Mucosal bile duct carcinoma with superficial spread

We describe a case of mucosal bile duct carcinoma with superficial spread in a 69-year-old man with gallstone pancreatitis. The patient was seen at the hospital because of abdominal pain, fever, and jaundice. Endoscopic retrograde cholangiography (ERC) demonstrated a protruding lesion in the lower third of the common bile duct (CBD) showing wall irregularity suggestive of malignancy. Percutaneous transhepatic cholangioscopy (PTCS) disclosed a papillary tumor with granular mucosa extending continuously to the middle third of the CBD. Cholangioscopic biopsy specimens taken from both the papillary tumor and surrounding granular mucosa revealed papillary adenocarcinoma. After this assessment of extent of cancer by PTCS, we performed pancreatoduodenectomy with extrahepatic bile duct resection and regional lymph node dissection. Pathology examination revealed papillary adenocarcinoma limited to the mucosal layer. The resected margin of the bile duct was free of tumor. We also reviewed 25 cases of early mucosal bile duct carcinoma described in detail in the Japanese literature, and we discuss the diagnostic advantages of PTCS.     

Endoscopic Findings of Primary Sclerosing Cholangitis—-Report of a Case—

Abstract: A case of primary sclerosing cholangitis in which an endoscopic inspection through the fistula produced by percutaneous transhepatic biliary drainage was performed for the treatment of progressive jaundice and supprative cholangitis is presented. These treatments benefited the patient to some degree. After 3 years from the onset, the patient died of multi-organ failure caused by disseminated intravascular coagulopathy. An autopsy revealed primary sclerosing cholangitis. No evidence of ductal stricture due to malignancy or underlying cholelithiasis was noted. This report may be the first which discusses the endoscopic findings of a biliary tract stricture in a patient with sclerosing cholangitis.     

Small pancreatic carcinoma misdiagnosed as superficially spreading cholangiocarcinoma

We report a case of small pancreatic carcinoma misdiagnosed as superficially spreading cholangiocarcinoma using percutaneous transhepatic cholangioscopy (PTCS). The patient was a 72-year-old man admitted to a local hospital with obstructive jaundice. The patient underwent percutaneous transhepatic biliary drainage and PTCS. He was referred to our hospital with a diagnosis of superficially spreading cholangiocarcinoma. Cholangiography revealed a stenosis of the common bile duct, and also revealed some irregularities from the common hepatic duct to the left hepatic duct, suggesting a superficial spread of cancer. No pancreatic tumor was identified by endoscopic retrograde pancreatography or by enhanced computed tomography. Cholangioscopy disclosed an elevated tumor with torsional vessels and granular mucosal lesions, which were extended to the left hepatic duct. Repeated cholangioscopic biopsies of the bile duct mucosa revealed adenocarcinoma. The patient was diagnosed with superficially spreading cholangiocarcinoma extending to the left hepatic duct and the right anterior hepatic duct. Left trisectionectomy combined with pancreatoduodenectomy was performed. The cut surface of the resected specimen showed a pancreatic head tumor that was 8 mm in diameter. Histological findings of the resected specimen revealed adenocarcinoma arising from the pancreatic head with invasion in the common bile duct. Additionally, extensive inflammatory granulation tissue was observed along the surface of the bile duct, without any evidence of carcinoma. This case implies to us that the results of PTCS, even after repeated biopsies, should be interpreted with great caution.     

Probable pseudotumor cerebri complex in 25 children. Further support of a concept

Background

Cerebrospinal fluid (CSF) opening pressure (OP) of ≥28 cm H₂O is now considered a diagnostic criterion for Pseudotumor cerebri syndrome (PTCS) in children. However, it has been proposed that a diagnosis of “probable” PTCS can be made with an OP < 28 cm H₂O if other diagnostic criteria are met. We report a group of children with probable PTCS.

经皮经肝胆道镜术在复杂肝内外胆管结石中的应用

目的 观察经皮经肝胆道镜(PTCS)治疗复杂肝内外胆管结石的临床效果。方法 选择130例肝内外胆管结石确诊患者,采用随机数字表法分为PTCS组和对照组,每组65例。PTCS组行PTCS术,对照组行常规开腹胆总管探查取石术。比较两组在结石取净率、出血量、术后并发症、住院时间、住院费用及随访复发等指标的差异。结果 PTCS组结石取净率(90.77%)与对照组(89.23%)比较差异无统计学意义(P>0.05)。PTCS组的术中出血量(38.46±7.54) mL低于对照组(125.68±12.37) mL(P<0.05)。PTCS组并发症发生率(6.16%)与对照组(10.77%)比较差异无统计学意义(P>0.05)。PTCS组的平均住院时间(11.8±3.56) d低于对照组(18.68±5.23) d,差异有统计学意义(P<0.05),PTCS组的平均住院费用(1.26±0.66)万元低于对照组(1.95±0.96)万元,差异有统计学意义(P<0.05)。出院1年后PTCS组结石复发率为19.05%,低于对照组的39.06%,差异有统计学意义(P<0.05)。结论 PTCS术手术成功率高,并发症和复发率低,值得临床推广。     

Pseudotumor cerebri syndrome in a patient with narcolepsy type 1

Type 1 narcolepsy (NT1) is a chronic primary disorder of hypersomnolence characterized by excessive daytime sleepiness, cataplexy, sleep paralysis, hypnagogic hallucinations and disrupted nocturnal sleep.NT1 is linked to hypothalamic hypocretin deficiency, strongly associated with Human Leukocyte Antigen (HLA) marker DQB1*06:02 and of probable autoimmune origin. NT1 is usually associated with increased rates of overweight and obesity, and sometimes with increases in overnight blood pressure and increased rates of hypoventilation with raised CO₂ levels overnight. Many of these are predisposing factors for pseudotumor cerebri syndrome (PTCS).We present a case of a young girl with both NT1 and PTCS that responded well to treatment with acetazolamide after early identification, with improvement of headache and resolution of hypoventilation.     

Is preoperative biliary drainage necessary according to evidence‐based medicine?

Preoperative biliary drainage has been in use for a long time and is still being performed today in some institutions, but there has been a long-standing issue as to whether the necessity of this procedure has been proven medically. Many problems existed previously, such as systemic complications due to the difficulty in diagnosing and differentiating obstructive jaundice from jaundice left untreated for a long time, or surgeon-based problems such as a lack of surgical skill or undeveloped surgical techniques, or even inexperience in perioperative patient management. These problems, however, are being overcome with time, and the advantages of preoperative biliary drainage are now being questioned according to evidence-based medicine. Several recent controlled trials have clearly shown that preoperative biliary drainage is not necessary for lower bile duct obstruction, although it was noted that surgery after reduction of jaundice by percutaneous transhepatic cholangial drainage (PTCD) was very easily performed. It is important to understand that preoperative biliary drainage is unnecessary for lower bile duct obstruction, whether the technique follows a percutaneous approach, an endoscopic apporach, or stenting. Although it is still being debated, there have already been several reports regarding whether preoperative biliary drainage is necessary for upper bile duct obstruction, such as hilar bile duct carcinoma. This also needs to be clarified by randomized controlled trials. Aside from preoperative biliary drainage, the utilization of biliary drainage or stenting has been fully recognized as important for removing intrahepatic stones or choledochal stones, as well as for emergency drainage for acute cholangitis and for the treatment of unresectable malignant biliary stenosis. Additionally, percutaneous transhepatic cholangioscopy (PTCS), using the PTCD, or percutaneous transhepatic biliary drainage (PTBD) route, plays a major role not only in the removal of biliary stones but also in the diagnosis of cases in which it is difficult to differentiate between benign and malignant lesions.     

经皮经肝胆道镜治疗肝内外胆管结石的探讨

经皮经肝胆道镜（PTCS）是治疗胆总管结石、肝内胆管结石非常有用的方法。我院应用PTCS下液电碎石术（EHI）治疗胆管结石27例。其中胆总管结石11例，肝内胆管结石16例（单纯肝内胆总管结石11例，合并胆总管结5例）。胆总管结石11例中11例（100％）、肝内胆管结石16例中15N（93．8％）结石全部取出。PTCS取石次数胆总管结石平均2．6次、肝内胆总管结石取石次数平均6．3次。所有病例均无严重并发症发生。不仅适用于经内镜治疗胆总管结石失败及肝内胆管结石的病例，对于高龄及高危人群也是安全有效的治疗方法。     

经皮经肝胆道镜治疗胆石症引起的梗阻性黄疸

１９９１￣１９９７年对８例因胆石和良性狭窄造成的梗阻性黄疸病人进行了ＰＴＣＳ治疗。８例均为胆道手术后病人，绝大部分为经过多次胆道手术，伴有严重并存病、和手术风险大的病人。并成功地治疗了两例ＰＯＣ和ＥＳＴ取石失败者。全部病例取净结石处理了胆道狭窄、解除梗阻性黄疸。本文结合文献也讨论了ＰＴＣＳ适应证及取石和治疗胆道狭窄的一些技术问题。／