cells containing foreign bodies, probably as a consequence of a previous cholecystectomy. The postoperative course was uneventful and the patient has been living well for the 5 years since the resection.     

Post-cholecystectomy amputation neuroma of the common bile duct with obstructive jaundice

Amputation neuroma of the common bile duct after surgery is a rare and mostly asymptomatic lesion. A 60-year old patient presented with obstructive jaundice three months after a cholecystectomy for symptomatic gallstones. Imaging investigations showed common extrahepatic bile duct stenosis. Surgical resection of the stricture with biliodigestive anastomosis was performed. Histological examination of the surgical specimen revealed an amputation neuroma. Despite its rarity, amputation neuroma of the common bile duct should be considered in patients with post-cholecystectomy syndrome following liver or extrahepatic bile duct surgical procedures.     

Curative reoperation for recurrent cancer of the extrahepatic bile duct: report of two cases

Local recurrence, following a resection for cancer of the extrahepatic bile duct, is usually incurable with second curative surgery being almost impossible. To determine the feasibility and significance of second curative surgery, our experiences are presented in this study. The medical records and clinical outcomes of two patients that underwent a re-resection for recurrent cancer of the extrahepatic bile duct were retrospectively reviewed. A 50-year-old female patient that had a recurrent disease at the intrahepatic and intrapancreatic bile duct, 66 months after a segmental resection of the bile duct for common bile duct (CBD) cancer, underwent a hepatopancreatoduodenectomy. A 29-year-old female patient had a recurrent tumor mass in the distal CBD, 28 months after a right hemihepatectomy and Roux-en-Y hepaticojejenostomy for a type IIIa Klatskin tumor, and underwent a segmental resection of the bile duct. The gross type of the above two cases was a papillary tumor. There was no operative mortality or morbidity. All patients are still alive after 46 and 9 months, respectively, without recurrence after the reoperation. It is concluded that a surgical re-resection is possible in selected patients with recurrent bile duct cancer, mostly of the papillary type. A primary operation for bile duct cancer should be performed with a wide surgical margin, and secondary curative surgery should be considered whenever possible in cases of recurrence.     

Asymptomatic T-tube remnant in common bile duct.

A 46-year-old lady presented with itching, five years after a primary common bile duct repair following cholecystectomy. Prior to this she underwent an interno-external biliary drainage. At laparotomy the horizontal limb of a T-tube was found in the common hepatic duct. Eleven months after a Roux loop hepatico-jejunostomy she is asymptomatic.     

单中心腹腔镜胆囊切除致胆管损伤近年变化及特点分析

目的总结单中心腹腔镜胆囊切除致胆管损伤近年的变化及特点。方法回顾性分析总结近期组（2003年6月至2009年3月）和早期组（1992年10月至1998年6月）进行腹腔镜胆囊切除术（LC）患者的临床资料,并进行对比分析。结果近期组18613例中发生胆管损伤11例（发生率0．06％）,包括胆管横断伤2例（1例是中转开腹以后发生）、胆管分离性损伤3例、电凝伤2例（肝总管1例、副肝管1例）、胆总管部分剪切伤2例、副肝管横断伤1例、中转开腹肝总管部分缝扎伤1例;早期组11796例中发生胆管损伤15例（发生率0．13％）,包括横断伤6例、电灼胆管侧壁伤6例、分离伤3例。近期组LC致胆管损伤的发生率明显低于早期组（χ2=3．92,P=0．04784）。结论近期组Lc致胆管损伤的发生率较早期组明显降低,损伤程度也在降低,但损伤种类在不断增加,依据胆管损伤的类型进行“个体化”处理可减少胆管进一步损伤以及术后并发症的发生。     

A Case Report of Anomalous Pancreaticobiliary Duct Connection with Choledocholithiasis and Acute Pancreatitis

Abstract: A 25-year-old man was admitted to hospital with epigastric pain. He had had a history of episodic abdominal pain since early childhood. An anomalous pancreaticobiliary duct connection was seen by endoscopic retrograde cholangiopancreatography. In many cases, this type of abnormality is caused by an anomaly in the ventral pancreas. In this case, however, the common bile duct, with calculi, was joined to the pancreatic duct which did not arise from the ventral pancreas but from the dorsal pancreas. The pancreatic duct arising from the ventral pancreas was absent in this case. The patient underwent a prophylactic cholecystectomy, a transduodenal sphincteroplasty, a choledocholithotomy, a partial resection of the common bile duct, and a hepaticojejunostomy, performed by a Roux-en-Y anastomosis. His postoperative recovery was satisfactory. An anomalous pancreatobiliary duct connection allows pancreatic juices and bile to mix. This is considered to be an etiological factor in pancreatitis and choledocholithiasis.     

Carcinoma of cystic duct leading to obstructive jaundice

Summary Twenty-one cases of primary carcinoma of the cystic duct have been reported in the literature. Most cases were characterized by a hydrops or cholecystitis, whereas only two patients presented with jaundice. To our knowledge, this is only the third case of obstructive jaundice caused by a primary cystic duct carcinoma. The patient was treated by cholecystectomy with resection of the cystic duct tumor and a portion of the common bile duct. Reconstruction was performed by a Roux-en-Y choledocojejunostomy.     

Adenomyoma of the common hepatic duct

BackgroundAdenomyoma occurs most commonly in the fundus of the gallbladder, seldom in other parts of the gallbladder and rarely in the extrahepatic biliary tree, where most lesions are localised to the common bile duct or papilla of Vater. Adenomyoma of the common hepatic duct is extremely rare. To the best of our knowledge, only three cases have been reported so far.Case outlineA 51-year-old woman was admitted with a three month history of attacks of right upper abdominal pain, nausea, vomiting and fever. Laboratory data, ultrasonography, ERCP and CT confirmed slight cholestasis and proximal bile duct dilatation due to a tumour within the common hepatic duct. Cholecystectomy was performed with excision of the suprapancreatic common bile duct including the convergence of the hepatic ducts plus lymphadenectomy and Roux-en-Y hepaticojejunostomy. Frozen section histology showed the benign nature of the lesion and a tumour-free resection line. Final histology showed adenomyoma. The patient has remained symptomfree for more than 30 months.DiscussionAlthough adenomyoma is a benign lesion and the surgical strategy has not been established, complete excision with frozen section is recommended to exclude small malignant foci and local recurrence as well as to avoid surgical over-treatment.     

Duct-to-duct biliary reconstruction after radical resection of Bismuth Ⅲ a hilar cholangiocarcinoma

At present, radical resection remains the only effective treatment for patients with hilar cholangiocarcinoma. The surgical approach for R0 resection of hilar cholangiocarcinoma is complex and diverse, but for the biliary reconstruction after resection, almost all surgeons use Roux-en-Y hepaticojejunostomy. A viable alternative to Roux-en-Y reconstruction after radical resection of hilar cholangiocarcinoma has not yet been proposed. We report a case of performing duct-to-duct biliary reconstruction after radical resection of Bismuth Ⅲa hilar cholangiocarcinoma. End-to-end anastomosis between the left hepatic duct and the distal common bile duct was used for the biliary reconstruction, and a singlelayer continuous suture was performed along the bile duct using 5-0 prolene. The patient was discharged favorably without biliary fistula 2 wk later. Evidence for tumor recurrence was not found after an 18 mo follow- up. Performing bile duct end-to-end anastomosis in hilar cholangiocarcinoma can simplify the complex digestive tract reconstruction process.     

Recurrent carcinoma of cystic duct remnant with subcutaneous implantation in abdominal wall

A case of recurrent carcinoma of the cystic duct remnant invading the common bile duct and portal vein with subcutaneous implantation of the abdominal wall is presented. The patient was a 55-year-old woman with an abdominal wall tumor at the site of the surgical scar of a cholecystectomy, performed at a local hospital 5 years ago for symptomatic cholelithiasis. The diagnosis was made by incisional biopsy of the tumor, computed tomography, percutaneous transhepatic cholangiography, and angiography. She underwent extended right hepatic lobectomy with en bloc resection of the caudate lobe, extrahepatic bile duct, and portal vein. The abdominal wall tumor was resected concomitantly. Histological examination showed that both the recurrent carcinoma of the cystic duct remnant and the abdominal wall implantation were moderately differentiated adenocarcinoma. This recurrence probably could have been prevented if both the macroscopic and microscopic examinations of the resected specimen had been precisely carried out after the previous cholecystectomy and the primary carcinoma identified and treated at that time.     

Surgical management in biliary restricture after Roux-en-Y hepaticojejunostomy for bile duct injury

AIM: To discuss the surgical method and skill of biliary restricture after Roux-en-Y hepaticojejunostomy for bile duct injury. METHODS: From November 2005 to December 2006, eight patients with biliary restricture after Roux-en-Y hepaticojejunostomy for bile duct injury were admitted to our hospital. Their clinical data were analyzed retrospectively. RESULTS: Bile duct injury was caused by cholecys- tectomy in the eight cases, including seven cases with laparoscopic cholecystectomy and one with mini- incision choleystectomy. According to the classification of Strasberg, type E1 injury was found in one patient, type E2 injury in three, type E3 injury in two and type E4 injury in two patients. Both of the type E4 injury patients also had a vascular lesion of the hepatic artery. Six patients received Roux-en-Y hepaticojejunostomy for the second time, and one of them who had type E4 injury with the right hepatic artery disruption received right hepatectomy afterward. One patient who had type E4 injury with the proper hepatic artery lesion underwent liver transplantation, and the remaining one with type E3 injury received external biliary drainage. All the patients recovered fairly well postoperatively. CONCLUSION: Roux-en-Y hepaticojejunostomy is still the main approach for such failed surgical cases with bile duct injury. Special attention should be paid to concomitant vascular injury in these cases. The optimal timing and meticulous and excellent skills are essential to the success in this surgery.     

Cholangiocellular carcinoma in the caudate lobe with intraluminal growth in the extrahepatic bile duct.

A case of cholangiocellular carcinoma in the caudate lobe with intraluminal growth in the extrahepatic bile duct is reported. The main tumor in the caudate lobe was detected by computed tomography and angiography, and two intraluminal tumors at the hepatic hilus and at the root of the right posterior segmental duct were well demonstrated by cholangiography and percutaneous transhepatic cholangioscopy. Independent total caudate lobectomy with bile duct resection was performed. Cholangiocellular carcinoma of the liver with intraluminal growth in the extrahepatic bile duct is very rare and has not been reported in the literature. Independent caudate lobe resection requires a rather complicated technique. However, this method has the advantage of reducing to a minimum the hepatic volume to be resected, and is useful for poor-risk patients or for cases with localized carcinoma at the hepatic hilus.     

Biliary cystadenoma

The diagnosis of cystadenoma is rare, even more so when located in the extrahepatic bile duct. Unspecific clinical signs may lead this pathology to be misdiagnosed. The need for pathological anatomy in order to distinguish cystadenomas from simple biliary cysts is crucial. The most usual treatment nowadays is resection of the bile duct, together with cholecystectomy and Roux-en-Y reconstruction.     

Pseudoaneurysm following laparoscopic cholecystectomy

BACKGROUND:Laparoscopic cholecystectomy(LC)is the operation of choice for removal of the gallbladder. Unrecognized bile duct injuries present with biliary peritonitis and systemic sepsis.Bile has been shown to cause damage to the vascular wall and therefore delay the healing of injured arteries leading to pseudoaneurysm formation.Failure to deal with bile leak and secondary infection may result in pseudoaneurysm formation. This study was to report the incidence and outcomes of pseudoaneurysm in patients with bile leak following LC referred to our hospital. METHODS:A retrospective analysis of our prospectively maintained liver database using pseudoaneurysm, bile leak and bile duct injury following laparoscopic cholecystectomy from January 2000 to December 2005 was performed. RESULTS:A total of 86 cases were referred with bile duct injury and bile leak following LC and of these,4 patients (4.5%)developed hepatic artery pseudoaneurysm(HAP) presenting with haemobilia in 3 and massive intra- abdominal bleed in 1.Selective visceral angiography confirmed pseudoaneurysm of the right hepatic artery in 2 cases,cystic artery stump in one and an intact but ectatic hepatic artery with surgical clips closely applied to the right hepatic artery at the origin of the cystic artery in the fourth case.Effective hemostasis was achieved in 3 patients with coil embolization and the fourth patient required emergency laparotomy for severe bleeding and hemodynamic instability due to a ruptured right hepatic artery.Of the 3 patients treated with coil embolization, 2 developed late strictures of the common hepatic duct. . (CHD)requiring hepatico-jejunostomy and one developed a stricture of left hepatic duct.All the 4 patients are alive at a median follow up of 17 months(range 1 to 65)with normal liver function tests. CONCLUSIONS:HAP is a rare and potentially life- threatening complication of LC.Biloma and subsequent infection are reported to be associated with pseudoaneurysm formation.Late duct stricture is common either due to unrecognized injury at LC or secondary to ischemia after embolization.     

胆囊切除术后发生原发性胆总管结石70例临床分析

目的探讨胆囊切除与原发性胆总管结石的关系以及原发性胆总管结石手术治疗模式。方法收集新安县人民医院2007年1月至2013年12月收治的70例胆囊切除术后远期胆总管结石患者的临床资料,结合有关文献进行了分析。结果 70例患者均行手术治疗,术中证实胆总管结石均为胆色素结石。术后并发症:切口感染8例,肺部感染5例,无胆漏、胆道出血等严重并发症,均治愈出院。胆总管结石复发8例,分别于结石复发后2.5~4年再次手术,行胆总管切开取石加胆总管离断、Roux-Y胆总管空肠吻合术治愈。结论胆囊切除术后远期发生的原发性胆总管结石,是一种老年疾病,它不是胆囊切除术后的远期并发症,胆囊切除若未发生胆道损伤,就不会增加原发性胆总管结石的发生率。原发性胆总管结石须手术治疗,对于胆总管扩张直径2.5 cm者或复发病例,建议行开腹手术胆总管离断、Roux-Y胆总管空肠吻合术。     

Curative resection of a huge bile duct cancer without pancreatoduodenectomy

A 71-year-old woman was admitted to our hospital with obstructive jaundice. Magnetic resonance cholangiography revealed a 9-cm spindle-shaped tumor in the common bile duct. Laboratory examination noted a high concentration of total serum bilirubin. Although the serum concentration of carcinoembryonic antigen was within normal limits, the serum concentration of carbohydrate antigen 19-9 was elevated. We diagnosed the lesion as an extrahepatic bile duct cancer and performed a laparotomy. The anterior wall of the common bile duct was incised, and the tumor was found to have a small base in only the posterior wall of the duct, and spread within the duct was from the common hepatic duct to the intrapancreatic bile duct. Bile duct resection, cholecystectomy with lymphadenectomy and hepaticojejunostomy were performed. Frozen sections of the proximal and distal surgical margins of the bile duct were free of cancer. Macroscopically, the lesion was an expansive polypoid tumor measuring 9x3cm in diameter arising from a 5-mm base. Histologic examination revealed that the tumor was a well-differentiated tubular adenocarcinoma that had infiltrated the fibromuscular layer at its base. Longitudinal spread was more extensive hepatopetally than hepatofugally. The patient is alive and well without any complaints 8 months after surgery.     

A traumatic neuroma of the bile duct: a case report

Traumatic neuroma of the bile duct is not a true neoplasm, but a reactive proliferation of pericholangial nerve tissue induced by injury. A 60-year-old Japanese man was admitted to investigate obstructive jaundice. He had undergone cholecystectomy and common bile duct exploration 17 years previously. Ultrasonography and computed tomography showed a pneumobilia with dilatation of the intrahepatic biliary ducts. Endoscopic retrograde cholangiography and spiral-computed tomography cholangiography revealed biliary stenosis in the hepatic hilus with dilatation of the intrahepatic biliary ducts. Celiac angiography and arterial portography showed neither tumor stains nor signs of vessel invasion. At surgery, the confluent portion of the intrahepatic biliary ducts in the hepatic hilus was hardly palpable and deformed, but frozen-section microscopic examination confirmed that no malignant cells were present. Anastomosis of the right and left extrahepatic bile duct to the jejunum, reconstructed by Roux-en-Y hepaticojejunostomy, was performed. Histological examination revealed a nodule composed of a haphazard proliferation of nerve fascicles in the fibromuscular layer of the bile duct which were positively stained for S-100 protein. The pathological diagnosis was traumatic neuroma of the bile duct. Thus, the possibility of traumatic neuroma should be considered in the differential diagnosis of patients with late-onset jaundice after biliary tract surgery.     

Neuroendocrine carcinoma of the extrahepatic bile duct: Case report and literature review

Neuroendocrine carcinoma (NEC) of the extrahepatic bile duct is rare, and only 22 cases have been reported. Only two of these were large-cell NEC (LCNEC); the vast majority were small-cell NEC. Here, we report a third case of LCNEC of the extrahepatic bile duct. A 76-year-old male presented to a local hospital with painless jaundice. Imaging studies revealed a tumor at the hepatic hilum. The patient underwent right hepatic lobectomy, bile duct resection, and cholecystectomy. The resection specimen showed a 5.0-cm invasive neoplasm involving the hilar bile ducts and surrounding soft tissue. Histologically, the tumor consisted of nests of medium to large cells with little intervening stroma. The tumor invaded a large portal vein branch. All four excised lymph nodes were positive for metastasis, and metastatic deposits were also present in the gallbladder wall. The tumor was diffusely positive for synaptophysin and focally positive for chromogranin A. Approximately 70%-80% of the tumor cells were positive for Ki-67, indicating strong proliferative activity. A diagnosis of LCNEC was made. A few bile ducts within and adjacent to the invasive tumor showed dysplasia of the intestinal phenotype and were focally positive for synaptophysin and chromogranin A, suggesting that the dysplastic intestinal-type epithelium played a precursor role in this case. A postoperative computer tomography scan revealed rapid enlargement of the abdominal and retroperitoneal lymph nodes. The patient died 21 d after the operation. NEC of the bile duct is an aggressive neoplasm, and its biological characteristics remain to be better defined.     

Biliary leakage due to a rapidly growing post-traumatic hepatic artery pseudoaneurysm: a case report

Post-traumatic hepatic pseudoaneurysms are rare. We report a very unusual case of bile duct injury complicated with an asymptomatic post-traumatic hepatic pseudoaneurysm. A previously healthy 17-year-old man sustained multiple traumas after a motorcycle accident. Post-traumatic hepatic pseudoaneurysms were detected after blunt liver injury. The rapid growth of the pseudoaneurysms in the hepatic hilus compressed the common hepatic bile duct and caused extrahepatic bile leakage at the lateral lobe. At first, the hepatic arterial pseudoaneurysms were embolized and bile leakage at the left lobe was treated conservatively. Finally, however, segment 2 and 3 partial liver resection should have been performed to stop the bile leakage. Post-traumatic pseudoaneurysm should be ruled out, in addition to the presence of biliary tract injury, if the intraperitoneal bile leakage appears after liver injury.