Metastatic melanoma to the common bile duct causing obstructive jaundice： A case report

Metastatic melanoma to the common bile duct is very rare with only 18 cases reported so far. We report a 46 year old women who, 18 mo after excision of a skin melanoma, developped a painless progressive obstructive jaundice. At operation a melanoma within the distal third of the common bile duct was found. There were no other secondaries within the abdomen. The common bile duct, including the tumor, was resected and anastomosed with Roux-en-Y jejunal limb. The patient survived 31 mo without any sign of local recurrence and was submitted to three other operations for axillar and brain secondaries, from which she finally died. Radical resection of metastatic melanoma to the common bile duct may result in lifelong relief of obstructive jaundice. It is safe and relatively easy to perform. In other cases, a less aggressive approach, stenting or bypass procedures, should be adopted.     

Double common bile duct： A case report

Double common bile duct （DCBD） is a rare congenital anomaly in which two common bile ducts exist. One usually has normal drainage into the papilla duodeni major and the other usually named accessory common bile duct （ACBD） opens in different parts of upper gastrointestinal tract （stomach, duodenum, ductus pancreaticus or septum）. This anomaly is of great importance since it is often associated with biliary lithiasis, choledochal cyst, anomalous pancreaticobiliary junction （APBJ） and upper gastrointestinal tract malignancies. We recently recognized a rare case of DCBD associated with APB3 with lithiasis in better developed common bile duct. The opening site of ACBD was in the pancreatic duct. The anomaly was suspected by transabdominal ultrasonography and finally confirmed by endoscopic retrograde cholangiopancreatography （ERCP） followed by endoscopic sphincterotomy and stone extraction. According to the literature, the existence of DCBD with the opening of ACBD in the pancreatic duct is most frequently associated with APB3 and gallbladder carcinoma. In case of DCBD, the opening site of ACBD is of greatest clinical importance because of its close implications with concomitant pathology. The adequate diagnosis of this rare anomaly is significant since the operative complications may occur in cases with DCBD which is not recognized prior to surgical treatment.     

Primary closure of the common bile duct in open laparotomy for common bile duct stones

It is common these days to treat common bile duct (CBD) stones using endoscopic techniques. However, severe complications sometimes lead to death despite the great benefit of these techniques. If the patient has many and/or large stones, it can take considerable time for duct clearance, and this is associated with high costs. Therefore, we do not hesitate to choose surgical procedures when necessary. In this study, our aim was to evaluate the usefulness of primary closure of the CBD in open laparotomy for CBD stones. Thirty-four patients with CBD stones were operated on by open laparotomy; primary closure was done in 17 patients (group PC), and T-tube insertion was done in 17 (group TT). We compared the patients' medical records, clinical features, laboratory data, complications, and postoperative hospital admission days. There were no significant intergroup differences in patients' medical records, clinical features, or laboratory data, except for the number of CBD stones. There were no differences in complications. All complications were minor and needed no extra care. The number of postoperative hospital admission days showed a significant difference: 18.3 days in group PC and 31.5 in group TT. There are so many methods to treat CBD stones now that the selection of the procedure can be important for the patient's benefit. We prefer primary closure, to get better quality of life postoperatively and to avoid further operations and any severe complications.     

The case for laparoscopic common bile duct exploration

The modern surgeon's approach to choledocholithiasis depends his or her view of cholangiography. During the early 1990 there was a swing away from cholangiography, which had previously been common practice. This was because of perceptions of difficulty with the technique, the time it took, and perhaps an implied increase in costs because of the time factor. There was no evidence on which to base this decision. This led to a marked upswing in the use of endoscopic retrograde cholangiopancreatography (ERCP). There were a large number of ERCPs with normal results performed prior to laparoscopic cholecystectomy. This paper states the case for intraoperative cholangiography and common bile duct clearance at the time of cholecystectomy. It is hoped that this technique will be adopted so patients can undergo a single procedure to remove their gallstones and common bile duct stones if they exist and to decrease the incidence of normal preoperative ERCPs and the need for a second procedure postoperatively to clear stones if they are found.     

胆总管神经纤维瘤1例报告

1病例资料 患者女性,47岁,因发现＂皮肤、巩膜黄染8 d＂于2015年10月8日入本院。病程中无明显腹痛、腹胀,寒战高热等症状。既往：2015年4月30日于吉林市华侨医院诊断为胆囊结石,胆管结石行腹腔镜胆囊切除术、胆道探查取石、T管引流术。5年前因子宫肌瘤行子宫次全切术。20年前行阑尾切除术。体格检查：皮肤、巩膜黄染。     

Technical aspects in the laparoscopic management of complicated common bile duct stones

The management of common bile duct (CBD) stones traditionally required open laparotomy and bile duct exploration. With the advent of endoscopic and laparoscopic technology in the latter half of last century, endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC) has become the mainstream treatment for CBD stones and gallstones in most medical centers around the world. However, in certain situations, ERCP cannot be feasible because of difficult cannulation and extraction. ERCP can also be associated with potential serious complications, in particular for complicated stones requiring repeated sessions and additional maneuvers. Since our first laparoscopic exploration of the CBD (LECBD) in 1995, we now adopt the routine practice of the laparoscopic approach in dealing with endoscopically irretrievable CBD stones. The aim of this article is to describe the technical details of this approach and to review the results from our series.     

Malignant metastatic melanoma of common bile duct: virtual CT cholangioscopy findings

Metastases from melanoma to biliary ducts are little known but not so rare, although only a few cases have been previously described. A case of metastasis from amelanotic melanoma to the common bile duct, appearing as a vegetating lesion and diagnosed by spiral computed tomography, using also computed tomography virtual cholangioscopy, is described. The clinical role of computed tomography virtual cholangioscopy is discussed. Metastases from melanoma are recommended to be considered in differential diagnosis of endoluminal soft masses in the biliary ducts.     

Transnasal biliary drainage for treatment of common bile duct leakage and bile peritonitis

Summary A new nonoperative method for treating postoperative common bile duct leaks by endoscopic placement of a nasobiliary stent is described. Two patients were treated successfully by placing a nasobiliary stent above the point of bile leakage, acting to divert the flow of bile and to allow the fistula to close.     

Resected cystadenoma of the common bile duct

Biliary cystadenoma in the extrahepatic bile ducts is a very rare tumor. A 62-year-old woman with jaundice was admitted to our hospital. Imaging studies revealed a 4-cm cystic lesion around the hepatic hilum, compressing the common bile duct (CBD). When laparotomy was performed, a cystic tumor was detected in the hepatic hilum, filling the lumen of the CBD. Bile duct resection that included the tumor was performed, followed by biliary reconstruction. Microscopically, the cyst wall was lined by a single layer of cuboidal epithelial cells, covering an ovarian-like stroma. The degree of atypia was low and warranted the diagnosis of cystadenoma.     

Pancreatitis complicating mucin-hypersecreting common bile duct adenoma

Villous adenomas of the bile ducts are extremely uncommon. We describe a 58-year-old man presenting with clinical signs and laboratory findings of acute pancreatitis and obstructive jaundice. Preoperative investigation demonstrated a dilated papillary orifice with mucus exiting (fish-mouth sign) and a filling defect in the distal common bile duct. He underwent a modified Whipple operation and histological examination of the surgical specimen showed villous adenoma with rich secretion of mucus.     

Embryonal rhabdomyosarcoma of the common bile duct mimicking choledochal cyst

Embryonal rhabdomyosarcoma of the common bile duct is a very rare malignancy of childhood. The radiological appearance of the lesion is similar to that of congenital choledochal cyst if there is no local invasion to the adjacent tissues. The authors present a case of embryonal rhabdomyosarcoma of the common bile duct which was considered to be a congenital choledochal cyst preoperatively, and they discuss this very rare childhood tumor, with a brief survey of the literature. In conclusion, it is important to know that this rare tumor can simulate congenital choledochal cyst; it should be considered in the differential diagnosis of obstructive jaundice in children.     

Hilar bile duct resection for bile duct carcinoma at the hilus of the liver

Hilar bile duct resection, by which only the bile duct is resected, was carried out in 31 patients with bile duct carcinoma at the hepatic hilus. However, curative resection was possible in only 4 patients (12.9%). The postoperative 1-, 3-, and 5-year survival rates were 58.1%, 19.4%, and 7.7%, respectively. These results indicate that treatment of this hilar bile duct carcinoma by hilar bile duct resection is of limited value. We believe that this operative procedure should be used only for papillary or nodular carcinoma at the hepatic confluence at relatively early stages of Bismuth's type I or II.     

经十二指肠镜括约肌切开胆总管结石的处理(附168例报告)

目的：采用各种方法处理不同大小的胆总管结石。方法：于1986年3月至1996年9月经内镜括约肌切开（EST）治疗胆总管结石168例，其中单颗结石63例，2颗结石56例，3颗以上结石49例，最多一例8颗结石，结石的直径为5～25mm不等。结果：165例（98．2％）切开成功，3例失败。161例（95．8％）结石排出，其中96例（59．6％）结石自然排入肠道，57例（35．4％）采用网篮或气囊取出结石，6例（3．7％）采用碎石网篮碎石后排出，2例（1．2％）经震波碎石后排出。术后出现胃肠道出血1例（0．6％），胰腺炎1例（0．6％），胆管炎3例（1．8％）。48例术后行胃肠钡餐检查，43例胆道内无钡剂返流，2例胆道内有积气，3例有钡剂返流入胆道，但无临床症状。结论：EST是目前治疗胆管结石的重要手段之一。     

内镜超声检查对胆总管扩张的诊断价值

目的评价内镜超声检查(EUS)对胆总管扩张的病因诊断价值。方法32例患者在EUS 前均做过体表B超检查。患者的病因诊断均在病理或手术(包括奥狄括约肌切开取石)后确定。结果(1)32例患者的B超及EUS对胆总管直径的测定结果分别为(1.04±0.41)cm和(0.97±0.36)cm,两者差异无显著性(P＞0.05)。(2)对胆总管扩张的病因诊断率EUS为29/32(90.6％),明显高于体表B超19/32(59.4％),P＜0.01;X线电子计算机断层扫描(CT)21/32(65.6％),P＜0.05。EUS与磁共振胆胰管成像(MRCP)13/16(81.3％)和内镜逆行胰胆管造影(ERCP)31/32(96.9％)诊断率 相似(P＞0.05)。结论EUS对胆总管扩张的病因有很高的诊断价值。     

胆总管下段梗阻44例影像学检查鉴别诊断体会

目的 总结影像学检查对胆总管下段梗阻的鉴别诊断经验.方法 选取胆总管下段梗阻住院患者44例作为研究对象,其中A组25例,为壶腹癌及胆总管下段癌患者;B组19例,为胆总管结石患者.统计两组患者的年龄、性别、首发症状和腹部B超、腹部CT、核磁共振（MRCP）、内镜逆行胰胆管造影（ERCP）测量的胆总管宽度及其对病变的诊断情况.结果 A组患者胆总管扩张程度高于B组,两组比较差异有显著性.对于胆总管结石的患者,除CT检查和B超与CT联合检查诊断率高于单用B超检查外,MRCP对胆总管下段结石的诊断率较高.结论 胆总管下段恶性梗阻患者的胆总管扩张程度高于胆总管结石,MRCP作为一种无创检查,在胆总管结石的诊断上具有较大优势.     

Synchronous double cancers of the common bile duct

We report an extremely rare case of synchronous double cancers of the common bile duct without pancreaticobiliary maljunction. Only two similar cases have been reported in the English literature. Endoscopic re-trograde cholangiopancreatography showed a tuberous filling defect in the middle and superior parts of the common bile duct, and mild stenosis in the inferior duct. Computed tomography (CT) showed a well enhanced mass in the middle and superior parts of the common bile duct. A single cancer of the middle and superior bile duct was suspected and extra-hepatic bile duct resection was performed. CT eleven months after surgery revealed enhanced inferior bile duct wall and a slightly enhanced tumor within it. Retrospective review of the CT images taken before first surgery showed enhanced inferior bile duct wall without intrabiliary tumor only on the delayed phase. The inferior bile duct tumor was suspected to have originally co-existed with the middle and superior bile duct tumor. Pancreaticoduodenectomy was performed subsequently. Histopathological examination revealed that the middle and superior bile duct tumor was a moderately differentiated tubular adenocarcinoma while the inferior bile duct tumor was a papillary adenocarcinoma. The two tumors were separated and had different histological findings and growth patterns, further suggesting that they were two primary cancers.     

Laparoscopic management of common bile duct stones

We reviewed our experience with the management of common bile duct (CBD) stones in 100 consecutive patients treated laparoscopicaly during the past 9 years (1990—1998) and evaluated the advantages, disadvantages, and feasibility of the treatment, to elucidate reasonable therapeutic strategies for patients harboring CBD stones. We conclude that the most rational management of CBD stones is that which is decided according to the size of the CBD, which, in turn, depends on the size, number, and location of stones. The cystic duct in patients with a non‐dilated CBD is narrow, because the size of the CBD depends on the size and number of stones that have migrated through the narrow cystic duct, and the stones in the non‐dilated CBD are therefore usually small in size and number. Patients with a dilated CBD, however, are good candidates to undergo single‐stage laparoscopic treatment. In our Department, therefore, even if complete removal of stones has failed in patients with non‐dilated CBD, further choledochotomy is not carried out, and a C‐tube is placed through the cystic duct for a subsequent postoperative transduodenal approach, because laparoscopic transcystic CBD exploration and choledochotomy may not be always feasible in those patients with non‐dilated CBD, and spontaneous migration of small stones into the duodenum is frequently noted. In fact, some stones demonstrated on intraoperative cholangiograms were not revealed by postoperative cholangiography. In contrast, retained stones detected postoperatively were successfully removed by postoperative endoscopic sphincterotomy (EST), the endoscopic papillary balloon dilatation technique (EPBDT), or postoperative cholangioscopy (POCS) without any injury to the sphinter of Oddi. With this approach, we believe that the causes of stone recurrence can be avoided in the majority of cases.     

Congenital web of the common bile duct in association with cholelithiasis

Congenital web formations are extremely rare anomalies of the extrahepatic biliary tree. The age at presentation and the clinical symptomatology of these anomalies depend on the grade of the biliary obstruction. We report a case of a common bile duct septum in association with cholelithiasis in a 30‐year‐old woman. The diagnosis was made on preoperative magnetic resonance cholangiopancreatography (MRCP) and confirmed with intraoperative cholangiography. Because all known causes of acquired web formation were excluded, a congenital origin of the web was assumed. The patient was treated with a hepaticoduodenostomy above the level of the septum. The embryological aspects of this rare anomaly are described.     

处置困难胆总管结石1例治疗体会

采用常规取石技术仍未能取出的结石,被认为是处置"困难"的胆总管结石。现将我院收治的1例处置困难的胆总管结石患者治疗经过和治疗体会报道如下。