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胆道恶性肿瘤多数起病隐匿,早期症状不明显,发病时多已届入中晚期,手术切除率低,预后极差。由于肿瘤起源相同以及可能发生胆道梗阻导致黄疸,胆道恶性肿瘤具有相似的生物学特性和治疗手段。近年来胆道恶性肿瘤的外科治疗取得了很大的进步,这与恶性肿瘤多学科综合治疗观念获得普遍的认可有密切关系。本文以1例肝门部胆管癌的诊治为例就胆道恶性肿瘤的多学科综合治疗予以论     

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.     

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.     

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.     

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.     

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.     

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.     

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。     

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.     

The clinical course of common bile duct stone clearance with endoscopic retrograde cholangio-pancreaticography*

Objectives: Two-stage treatment of common bile duct stones by Endoscopic Retrograde Cholangio-Pancreatography and subsequent laparoscopic cholecystectomy is well established. In many cases multiple procedures are needed before clearance of the common bile duct is obtained. This study aimed to describe the clinical course from common bile duct stone diagnosis to successful clearance.

Materials and Methods: A prospective observational study from 2011 to 2014 of consecutive patients diagnosed with common bile duct stones undergoing Endoscopic Retrograde Cholangio-Pancreatography at a public university hospital.

Results: In this study 297 patients with common bile duct stones were identified. More than one Endoscopic Retrograde Cholangio-Pancreatography was performed in 174 (59%) patients and more than two in 51(17%) before clearance. A sphincterotomy was performed in 269 (91%) patients and 189 (64%) had a stent inserted. Bleeding occurred in 17 (6%) requiring injection treatment and post procedure complications occurred in 38 (13%). Subsequent laparoscopic cholecystectomy was performed in 180 (61%) patients. Overall, the patients were hospitalized for 11 (8.5) days and the length of treatment from diagnose to stone clearance was 49 (84.5) days. Overweight, pancreatitis at admission, universal anesthesia, and expert level endoscopist inversely determined common bile duct clearance failure.

Conclusions: Common bile duct clearance by Endoscopic Retrograde Cholangio-Pancreatography requires multiple procedures and complications are frequent leading to prolonged treatment and hospitalization suggesting a limited efficacy.     

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.     

Benign giant-cell tumor of the common bile duct: A case report

Primary giant-cell tumors rarely arise in the common bile duct. We herein report a case of primary giant-cell tumor of the common bile duct. The patient was an 81-year-old male who was diagnosed with a well-defined 1.2-cm mass projecting into the lumen of the middle common bile duct. Excision of the gallbladder and extrahepatic bile duct and a Roux-en-Y cholangiojejunostomy were performed. Histologically, the tumor had no association with carcinomas of epithelial origin and was similar to giant-cell tumors of the bone. The tumor consisted of a mixture of mononuclear and multinucleated osteoclast-like giant cells. The mononuclear cells showed no atypical features, and their nuclei were similar to those of the multinucleated giant cells. CD68 was expressed on the mononuclear and multinucleated osteoclast-like giant cells, whereas CD163 immunoreactivity was restricted to the mononuclear cells. Six months after the operation, the patient was still alive and had no recurrence. The interest of this case lies in the rarity of this entity, the difficulty of preoperative diagnosis, and this tumor’s possible confusion with other malignant tumors.     

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.     

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.     

Spontaneous passage of common bile duct stones in jaundiced patients

BACKGROUND:Common bile duct(CBD)stones are known to pass spontaneously in a significant number of patients. This study investigated the rate of spontaneous CBD stones passage in a series of patients presenting with jaundice due to gallstones.The patients were managed surgically,allowing CBD intervention to be avoided in the event of spontaneous passage of CBD stones. METHOD:Retrospective analysis of patients presenting with jaundice due to CBD stones,and managed surgically with laparoscopic cholecystectomy ...     

术中胆道镜在发现和诊断胆管下段肿瘤中的价值

目的探讨术中胆道镜在发现和诊断胆总管下段肿瘤中的价值。方法回顾自2005年来术中胆道镜诊断术前未能发现的胆总管下端肿瘤的典型病例。结果 4例患者均使用术中胆道镜发现和诊断了胆管下段肿瘤,避免了漏诊,并及时采取胰十二指肠切除术治疗。结论术中胆道镜可弥补术前各种影像学的不足,发现和诊断同时合并的胆总管下段肿瘤,对有胆道探查指征者,推荐使用术中胆道镜探查。     

Granular cell tumor of the common bile duct: A Japanese case

Granular cell tumor (GCT) of the biliary system is rare. It is reported that it occurs more commonly in young black women. We report here our seldom experience of a Japanese case in whom icterus was found as a first symptom just after a caesarean operation. A 36-year-old Japanese woman developed icterus after delivery by the Caesarean operation. A surgical operation was performed without can deny that there was a tumor-related change in a bile duct as a result of examination for various images. As a result of pathological evaluation, GCT was diagnosed. By the preoperative organization biomicroscopy result, it was not able to be attachd a right diagnosis. It was thought that this tumor, although rare, should be considered as one of the causes of biliary stenosis in the younger population.