Colangiografía: duplicación vesicular verdadera / Cholangiography: true gallbladder duplication / Colangiografia: duplicação verdadeira da vesícula biliar

Se presenta una variante anatómica de la vía biliar extrahepática, como lo es la verdadera duplicación vesicular. Las malformaciones congénitas vesiculares se categorizan en anormalidades posicionales y morfológicas, la duplicación vesicular está incluida en este último. La clasificación aceptada es la de Boyden. Basado en la relación del conducto cístico con el cuerpo vesicular describió la "vesica fellea divisa" (vesícula bilobulada que drena a un solo conducto cístico y comparte origen embriológico común) y "vesica fellea duplex" (verdadera duplicación vesicular, dos vesículas separadas con conductos císticos independientes, origen embriológico doble).

Dilataciones quísticas congénitas de las vías biliares (segunda parte). Vías biliares extrahepáticas / Congenital bile duct cystic dilatations (part 2). Extrahepatic bile ducts

RESUMEN Las dilataciones quísticas congénitas de la vía biliar extrahepática son infrecuentes, principalmente en Occidente, y afectan sobre todo a niños pero son poco comunes en adultos. El diagnóstico requiere un alto índice de sospecha y suele llevarse a cabo con estudios colangiográficos de los cuales la CRMN es, en la actualidad, el de mayor utilidad. Es conocido el aumento de malignización de estas dilataciones, por lo que el tratamiento completo de la bolsa quística es obligatorio.

ABSTRACT Congenital dilatation of extrahepatic bile ducts is rare in the Western countries and is more common in children than in adults. The diagnosis requires high level of suspicion and is made by cholangiography tests, among which MRCP is the most useful nowadays. Malignant transformation of these cystic dilatations is well-known; therefore, complete resection of the cystic pouch is mandatory.

Morphometric study of extra-hepatic biliary pathways: study in human corpses / Estudio morfométrico de las vías biliares extrahepáticas: estudio en cadáveres humanos

SUMMARY: Adverse events (AE) contribute significantly to postoperative morbidities and comorbidities. Many AEs occur due to a lack of anatomical knowledge and its variants. Latrogenic bile duct injuries, for instance, represent a serious surgical complication of laparoscopic cholecystectomy. Anatomical knowledge for the identification and adequate drainage of all ducts is relevant and fundamental in order to avoid future errors. The objective of the study was to morphometrically analyze the bile ducts in adult human corpses. 13 livers were extracted from adult human corpses to obtain the ducts: choledochal, common hepatic and cystic. After morphological analysis, duct measurements (length and diameter) were continued using a digital caliper. The data obtained were tabulated in SPSS 21 program, performing descriptive analysis with mean and standard deviation. The averages of bile ducts were 61.05 (± 16.43) mm in length and 3.86 (± 0.72) mm in diameter. The cystic duct length and diameter averages were 33.59 (± 12.29) mm and 3.40 (± 0.79) mm, respectively. The common hepatic ducts had an average of 30.02 (± 7.19) mm in length and 3.74 (± 1.18) mm in diameter. The analyzed samples presented different values ?? from those already described in the literature, where the length of the cystic ducts was greater, while the length of the common hepatic ducts was numerically smaller. This work is very significant, as the morphometric variability of the bile ducts allows for varying morphological situations that can compromise the hepatobiliar physiology.

RESUMEN: Los eventos adversos (EA) contribuyen significativamente a las morbilidades y comorbilidades postoperatorias. Muchos EA se deben a la falta de conocimiento de la anatomía y sus variaciones. Por ejemplo, las lesiones iatrogénicas de las vías biliares representan una complicación quirúrgica grave de la colecistectomía laparoscópica. El conocimiento anatómico para la identificación y drenaje adecuado de todos los conductos es relevante y fundamental para evitar futuros errores. El objetivo del estudio fue analizar morfométricamente las vías biliares en cadáveres humanos adultos. Se extrajeron 13 hígados de cadáveres humanos adultos y se retiraron los conductos: colédoco, hepático común y cístico. Después del análisis morfológico, se continuó con las mediciones de los conductos (longitud y diámetro) utilizando un calibrador digital. Los datos fueron tabulados en el programa SPSS 21, mediante análisis descriptivos con media y desviación estándar. Los promedios de las vías biliares fueron de 61,05 (± 16,43) mm de longitud y 3,86 (± 0,72) mm de diámetro. Los promedios de longitud y diámetro del conducto cístico fueron 33,59 (± 12,29) mm y 3,40 (± 0,79) mm, respectivamente. Los conductos hepáticos comunes tenían un promedio de 30,02 (± 7,19) mm de longitud y 3,74 (± 1,18) mm de diámetro. Las muestras analizadas presentaron valores diferentes a los ya descritos en la literatura, donde la longitud de los conductos císticos era mayor, mientras que la longitud de los conductos hepáticos comunes fue numéricamente menor. Este trabajo es significativo, debido a que la variabilidad morfométrica de las vías biliares y permite identificar situaciones morfológicas que pueden comprometer la fisiología hapatobiliar.

Estudio complementario de la patología biliar complicada y el manejo de la litiasis coledociana en dos tiempos / Complementary evaluation of complicated gallstone disease and two-stage management of choledochal lithiasis

RESUMEN Antecedentes: la litiasis biliar tiene una prevalencia actual en Occidente del 10-20%. El 7-16% de los pacientes presentan también coledocolitiasis. El diagnóstico preoperatorio de coledocolitiasis es difícil de establecer. Objetivo: establecer nuestra experiencia en el estudio de la patología biliar complicada y el manejo de la coledocolitiasis en dos tiempos, como terapéutica de elección. Material y métodos: estudio prospectivo, observacional. Pacientes con patología biliar sometidos a procedimientos en el Servicio de Cirugía General del Hospital Vidal, desde el 30/06/2019 al 30/12/2019. Resultados: la ecografía hepato-bilio-pancreática (HPB) es específica, con exactitud del 80,9% y sensibilidad del 50%. La colangio resonancia magnética (CRNM) es 100% específica, tiene exactitud del 84,6% y sensibilidad de 67%. La colangio pancreatografía retrógrada endoscópica (ERCP -por sus siglas en inglés-), durante la primera colangiografía mostró en el 100% litiasis coledociana, pero, luego del tratamiento, la colangiografía de "control" muestra 0% de sensibilidad, 100% especificidad, con exactitud del 15,4%. En los hallazgos intraoperatorios, el cístico dilatado en asociación con alteraciones humorales ha demostrado una sensibilidad del 100%, especificidad del 90% y tasa de exactitud de 93,6%. Conclusión: la colangiografía intraoperatoria (CIO) es el procedimiento de referencia ("gold standard") en el abordaje de la patología biliar complicada, siendo su uso sistemático. La asociación entre alteraciones de parámetros humorales y el cístico dilatado resulta un parámetro con alto valor predictivo para la presencia de litiasis coledociana.

ABSTRACT Background: Nowadays, the prevalence of gallstones ranges between 10 and 20% in Western world, and 7-16% of the patients also present choledocholithiasis. The preoperative diagnosis of choledocholithiasis is difficult. Objective: To establish our experience in the evaluation of complicated gallstone disease and two-stage management of choledochal lithiasis as standard or care. Material and methods: This prospective and observational study included patients hospitalized with gallstone disease undergoing procedures in the Department of General Surgery of Hospital Vidal from June 30, 2019, to December 30, 2019. Results: Ultrasound of the liver, biliary tract and pancreas was specific, with accuracy of 80.9% and sensitivity of 50%. Magnetic resonance cholangiopancreatography (MRCP) had a sensitivity of 100%, accuracy of 84.6% and sensitivity of 67%. As for endoscopic retrograde cholangiopancreatography (ERCP), the diagnosis of choledocholithiasis was made in 100% of the cases during the first cholangiography while "control" cholangiography had a sensitivity of 0%, specificity of 100% and accuracy of 15.4%. The presence of a dilated cystic duct intraoperatively in association with abnormal biochemical parameters had a sensitivity of 100%, specificity of 90%, and accuracy of 93.6%. Conclusion: Intraoperative cholangiography (IOC) is the gold standard procedure for the management of complicated gallstone disease. The association of biochemical parameters and a dilated cystic duct has high predictive value for choledochal lithiasis.

Ansa pancreática: desafio no diagnóstico etiológico em paciente jovem com pancreatite grave / Ansa pancreatica: etiological diagnosis challenge in a young patient with severe pancreatitis

A ansa pancreática é uma variação anatômica rara dos ductos pancreáticos. Consiste numa comunicação entre o ducto pancreático principal (Wirsung) e o ducto pancreático acessório (Santorini). Recentemente, estudos têm demonstrado estar essa variação anatômica implicada como fator predisponente e significativamente associada a episódios recorrentes de pancreatite aguda. A pancreatite é uma entidade clínica pouco frequente na infância. Diferente dos adultos, as causas mais comuns incluem infecções virais, por ascaris, medicamentosas, traumas e anomalias estruturais. O objetivo deste estudo foi relatar um caso de pancreatite aguda grave não alcoólica e não biliar, em um paciente jovem de 15 anos, em cuja propedêutica imagenológica evidenciou-se alça, comunicando com os ductos pancreáticos ventral e dorsal, compatível com ansa pancreática.

Ansa pancreatica is a rare anatomical variation of the pancreatic ducts. It consists of communication between the main pancreatic duct (Wirsung) and the accessory pancreatic duct (Santorini). Recently, studies have shown that this anatomical variation is implicated as a predisposing factor and significantly associated with recurrent episodes of acute pancreatitis. Pancreatitis is a rare clinical entity in childhood. Different from that in the adults, the most common causes include viral and ascaris infections, drugs, traumas, and structural abnormalities. The objective of this study was to report a case of a severe non-alcoholic and non-biliary acute pancreatitis in a 15-year-old patient, whose propedeutic imaging showed a loop communicating with the ventral and dorsal pancreatic ducts, consistent with ansa pancreatica.

Colecistogastrostomía guiada por ultrasonografía endoscópica en un paciente con cáncer pancreático: primer caso en Colombia (con video) / Endoscopic ultrasonography-guided cholecystogastrostomy in a patient with pancreatic cancer: the first case in Colombia (with video)

Resumen El tratamiento actual para la obstrucción biliar maligna es la derivación biliar no quirúrgica con propósito paliativo. La cirugía tiene indicaciones específicas en pacientes con patología maligna con propósito curativo. Sin embargo, la obstrucción duodenal y del conducto biliar intra o extrahepático no dilatado hace que esta cirugía y el procedimiento endoscópico guiado por ultrasonografía endoscópica (USE) sean difíciles de realizar. Presentamos nuestra experiencia con el primer caso en Colombia, un país latinoamericano del tercer mundo. Consistió en una colecistogastrostomía guiada por USE, a partir de la utilización de una endoprótesis luminal (Lumen-apposing metal stents, LAMS) (HOT AXIOS stent, Xlumena Inc.; Mountain View, CA, Estados Unidos) de 15 mm × 10 mm, en un paciente masculino con cáncer pancreático inoperable e invasión duodenal con conducto colédoco dilatado. La colecistogastrostomía guiada por USE podría ser considerada como una opción de más importancia para la descompresión biliar que el drenaje percutáneo, ya que es superior en términos de viabilidad técnica, seguridad y eficacia en casos específicos de estenosis ampular e invasión duodenal. Además, puede ser realizada en países del tercer mundo, cuando se cuenta con el entrenamiento y los instrumentos adecuados. La endoprótesis metálica totalmente recubierta, aplicada a luz (HOT AXIOS stent, Xlumena Inc.; Mountain View, CA, Estados Unidos), es ideal para la colecistogastrostomía guiada por USE, a fin de minimizar complicaciones como fugas biliares. Se necesitan estudios comparativos adicionales para validar los beneficios de esta técnica.

Abstract The current treatment of malignant biliary obstruction is non-surgical biliary diversion with palliative intent. The surgery having specific indications in patients with malignant pathology with curative intent. However, duodenal obstruction and non-dilated intra- or extrahepatic bile duct make these surgical and endoscopic procedures guided by EUS difficult. We present our experience with the first case in Colombia, a third-world country in Latin America, of a cholecystogastrostomy guided by endoscopic ultrasound (EUS) in a patient with unresectable pancreatic cancer and duodenal invasion with dilated common bile duct using a luminal stent (LAMS) (HOT AXIOS stent, Xlumena Inc.; Mountain View, CA, USA) 15 mm × 10 mm. EUS-guided cholecystogastrostomy should be considered as an option for biliary decompression of greater importance than percutaneous drainage since it is superior in terms of technical feasibility, safety and efficacy in specific cases of ampullary stenosis and duodenal invasion. In addition, it can be done in third world countries when it has the appropriate training and implements. The fully covered metal stent applied to light (HOT AXIOS stent, Xlumena Inc.; Mountain View, CA, USA) is ideal for EUS guided cholecystogastrostomy to minimize complications such as bile leakage. Additional comparative studies are needed to validate the benefits of this technique.

Palliative Measures with Ethanol Gallbladder Ablation and Endobiliary Radiofrequency Ablation Followed by Endoscopic Biliary Stent Placement in an Advanced Case of Common Bile Duct Cancer: A Case Report / 대한소화기학회지

Endobiliary radiofrequency ablation (RFA) is a procedure performed widely to induce locoregional tumor control by the transfer of thermal energy to the lesion and subsequent tumor necrosis. A 72-year-old male with a prior history of acute calculous cholangitis and perforated cholecystitis was admitted to the Kyungpook National University Hospital complaining of fever and nausea. He had an indwelling percutaneous transhepatic gallbladder drainage (PTGBD) catheter from the previous episode of perforated cholecystitis. An abdominal CT scan showed marked dilation of both the intrahepatic and extrahepatic bile ducts. Common bile duct cancer was confirmed histologically after an endobiliary biopsy. A surgical resection was considered to be the initial treatment option. During open surgery, multiple metastatic nodules were present in the small bowel mesentery and anterior abdominal wall. Resection of the tumor was not feasible, so endobiliary RFA was performed prior to biliary stenting. Cholecystectomy was required for the removal of the PTGBD catheter, but the surgical procedure could not be performed due to a cystic ductal invasion of the tumor. Instead, chemical ablation of the gallbladder (GB) with pure ethanol was performed to breakdown the GB mucosa. Palliative treatment for a biliary obstruction was achieved successfully using these procedures. In addition, a PTGBD catheter was removed successfully without significant side effects. As a result, an improvement in the patient's quality of life was accomplished.

Incidence and Overall Survival of Biliary Tract Cancers in South Korea from 2006 to 2015: Using the National Health Information Database

BACKGROUND/AIMS: There have been no nationwide studies to investigate the trends in incidence and 5-year survival rates of intra- and extrahepatic bile duct cancers and gall-bladder cancer. Therefore, our study aimed to describe the incidence and 5-year survival rates of biliary tract cancers by subsites in South Korea. METHODS: A total of 86,134 patients with biliary tract cancers were selected from the National Health Information Database. Age-standardized incidence rates and annual percentage changes were calculated. Life-table methods and log-rank tests were used to determine the differences in survival rates. Cox-proportional hazard models were used to estimate the hazard ratio of the patients with biliary tract cancers. RESULTS: The incidence rate of intra-hepatic bile duct cancer decreased by 1.3% annually from 8.8 per 100,000 in 2006 to 7.8 per 100,000 in 2015. Extrahepatic bile duct cancer also showed a decreasing trend by 2.2% per year from 8.7 per 100,000 in 2006 to 6.7 per 100,000 in 2015. Gallbladder cancer showed the greatest decline, with an annual percentage change of 2.8% from 6.3 per 100,000 to 5.2 per 100,000 during the same period. The 5-year survival rates were 30.0% in gallbladder cancer, 27.8% in extrahepatic bile duct cancer, and 15.9% in intra-hepatic bile duct cancer. CONCLUSIONS: The overall incidence rates of intrahepatic and extrahepatic bile duct cancer and gallbladder cancer decreased from 2006 to 2015. Among biliary tract cancers, intrahepatic bile duct cancers exhibited the highest incidence rate and the worst survival rate.

Characterization of Intraductal Papillary Neoplasm of the Bile Duct with Respect to the Histopathologic Similarities to Pancreatic Intraductal Papillary Mucinous Neoplasm

Intraductal papillary neoplasms of the bile duct (IPNBs) are known to show various pathologic features and biological behaviors. Recently, two categories of IPNBs have been proposed based on their histologic similarities to pancreatic intraductal papillary mucinous neoplasms (IPMNs): type 1 IPNBs, which share many features with IPMNs; and type 2 IPNBs, which are variably different from IPMNs. The four IPNB subtypes were re-evaluated with respect to these two categories. Intestinal IPNBs showing a predominantly villous growth may correspond to type 1, while those showing papillay-tubular or papillay-villous growth correspond to type 2. Regarding gastric IPNB, those with regular foveolar structures with varying numbers of pyloric glands may correspond to type 1, while those with papillary-foveolar structures with gastric immunophenotypes and complicated structures may correspond to type 2. Pancreatobiliary IPNBs that show fine ramifying branching may be categorized as type 1, while others containing many complicated structures may be categorized as type 2. Oncocytic type, which displays solid growth or irregular papillary structures, may correspond to type 2, while papillary configurations with pseudostratified oncocytic lining cells correspond to type 1. Generally, type 1 IPNBs of any subtype develop in the intrahepatic bile ducts, while type 2 IPNBs develop in the extrahepatic bile duct. These findings suggest that IPNBs arising in the intrahepatic ducts are biliary counterparts of IPMNs, while those arising in the extrahepatic ducts display differences from prototypical IPMNs. The recognition of these two categories of IPNBs with reference to IPMNs and their anatomical location along the biliary tree may deepen our understanding of IPNBs.

Squamous Cell Carcinoma of the Extrahepatic Common Hepatic Duct

We report a rare case of hilar squamous cell carcinoma. A 62-year-old Korean woman complaining of nausea was referred to our hospital. Her biliary computed tomography revealed a 28 mm-sized protruding solid mass in the proximal common bile duct. The patient underwent left hemihepatectomy with S1 segmentectomy and segmental excision of the common bile duct. Microscopically, the tumor was a moderately differentiated squamous cell carcinoma of the extrahepatic bile duct, without any component of adenocarcinoma or metaplastic portion in the biliary epithelium. Immunohistochemically, the tumor was positive for cytokeratin (CK) 5/6, CK19, p40, and p63. Squamous cell carcinoma of the extrahepatic bile duct is rare. To date, only 24 cases of biliary squamous cell carcinomas have been reported. Here, we provide a clinicopathologic review of previously reported extrahepatic bile duct squamous cell carcinomas.

A Case of Alveolar Echinococcosis Occurring in the Hilar Bile Duct

Echinococcosis is a disease caused by the Echinococcus species that parasitizes in humans. Alveolar echinococcosis (AE) which is caused by Echinococcus multilocularis is harmful to humans. AE mainly occurs in the liver and can be transferred to retroperitoneal lymph nodes, lung, brain, bone, spleen and other organs through lymphatic and blood vessels. Cholangiocarcinoma can occur in the intrahepatic and extrahepatic bile ducts and is more common in the hilar. We reported a case of hilar bile duct alveolar echinococcosis which was originally misdiagnosed an cholangiocarcinoma.

Ultrasound-guided transhepatic computed tomography cholecystography in beagle dogs

This study was performed to evaluate the feasibility of ultrasound-guided computed tomography (CT) cholecystography and to establish an optimal protocol. In 8 healthy beagles, CT cholecystography was conducted using four contrast formulas; two dilution ratios (1:1 vs. 1:3) and two total volumes (8 mL vs. 16 mL) of 300 mgI/kg iohexol after ultrasound-guided percutaneous contrast injection into the gallbladder. CT images were obtained at 3, 10, and 30 min after injection and assessed qualitatively and quantitatively. For all contrast formulas, CT cholecystography showed the gallbladder and the intra- and extrahepatic bile ducts. The volume of the gallbladder and size of bile duct were significantly larger when using a volume of 16 mL iohexol than an 8 mL volume regardless of the dilution ratio. The distinction between the common bile duct and duodenum, the filling of the gallbladder, and the patency of bile duct were effectively assessed using a 16 mL volume of contrast agent with either dilution ratio. Beam-hardening artifacts deteriorated CT image quality for visualizing the biliary system when using the dilution ratio of 1:1. Patency of the bile tract could be easily evaluated using a curvilinear planar reconstruction. There was no significant difference in CT scan time among the different conditions. Minor leakage of contrast agent temporarily occurred after contrast injection in 30% of 32 sets of CT cholecystography. Ultrasound-guided percutaneous cholecystography can visualize both gallbladder and biliary tract with minimal artifacts using a contrast agent volume of 16 mL with a 1:3 dilution ratio.

Risk Factors for Pancreatitis and Cholecystitis after Endoscopic Biliary Stenting in Patients with Malignant Extrahepatic Bile Duct Obstruction

BACKGROUND/AIMS: For the treatment of malignant biliary obstruction, endoscopic retrograde biliary drainage (ERBD) has been widely accepted as a standard procedure. However, post-ERBD complications can affect the lives of patients. The purpose of this study was to identify the predictive factors for these complications, including the patient’s status, cancer status, and stent type.METHODS: This was a retrospective analysis conducted in a single tertiary hospital from January 2007 to July 2017. The following variables were evaluated: sex, age, body mass index, cancer type, history of pancreatitis, gallbladder stone, previous biliary stenting, precut papillotomy, stent type, contrast injection into the pancreatic duct or gallbladder, cystic duct invasion by the tumor, and occlusion of the cystic duct orifice by a metal stent.RESULTS: Multivariate analysis showed that contrast injection into the pancreatic duct was a risk factor for pancreatitis. Patients with a history of bile drainage showed a lower risk of pancreatitis. For cholecystitis, the analysis revealed contrast injection into the gallbladder and cystic duct invasion by the tumor as important predictive factors. Metal stents showed a greater risk of post-procedure pancreatitis than plastic stents, but did not affect the incidence of cholecystitis.CONCLUSIONS: Considering that contrast injection is the most important factor for both complications, a careful approach by the physician is essential in preventing the occurrence of any complications. Further, choosing the type of stent is an important factor for patients at a risk of post-procedure pancreatitis.

Biliary tract in trident, an anatomical variation between the cystic duct and its union to the common hepatic duct: a rare case report / Tracto biliar en tridente, una variación anatómica entre el conducto cístico y su unión al conducto hepático común: un caso raro

SUMMARY: Given that the gallbladder and the biliary tract are subject to multiple anatomical variants, detailed knowledge of embryology and its anatomical variants is essential for the recognition of the surgical field when the gallbladder is removed laparoscopically or by laparotomy, even when radiology procedures are performed. During a necropsy procedure, when performing the dissection of the bile duct is a rare anatomical variant of the bile duct, in this case the cystic duct joins at the confluence of the right and left hepatic ducts giving an appearance of trident. This rare anatomical variant in the formation of common bile duct is found during the exploration of the bile duct during a necropsy procedure, it is clear that the wrong ligation of a common hepatic duct can cause a great morbi-mortality in the postsurgical of biliary surgery. This rare anatomical variant not previously described is put in consideration to the scientific community. Anatomical variants of the biliary tract are associated with high rates of morbidity and mortality, causing serious bile duct injuries. Only the surgical skill of the surgeon and his open mind to the possibilities of abnormalities make the performance of cholecystectomy a safe procedure.

RESUMEN: Dado que la vesícula biliar y el tracto biliar están sujetos a múltiples variantes anatómicas, el conocimiento detallado de la embriología y sus variantes anatómicas es esencial para el reconocimiento del campo quirúrgico cuando la vesícula biliar se extirpa laparoscópicamente o por laparotomía, incluso cuando se realizan procedimientos de radiología. Durante un procedimiento de necropsia, se realiza la disección del conducto biliar y se observa una variante anatómica inusual del conducto biliar; en este caso, el conducto cístico se une a la confluencia de los conductos hepáticos derecho e izquierdo dando una apariencia de tridente. Esta rara variante anatómica en la formación del conducto biliar común puede causar una gran morbimortalidad en la cirugía biliar asociado a una ligadura incorrecta. Esta extraña variante anatómica no descrita anteriormente se reporta a la comunidad científica, debido a que las variantes anatómicas del tracto biliar se asocian con altas tasas de morbilidad y mortalidad, al causar lesiones graves en el conducto biliar. Solo la habilidad quirúrgica del cirujano y su mente abierta a las posibilidades de variaciones anatómicas hacen que la realización de la colecistectomía sea un procedimiento seguro.

Detalles técnicos de la doble anastomosis hepático-yeyuno en Y de Roux, con base en la descripción de un caso / Technical details of double Roux-en-Y hepaticojejunostomy based on a clinical case description

La anastomosis hepático-yeyuno en Y de Roux se considera la técnica de elección para tratar lesiones quirúrgicas de la vía biliar, como su sección o resección. La pérdida de confluencia de los conductos hepáticos principales derecho e izquierdo es uno de los factores que incrementan la complejidad técnica durante el procedimiento y, en algunos de estos pacientes, se requiere una doble anastomosis hepático-yeyuno para garantizar resultados satisfactorios a largo plazo. Se describen los aspectos técnicos y los resultados posoperatorios del tratamiento quirúrgico empleado, con base en la intervención de una paciente con una lesión quirúrgica de la vía biliar y pérdida de la confluencia de los conductos hepáticos. La evolución de la paciente fue satisfactoria y se mantiene asintomática después de 12 meses de seguimiento. A pesar de ser una técnica compleja, la doble anastomosis hepático-yeyuno en Y de Roux resultó una opción segura de tratamiento en esta paciente

Roux-en-Y hepato-jejunostomy (RYHJ) is the technique of choice for the surgical treatment of bile duct injuries (BDI), such as section or resection. The loss of the hepatic confluence (LHC) increases the technical difficulties during the procedure and, in some of these patients, a doble-RYHJ is required to achieve a long term successful result. We report the technical aspects of the surgical technique as well as the results, based on the case of a young female patient with BDI and LHC. The patient shows a satisfactory evolution and remains asymptomatic during the 12 months of follow up. Double RYHJ, although technically demanding, resulted a safe option for treating this patient

Primary Neuroendocrine Tumor of the Extrahepatic Bile Duct / 대한소화기학회지

No abstract available.

Comparison of the Clinicopathologic Characteristics of Intraductal Papillary Neoplasm of the Bile Duct according to Morphological and Anatomical Classifications

BACKGROUND: Intraductal papillary neoplasm of the bile duct (IPNB) is a recently defined entity and its clinical characteristics and classifications have yet to be established. We aimed to clarify the clinical features of IPNB and determine the optimal morphological classification criteria. METHODS: From 2003 to 2016, 112 patients with IPNB who underwent surgery were included in the analysis. After pathologic reexamination by a specialized biliary-pancreas pathologist, previously suggested morphological and anatomical classifications were compared using the clinicopathologic characteristics of IPNB. RESULTS: In terms of histologic subtypes, most patients had the intestinal type (n = 53; 48.6%) or pancreatobiliary type (n = 33; 30.3%). The simple “modified anatomical classification” showed that extrahepatic IPNB comprised more of the intestinal type and tended to be removed by bile duct resection or pancreatoduodenectomy. Intrahepatic IPNB had an equally high proportion of intestinal and pancreatobiliary types and tended to be removed by hepatobiliary resection. Morphologic classifications and histologic subtypes had no effect on survival, whereas a positive resection margin (75.9% vs. 25.7%; P = 0.004) and lymph node metastasis (75.3% vs. 30.0%; P = 0.091) were associated with a poor five-year overall survival rate. In the multivariate analysis, a positive resection margin and perineural invasion were important risk factors for survival. CONCLUSION: IPNB showed better long-term outcomes after optimal surgical resection. The “modified anatomical classification” is simple and intuitive and can help to select a treatment strategy and establish the proper scope of the operation.

Large Cell Neuroendocrine Carcinoma of the Extrahepatic Bile Duct / 대한소화기학회지

Primary neuroendocrine tumors originating from the extrahepatic bile duct are rare. Among these tumors, large cell neuroendocrine carcinomas (NECs) are extremely rare. A 59-year-old man was admitted to Sanggye Paik Hospital with jaundice that started 10 days previously. He had a history of laparoscopic cholecystectomy, which he had undergone 12 years previously due to chronic calculous cholecystitis. Laboratory data showed abnormally elevated levels of total bilirubin 15.3 mg/dL (normal 0.2–1.2 mg/dL), AST 200 IU (normal 0–40 IU), ALT 390 IU (normal 0–40 IU), and gamma-glutamyl transferase 1,288 U/L (normal 0–60 U/L). Serum CEA was normal, but CA 19-9 was elevated 5,863 U/mL (normal 0–37 U/mL). Abdominal CT revealed a 4.5 cm sized mass involving the common bile duct and liver hilum and dilatation of both intrahepatic ducts. Percutaneous transhepatic drainage in the left hepatic duct was performed for preoperative biliary drainage. The patient underwent radical common bile duct and Roux-en-Y hepaticojejunostomy for histopathological diagnosis and surgical excision. On histopathological examination, the tumor exhibited large cell NEC (mitotic index >20/10 high-power field, Ki-67 index >20%, CD56 [+], synaptophysin [+], chromogranin [+]). Adjuvant concurrent chemotherapy and radiotherapy were started because the tumor had invaded the proximal resection margin. No recurrence was detected at 10 months by follow-up CT.

Bile Duct Stricture and Intrahepatic Cystic Formation after Abdominal Injury due to Child Abuse: A Case Report

A 6-year-old male who lived with a mother in a single-parent family was referred to the emergency room with multiple traumas. There was no specific finding on CT scan of the other hospital performed 55 days before admission. However, CT scan at the time of admission showed common bile duct (CBD) stenosis, proximal biliary dilatation and bile lake formation at the segment II and III. Endoscopic retrograde biliary drainage was performed, but the tube had slipped off spontaneously 36 days later, and follow-up CT scan showed aggravated proximal biliary dilatation above the stricture site. He underwent excision of the CBD including the stricture site, and the bile duct was reconstructed with Roux-en-Y hepaticojejunostomy. Pathologic report of the resected specimen revealed that the evidence of trauma as a cause of bile duct stricture. While non-iatrogenic extrahepatic biliary trauma is uncommon, a level of suspicion is necessary to identify injuries to the extrahepatic bile duct. The role of the physicians who treat the abused children should encompass being suspicious for potential abdominal injury as well as identifying visible injuries.

Feasibility of Endoscopic Papillary Large Balloon Dilation in Patients with Difficult Bile Duct Stones without Dilatation of the Lower Part of the Extrahepatic Bile Duct

BACKGROUND/AIMS: There is no consensus for using endoscopic papillary large balloon dilation (EPLBD) in patients without dilatation of the lower part of the bile duct (DLBD). We evaluated the feasibility and safety of EPLBD for the removal of difficult bile duct stones (diameter ≥10 mm) in patients without DLBD. METHODS: We retrospectively reviewed the records of 209 patients who underwent EPLBD for the removal of bile duct stones from October 2009 to July 2014. Primary outcomes were the clearance rate and additional mechanical lithotripsy. Secondary outcomes were the incidence of complications and recurrence rate. RESULTS: Fifty-seven patients had DLBD (27.3%), and 152 did not have DLBD (72.7%). There were no significant differences in the overall success rate or the use of mechanical lithotripsy. Success rate during the first session and procedure time were better in the DLBD than the without-DLBD group (75.7% vs 66.7%, 48.1±23.0 minutes vs 58.4±31.7 minutes, respectively). As for complications, there were no significant differences in the incidence of pancreatitis, perforation or bleeding after endoscopic retrograde cholangiopancreatography. The recurrence rate did not differ significantly between the two groups. CONCLUSIONS: EPLBD is a useful and safe method for common bile duct stone removal in patients without DLBD.