OPTIMUM NUMBER OF PERCUTANEOUS TRANSHEPATIC CHOLANGIOSCOPY‐GUIDED BIOPSIES FOR HISTOLOGIC DIAGNOSIS OF BILE DUCT CARCINOMA

Background: Percutaneous transhepatic cholangioscopy (PTCS)‐guided biopsy is used for the diagnosis of bile duct carcinoma, but the number of biopsy specimens required for diagnosis is unclear. The aim of this study was to clarify whether multiple PTCS‐guided biopsies are needed for accurate histologic diagnosis. Methods: We examined the relationships between size of the first biopsy specimen, endoscopic, cholangiographic, and pathologic features, and the presence of carcinoma in the first biopsy specimen of the primary lesion in 27 bile duct carcinomas. Results: Twenty‐six of 27 carcinomas (96%) were histologically diagnosed by PTCS‐guided biopsy; 20 (74%) were detected in the first biopsy specimen, six in the second or third biopsy specimen, and one was not detected in four biopsy specimens. Carcinomas with papillogranular mucosa by endoscopy, convex margins by cholangiography, or macroscopic types (except for sclerosing type) were detected on the first biopsy specimen more frequently than were others (15/15 vs 5/12, P <0.001; 13/13 vs 7/14, P <0.01; and 15/16 vs 5/11, P <0.01, respectively). There was no relationship between positivity for carcinoma and size of the first biopsy specimen, vascular dilatation by endoscopy, or histologic type. With the combination of preoperative endoscopy and cholangiography, main lesions with papillogranular mucosa and/or convex margins were proven to be carcinoma on the first biopsy specimen significantly more frequently than were others (17/17 vs 3/10, P <0.0001). Conclusion: If the main lesion contains neither papillogranular mucosa nor a convex margin, multiple PTCS‐guided biopsies should be performed in order to increase the sensitivity for diagnosing bile duct carcinoma.     

Nutritional support through percutaneous transhepatic internal drainage route in common bile duct cancer

Abstract A 69 year old female with a duodenal bulb obstruction due to direct invasion of common bile duct cancer who received total enteral nutrition through the route of percutaneous transhepatic internal drainage (PTID) was presented. The tip of PTID tube was placed over the duodeno-jejunal flexure. Jejunal infusion of all nutrients and the bile juice through this route kept her in good nutritional condition until the terminal stage of primary disease. This procedure did not cause the infection of the biliary system. Major problems, tube obstruction and diarrhoea, were easily resolved with the selection of an appropriate infusion schedule and nutrient concentration. We conclude that nutritional support through the PTID route is a beneficial means for compromised patients without laparotomy or hospitalization.     

Bile duct clearance,endoscopic or laparoscopic?

Endoscopic sphincterotomy (ES) has become the gold standard nonoperative modality for the removal of common bile duct (CBD) stones. Morbidity is 2%–10%, and mortality less than 2%. Immediate complications include bleeding, cholangitis, pancreatitis, and duodenal perforation, but many of these can be prevented by using various tools, including an alternating coagulating and cutting diathermy unit, routine biliary stenting, frequent use of guide‐wires to avoid precutting, and mechanical lithotripsy. Long‐term results have shown that the stone recurrence rate reaches 15%, probably due to a strong recurrent tendency inherent to bilirubinate stones. Choice of the appropriate lithotomy modality is of paramount importance to reduce invasiveness. ES is the choice for recurrent or residual stones and for choledocholithiasis alone. Acalculous gallbladders left in place carry no risk of acute cholecystitis. In patients with cholecystocholedocholithiasis, CBD stones should be removed via the cystic duct or by choledochotomy during laparoscopic cholecystectomy, not to preserve the sphincter of Oddi but to reduce the interventional burden. Safety and safeguards of papillary balloon dilation must still be investigated in a limited number of institutions. Marked progress in lithotomy/lithotripsy procedures has almost obviated the need for laparotomy. Patients with CBD stones benefit from the less invasive and more efficient modalities of transpapillary, percutaneous, and laparoscopic lithotomy.     

Role of prophylactic endoscopic sphincterotomy in patients with acute biliary pancreatitis due to transient common bile duct obstruction

BACKGROUND AND AIM: The role of prophylactic endoscopic sphincterotomy in patients with transient common bile duct obstruction is controversial. The aim of this study was to assess the value of performing prophylactic endoscopic sphincterotomy in patients suffering from acute biliary pancreatitis and absent common bile duct stones on endoscopic retrograde cholangiopancreatography (ERCP). METHODS: Hospital notes of patients admitted to our unit with a diagnosis of acute pancreatitis from January 2000 to January 2005 were reviewed. Endoscopic sphincterotomy was performed when patients were deemed unfit for cholecystectomy, suffering from a severe attack of acute pancreatitis and/or showing evidence of transient common bile duct obstruction. The outcomes of patients with and without endoscopic sphincterotomy were compared. RESULTS: A total of 427 patients were admitted with a diagnosis of acute pancreatitis during the study period. Eighty-eight patients with absent common bile duct stones on ERCP were identified. Endoscopic sphincterotomy was performed in 71 patients and not performed in 17 patients. There was no significant difference in recurrent pancreatitis rates (1.4% vs 5.8%, P = 0.35), recurrent biliary complication rates (5.6% vs 5.9%, P = 1) or mortality rates (5.8% vs 1.5%, P = 0.35). The time to recurrent complications (38.4 days vs 41.0 days, P = 0.38) was not significantly different between the two groups. There was no ERCP-related morbidity or mortality. CONCLUSION: Prophylactic endoscopic sphincterotomy is not recommended in patients with transient common bile duct obstruction or as an option to cholecystectomy in elderly patients. Early cholecystectomy should be performed.     

Use of magnetic resonance cholangiography in the diagnosis of choledocholithiasis: prospective comparison with a reference imaging method

Background—Magneticresonance cholangiography (MRC) is a new technique for non-invasiveimaging of the biliary tract.
Aim—To assess theresults of MRC in patients with suspected bile duct stones as comparedwith those obtained with reference imaging methods.
Patients/Methods—70patients (34 men and 36 women, mean (SD) age 71 (15.5) years; median75) with suspected bile duct stones were included (cholangitis, 33;pancreatitis, three; suspected post-cholecystectomycholedocholithiasis, nine; cholestasis, six; stones suspected onultrasound or computed tomography scan, 19). MR cholangiograms with twodimensional turbo spin echo sequences were acquired. Endoscopicretrograde cholangiography with or without sphincterotomy (n = 63),endosonography (n = 5), or intraoperative cho- langiography (n = 2)were the reference imaging techniques used for the study and wereperformed within 12 hours of MRC. Radiologists were blinded to theresults of endoscopic retrograde cholangiography and previous investigations.
Results—49patients (70%) had bile duct stones on reference imaging (common bileduct, 44, six of which impacted in the papilla; intrahepatic, four;cystic duct stump, one). Stone size ranged from 1 to 20 mm (mean 6.1, median 5.5). Twenty seven patients (55%) had bile duct stones smallerthan 6 mm. MRC diagnostic accuracy for bile duct lithiasis was:sensitivity, 57.1%; specificity, 100%; positive predictive value,100%; negative predictive value, 50%.
Conclusions—Stonessmaller than 6 mm are still often missed by MRC when standard equipmentis used. The general introduction of new technical improvements isneeded before this method can be considered reliable for the diagnosisof bile duct stones.

Keywords:bile duct calculi; endoscopic retrogradecholangiography; magnetic resonance cholangiography