Gallbladder carcinoma with choledochoduodenal fistula: a case report with surgical treatment.

A 79 year-old man was admitted to our hospital because of upper abdominal pain and nausea. A mobile tumor was palpable in the right upper abdomen. Abdominal ultrasonography, computed tomography and celiac angiography revealed a gallbladder tumor. Endoscopic retrograde cholangiopancreatography revealed a fistula 1.5 cm oral to the orifice of the papilla of Vater, dilatation of the common bile duct, and a filling defect in the gallbladder. Pancreatoduodenectomy associated with reconstruction using Imanaga's method was performed under a pre-operative diagnosis of gallbladder carcinoma with choledochoduodenal fistula. The gallbladder contained a tumor and two bilirubin stones impacted in the orifice of the duodenal papilla. Histological studies confirmed that the gallbladder tumor was a mucinous adenocarcinoma and had not infiltrated the bile duct. We speculated that choledochoduodenal fistula stimulated the development of cancer due to chronic irritation from pancreatic juice reflux.     

Clinical application of plasma shock wave lithotripsy in treating impacted stones in the bile duct system

AIM:To verify the safety and efficacy of plasma shockwave lithotripsy (PSWL) in fragmenting impacted stonesin the bile duct system.METHODS:From September 1988 to April 2005,67 pa-tients (26 men and 41 women) with impacted stones un-derwent various biliary operations with tube (or T-tube)drainage.Remnant and impacted stones in the bile ductsystem found by cholangiography after the operationwere fragmented by PSWL and chotedochofiberscopy.Atotal of 201 impacted stones were fragmented by PSWLsetting the voltage at 2.5-3.5 kV,and the energy outputat 2-3 J for each pulse of PSWL.Then the fragmentedstones were extracted by choledochofiberscopy.Thesafety and efficacy of PSWL were observed during andafter the procedure.RESULTS:One hundred and ninety-nine of 201 impact-ed stones (99.0%) in the bile duct system were success-fully fragmented using PSWL and extracted by choledo-chofiberscopy.The stone clearance rate for patients was97% (65/67).Ten patients felt mild pain in the right up-per quadrant of the abdomen,and could tolerate it well.Eleven patients had a small amount of bleeding from themucosa of the bile duct.The bleeding was transient andstopped spontaneously within 2 min of normal saline ir-rigation.There were no significant complications duringand after the procedure.CONCLUSION:PSWL is a safe and effective method forfragmenting impacted stones in the bile duct system.     

Choledocholithiasis: Evaluation with MR Cholangiography

This retrospective study compared imaging results with surgery findings in 26 choledocholithiasis patients who were examined with two-dimensional fast spin-echo (2D-FSE) MR cholangiography and half-Fourier acquisition single-shot turbo spin-echo (HASTE) MR cholangiography. Patients were examined using a 1, 5 T Philips Gyroscan ACS\11 MR scanner and a 1 T Siemens Harmony MR scanner. A total of 21 of the 26 patients with diagnosed choledocholithiasis on imaging were proven to have common bile ducts stones. Two patients had another small stone which was impacted into the Vater and which was not detected with MR cholangiography. One patient with mild dilated common bile duct and pancreatic duct also had a small impacted stone which was not detected by MR cholangiography. One patient had an irregular stone in the hepatic duct, extending partially into the left hepatic duct which was misintepretated as carcinoma. The last patient had a dilated common bile duct due to a small impacted stone which was not detected and biliary sludge which was misintepretated as a stone. The overall sensitivity of MR cholangiography in the detection of common bile duct stones was 80.8%. In conclusion MR cholangiography can rapidly evaluate the common bile duct for stones. The only problem we encountered was in the evaluation of small impacted stones at the Vater. (Dig Endosc 1999; 11: 220–224)     

Percutaneous placement of biliary stents for the treatment of high risk patients with jaundice due to common bile duct stones

OBJECTIVE: Percutaneous treatment of eight high risk patients with jaundice due to common bile duct stones who were unfit for, or refused surgery and in whom endoscopic therapy failed. METHODS: Fine needle percutaneous cholangiography was followed by catheterization of the bile duct and insertion of a 10-Fr double pigtail Teflon stent in seven cases and a metal stent in one patient with bile duct stones and noncalculous lower common bile duct obstruction. RESULTS: Stent insertion was successful in all patients. Two patients showed pus in the common bile duct. Stent insertion in these relieved the jaundice, but one patient died from sepsis at 72 h. The other patient died from renal and respiratory failure 3 wk after stent insertion with resolution of the jaundice. In six patients, stent therapy relieved the jaundice for periods up to 3 yr or death from other causes. CONCLUSIONS: These findings suggest that percutaneous transhepatic stent insertion is a reasonable alternative for the management of common bile duct stones when endoscopic stent insertion fails.     

Endoscopic ultrasound guided therapy of benign and malignant biliary obstruction: a case series

OBJECTIVES: Endoscopic retrograde cholangiography is an established method for treatment of common bile duct stones as well as for palliation of patients with malignant pancreaticobiliary strictures. It may be unsuccessful in the presence of a complex peripapillary diverticulum, prior surgery, obstructing tumor, papillary stenosis, or impacted stones. Percutaneous transhepatic biliary drainage and surgery are alternative methods with a higher morbidity and mortality in these cases. Recently, endoscopic ultrasound (EUS) guided biliary stent placement has been described in patients with malignant biliary obstruction. We describe our experience with this method that was also used for the treatment of cholangiolithiasis for the first time. METHODS: The EUS guided transduodenal puncture of the common bile duct with stent placement was performed in 5 patients. In 2 of these patients, the stents were removed after several weeks and common bile duct stones were extracted. In another patient with gastrectomy, the left intrahepatic bile duct was punctured transjejunally and a metal stent was introduced transhepatically to bridge a distal common bile duct stenosis. RESULTS: Biliary decompression was successful in all 6 patients. No immediate complications occurred. One patient developed a subacute phlegmonous cholecystitis. CONCLUSIONS: Interventional EUS guided biliary drainage is a new technique that allows drainage of the biliary system in benign and malignant diseases when the bile duct is inaccessible by conventional ERCP.     

Intrahepatic cholesterol stones associated with peripheral cholangiocellular carcinoma: an autopsy case

A rare autopsy case of intrahepatic cholesterol stones associated with peripheral intrahepatic cholangiocellular carcinoma is presented. The patient, a 60-yr-old man, was diagnosed as having peritoneal dissemination of adenocarcinoma, and died of respiratory failure 4 months later. At autopsy, intrahepatic cholangiocellular carcinoma was found at the left lateral segment of the liver. The cancer was extensively disseminated to the peritoneal cavity. In addition, the liver harbored a cholesterol stone (1.0 cm in diameter) impacted in the right peripheral bile duct, as well as tiny cholesterol stones (0.1-0.2 cm in diameter) scattered in the intrahepatic peripheral bile ducts. A few tiny cholesterol stones were also present in the cancerous bile ducts. Although the causal relationship between the intrahepatic cholesterol stones and cholangiocellular carcinoma remains speculative, clinicians should be aware of this association.     

Difficult bile duct stones

Opinion statement Bile duct stones are routinely removed at time of endoscopic retrograde cholangiopancreatography (ERCP) after biliary sphincterotomy with standard balloon or basket extraction techniques. However, in approximately 10% to 15% of patients, bile duct stones may be difficult to remove due to challenging access to the bile duct (periampullary diverticulum, Billroth II anatomy, Roux-en-Y gastrojejunostomy), large (> 15 mm in diameter) bile duct stones, intrahepatic stones, or impacted stones in the bile duct or cystic duct. The initial approach to the removal of the difficult bile duct stone is to ensure adequate biliary sphincter orifice diameter with extension of biliary sphincterotomy or balloon dilation of the orifice. Mechanical lithotripsy is a readily available adjunct to standard stone extraction techniques and should be available in all ERCP units. If stone extraction fails with these maneuvers, two or more bile duct stents should be inserted, and ursodiol added to aid in duct decompression, stone fragmentation, and stone dissolution. Follow-up ERCP attempts to remove the difficult bile duct stones may be performed locally if expertise is available or alternatively referred to a tertiary center for advanced extracorporeal or intracorporeal fragmentation (mother-baby laser or electrohydraulic lithotripsy) techniques. Nearly all patients with bile duct stones can be treated endoscopically if advanced techniques are utilized. For the rare patient who fails despite these efforts, surgical bile duct exploration, percutaneous approach to the bile duct, or long-term bile duct stenting should be discussed with the patient and family to identify the most appropriate therapeutic option. A thoughtful approach to each patient with difficult bile duct stones and a healthy awareness of the operator/endoscopy unit limitations is necessary to ensure the best patient outcomes. Consultation with a dedicated tertiary ERCP specialty center may be necessary.     

Pigtail stents: an alternative in the treatment of difficult bile duct stones

BACKGROUND: When bile duct stones cannot be removed after sphincterotomy by balloon or basket extraction, stent placement can serve as a bridge to additional procedures. Biliary stents may also fragment large stones, allowing them to pass spontaneously or making them easier to extract at a later time. METHODS: Twenty patients with difficult to extract bile duct stones were prospectively studied. The patients underwent ERCP and placement of a 7F double-pigtail stent in the bile duct for 6 months. Results: In seven patients (35%), repeat ERCP revealed no stones in the duct. Four patients (20%) had small stone fragments that were easily extracted with a balloon. Six patients (30%) continued to have large stones at repeat ERCP; two of these patients eventually underwent surgery, the duct was cleared in three with mechanical lithotripsy, and one had long-term stenting. Three patients (15%) did not undergo repeat ERCP and were therefore treated with long-term stent placement. CONCLUSIONS: This study suggests that placement of a pigtail biliary stent is a safe and effective alternative in the management of bile duct stones that resist extraction if lithotripsy is not available. After 6 months of stent placement, stones may pass or become easier to remove in a significant proportion of patients.     

Hemobilia and liver flukes in a patient from Thailand

A patient from Southeast Asia presented with abdominal pain, fever, jaundice, and upper gastrointestinal bleeding of unknown origin. Opisthorchis viverrini eggs were found in the stool and multiple hepatic filling defects were noted on liver scan and sonogram. Endoscopic retrograde cholangiopancreatography revealed cholelithiasis and crescent-like filling defects in the biliary system. At surgery, the gallbladder was filled with clotted blood and pigmented stones. During T-tube drainage of the common bile duct, small elliptical flukes (4 X 3 mm) identified as O. viverrini were recovered. Despite adequate biliary drainage, the patient continued to have high fevers. On the 53rd postoperative day, a larger fluke (2.8 X 0.8 cm) identified as a Fasciola hepatica migrated down the T-tube. Institution of therapy with bithional resulted in complete clinical resolution within 3 wk. Six years later the patient returned with fever, jaundice, and right upper quadrant pain. Two large pigmented stones were found in the common bile duct and were removed after endoscopic sphincterotomy. The stones had developed even though there was no evidence of recurrent helminthic infection.     

Morphological study of cholesterol hepatolithiasis. Report of three cases

Three cases of pure cholesterol intrahepatic stones are compared morphologically to those of calcium bilirubinate stones. Cholesterol stones were found in the intrahepatic bile duct of the left lateral lobe in two cases and in both the left lateral and the right posterior lobe in one. Although the chronic inflammatory reaction and fibrous thickening of bile duct wall were similar in both types of hepatolithiasis, the proliferation of intrahepatic periductal glands and the production of mucin were rather mild, compared to that is the liner containing calcium bilirubinate stones. Multiple intramural cholesterol calculi and cholesterin granulomas (cholesterin crystals surrounded by foreign-body giant cells) were found within the cystically dilated small bile duct branches and/or conduits of periductal glands. The calculi and granulomas were characteristic for cholesterol hepatolithiasis. These findings suggest that the formation of the cholesterol stones differs from that of calcium bilirubinate stones; the perturbation of factors influencing cholesterol nucleation in the hepatic bile may be related to the changed microenvironment of the intrahepatic bile ducts, which is followed by the formation of cholesterol stones.     

Die akute Gallenkolik

Acute biliary pain represents the main symptom of gallbladder stones, less frequently of common bile duct stones or functional disorders of the biliary tract. The pain lasts at least 15 minutes, is typically localized to the epigastrium or the right upper quadrant of the abdomen and my radiate to the right shoulder. Diagnosis of biliary pain is primarily based on clinical criteria, ultrasound allows detection of causative gallstones with high sensitivity and specificity. Analgesics and laparoscopic cholecystectomy are widely accepted as standard therapy for the majority of patients.     

Acute biliary colic. Etiology,diagnosis and therapy

Acute biliary pain represents the main symptom of gallbladder stones, less frequently of common bile duct stones or functional disorders of the biliary tract. The pain lasts at least 15 minutes, is typically localized to the epigastrium or the right upper quadrant of the abdomen and my radiate to the right shoulder. Diagnosis of biliary pain is primarily based on clinical criteria, ultrasound allows detection of causative gallstones with high sensitivity and specificity. Analgesics and laparoscopic cholecystectomy are widely accepted as standard therapy for the majority of patients.     

Giant choledocholithiasis treated by mechanical lithotripsy using a gastric bezoar basket

Mechanical lithotripsy (ML) is usually considered as a standard treatment option for large bile duct stones. However, it is impossible to retrieve oversized stones because the conventional lithotripsy basket may not be able to grasp the stone. However, there is no established endoscopic extraction method for such giant stone removal. We describe a case of successful extraction of a 4-cm large stone using a gastric bezoar basket. A 78-year-old woman had suffered from upper abdominal pain for 20 d. Contrast-enhanced computed tomogram revealed a 4-cm single stone in the distal common bile duct (CBD). Endoscopic stone retraction was decided upon and endoscopic papillary balloon dilation was performed using a large balloon. An attempt to capture the stone using a standard lithotripsy basket failed due to the large stone size. Subsequently, we used a gastric bezoar basket to successfully capture the stone. The stone was fragmented into small pieces and extracted. The stone was completely removed after two sessions of endoscopic retrograde cholangiopancreatography; each of which took 30 min. No complications occurred during or after the procedure. The patient was fully recovered and discharged on day 11 of hospitalization. ML using a gastric bezoar basket is a safe and effective retrieval method in select cases, and is considered as an alternative nonoperative option for the management of difficult CBD stones.     

Drug-associated cholelithiasis: a case of sulindac stone formation and the incorporation of sulindac metabolites into the gallstones

A case of drug-associated cholelithiasis (sulindac chlecystohepatolithiasis) in a 63-yr-old woman is reported. The patient was admitted to our hospital to undergo treatment for rheumatoid arthritis of 20 yr duration. She was treated with nonsteroidal anti-inflammatory drugs (NSAID: sulindac). Two months later, she presented with right upper quadrant pain. Diagnostic studies including ultrasonography (US), computed tomography (CT) and endoscopic retrograde cholangiography (ERC), led to the diagnosis of cholecystohepatolithiasis. She underwent cholecystectomy and choledochotomy with an extraction of intrahepatic stones. The intrahepatic stones were light yellow in color with a claylike appearance. Unexpectedly, an infrared spectroscopic analysis of the stone showed it to consist of sulindac metabolites. In addition, the dilated segment of the intrahepatic bile duct naturally returned to its normal size after the discontinuation of the drug administration. This is the first reported case of sulindac stone formation in the bile duct. No similar problems with other NSAIDs have been reported previously.     

Retained common bile duct stones after endoscopic sphincterotomy: temporary and longterm treatment with biliary stenting.

Basket extraction after endoscopic sphincterotomy failed to clear the bile ducts immediately in 85 (30%) of 283 consecutive patients with common bile duct stones. Temporary biliary drainage was established by the insertion of a single 7 Fr double pigtail stent before further planned endoscopic attempts at stone removal. In 84 patients (21 male: 63 female, mean age 77 years) this measure relieved biliary obstruction, mean serum bilirubin falling from 101 to 18 umol/l by the time of the second endoscopic retrograde cholangiopancreatography. Six patients died from non-biliary causes with temporary stents in situ. Common bile duct stone extraction was achieved endoscopically in 50 of the remaining 79 patients after a mean of 4.3 months (range 1-12), 34 (68%) requiring only one further procedure. Three patients were referred for biliary surgery. Single stents were also effective for longterm biliary drainage in the remaining 26 elderly patients with unextractable stones. The main biliary complication of stenting was 13 episodes of cholangitis but all except one responded to medical treatment and early stent exchange. If common bile duct stones remain after endoscopic sphincterotomy, a single 7 Fr double pigtail stent is effective and safe for temporary biliary drainage before further endoscopic attempts at duct clearance and for longterm biliary drainage especially in the old and frail.     

Impaction of a lithotripsy basket during endoscopic lithotomy of a common bile duct stone

The treatments for common bile duct (CBD) stones are being continually developed. Impaction of the lithotripsy basket during endoscopic removal of CBD stones was seen in 5.9% patients. We report the case of a 66-yearold woman who underwent surgery for the removal of an impacted biliary basket. She was admitted to our hospital with a complaint of right upper abdominal pain. Magnetic resonance cholangiopancreatography revealed a CBD stone (20 mm × 15 mm). We diagnosed her with choledocholithiasis and performe...     

Experience with MTBE as a solvent for common bile duct stones in patients with T-tube in situ

The postcholecystectomy patients who have a T-tube in situ offer a convenient route through the T-tube to perfuse solvents into the common bile duct (CBD) for dissolving any retained common duct stones. If successful, this approach is much simpler and cheaper than the usual therapeutic modality used for CBD stones, namely, endoscopic papillotomy. Thus a most potent cholesterol solvent, methyl t-butyl ether (MTBE) was perfused through the T-tube into the CBD of five patients with retained common duct stones. The dose of the solvent varied, 1.5-5 mL 0.5-1 h, given 7-13 times amounting to a total of 20-66 mL. Instillation of MTBE in the T-tube was alternated with aspiration of the bile through T-tube. Only one patient showed complete disappearance of the bile duct stone following MTBE perfusion. Others did not show any appreciable response and had to be treated by endoscopic papillotomy (three patients) or mono-octanoin perfusion (one patient). Side-effects of MTBE perfusion included pain in the abdomen in all patients, somnolence and nausea/vertigo in two patients and the smell of ether on the breath in two patients. It is concluded that MTBE is not an effective agent for dissolution of retained CBD stones in patients with T-tube in situ.     

Basketing a basket: A novel emergency rescue technique

Fracture of the central lead wire of an impacted basket during a mechanical lithotripsy for large common bile duct(CBD) stones poses a special challenge.Different maneuvers have been described to resolve this problem.Most techniques require equipment or facilities which may not be readily available in small community hospitals.We present here a similar situation in a patient with a large stone at the level of the cystic duct.Through the duodenoscope,a smaller Dormia basket was introduced into the CBD along the side of the impacted broken basket.The tip of the impacted basket was grasped and,by pulling downwards,the basket was disengaged from the stone.The two baskets were then removed successfully.We suggest this simple technique should be tried initially,before resorting to more advanced procedures.     

Combination of Preoperative EST,Laparoscopic Cholecystectomy with Choledochotomy,and Postoperative Cholangioscopy in the Treatment of Common Bile Duct Stones

A case of common duct stones, successfully managed with a combination of preoperative EST, laparoscopic choledochotomy and postoperative choledochoscopic stone extraction, is reported. A 32-year-old man was admitted to our hospital because of jaundice and right hypochon-dralgia of several-days' duration. CT, US and ERCP revealed stones in the gallbladder and common bile duct. EST was performed to remove the stones in the common bile duct prior to laparoscopic cholecystectomy. However, the patient developed pancreatitis as a complication of EST, which was successfully managed by conservative therapy. Though some stones remained in the common duct following the first trial of EST, the patient rejected a second round of EST. Laparoscopic cholecystectomy and choledochotomy were performed to remove the gallbladder and the stones remaining in the common bile duct. A T tube was placed in the incised common bile duct for management of possible retained stones. Twenty days after the surgery, successful postoperative cholangioscopy was performed, and the stones remaining in the common duct were removed. Hyperamylasemia and pancreatitis are relatively common complications of EST occurring in about 7% of cases, but only 3% of these patients experience severe pancreatitis, requiring hospitalization. Conservative therapy is always the treatment of choice. In our particular patient, pancreatitis caused by EST was successfully managed by decompression with ENBD and administration of ulinastatin. Residual stones in the CBD were completely removed by laparoscopic common bile duct exploration following EST and postoperative cholangioscopy through the T tube fistula.     

Successful treatment of complex cholangiolithiasis following orthotopic liver transplantation with interventional radiology

Bile duct stones are a serious and the third most common complication of the biliary system that can occur following liver transplantation.The incidence rate of bile duct stones after liver transplantation is1.8%-18%.The management of biliary stones is usually performed with endoscopic techniques;however,the technique may prove to be challenging in the treatment of the intrahepatic bile duct stones.We herein reporta case of a 40-year-old man with rare,complex bile duct stones that were successfully eliminated with percutaneous interventional techniques.The complex bile duct stones were defined as a large number of bile stones filling the intra-and extrahepatic bile tracts,resulting in a cast formation within the biliary tree.Common complications such as hemobilia and acute pancreatitis were not present during the perioperative period.The follow-up period was 20 mo long.During the postoperative period,the patient maintained normal temperature,and normal total bilirubin and direct bilirubin levels.The patient is now living a high quality life.This case report highlights the safety and efficacy of the percutaneous interventional approach in the removal of complex bile duct stones following liver transplantation.