Diagnostic significance of bile cytology in obstructive jaundice

Cytological examination of exfoliated cells in the bile or irrigated fluid from a percutaneous transhepatic choledochal drainage (PTCD) tube and other jaundice-reducing fistula was performed in 59 patients with obstructive jaundice. Malignant cells were found in 22 of 27 patients with choledochal cancer, 50 of 17 patients with pancreatic cancer, 3 of 6 patients with gallbladder cancer, and one of 5 patients with other malignancies. Exfoliated malignant cells were found at a higher rate in the washed fluid of the PTCD tube than in the pure bile aspirated from the PTCD tube. Half of the positive cases were diagnosed as such upon the first cytological examination, and the remaining in second or subsequent cytological examinations. The cytological appearance of cells in the washed fluid or bile reflected the type of cancer cells found by touch-smear of the lesion and also the histological type. This method requires no special technique and facilitates accurate diagnosis in patients with malignant lesion of the choledochal duct.     

Does seeding of intraluminal tumour cells cause anastomotic recurrence after oesophageal resection?

BACKGROUND: Recurrence at the cervical anastomosis of a tumour of the oesophagogastric junction after resection of the oesophagus with gastric tube reconstruction is a peculiar phenomenon in view of the distance of the primary tumour from the proximal anastomosis. It is hypothesised that contamination with tumour cells from the nasogastric tube or the gastric reconstruction tube could be responsible for this phenomenon. METHOD: Fifteen patients with a tumour of the oesophagus or gastric cardia were included. During the operation the nasogastric tube was left in the resected specimen. Debris from the tube was washed out for cytological examination. Also the gastric reconstruction tube was washed out and the debris examined for malignant cells. RESULTS: In all of the patients with a tumour extending intraluminally malignant cells were found in the nasogastric tube or the gastric reconstruction tube or both. In 92% of these patients malignant cells were found in the nasogastric tube, while 60% of the gastric reconstruction tubes were contaminated with tumour cells. CONCLUSION: The presence of intraluminal malignant cells during oesophageal resection and gastric tube reconstruction is very high, possibly leading to anastomotic recurrence. Measures should be taken to minimise local contamination with tumour cells.     

Segmental primary sclerosing cholangitis mimicking bile duct cancer—Report of a case and review of the Japanese literature

A rare case of the segmental type of primary sclerosing cholangitis (PSC) is reported herein. A 27 year old Japanese man with obstructive jaundice was referred to our hospital with a provisional diagnosis of bile duct cancer at the hepatic hilum. A PTCD tube had been inserted from the right anterior segmental duct and direct cholangiograms showed complete obstruction of the bile duct at the confluence of the right and left hepatic ducts. Resection of the extrahepatic bile duct and partial hepatectomy were thus performed, however, the postoperative histological examination revealed no malignant features. Instead, the lesion was shown to be compatible with PSC microscopically. A diagnosis of PSC was finally established on the basis of clinical features, cholangiographic appearance and the pathological report.     

Segmental primary sclerosing cholangitis mimicking bile duct cancer--report of a case and review of the Japanese literature.

A rare case of the segmental type of primary sclerosing cholangitis (PSC) is reported herein. A 27 year old Japanese man with obstructive jaundice was referred to our hospital with a provisional diagnosis of bile duct cancer at the hepatic hilum. A PTCD tube had been inserted from the right anterior segmental duct and direct cholangiograms showed complete obstruction of the bile duct at the confluence of the right and left hepatic ducts. Resection of the extrahepatic bile duct and partial hepatectomy were thus performed, however, the postoperative histological examination revealed no malignant features. Instead, the lesion was shown to be compatible with PSC microscopically. A diagnosis of PSC was finally established on the basis of clinical features, cholangiographic appearance and the pathological report.     

Malignant tumors in choledochal cysts.

Between 1960 and 1975, 17 patients with congenital cystic dilatation of the common bile duct (choledochal cyst) were treated and three were associated with malignant tumors in the cysts and one was with carcinoma of the gallbladder. Preoperative diagnosis of adenocarcinoma in the choledochal cyst was established in one patient by cytologic examination of the bile which was obtained during the procedure of endoscopic pancreaticocholangraphy (EPCG) and percutaneous transhepatic cholangiography (PTC). Definitive treatment of the choledochal cysts associated with malignant tumors in the biliary tract was accomplished by excision of the cysts with tumor and choledochojejunostomy in two patients, by cystoduodenostomy following external drainage in one and by cholecystectomy with resection of invaded transverse colon in one with cancer of the gallbladder. Successful excision of choledochal cysts in 11 patients including three cases associated with malignant tumors in the biliary tract during the last 15 year period is the basis of this report.     

经皮肝穿胆管内钳夹组织活检及毛刷细胞学检查对梗阻性黄疸病因的诊断价值

目的探讨可疑恶性梗阻性黄疸患者经皮肝穿胆道引流（percutaneous transhepatic cholangiodrainage，PTCD）通道钳夹活检及毛刷活检取得组织病理学的诊断诊值。方法2005年4月～2006年4月，对24例梗阻性黄疸行PTCD和胆道内支架置人术，PTCD同时采用钳夹、毛刷2种方法活检行组织病理学检查。结果24例接受钳夹活检，14例同时接受毛刷活检。24例钳夹活检均获得病变组织，病理结果：腺癌15例，查到异型细胞4例（认为是阳性结果）；炎性组织1例，为支架置入术后再狭窄病例；纤维组织1例；3例取得组织为胆管上皮，其中1例临床诊断为胃癌术后胰头周围淋巴结转移，2例为胆管癌，活检阳性率为79．2％（19／24）。4例支架置入术后再狭窄组织病理学结果：炎性组织1例，腺癌2例，异型细胞1例。14例毛刷组织细胞学检查：2例查出瘤细胞，2例查出异型细胞（认为是阳性结果），阳性率为28．6％（4／14），其余均为阴性结果。结论经PTCD胆管内活检简单、安全，并发症少，准确率高，行PTCD引流减黄治疗的同时可得到病理学的诊断，为下一步治疗提供病理学依据。     

Value of DNA analysis in addition to cytological testing in the diagnosis of malignant pleural effusions.

BACKGROUND--Aneuploidy appears to be a highly specific marker for cancer, and measurement of cellular DNA content by flow cytometry is rapid and reliable. This study was undertaken to determine if the addition of DNA analysis improved the sensitivity of cytological diagnosis of malignancy in pleural fluid. METHODS--Pleural effusions from 92 patients were studied by cytological examination and flow cytometry. RESULTS--In 41 patients the final diagnosis was malignancy, there were 40 cases of benign effusions including 22 with pleural tuberculosis, and in the remaining 11 patients with biopsy proven cancer the presence of malignant cells was not found by cytological and histological means in the pleural fluid. Aneuploidy and cytological malignancy were found in 14 samples. There were seven cases with abnormal flow cytometry and negative cytological results. In 12 patients the cytological test results were positive but DNA analysis was normal. Thirty six samples of fluid were both diploid and cytologically negative. Of the 22 tuberculous effusions seven contained aneuploid cells. The sensitivity of DNA and cytological analysis was 51.2% and 63.4%, respectively. The specificity of DNA analysis was 74.5%. CONCLUSIONS--DNA analysis of cells in malignant pleural effusions is both less sensitive and specific than the cytological diagnosis. Flow cytometric analysis is not recommended for routine use in the diagnosis of pleural effusions.     

肝脏肿瘤动脉栓塞化疗术后胆管狭窄

目的 分析肝脏经导管动脉栓塞化疗(transcatheter arterial chemoembolization,TACE)术后胆管狭窄致梗阻性黄疸的外科治疗方法.方法 回顾性分析1994年6月至2010年3月在浙江省人民医院及上海交通大学医学院附属新华医院行肝脏TACE治疗后出现胆管狭窄的15例患者的临床资料.7例为原发性肝癌,5例为肝脏血管瘤,3例为转移性肝癌,原发疾病分别为结肠癌2例和胰腺癌1例.肝脏TACE后出现梗阻性黄疸的时间为5～16个月,中位时间为9个月.结果 15例胆管狭窄病例均出现不同程度的梗阻性黄疸,13例经外科手术或经皮肝穿刺胆管造影(percutaneous transhepatic cholangiography,PTC)+放置胆管支架,2例仅行经皮肝穿刺胆道引流(percutaneous transhepatic cholangial drainage,PTCD).术后梗阻性黄疸均获得明显缓解.5例肝血管瘤状况良好;2例原发性肝癌TACE后梗阻性黄疸随访2年,无胆管梗阻再发和肿瘤复发;其余8例随访3～18个月,均死于原发病恶化.结论手术或介入手段治疗肝脏TACE术后胆管狭窄致梗阻性黄疸可获得良好的治疗效果,应根据原发病和胆管梗阻的部位、范围决定治疗方式.

Abstract：

Objective To evaluate the treatment of obstructive jaundice caused by bile duct strictures after hepatic transcatheter arterial chemoembolization in hepatic tumor patients. Methods A retrospective review (Jun 1994 - Mar 2010) of databases at two institutions (Zhejiang Provincial People's Hospital and Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine) identified 15patients with obstructive jaundice caused by liver bile duct stricture after transcatheter arterial chemoembolization. There were 7 cases of primary liver cancer, 5 patients of liver hemangioma, 3 cases of metastatic liver cancer including 2 cases of colonic cancer and one of pancreatic cancer. Obstructive jaundice appeared in a period of 5 months to 16 months after TACE. The median time was 9 months. Results The obstructive jaundice was relieved by surgically constructed hepatobiliary drainage or PTC+stenting treatment in 13 cases and PTCD in 2 cases. All patients of hepatic hemangioma were doing well after treatment. Two cases of primary liver cancer patients with obstructive jaundice after TACE were followed up for 2 years with no recurrence of hepatic carcinoma and bile duct obstruction. The other 8 patients were followed up from 3months to 18 months until to their death from primary disease progress. Conclusions Surgery and or PTCD plus stent can effectively relieve the obstructive jaundice caused by TACE in benign or malignant liver tumors.     

肝脏肿瘤动脉栓塞化疗术后胆管狭窄

目的 分析肝脏经导管动脉栓塞化疗(transcatheter arterial chemoembolization,TACE)术后胆管狭窄致梗阻性黄疸的外科治疗方法.方法 回顾性分析1994年6月至2010年3月在浙江省人民医院及上海交通大学医学院附属新华医院行肝脏TACE治疗后出现胆管狭窄的15例患者的临床资料.7例为原发性肝癌,5例为肝脏血管瘤,3例为转移性肝癌,原发疾病分别为结肠癌2例和胰腺癌1例.肝脏TACE后出现梗阻性黄疸的时间为5～16个月,中位时间为9个月.结果 15例胆管狭窄病例均出现不同程度的梗阻性黄疸,13例经外科手术或经皮肝穿刺胆管造影(percutaneous transhepatic cholangiography,PTC)+放置胆管支架,2例仅行经皮肝穿刺胆道引流(percutaneous transhepatic cholangial drainage,PTCD).术后梗阻性黄疸均获得明显缓解.5例肝血管瘤状况良好;2例原发性肝癌TACE后梗阻性黄疸随访2年,无胆管梗阻再发和肿瘤复发;其余8例随访3～18个月,均死于原发病恶化.结论手术或介入手段治疗肝脏TACE术后胆管狭窄致梗阻性黄疸可获得良好的治疗效果,应根据原发病和胆管梗阻的部位、范围决定治疗方式.     

肝脏肿瘤动脉栓塞化疗术后胆管狭窄

目的 分析肝脏经导管动脉栓塞化疗(transcatheter arterial chemoembolization,TACE)术后胆管狭窄致梗阻性黄疸的外科治疗方法.方法 回顾性分析1994年6月至2010年3月在浙江省人民医院及上海交通大学医学院附属新华医院行肝脏TACE治疗后出现胆管狭窄的15例患者的临床资料.7例为原发性肝癌,5例为肝脏血管瘤,3例为转移性肝癌,原发疾病分别为结肠癌2例和胰腺癌1例.肝脏TACE后出现梗阻性黄疸的时间为5～16个月,中位时间为9个月.结果 15例胆管狭窄病例均出现不同程度的梗阻性黄疸,13例经外科手术或经皮肝穿刺胆管造影(percutaneous transhepatic cholangiography,PTC)+放置胆管支架,2例仅行经皮肝穿刺胆道引流(percutaneous transhepatic cholangial drainage,PTCD).术后梗阻性黄疸均获得明显缓解.5例肝血管瘤状况良好;2例原发性肝癌TACE后梗阻性黄疸随访2年,无胆管梗阻再发和肿瘤复发;其余8例随访3～18个月,均死于原发病恶化.结论手术或介入手段治疗肝脏TACE术后胆管狭窄致梗阻性黄疸可获得良好的治疗效果,应根据原发病和胆管梗阻的部位、范围决定治疗方式.     

经皮肝穿刺胆管引流术的常见并发症及防治

目的分析经皮肝穿刺胆管引流术（PTCD）的常见并发症,提出防治措施。方法对220例接受PTCD治疗的梗阻性黄疸患者的资料进行回顾性分析。结果 220例患者中,218例为肝外梗阻性黄疸,其中良性梗阻9例,恶性梗阻209例;2例为肝内梗阻性黄疸,其中硬化性胆管炎1例,肝转移瘤肝内胆管广泛受侵1例。穿刺成功率为99.09%,穿刺失败的2例均为肝内梗阻性黄疸。9例患者于PTCD术后24～72h内死亡。PTCD术中出现胆心反射35例,术后出血6例,感染16例,胸膜损伤3例,胆汁性腹膜炎1例,急性肾衰竭1例,引流管脱出14例,胆汁过度分泌1例,急性前壁心肌梗死1例。结论 PTCD的并发症种类较多,一些严重的并发症可导致患者死亡,但通过术前充分准备、术中及术后积极处理,可有效防止多数并发症的发生。     

ARE SECONDARY BILE ACIDS IN CHOLEDOCHAL CYSTS IMPORTANT AS A RISK FACTOR IN BlLlARY TRACT CARCINOMA?

Since secondary bile acids have mutagenic potency and choledochal cyst patients with or without cyst-enterostomy have a high risk of developing bile duct carcinoma, we examined the hypothesis that secondary bile acids are elevated in the choledochal cyst and possibly cause biliary tract carcinoma. Eleven choledochal cyst patients with or without previous cyst-enterostomy or biliary tract carcinoma, seven patients with biliary tract carcinoma not associated with choledochal cyst and five patients with cholecystolithiasis were examined. Samples were directly needle aspirated from the cyst or by cannulating a tube into the common bile duct through the cystic duct. The concentrations of each bile acid in these samples were quantified by gas-liquid chromatography and compared. Neither the relative composition nor the absolute concentration of secondary bile acids (deoxycholic acid, lithocholic acid) elevated in patients with choledochal cyst compared with the values in the non-choledochal cyst patients with or without biliary tract carcinoma. The presence of biliary tract carcinoma or previous cyst-enterostomy did not affect the concentrations of secondary bile acids. The results suggest that the factor other than secondary bile acids can be primarily responsible for the high risk of bile duct carcinoma in patients with choledochal cyst.     

Nonmalignant pericardial effusion associated with thymic cancer

We report a case of thymic carcinoma with massive pericardial effusion in a 74-year-old man. This patient with dyspnea was referred to our hospital because of pericardial effusion detected by echocardiography. A chest computed tomography and magnetic resonance imaging showed an anterior mediastinal mass measuring 8.0 × 5.0 cm with massive pericardial effusion. The mass lesion was suggestive of thymic carcinoma or invasive thymoma. Initially, he underwent pericardial drainage. The collected fluid was serous and yellow, and cytological examination found no malignant cells. The tumor with partial pericardium was resected. Histopathological findings confirmed the lesion to be squamous cell carcinoma of the thymus. The etiology of a massive nonmalignant pericardial effusion associated with thymic carcinoma warrants further studies. The patient is alive without recurrence and without pericardial effusion at 3 years to date after the operation. Not all pericardial effusion associated with thymic cancer involves malignant effusion.     

Bronchoscopic evaluation of peripheral lung tumours.

The results obtained from fibreoptic bronchoscopy preformed under fluoroscopic guidance were evaluated in a prospective study of 71 consecutive patients with a peripheral lung lesion more than 2 cm in diameter on the chest radiograph. A peripheral lung lesion was defined as a lesion that was not seen within the bronchial tree at fibreoptic bronchoscopy. Small volume washings, bronchoalveolar lavage, transbronchial biopsy, and bronchial brushings were carried out and fluid or tissue was sent for cytological or histological examination as appropriate. Of the 71 patients, 51 were subsequently shown to have malignant disease. In 38 of the patients the diagnosis of malignancy was made by bronchoscopy, from histological specimens alone or in conjunction with cytological specimens in 33, from brushings alone in two, and from bronchoalveolar lavage fluid alone in three patients. There were no important complications. Thus fibreoptic bronchoscopy in conjunction with fluoroscopic screening appears to be an effective and safe method for the initial investigation of a peripheral lung lesion more than 2 cm in diameter.     

Surgical treatment of type IV choledochal cysts

The benefit of total resection of the dilated bile duct has remained unclear. We describe here our surgical management of 13 patients with type IV choledochal cysts. All six younger patients (25–35 years old) underwent resection of the extrahepatic bile duct (EHBD) and hepaticojejunostomy (HJ), whereas three of the seven older patients (50–68 years old) underwent resection of the EHBD resection and HJ, with the remaining four older patients undergoing total resection of the dilated bile duct and removal of a pancreatobiliary maljunction (PBMJ) in the form of a S4a+S5 hepatectomy (so-called Taj Mahal) and/or pancreas head resection with second portion pancreaticoduodenectomy. No malignancies were detected in the dilated bile duct after resection in the younger patients, but cancer of the gallbladder and/or the dilated bile duct was found in two (27.5%) of the older patients. No cancers were detected during the long-term follow up (1974–2008) in those patients who underwent EHBD resection plus partial hepatectomy, but cancer developed in the remnant duct in one of the older patients who underwent EHBD resection alone. Based on our findings, we recommend that type IV choledochal cysts should be treated by total excision of the dilated bile duct, including the PBMJ, due to its frequent association with malignancy, and to prevent the development of cancer in the remnant duct and improve the long-term survival rate.     

胆道再手术的原因及对策

目的：探讨胆道再手术的原因和对策。方法：对1994年12月－20000年12月间胆道再手术102例进行回顾性分析。结果：75例行胆管切开取石,其中12例同时行肝叶切除,5例胆总管十二指肠合改行胆总管空肠Roux-en-Y吻合或再做其他术式,12例胆道恶性肿瘤分别行根治术,内外引流和PTCD,4例行胆管整形和胆肠吻合术,4例行囊肿切除胆肠Roux-en-Y吻合,2例行残余胆囊和胆囊残株炎切除,胆道再手术主要原因是结石复发（52．0％）,残石（21．6％）,恶性肿瘤（11．8％）,术式选择或操作不当（8．8％）,及胆管狭窄（3．9％）,续集：为降低胆道再手术率,强调应明确术前诊断,采用正确的术式,术中胆道镜,胆道造和B超检查,审真操作,积极进行根治性手术,尽量避免急诊手术和术后经T管窦道取石。     

Effectiveness of intraoperative cytological examination of peritoneal washings for patients with pancreatic cancer]

To confirm the effectiveness of cytological examination of peritoneal washings for detecting invisible micro-peritoneal dissemination in patients with pancreatic cancer, results were analyzed with the survival and the background factors of the patients. Cytological examination of peritoneal washings or ascitic fluid at recto-vesical pouch or pouch of Douglas was performed in 37 patients with primary pancreatic cancer. Positive results for cancer cells were obtained in five of 9 patients (55.6%) who received cytological examination of ascitic fluid and in seven of 28 patients (25.0%) who received that of peritoneal washings. Four of 6 patients (66.7%) with visible peritoneal dissemination showed positive results. These 6 patients died of peritoneal dissemination with about 10 months. Eight of 31 patients (25.8%) without visible peritoneal dissemination showed positive results of the cytological examination. Two of the 8 patients received resection of the tumor. Other 6 patients without resection developed clinically evident peritoneal carcinomatosis. A high positive rate (66.7%) of cytological examination of the patients with visible peritoneal dissemination and a high incidence of appearance of peritoneal carcinomatosis in patients with positive cytological results but without visible peritoneal dissemination (75.0%; positive vs 26.1%; negative) indicate a high reliability of the cytological examination to detect invisible micro-peritoneal dissemination.     

恶性梗阻性黄疸介入治疗与手术引流比较

目的比较恶性梗阻性黄疸经皮经肝穿刺胆管引流(PTCD)与手术引流的疗效。方法收集不能手术切除的恶性梗阻性黄疸患者资料131例,其中102例常规经皮经肝穿刺胆管造影后放置内、外引流管或者留置金属内支架(介入治疗组),解除胆管梗阻;另29例为同期术前判断有手术切除可能而术中证实不能行根治性手术或者不同意行PTCD治疗患者(手术引流组),行开腹胆管内、外引流术。比较2组治疗前、后总胆红素变化、术后并发症发生情况、住院时间以及住院费用。结果介入治疗组穿刺成功率100%,与手术引流组比较,介入治疗组平均胆红素下降50%时间、术后总并发症发生率差异均无统计学意义(P0.05),但平均住院时间和平均住院费用均少于手术引流组(P0.05)。结论与手术引流比较,介入治疗具有微创性,可以重复操作,明显缩短住院时间,减少住院费用,且并不增加并发症发生率,并可以为后续治疗创造条件,是不能手术切除恶性梗阻性黄疸治疗的首选方法。     

胆道恶性梗阻胆汁病原菌与敏感抗生素及有关因素分析

目的对胆道恶性梗阻患者胆汁病原菌的菌群分布、临床常用抗菌药物的敏感性及有关因素进行分析,为胆道感染抗菌药物的合理应用提供参考。方法 2008年5月～2011年8月,92例行ERCP或PTCD的胆道恶性梗阻患者,ERCP术中插管成功并确认进入胆道或PTCD术中用22G穿刺针行胆管穿刺成功确认在胆管内后,抽取胆汁进行细菌学培养和抗菌药物敏感性检测,分析细菌谱与梗阻的部位、程度等有关因素的关系。结果 92例胆道恶性梗阻共送检124份胆汁。90份细菌培养阳性胆汁中,胆道感染的主要病原菌为肠球菌属（24.4%,22份）、大肠埃希菌（18.9%,17份）、肺炎克雷伯菌（7.8%,7份）、铜绿假单胞菌（5.6%,5份）。革兰阳性球菌对万古霉素和利奈唑胺的敏感率均为100%（37/37）,对呋喃妥因、夫西地酸和左氧氟沙星的敏感率分别为73.0%（27/37）、45.9%（17/37）和37.8%（14/37）;革兰阴性杆菌对亚胺培南、阿米卡星、哌拉西林/他唑巴坦、头孢吡肟和左氧氟沙星的敏感率分别为93.8%（45/48）、85.4%（41/48）、68.8%（33/48）、39.6%（19/48）、33.3%（16/48）。大肠埃希菌的超广谱β-内酰胺酶（ESBL）的阳性率为64.7%（11/17）,肺炎克雷伯菌为42.9%（3/7）。中低位梗阻细菌培养阳性率为49.0%（25/51）,高位梗阻为85.4%（35/41）（χ2=13.236,P=0.000）。血总胆红素水平低（20.2～171μmol/L）、中（172～342.1μmol/L）、高水平（≥342.1μmol/L）细菌培养阳性率分别为74.4%（29/39）、62.5%（25/40）、46.2%（6/13）（χ2=3.650,P=0.161）。结论胆道恶性梗阻患者的胆道感染以肠球菌属占首位,且高位恶性梗阻的患者细菌培养阳性率高。因此,对恶性梗阻性胆道感染的治疗,应尽早解除胆道梗阻,并根据药物敏感性选择合适的抗生素,尤其要注意考虑到覆盖肠球菌属。     

经皮肝径路胆胰镜下钬激光碎石术治疗胆管结石初探

目的 探讨经皮肝胆管穿刺置管胆胰镜下钬激光碎石术治疗胆管结石的可行性。方法 选取12例难以耐受手术或难以实施手术的肝内外胆管多发结石患者,经皮肝径路行胆胰镜下钬激光碎石术,术后行PTCD引流,CT提示胆总管无结石残留、无胆道梗阻后拔出PTCD管。结果 12例均顺利施行经皮肝胆胰镜下钬激光碎石术,手术时间1.0～3.5 h,平均2.5 h;5例行单次碎石术,6例行2次碎石术,1例行3次碎石术;1例术中出现发热反应,1例出现PTCD管脱落。结论 经皮肝胆管穿刺置管胆胰镜下钬激光碎石术治疗肝内外胆管多发结石是一微创、安全、有效的术式。