Therapeutic effect of fully covered self-expandable metal stents on benign biliary stricture / 中华消化内镜杂志

Objective To evaluate the efficacy and safety of fully covered self-expandable metal stents (FCSEMS) implanted by endoscopic retrograde cholangiopancreatography (ERCP) for patients with benign biliary stricture (BBS).Methods The clinical data of 38 patients with BBS underwent ERCP and FCSEMS placement between January 2012 and January 2016 were retrospectively recorded.Success rate of BBS,adverse events related to ERCP and stricture recurrence were analyzed.Results A total of 38 patients underwent FCSEMS placement with a mean time of stent in dwelling for 8 months (range:3-13months).During follow-up after the stent was removed,death of 1 patient after liver transplantation was due to unrelated cause.The mean follow-up time was 13 months (range:2-52 months) for other patients.Stricture recurrence occurred in 6 patients,including 2 cases of gallstone-related biliary strictures,1 case of chronic pancreatitis-related biliary strictures,2 cases of liver transplantation-related biliary strictures,and 1 case of post surgical-related biliary strictures.Stricture resolution occurred in 31 cases with 83.8％ (31/37) success rate,including 90.0％ (18/20) gallstone-related biliary strictures,75.0％ (3/4) chronic pancreatitis-related biliary strictures,80.0％ (8/10) liver transplantation-related biliary strictures,and 66.7％ (2/3)post surgical-related biliary strictures.The incidence of post-ERCP complications was 21.1％ (8/38),including mild pancreatitis in 5 case,hyperamylasemia in 2 cases,cholangitis in 1 case.All patients were cured by conservative treatment.Conclusion FCSEMS are effective and safe for BBS.Further studies are needed to assess the indwelling time of FCSEMS,whether FCSEMS are superior to multiple plastic stents and the different efficacy of FCSEMS for BBS caused by different etiology.

Intraluminal Filling Defects of the Bile Ducts: Differentiation of Stones from Tumors-the Value of Magnetic Resonance Cholangiography in Conjunction with a 3D Spoiled Gradient Echo Gadolinium Enhanced Dynamic Sequence

PURPOSE: We wanted to determinate the value of a dynamic volumetric interpolated breath-hold examination (VIBE) as a supplement to MR cholangiography for differentiating biliary stones from tumors when patient are suspected of having intraluminal filling defects on direct cholangiography. MATERIALS AND METHODS: A retrospective analysis was performed for 49 patients who underwent MRI among all the patients who showed intraluminal filling defects on direct cholangiography for evaluating the cause of their jaundice from June 2002 to June 2003. After dividing these patients into two groups, i.e., the group with stones and the group with tumors, we analyzed and compared each MR patterns of 1) signal intensity, 2) shape, and 3) enhancement. RESULTS: High signal intensity on T1-weighted images (p< 0.001, chi-square test), dark signal intensity on T2-weighted images (p< 0.01, Fisher's exact test) or smooth contour of intraluminal filling defects (p< 0.001, chi-square test) could be significantly suggestive findings of stone rather than a tumor mass. Dynamic VIBE is the most specific sequence for differentiating non-enhancing stone from an enhancing mass (p< 0.001, Fisher's exact test). CONCLUSION: We showed that MR cholangiography, when added to the dynamic VIBE sequences, could be an important imaging technique for patients who are suspected of having intraluminal filling defects on direct cholangiography to differentiate stones from tumors. Especially, the addition of dynamic VIBE images can provide the increased level of confidence in the diagnosis.

Usefulness of Magnetic Resonance Cholangiography and Additional T2-Weighted Axial Image in Evaluating Focal Intrahepatic Ductal Dilatation

PURPOSE: To evaluate the value of MR cholangiography (MRC) and MRC with additional T2-weighted axial imaging for evaluating the cause and determining the therapeutic plan in patients with a focal dilatation of the intrahepatic bile ducts(IHBD). MATERIALS AND METHODS: Forty nine patients (male, 27; female, 22; age range, 12-72 (mean, 51) years) with a focal intrahepatic ductal dilatation confirmed surgically and pathologically (lobectomy, 34; biopsy, 7; surgical finding and T-tube cholangiography, 7; percutanous transhepatic biliary drainage with bile cytology, 1) underwent MRC and T2-weighted axial imaging. The MRC were obtained in one of two ways (a single slab or multi-slice acquisition under chemical fat saturation) using RARE (31 patients, source images and single slice images), or TSE (18 patients, source images and MIP reconstruction images). Two radiologists reviewed the MRC images alone, and the MRC images with the T2-weighted axial images. A diagnosis was determined by consensus. RESULTS: In 37 out of 49 patients, the causes of a bile duct dilation were benign diseases (IHBD stones in 33 cases, liver abscesses with IHBD stones in three cases, one inflammatory pseudotumor). Twelve patients had cholangiocarcinomas (mass-forming type in seven cases, intraductal type in three cases, and periductal infiltrating type in two cases). A correct diagnosis was confirmed in 47 out of 49 cases(96.0%), i.e. all the 37 benign lesions and 10 out of 12 malignant lesions. The addition of the T2-weighted axial image to the MRC did not alter the diagnosis of the causes of the focal intrahepatic ductal dilatation, but was helpful in 10 cases (20.4%). Nine cases (7 cholangiocarcinomas and 2 abscesses), in which MRC showed masses, were visualized more definitely on the additional T2-weighted axial images to the MRC than on the MRC alone. The remaining cases were hepatolithiasis, where stones could be easily differentiated from air by the air-fluid level on the axial images. CONCLUSION: MRC is a good diagnostic modality for evaluating a focal dilatation of IHBD, and the addition of T2-weighted axial image to MRC is helpful.

Usefulness of MRCP in the Diagnosis of Common Bile Duct Dilatation caused by Non-stone or Non-tumorous Conditions

PURPOSE: To evaluate the usefulness of MRCP in the diagnosis of the variable causes of common bile duct(CBD) dilatation, except stone or tumor MATERIALS AND METHODS: Twenty-six patients(M:F=15:11, mean age; 62 years) with both MRCP and ERCP were included in this study. Dynamic MRCP(n=12) and contrast-enhanced MRI(n=10) of abdomen were also added. Dilatation of CBD, intrahepatic ducts and pancreatic duct was evaluated, including coexistence of intrahepatic ductal stone, pancreatic pseudocyst, and papillitis or papillary edema. The criteria of CBD dilatation was over than 7 mm(n=21, without cholecystectomy) or 10 mm(n=5, with cholecystectomy) in diameter on T2-weighted coronal image. RESULTS: The mean diameter of CBD was 12.7 mm without cholecystectomy(9-19 mm) and 13.0 mm with cholecystectomy(10-15 mm), respectively(p>0.05). Cholangitis(n=11, 42.3%), chronic pancreatitis(n=8, 30.8%), stenosis of distal CBD(n=6, 23.1%), periampullary diverticulum(n=3, 11.5%), stenosis of ampulla of Vater(n=2, 7.7%), dysfunction of sphincter of Oddi(n=2, 7.7%), acute focal pancreatitis in the pancreatic head(n=2, 7.7%), papillitis(n=1, 3.8%), pseudocyst in the pancreatic head(n=1, 3.8%), and ascaris in CBD(n=1, 3.8%) were noted. Pancreatic duct dilatation(n=10, 38.5%) and duodenal diverticulum(n=3, 11.5%) were also seen on MRCP. On dynamic MRCP(12 patients), distal CBD was visualized in 2 patients(16.7%), which was not shown on routine MRCP. Only 1 patient(10.0%) showed papillitis with slightly enhancing papilla on contrast-enhanced MRI(10 patients). CONCLUSION: MRCP was thought to be helpful in the evaluation of the causes of CBD dilatation, not caused by stone or tumor, especially in the cases of stenosis of distal CBD and chronic pancreatitis, dysfunction of sphincter of Oddi on dynamic MRCP, and cholangitis and pericholangitic abnormality on contrast-enhanced MRI

Intraluminal Brachytherapy after Metallic Stent Placement in Primary Bile Duct Carcinoma

PURPOSE: To determine the effect of intraluminal brachytherapy on stent patency and survival after metallic stent placement in patients with primary bile duct carcinoma. MATERIALS AND METHODS: Twenty-seven patients with primary bile duct carcinoma underwent metallic stent placement; in 16 of the 27 intraluminal brachytherapy with an iridium-192 source (dose, 25 Gy) was the performed. Obstruction was due to either hilar (n=14) or non-hilar involvement (n=13). For statistical comparison of patients who underwent/did not undergo intraluminal brachytherapy, stent patency and survival were calculated using the Kaplan-Meier method and an independent t test. RESULTS: The mean durations of stent patency and survival were 9.1 and 10.0 months respectively in patients who underwent intraluminal brachytherapy, and 4.2 and 5.0 months in those who did not undergo this procedure (p<0.05). The mean durations of stent patency and survival among the 22 patients who died were 7.6 (range, 0.8 -16.1) and 8.3 (range, 0.8-17.3) months, respectively, in the eleven patients who underwent intraluminal brachytherapy, and 4.2 (range, 0.9-8.0) and 5.0 (range, 0.9-8.4) months in those whom the procedure was not performed (p<0.05). CONCLUSION: Intraluminal brachytherapy after stent placement extended both stent patency and survival in patients with primary bile duct carcinoma.

Percutaneous Placement of Self-expandable Metallic Biliary Stents in Malignant Extrahepatic Strictures: Indications of Transpapillary and Suprapapillary Methods

OBJECTIVE: To compare the efficacy of suprapapillary and transpapillary meth-ods of transhepatic biliary metallic stent placement in malignant biliary strictures and to specify the indications of each method applied. MATERIALS AND METHODS: Stents were placed in 59 patients. Strictures were cat-egorized as type A (within 3 cm of the ampulla, n = 27), type B (over 3 cm from ampulla, n = 7), type C (within 3 cm of the bending portion, n = 9), or type D (over 3 cm above the bending portion, n=16). The stenting method was suprapapillary in 34 cases and transpapillary in 25. The rates of initial and long-term patency and of early recurrence were compared. RESULTS: Initial patency rates for the suprapapillary and transpapillary methods were 1/7 (14.3%) and 20/20 (100%) respectively for type A (p < 0.0001), 4/5 (80.0%) and 2/2 for type B, 3/7 (42.9%) and 2/2 for type C, and 15/16 (93.8%) and 0/0 for type D. Early recurrence rates were 7/30 (23.3%) using the suprapap-illary method and 4/29 (13.8%) using the transpapillary method (p = 0.51). The long-term patency rate did not differ significantly according to either type (p =0.37) or method (p = 0.62). CONCLUSION: For good initial patency, the transpapillary method is recommended for strictures of the distal extrahepatic duct near the ampulla and just above the bending portion. Long-term patency is not influenced by the stenting method employed.

Percutaneous Placement of Self-expandable Metallic Biliary Stents in Malignant Extrahepatic Strictures: Indications of Transpapillary and Suprapapillary Methods

OBJECTIVE: To compare the efficacy of suprapapillary and transpapillary meth-ods of transhepatic biliary metallic stent placement in malignant biliary strictures and to specify the indications of each method applied. MATERIALS AND METHODS: Stents were placed in 59 patients. Strictures were cat-egorized as type A (within 3 cm of the ampulla, n = 27), type B (over 3 cm from ampulla, n = 7), type C (within 3 cm of the bending portion, n = 9), or type D (over 3 cm above the bending portion, n=16). The stenting method was suprapapillary in 34 cases and transpapillary in 25. The rates of initial and long-term patency and of early recurrence were compared. RESULTS: Initial patency rates for the suprapapillary and transpapillary methods were 1/7 (14.3%) and 20/20 (100%) respectively for type A (p < 0.0001), 4/5 (80.0%) and 2/2 for type B, 3/7 (42.9%) and 2/2 for type C, and 15/16 (93.8%) and 0/0 for type D. Early recurrence rates were 7/30 (23.3%) using the suprapap-illary method and 4/29 (13.8%) using the transpapillary method (p = 0.51). The long-term patency rate did not differ significantly according to either type (p =0.37) or method (p = 0.62). CONCLUSION: For good initial patency, the transpapillary method is recommended for strictures of the distal extrahepatic duct near the ampulla and just above the bending portion. Long-term patency is not influenced by the stenting method employed.

Management of Advanced Hilar Biliary Malignancy with X-shaped Stenting Technique

PURPOSE: To report X-shaped stent insertion and its result in the patients with advanced hilar malignancy. MATERIALS AND METHODS:X-shaped stents were inserted in six patients with advanced hilar malignancy involving segmental branches of both intrahepatic bile ducts (IHD). The causes were cholangiocarcinomas in five patients and recurrent GB cancer in one. The procedure includes three steps: 1) the insertion of two wires through three IHDs in an X configuration, using a stone basket; 2) balloon dilatation of lesions, and 3) the in-sertion of two stents in an as X configuration. Stents were inserted after balloon dilatation in five patients, and without balloon dilatation in one. Changes in serum bilirubin levels and procedure-related problems were reviewed. RESULTS: In all patients, serum bilirubin levels gradually decreased, but in two, they increased again. One of these two died of sepsis after 1 month. There was bile leakage through the puncture and bile was extracted from malignant ascites. In the other patient, occlusion of the left stent tip occurred, and additional left PTBD was performed 3 months later. Hemobilia developed in all five patients with balloon dilatation, these all experianced pain during dilatation , but afterwards this disappeared. One stent without pre-balloon dilation showed incomplete self-expansion at the crossing part and supplementary balloon dilatations were performed. CONCLUSION: In patients with advanced hilar malignancy, X-shaped stent insertion is a new palliation. Problems such as hemobilia, pain, and intraperitoneal bile leakage may, however, occur.

Utility of Single Shot Fast Spin Echo Technique in Evaluating Pancreaticobiliary Diseases : T 2 - weighted Image and Magnetic Resonance Cholangiopancreatography

PURPOSE: To evaluate the accuracy of T2-weighted imaging and MR cholangiopancreatography using the single shot fast spin-echo technique for evaluating pancreaticobiliary disease. MATERIALS AND METHODS: B e t ween March and July 1997, axial and coronal T2-weighted images ( T E : 8 0 -2 00 msec) and MR cholangiopancreatograms(TE:800 -1 2 00 msec) were obtained in two ways [single slab (thickness:30 -50 mm) and multislice acquisition under chemical fat saturation] using SSFSE pulse sequencing in 131 cases of suspected pancreati-cobiliary disease. The accuracy of SSFSE MR imaging was assessed in 89 lesions of 74 patients [male,48; female,26; age range, 3 0 -86 (mean,59)years] confirmed surgicopathologically(50 lesions in 39 patients) and clinically (39 lesions in 35 patients). Two radiologists reviewed the MR images and diagnosis was determined by consensus. RESULTS: Correct diagnosis was confirmed in 84 of 89 lesions (94 %). Seven lesions were falsely interpreted, false positive and false negative results accounting for two and five cases, respective l y. Two pancreatic cancers were misdiagnosed as pancreatitis and a cancer of the proximal common bile duct(CBD) was interpreted as a distal CBD cancer. The sensitivity of SSFSE MR imaging for malignancy was 93 %. One CBD stone revealed by endoscopic retrograde cholangiopancreatography (ERCP) was not detected on MR images. In contrast, a stone in the CBD seen on MR images was not apparent on subsequent ERC P. Sensitivity and specificity for calculous disease were 96 % and 99.7 %, respective l y. A benign stricture of the ampulla of Vater was falsely interpreted as normal, and correct diagnosis was possible in two falsely diagnosed cases when MR images were rev i ewed retrospectively. CONCLUSION: The combination of T2-weighted and cholangiographic images using SSFSE is an accurate method for diagnosing pancreaticobiliary diseases.

Intervention of Malignant Biliary Obstruction with Hanaro Spiral Stent

PURPOSE: To evaluate the long-term patency of the Hanaro spiral stent (Solco Intermed, Seoul, Korea) when used as a palliative in patients with inoperable malignant biliary obstruction. MATERIALS AND METHODS: Between April 1996 and July 1998, 39 patients with malignant biliary obstruction underwent percutaneous placement of 48 Hanaro spiral stents. The causes of obstruction were bile duct carcinoma(n=18), pancreatic carcinoma (n=8), metastatic lymphadenopathy (n=5), gallbladder carcinoma (n=5), hepatocellular carcinoma (n=1) and other tumors (n=2). Using the kaplan-Meier method, patient survival and stent patency rates were estimated with regard to level of obstruction. RESULTS: As regards stent insertion, there was no technical failure. Overall 25- and 50-week survival rates for the entire patient group were 50% and 11%, respectively, while overall stent patency rates at 25 and 50 weeks were 42 % and 11 %, respectively. Twenty-five-week stent patency rates in patients with common bile duct (CBD) and hilar obstruction were 51 % and 18 %, respectively. The stent patency rates in the CBD obstruction group was significantly higher than that in the hilar obstruction group (p < 0.05). CONCLUSION: In patients with CBD obstruction, the clinical efficacy of Hanaro spiral stent was superior to that in patients with hilar obstruction. However, Hanaro spiral stents showed a lower patency rate with regard to patient survival, and further investigation is required.

Differentiation of Hepatocellular Carcinoma from Intrahepatic Cholangiocarcinoma as the Cause of Biliary Obstruction: Value of Dynamic CT During the Hepatic Arterial Phase

PURPOSE: To evaluate the usefulness of dynamic CT during the hepatic arterial phase with rapid IV injection ofcontrast material in distinguishing hepatocellular carcinoma (HCC) from intrahepatic cholangiocarcinoma (ICAC) asthe cause of biliary obstruction. MATERIALS AND METHODS: We retrospectively reviewed two-phase dynamic incrementalCT or helical CT findings in 22 patients with intrahepatic duct obstruction secondary to pathologically provenHCCs (n=12) or ICACs (n=10). Two-phase CT scans were obtained 20-45 seconds (hepatic arterial phase) or 2 minutes(equilibrium phase) after the initiation of a bolus injection of contrast material (5 mL/sec, 150 mL). Theenhancement patterns of tumors, as seen on two-phase images, were classified as hypo-, iso-, or hyperattenuated,relative to surrounding liver parenchyma. Two-phase images were compared and correlated with pathologic findings. RESULTS: During the hepatic arterial phase, diffuse high-enhancement was seen in nine HCCs (75%) and partialenhancement in three (25%); five (50%) of the ten ICACs were hypodense and five (50%) were hypodense withperipheral enhancement. During the equilibrium phase, however, all HCCs were hypodense and capsular enhancementwas seen in four cases (33.3%). All ICACs were hypodense with mild peripheral or central heterogeneousenhancement. Contrast enhancement patterns of HCCs during the hepatic arterial phase were significantly different(P<.0001) from those of ICACs. CONCLUSION: Our results suggest that dynamic CT during the hepatic arterial phase,with rapid IV injection of contrast material, is useful for the differentiation of HCC from ICAC as the cause ofbiliary obstruction.

Atrophy of the Left Hepatic Lobe Caused by a Biliary Tract Disease

PURPOSE: To study the CT patterns of left lobar atrophy, including pathologic and hemodynamic features, incases of primary biliary disease. MATERIALS AND METHODS: CT findings of left hepatic lobar and segmental atrophyin 26 patients with histologically or radiologically-proven underlying bile-duct disease were reviewed. Seventeen cases were oriental cholangiohepatitis (OCH) with left intrahepatic stones and nine were cholangiocarcinomainvolving the hilar or left hepatic bile duct. The distribution and appearance of atrophy and adjacent lobarhypertrophy were studied. CT scans were examined for the presence of stenosis or obstruction of the left portalvein, and the enhancing pattern of lobar atrophy was analysed. In patients who had undergone left lobectomy, themechanism of lobar atrophy was correlated with radiographic and pathologic features. RESULTS: All patients showedbile duct dilatation localized to atrophic left hepatic segments. In cholangiocarcinoma, the distribution ofatrophy was characteristically lobar, in contrast to segmental distribution in OCH. Compensatory hypertrophy wasmore common in OCH and particularly involved the caudate lobe. Organic and functional occlusion of the left portalvein was a cause of atrophy, even in OCH. Periportal fibrosis and inflammation were the main pathological featureof atrophy. On spiral CT scan, delayed enhancement of atrophic liver parenchyma was the characteristic feature. CONCLUSION: Lobar or segmental left hepatic lobe atrophy is seen in bile duct disease caused by OCH orcholangiocarcinoma. This finding suggests that the disease process is advanced, and that there is obstruction ornarrowing of the left portal vein, associated with periportal fibrosis and inflammation.

Efficacy of Percutaneous Transhepatic Choledochoplasty of the Biliary Stricture, Using a 16F Silastic Catheter, in Patients with Recurrent Pyogenic Cholangitis

PURPOSE: To evaluate the efficacy of percutaneous transhepatic choledochoplasty of the main biliary stricture, using a 16F silastic foley catheter, in patients suffering from recurrent pyogenic cholangitis MATERIALS AND METHODS: In nine patients who had undergone stenting procedure at the site of the main stricture after the total removal of biliary stones, a 16F silastic catheter was held in position for 1-4 (mean, 2.7) months. Using ultrasonogrophy, we assessed the diameter of the bile duct 5 cm above the main stricture. RESULTS: During the follow-up period of 1-30 (mean, 18.1) months, the diameter of the bile duct above the main stricture was, in all cases, under 3 mm. CONCLUSION: In patients with recurrent pyogenic cholangitis, choledochoplasty of the biliary stricture, using a 16F silastic catheter, was therapeutically effective.

PTBD Spiral CT Cholangiography: Utility in Patients with Extrahepatic Biliary Obstruction

PURPOSE: The purpose of this study is to assess the utility of PTBD spiral CT cholangiography, after infusion of contrast media through a PTBD tube, for evaluation of a biliary lesion after emergency PTBD due to severe jaundice. MATERIALS AND METHODS: Forty patients with emergency PTBD due to extrahepatic biliary obstruction were transferred to our clinic and prospectively studied. The causes of obstruction were 17 extrahepatic cholangiocarcinomas (including three Klatskin's tumors), seven pancreatic head carcinomas, six calculous diseases of the common bile duct, six periampullary lesions, two ampulla of Vater carcinomas, one gall bladder carcinoma with invasion of the common hepatic duct, and one cholangitis. Diagnosis was on the basis of pathologic, radiologic, and clinical findings. Pre-contrast CT scanning was performed. After the infusion of contrast media (iothalamate : normal saline=1:10) through a PTBD tube, spiral CT scans were obtained. After IV infusion of contrast media (Ultravist, 100cc), early- and delayed-phase spiral CT scans were obtained at 45 and 210 seconds, respectively, with an interscan interval of 5mm. 3-D CT cholangiograms were then reconstituted. Spiral CT without infusion of contrast media through a PTBD tube and PTBD spiral CT cholangiography were performed in 14 cases. The level of extrahepatic biliary obstruction was categorized as either upper, middle, or lower third. In 21 surgically confirmed cases, we evaluated the accuracy with which the level and cause of obstruction was determined; levels and causes during surgery and by as seen on PTBD cholaniography were compared. RESULTS: The levels of obstruction diagnosed on PTBD spiral CT cholangiography and on 3-D CT cholangiography corresponded in all cases to the levels during surgery and on PTBD cholangiography [upper third (n=7), middle third (n=12), lower third (n=21)], and the level diagnosed on spiral CT without infusion of contrast media through a PTBD tube corresponded to the level during surgery in ten of 14 cases. The cause of obstruction diagnosed on PTBD spiral CT cholangiography corresponded to pathologic findings in 19 of 21 cases. In 15 cases, 3-D CT cholangiography was diagnostically helpful. CONCLUSION: PTBD spiral CT cholangiography is a useful diagnostic method for determining the level and cause of biliary obstruction.

Radiologic Characteristics of Hepatocellular Carcinoma with Intrabile Duct Tumor Growth and Extension

PURPOSE: To determine the radiologic characteristics of the hepatocellular carcinoma with intrabile ducttumor growth and extension. MATERIALS AND METHODS: We analyzed the arterial-dominant phase(ADP) CT scans, hepaticangiograms and cholangiograms in nine cases of hepatocellular carcinomas with intrabile duct tumor growth andextension confirmed by tumor thrombectomy. RESULTS: The gross types were nodular in three cases and massive infive. Two masses were larger than 6cm, four were between 3 and 6cm, and three were less than 3cm. Among six casesof ADP-CT scan, dense contrast enhancement was observed in four, minimal enhancement in one, and no enhancement inone. In one case we were unable to find a primary mass. With regard to tumor staining on hepatic arteriograms, five cases were hypervascular, one case was hypovascular, and the remaing one was not found. All tumor thrombi were seen as filling defects which were dilating the bile duct on cholangiograms. Among five intrabile ducttumors, thrombi were detected on ADP-CT scan(n=6), dense contrast enhancement was observed in one case, minimalenhancement in two cases and no enhancement in two cases. CONCLUSION: Intrabile duct tumor growth and extensionin hepatocellular carcinoma(HCC) does not correlate with location, mass size or tumor vascularity. It was concluded that tumor thrombi were formed through the direct invasion by a tumor of a branch of the intrahepaticduct, its growth in the distal direction in the biliary tree and subsequent extension to the common bile duct. Thrombi were more hypovascular than primary mass.

Percutaneous Cholecystostomy : 60 Cases of Experience

PURPOSE: To review the effectiveness and complication of percutaneous cholecystostomy(PCCS). MATERIALS AND METHODS: We performed PCCS in 60 patient who presented with acute cholecystitis. The causes of acutecholecystitis were as follows : acalculous cholecystitis(n=8), calculous cholecystitis(n=23), GB hydrops(n=3), GBempyema(n=15), septic cholangitis(n=11). Of 60 patients, 36 patients had high risk factor for cholecystectomy :underlying malignancy(n=13), severe trauma(n=2), liver cirrhosis(n=3), diabetes mellitus(n=6), end stage renal disease(n=3), cardiac disease(n=3) and others(n=6). Cholecystostomy was done under ultrasonographic and fluoroscopic guide. RESULTS: The cholecystostomy was successfully in 59 patients, and failed in 1 patients. 15 patients improved without other procedure. 16 patients underwent cholecystectomy after improvement of their general condition. Severe complications of PCCS are as follows : bile peritonitis(n=6), hemoperitoneum(n=1), subphrenic abscess(n=1). Mild complication, such as pain, occured in most patients. Emergency operation was done in one patient who developed bile peritonitis. DISCUSSION: Cholecystostomy is effective and safe, especially incases of in operable patients who represent acute cholecystitis. Percutaneous cholecystostomy may substitiute surgical cholecystostomy.

Non-breath-hold MR Cholangiography for the Evaluation of Obstructive Biliary Diseases

PURPOSE: MR cholangiography(MRC) in patients with obstructive biliary diseases was evaluated in order to compare its role with that of ERCP or PTC. MATERIALS AND METHODS: Twenty consecutive patients with obstructive biliary and peribiliary diseases (Eleven biliary and peribiliary carcinomas, seven intrahepatic stone diseases and seven extrahepatic stone diseases) were included and ERCP(16 ccases) or PTC(four cases) was performed in all twenty cases. Non-breasth-hold, heavily T2-weighted, fast spin echo MRC was carried out and 2-D axial, coronal images and 3-D images with maximum intensity projection protocol were obtained. We regarded ERCP or PTC as thegold standard and then comparedn MRC with ERCP of PTC retrospectively. RESULTS: In 11 patients with biliary and peribiliary carcinomas, the level of obstruction was depicted in nine cases(83%) on MRC and in six of seven cases(86%) on ERCP. The causes of obstruction were demonstrated in eight cases(73%) on MRC and in six of seven cases(86%) on ERCP. On MRC, Seven cases(64%) revealed similar findings to ERCP or PTC. Of seven cases of EHD and seven of IHD stone diseases, EHD stones were detected in six cases(86%) on MRC and in seven cases (100%) on ERCP,IHD stones were detected in four cases(57%) on MRC and in five cases(71%) on ERCP. 2D-MRC was superior to 3D-MRCin the detection of stones. The extent and grade of ductal dilatiation was accurately revealed in six cases(86%)on MRC and in seven cases(100%) on ERCP of EHD stones, in six cases(86%) on MRC and in three cases(43%) on ERCP of IHD stones. Six cases(86%) of EHD stones and two cases(29%) of IHD stones revealed similar findings between MRCand ERCP. CONCLUSION: MRC findings were similar to those of ERCP or PTC in the evaluation of malignant biliary diseases or extrahepatic stone diseases and was valuable in their diagnoses. In the evaluation of intrahepaticstone diseases, MRC demonstrated dilated peripheral IHDs with stones more difinitely than ERCP but in the detection its accuracy was low. Further studies may therefore be needed.

Experimental study on the use of ~(103)Pd radioactive stent in the prevention of post-traumatic bile duct stricture in dogs / 中国普通外科杂志

Objective To investigate the preventive effects of 103 Pd radioactive stent on stenosis after bile duct injury in dogs.Methods Twelve healthy dogs (15～20kg) were randomly divided into 103 Pd radioactive stent group (n=6) and control group (n=6). Immediately after balloon dilatation injury to the bile duct, the 103 Pd radioactive stent(experiment group) or the ordinary stent(control group) was positioned into the target segment. The dogs were killed one month later. The injured bile duct segments were dissected free from the dogs, and were examined radionucleonically, immunohistochemically and pathologically. Muscular proliferation area and lumen area were determined by computer assisted picture analysis system. Results In the control group, 30 days after ductal injury, the mucosa of the bile duct was fractured, the mucosa was proliferated and the lumen stenosed.Compared with the control group, 103 Pd radioactive stent significantly reduced muscular proliferation area (P