Triple non-invasive diagnostic test for exclusion of common bile ducts stones before laparoscopic cholecystectomy

AIM： To evaluate the impact of a preoperative ＂triple non-invasive diagnostic test＂ for diagnosis and/or exclusion of common bile duct stones. METHODS： All patients with symptomatic gallstone disease, operated on by laparoscopic cholecystectomy from March 2004 to March 2006 were studied retrospectively. Two hundred patients were included and reviewed by using a triple diagnostic test including： patient＇s medical history, routine liver function tests and routine ultrasonography. All patients were followed up 2-24 mo after surgery to evaluate the impact of triple diagnostic test. RESULTS： Twenty-five patients were identified to have common bile duct stones. Lack of history of stones, negative laboratory tests and normal ultrasonography alone was proven to exclude common bile duct stones in some patients. However, a combination of these three components （triple diagnostic）, was proven to be the most statistically significant test to exclude common bile duct stones in patients with gallstone disease. CONCLUSION： Using a combination of routinely used diagnostic components as triple diagnostic modality would increase the diagnostic accuracy of common bile duct stones preoperatively. This triple non-invasive test is recommended for excluding common bile duct stones and to identify patients in need for other investigations.     

INTRADUCTAL ULTRASONOGRAPHY FOR THE STAGING OF BILE DUCT CARCINOMA

Intraductal ultrasonography is useful in the staging of extrahepatic bile duct cancer including tumor depth infiltration, pancreatic parenchymal invasion, portal vein invasion, and right hepatic artery invasion. However, it has limitations in assessing lymph node metastases. The assessment of longitudinal cancer extension along the bile duct is a promising aspect of this area. However, a thickening of the bile duct wall may represent either inflammatory changes that may result from mechanical irritation by a biliary drainage catheter or other factors, or the longitudinal extension of the cancer.     

Multiple early bile duct carcinoma associated with congenital choledochal cyst

Emergency ultrasonography showed a protruding tumor in the markedly dilated common bile duct of a 33-year-old Japanese woman. Magnetic resonance cholangiopancreatography also demonstrated the tumor clearly, almost as clearly as did percutaneous transhepatic cholangiography. With a diagnosis of common bile duct carcinoma associated with congenital choledochal cyst, pancreaticoduodenectomy was performed. In the resected specimen, as well as the protruding tumor, there was also a small slightly elevated lesion. Pathology examination showed adenocarcinoma limited to the fibromuscular layer in the protruding tumor, and adenocarcinoma limited to the mucosa in the elevated lesion. Prophylactic total excision of the choledochal cyst before the occurrence of malignant change is strongly recommended in patients with congenital choledochal cyst. However, in those who are reluctant to undergo the operation, periodic follow-up with ultrasonography and magnetic resonance cholangiopancreatography would be ideal to achieve early detection of malignant change. (Received May 9, 1997; accepted Sept. 26, 1997)     

Primary malignant peripheral nerve-sheath tumor of the common bile duct

Primary malignant peripheral nerve-sheath tumors of the common bile duct are extremely rare. To our knowledge, the published literature contains no previous case report of this disease. Here we report on a 58-year-old Japanese woman with a primary malignant peripheral nerve-sheath tumor of the common bile duct, which was completely resected. A hypoechoic mass was identified in the hepatic hilus, using ultrasonography and computed tomography. Endoscopic retrograde cholangiography revealed a smooth stricture and deviation of the common bile duct. Laparotomy exposed a firm mass around the common bile duct that had not invaded the surrounding tissues. Partial resection of the common bile duct and cholecystectomy were performed as the treatment of choice. The final histopathological diagnosis was malignant peripheral nerve-sheath tumor arising from the wall of the common bile duct.     

Choledochocele associated with superficial spreading cancer with cholesterolosis of the bile duct

A 74-year-old woman, who had suffered from acute cholangitis, was referred to our department for further evaluation of the biliary tree. A diagnosis of choledochocele was made by endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography. A small flat elevation with cholesterolosis was observed in the lower bile duct, and circumferential wall thickening was apparent in some parts of the upper and middle bile duct by intraductal ultrasonography and peroral cholangioscopy. With the diagnosis of choledochocele associated with superficial spreading cancer and cholesterolosis of the bile duct, pylorus-preserving pancreaticoduodenectomy was carried out. Microscopically, the tumor had spread extensively from the lower to the upper bile duct. Its invasion was limited to the mucosa for the most part, with microinvasion of the subserosa in the upper bile duct. In the lower bile duct, foamy cells were located beneath the neoplastic epithelium of the elevation. The number of cases of choledochocele associated with biliary cancer is becoming higher than previously reported. This anomaly may play some role in the development of biliary malignancy. Histological examination seems to be mandatory before making a diagnosis of cholesterolosis of the bile duct, since this condition may occasionally accompany cancer.     

DIAGNOSTIC UTILITY OF PERORAL CHOLANGIOSCOPY AND TRANSPAPILLARY INTRADUCTAL ULTRASONOGRAPHY FOR BILE DUCT CARCINOMA

Recently, new diagnostic procedures such as video peroral cholangioscopy (POCS) and transpapillary intraductal ultrasonography (IDUS) have been available for diagnosis of biliary diseases. These new modalities are especially useful for diagnosis of minute bile duct lesions on cholangiogram and correct diagnosis of lateral extension of bile duct carcinoma. In this paper, showing some effective cases of POCS and IDUS, we present our diagnostic approach for bile duct carcinoma and discuss the future prospects of POCS and IDUS.     

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.     

Three-dimensional imaging identified the accessory bile duct in a patient with cholangiocarcinoma

The development of diagnostic imaging technology, such as multidetector computed tomography (MDCT) and magnetic resonance cholangiopancreatography (MRCP), has made it possible to obtain detailed images of the bile duct. Recent reports have indicated that a 3-dimensional (3D) reconstructed imaging system would be useful for understanding the liver anatomy before surgery. We have investigated a novel method that fuses MDCT and MRCP images. This novel system easily made it possible to detect the anatomical relationship between the vessels and bile duct in the portal hepatis. In this report, we describe a very rare case of extrahepatic cholangiocarcinoma associated with an accessory bile duct from the caudate lobe connecting with the intrapancreatic bile duct. We were unable to preoperatively detect this accessory bile duct using MDCT and MRCP. However, prior to the second operation, we were able to clearly visualise the injured accessory bile duct using our novel 3D imaging modality. In this report, we suggest that this imaging technique can be considered a novel and useful modality for understanding the anatomy of the portal hepatis, including the hilar bile duct.     

塑料支架内引流在老年难取性胆管结石中的应用

目的:回顾性分析在老年性难取性胆总管结石患者中胆道塑料支架置入治疗的安全性和有效性.方法:先行常规逆行性胆胰管造影(ERCP)明确诊断,根据胆管扩张及结石大小情况,行十二指肠乳头括约肌切开后经导丝引导放置胆道塑料支架通畅引流.结果:103例取石困难患者在常规ERCP后置入塑料支架.3-6mo后复查ERCP显示有60例(58.2%)结石成为小结石,经内镜应用网篮取出;13例(12.6%)结石未变化,重新更换支架引流;11例(10.6%)最后行腹腔镜胆囊切除胆管探查取石治疗;16例(15.5%)患者因无特殊不适未复查ERCP,长期行内支架引流.结论:对于老年性难取性胆管结石患者,塑料支架内引流是一种十分有效和相对安全的手术方式.     

Diagnosis of common bile duct calculi with intraductal ultrasonography during endoscopic biliary cannulation

BACKGROUND: Choledocholithiasis can be difficult to diagnose, even with direct cholangiography. We examined the role of biliary intraductal ultrasonography in detecting common bile duct stones that had been overlooked during endoscopic retrograde cholangiopancreatography. METHODS: Eighty consecutive patients who underwent endoscopic retrograde cholangiography for suspected choledocholithiasis with negative results were evaluated with intraductal ultrasonography (20 MHz) for the presence of biliary concrements. The diagnostic criterion for stones was a strong-echo structure with acoustic shadowing. Materials of low amplitude echoes without acoustic shadowing were considered sludge. RESULTS: Intrabile duct scanning was successful in all patients. Of the 80 patients, 20 (25%) had ultrasonic evidence of common bile duct stones. The stones measured 5 mm or less on ultrasound and their presence was confirmed macroscopically during endoscopic (17 patients) or laparoscopic (three patients) bile duct clearance. Another 37 patients (46%) had biliary sludge alone and have been followed up uneventfully. CONCLUSIONS: Biliary intraductal ultrasonography may become a useful adjunct to establish the diagnosis of occult bile duct concrements and a guide to appropriate therapeutic selection during endoscopic biliary cannulation.     

A modern approach to malignant hilar biliary obstruction

Management of patients with malignant hilar biliary obstruction is challenging for all specialists involved in their care. Evaluation should focus on potential surgical resection, which offers the principal chance of cure; liver transplantation is offered as an experimental treatment at a few centers. Attempt at curative surgical resection is appropriate for selected tumors and often requires partial hepatectomy. Diagnosis and staging is now facilitated by the use of magnetic resonance cholangiopancreatography (MRCP), spiral computed tomography, and endoscopic ultrasonography, which should largely supplant invasive cholangiography. Use of endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography should be limited primarily to palliation of jaundice in patients with unresectable tumors and to establish tissue diagnoses in ambiguous cases. Palliation of jaundice is optimal with self-expanding metallic stents. Safe and effective drainage can be achieved by using MRCP for targeted endoscopic placement of unilateral metal stents in most cases, with bilateral stents rarely required unless undrained ducts are contaminated. Other palliative modalities for bile duct tumors include surgical bypass, intraluminal and external beam radiation therapy, chemotherapy, and photodynamic therapy.     

CLINICAL EVALUATION OF THE PERCUTANEOUS TRANSHEPATIC VIDEOCHOLANGIOSCOPE WITH THIN DIAMETER (XCHF‐XP240)

We developed a percutaneous transhepatic videocholangioscope with thin diameter (XCHF‐XP240, video PTCS) in collaboration with Olympus Optical Co., Ltd. (Tokyo, Japan). Its outer diameter is 3.7 mm and channel diameter, 1.2 mm. We used it 40 times in 19 cases (M : F = 15 : 4; average age, 69.1) between April 1998 and October 2004. The indication for use were differential diagnosis of bile duct cancer from other diseases in eight cases, diagnosis of tumor extension of papillary‐type bile duct cancer in three cases, diagnosis of postoperative recurrences of remnant bile duct cancer in three cases, treatment of bile duct stone in two cases, evaluation after placement of expandable metallic stent in two cases and evaluation after radiation therapy for mucin‐producing bile duct tumor in one case. Advantages of the videocholangioscope are: (i) because of the thin diameter, it can be used via expanding percutaneous transhepatic biliary drainage fistula to the size of 12 Fr; (ii) clear images are obtained; (iii) a multiple number of people can observe through the monitor screen; and (iv) it can be used for biliary stone treatment. It is particularly useful for the evaluation of intramucosal superficial extension of papillary‐type bile duct cancer. As it can be applicable not only in preoperative close examination or stone treatment but also to surgical operation. Production of the device for the market is highly anticipated.     

Endoscopic diagnosis of pancreatic cancer using intraductal ultrasonography

BACKGROUND/AIMS: At present developed modalities are not sufficient for detecting early stage pancreatic cancer. We previously reported the clinical usefulness of intraductal ultrasonography in various pancreatobiliary diseases. In the present study we assessed the usefulness of intraductal ultrasonography in diagnosing pancreatic cancer. METHODOLOGY: Thirty-one patients with pancreatic cancer were examined by intraductal ultrasonography. We approached the main pancreatic duct (pancreatic duct-intraductal ultrasonography) in 24 of 31 patients and the bile duct (bile duct-intraductal ultrasonography) in 20 patients with pancreatic cancer. We compared the diagnostic ability of pancreatic duct-intraductal ultrasonography with that of extracorporeal ultrasonography, computed tomography, endoscopic ultrasonography or endoscopic retrograde pancreatography. We examined the usefulness of bile duct-intraductal ultrasonography in diagnosing tumor invasion to the bile duct. RESULTS: Pancreatic duct-intraductal ultrasonography was able to demonstrate a tumor in 22 of 24 patients. Extracorporeal ultrasonography, computed tomography, endoscopic ultrasonography or endoscopic retrograde pancreatography detected tumors in 26, 27, 29, 29 of 31 patients, respectively. In two patients, only intraductal ultrasonography could demonstrate a tumor, which was not detected by any other modalities. We examined bile duct invasion of the tumor according to our grading system. The overall accuracy rate was 90%. No complications were noted in any patients throughout the study period. CONCLUSIONS: Intraductal ultrasonography is useful to diagnose pancreatic cancer, and it is suggested that it should be actively performed after endoscopic retrograde pancreatography.     

An endoscopic approach to the management of surgical bile duct injuries: nine years’ experience

BACKGROUND: The evaluation of the endoscopic treatment of surgical bile duct injuries, especially in the management of post-operative strictures, remains controversial. AIM: The aim of this study was to evaluate the feasibility of using endoscopic management from a study of the clinical reports of two of the main endoscopy units in Sicily. PATIENTS AND METHODS: A total of 137 consecutive patients were selected. There were 85 simple biliary fistulas: 64 from the cystic duct stump; 19 from the gall bladder bed; and two from intra-hepatic bile ducts. There were 52 biliary lesions: 15 complete transections; 12 incomplete lesions of the common bile duct with six associated strictures; five complete or incomplete sections of the right antero-medial duct; and 20 incomplete strictures (without leak). RESULTS: The success rate was 96.3% for simple biliary fistulas. Endoscopic therapy was feasible only in 40.6% of lesions of the common bile duct or the right antero-medial duct (13/32), but with 100% success. In the case of strictures (with or without associated leak), there was a good outcome in 88.2% of patients who completed the therapeutic procedure. CONCLUSIONS: Endoscopic management of simple biliary fistulas and incomplete lesions of the common bile duct is the preferred approach. If continued for 12-24 months, with the placement of three or more 10F stents, the management of stenoses is guaranteed to yield good results.     

Congenital left intrahepatic bile duct draining into gastric wall mimicking biliary reflux gastritis

Abnormalities and variations of the biliary ducts are not rare.Most aberrant bile ducts eventually drain into the descending part of duodenum through the papilla of vater.However,drainage of the left hepatic bile duct into the stomach is extremely rare.A 29-year old man was admitted to the hospital with the diagnosis of biliary reflux gastritis.Comprehensive imaging modalities were performed including electronic endoscopy,endoscopic ultrasonography,endoscopic retrograde cholangiopancreatography and magnetic resonance cholangio-pancreatography.Finally,congenital ectopic left intrahepatic bile duct draining into the stomach was found,which caused biliary reflux gastritis.The patient did not receive any surgery.Good recovery was achieved by medical treatment.     

Long-term prognosis of patients with endoscopically treated postoperative bile duct stricture and bile duct stricture due to chronic pancreatitis

Aim:  To compare the outcome of endoscopic therapy for postoperative benign bile duct stricture and benign bile duct stricture due to chronic pancreatitis, including long-term prognosis.
Methods:  The subjects were 20 patients with postoperative benign bile duct stricture and 13 patients with bile duct stricture due to chronic pancreatitis who were 2 years or more after initial therapy. The patients underwent transpapillary drainage with tube exchange every 3 to 6 months until being free from the tube. Successful therapy was defined as a stent-free condition without hepatic disorder.
Results:  Endoscopic therapy was successful in 90% (18/20) of the patients with postoperative bile duct stricture. The stent was removed (stent free) in 100% (20/20) of the patients, but jaundice resolved in only 10% (2/20) of patients while biliary enzymes kept increasing. Restricture occurred in 5% (1/20) of the patients, but after repeat treatment the stent could be removed. In patients with bile duct stricture due to chronic pancreatitis the therapy was successful in only 7.7% (1/13) of the patients; the stent was retained in 92.3% (12/13) of the patients during a long period. Severe acute pancreatitis occurred in 3.0% (1/33) of the patients as an accidental symptom attributable to endoscopic retrograde cholangiopancreatography (ERCP); however, it remitted after conservative treatment.
Conclusion:  Our results further confirm the usefulness of endoscopic therapy for postoperative benign bile duct strictures and good long-term prognosis of the patients.     

Endoscopic management of postoperative bile leaks

BACKGROUND: Significant bile leak as an uncommon complication after biliary tract surgery may constitute a serious and difficult management problem. Surgical management of biliary fistulae is associated with high morbidity and mortality. Biliary endoscopic procedures have become the treatment of choice for management of biliary Gstulae. METHODS: Ninety patients presented with bile leaks after cholecystectomy ( open cholecystectomy in 45 patients, cholecystectomy with common bile duct exploration in 20 and laparoscopic cholecystectomy in 25). The presence of bile leaks was confirmed by ERCP and the appearance of bile in percutaneous drainage of abdominal collections. Of the 90 patients with postoperative bile leaks, 18 patients had complete transaction of the common bile duct by ERCP and were subjected to bilioenteric anastomosis. In the remaining patients after cholangiography and localization of the site of bile leaks. therapeutic procedures like sphinctero-tomy, biliary stenting and nasobiliary drainage ( NBD ) were performed. If residual stones were seen in the common bile duct, sphincterotomy was followed by stone extraction using dormia basket. Nasobiliary drain or stents of 7F size were placed according to the standard techniques. The NBD was removed when bile leak stopped and closure of the fistula confirmed cholangiographically. The stents were removed after an interval of 6-8 weeks. RESULTS: Bile leaks in 72 patients occurred in the cystic duct (38 patients), the common bile duct (30 ), and the right hepatic duct (4). Of the 72 patients with post-operative bile leak, 24 had associated retained common bile duct stones and 1 had ascaris in common bile duct. All the 72 patients were subjected to therapeutic procedures including sphincterotomy with stone extraction followed by biliary stenting (24 patients), removal of ascaris and biliary stenting (1), sphincterotomy with biliary stenting (18), sphincterotomy with NBD (12), biliary stenting alone (12), and NBD alone (5). Bile leaks stopped in all patients at a median interval of 3 days (range 3-16 days) after endoscopic in- terventions. No difference was observed in efficacy and in time for the treatment of bile leak by sphincterotomy with endoprosthesis or endoprosthesis alone in patients with bile leak after surgery. CONCLUSIONS: Post-cholecystectomy bile leaks occur most commonly in the cystic duct and associated common bile duct stones are found in one-third of cases. Endoscopic therapy is safe and effective in the management of bile leaks and fistulae after surgery. Sphincterotomy with endoprosthesis or endoprosthesis alone is equally effective in the management of postoperative bile leak.     

胆管癌栓致阻塞性黄疸9例外科治疗分析

目的探讨胆管癌栓致阻塞性黄疸外科治疗情况及治疗效果。方法对1990年2月至2002年8月间收治的9例原发性肝癌及胆管癌合并胆管癌栓患者的外科治疗情况进行回顾性分析和总结。结果4例行原发肿瘤及胆管癌栓根治切除术;5例行姑息性胆管癌栓清除术加T管引流术。5例患者经胆管切开癌栓清除术后黄疸症状及体征缓解1～4月,平均生存期4—6月;4例患者经左肝叶切除术或胆管癌根治术后1．5—2年内复发或远处转移。结论胆管癌栓致阻塞性黄疸并非手术治疗的禁忌,施行外科手术解决梗阻可能是一种积极的治疗方法。     

Bile duct carcinoma following abdominal radiation for urologic neoplasms

This report concerns three cases of bile duct carcinoma which occurred 15–40 years after patients received treatment for urogenital neoplasia. All three patients had initially received radiation therapy in addition to urological surgery. Jaundice was the major clinical symptom of the second tumor. Two of the three patients were able to be surgically treated when presenting with their second carcinoma (partial pancreaticoduodenectomy, bile duct resection; central liver resection), whereas the third patient was in such a poor state of health that he was biopsied only and treated with a pigtail drain. All three patients died within 3 months to 3 years following the diagnosis of the second tumor. The more than coincidential occurrence of the rare bile duct carcinoma in our three patients with previous urogenital neoplasia warrants a new discussion concerning the connection between primary carcinoma, radiation therapy, and the occurrence of a second tumor.     

Magnetic resonance cholangiographic assessment of a delayed radiation-induced bile duct stricture

Radiation-induced bile duct strictures are rare since bile ducts are considered to be resistant in radiation injury. We report a case of bile duct stenosis where evidence is presented that bile duct stricture was the result of radiation injury and which illustrates the major contribution of magnetic res-onance cholangiography in biliary tract disease evaluation.