Estenosis crítica de conducto hepático común por anillo vascular: reporte de un caso / Common bile duct stricture caused by vascular ring: A case report

Introduction: The most common congenital malformations of the bile duct are biliary atresia and choledochal cyst. In addition, the most common liver anatomical variation is the right hepatic artery aberration. The goal of this study is to characterize a patient with this disease and propose the hepatoduodenal anastomosis as surgical treatment. Case report: One-month-old patient with suspected congenital biliary atresia due to progressive jaundice and acholia since birth. Liver tests consistent with a cholestatic pattern and brain MRI scan consistent with biliary atresia. Periods of decreased bilirubin and sporadic slight pigmentation of depositions were described. The surgical finding was a bile duct stricture due to a vascular ring caused by aberrant right hepatic artery. Resection of bile duct and hepatic-duodenal bypass were performed. The patient evolved satisfactorily from this condition. Conclusion: There are few reports of biliary obstruction due to vascular malformations. It is important to keep in mind that not all neonatal jaundice episodes are caused by biliary atresia or choledo-chal cyst. The clinical course, laboratory tests and imaging should be considered and in the case of suspicion, further exploration should take place.

Introducción: Las malformaciones congénitas de la vía biliar más frecuentes son la atresia de vías biliares y quiste de colédoco. Por otro lado, la variante anatómica hepática más común es la aberración de la arteria hepática derecha. El objetivo es caracterizar un paciente portador de esta patología y plantear la hepato-duodeno anastomosis como tratamiento quirúrgico. Caso clínico: Paciente de 1 mes de edad, con sospecha de Atresia de Vía Biliar congénita por ictericia progresiva y acolia desde recién nacido. Pruebas hepáticas concordantes con un patrón colestásico y resonancia magnética compatible con atresia de vías biliares. Evolucionó con períodos de descenso de bilirrubina y leve pigmentación, esporádica, de deposiciones. El hallazgo quirúrgico fue una estenosis crítica de vía biliar a nivel del conducto hepático común debido a un anillo vascular por una arteria hepática derecha aberrante. Se realizó una sección de vía biliar y una derivación hepato-duodenal. Evolucionó con una resolución completa de su patología. Conclusión: Existen pocos reportes de obstrucción de vía biliar por malformaciones vasculares. Es importante tener presente que no todas las ictericias neonatales son por atresia de vías biliares o quiste de colédoco. Se debe considerar la evolución clínica, laboratorio e imágenes, y si existen sospechas, explorar.

Ampullary tumours (ampullomas) in the elderly – an interdisciplinary problem.

Background & objectives: Ampullary cancer is one of the periampullary tumours with better prognosis, but relapses occur early in some patients. This study was carried out to assess whether pancreatoduodenectomy (PDE, Whipple operation) could be a safe therapeutic procedure for elderly patients with periampullary tumours. Methods: Between 2005 and 2007, 19 patients (12 male, 7 female) aged over 65 yr (range 66 and 83 yr) with diagnosis of ampulloma were operated. Results: Of the 19 patients, 6 underwent local surgical ampullectomy with reinsertion of ductus choledochus and Wirsungi’s duct for benign or early cancer lesion and 13 underwent PDE (Whipple operation). Of these 13, only one was in T1 stage, one was in T4 stage, two patients were T3 and the rest in T2 stage. Lesion of lymphatic system had 40 per cent of patients in T2 stage and all in T3 and T4 stages. One patient died of pulmonary embolism several days after operation. Post-operative complications occurred in 3 cases: 1 patient with partial dehiscence of gastroenteroanastomosis – treated by conservative approach, 2 patients with dehiscence of pancreatojejunoanastomosis. Interpretation & conclusions: Diagnosis and therapy of ampullary tumours is multimodal. With careful patient selection, PDE can be performed in elderly people (>65 yr) safely. The post-operative morbidity in this group is essentially influenced by their multi-morbidity.

Efficacy of a Self-designed Protective Lead Shield in Reduction of Radiation Exposure Dose During Endoscopic Retrograde Cholangiopancreatography / 대한소화기학회지

BACKGROUND/AIMS: The increasing use of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) calls for greater consideration of radiation exposure risk to endoscopists and assistants, and emphasizes the proper system of radiation protection. This study was designed to assess the effect of a newly developed, self-designed, protective lead shield. METHODS: A curtain-shaped protective shield composed of seven movable lead plates was developed, each with the following dimensions: depth, 0.1 cm; width, 15 cm; length, 70 cm. The curtain-shaped protective shield was designed to be located between the patient and the endoscopist. Twenty-nine patients (11 men and 18 women) undergoing ERCP between January 2010 and March 2010 were selected for this study. The dose of radiation exposure was recorded with or without the protective lead shield at the level of the head, chest, and pelvis. The measurement was made at 50 cm and 150 cm from the radiation source. RESULTS: The mean patient age was 64 years. The mean patient height and weight was 161.7+/-6.9 cm and 58.9+/-9.9 kg, respectively. The mean body mass index (BMI) was 22.5+/-3.0 kg/m2. Endoscopists received 1522.2+/-537.0 mR/hr without the protective lead shield. At the same distance, radiation exposure was significantly reduced to 68.8+/-88.0 mR/hr with the protective lead shield (p-value<0.0001). The radiation exposure to endoscopists and assistants was significantly reduced by the use of a protective lead shield (p value<0.0001). The amount of radiation exposure during ERCP was related to the patient's BMI (r=0.749, p=0.001). CONCLUSIONS: This self-designed, protective lead shield is effective in protecting endoscopists and assistants from radiation exposure.

Safety and Efficacy of Endoscopic Retrograde Cholangiopancreatograpy in Very Elderly Patients / 대한소화기학회지

BACKGROUND/AIMS: Endoscopic retrograde cholangiopancreatograpy (ERCP) is often used for the diagnosis and treatment of pancreaticobiliary diseases in the elderly patients. However, few studies have assessed its efficacy and safety in the very elderly. The purpose of this study was to evaluate the clinical outcomes of ERCP in the very elderly patients. METHODS: Eight hundreds two patients who underwent ERCP at Seoul National University Bundang hospital were enrolled retrospectively. They were divided into three groups according to their ages (non-elderly group, elderly group and very-elderly group; or =80, respectively). The indications and clinical outcomes including the complications of ERCP were compared among groups. RESULTS: The most common indication of ERCP was acute cholangitis in all the three groups. Periampullary diverticulum was more frequently observed in elderly and very-elderly patients than in younger patients. Mean duration of hospitalization was not different among three groups. ERCP success rate in all enrolled patients was approximately 90%, and there was no difference in terms of technical success rate between groups (p=0.1). However, the number of ERCP sessions was significantly higher in the very-elderly patients compared to in the non-elderly and elderly (1.38 vs. 1.13 and 1.18 respectively; p<0.001). There was no difference in mortality and complication rate between groups. CONCLUSIONS: ERCP can be performed safely in very-elderly patients. Therefore, only age should not be regarded as one of the major determining factors whether to perform ERCP.

Safety and Efficacy of Endoscopic Retrograde Cholangiopancreatograpy in Very Elderly Patients / 대한소화기학회지

BACKGROUND/AIMS: Endoscopic retrograde cholangiopancreatograpy (ERCP) is often used for the diagnosis and treatment of pancreaticobiliary diseases in the elderly patients. However, few studies have assessed its efficacy and safety in the very elderly. The purpose of this study was to evaluate the clinical outcomes of ERCP in the very elderly patients. METHODS: Eight hundreds two patients who underwent ERCP at Seoul National University Bundang hospital were enrolled retrospectively. They were divided into three groups according to their ages (non-elderly group, elderly group and very-elderly group; or =80, respectively). The indications and clinical outcomes including the complications of ERCP were compared among groups. RESULTS: The most common indication of ERCP was acute cholangitis in all the three groups. Periampullary diverticulum was more frequently observed in elderly and very-elderly patients than in younger patients. Mean duration of hospitalization was not different among three groups. ERCP success rate in all enrolled patients was approximately 90%, and there was no difference in terms of technical success rate between groups (p=0.1). However, the number of ERCP sessions was significantly higher in the very-elderly patients compared to in the non-elderly and elderly (1.38 vs. 1.13 and 1.18 respectively; p<0.001). There was no difference in mortality and complication rate between groups. CONCLUSIONS: ERCP can be performed safely in very-elderly patients. Therefore, only age should not be regarded as one of the major determining factors whether to perform ERCP.

A Case of Hyperplastic Polyp at Distal Common Bile Duct / 대한소화기학회지

No abstract available.

The Usefulness of Endoscopic Ultrasonography in the Diagnosis of Choledocholithiasis without Common Bile Duct Dilatation / 대한소화기학회지

BACKGROUND/AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) is the most accurate modality in diagnosis of choledocholithiasis. However, it carries some complications. Endoscopic ultrasonography (EUS) is less invasive than ERCP and used for the diagnosis of choledocholithiasis. Recent studies showed that a usefulness of EUS for the diagnosis of small choledocholithiasis without common bile duct (CBD) dilatation. For such a reason, ERCP is being replaced by EUS in the diagnosis of bile duct stones. The aim of this study was to investigate the accuracy of EUS for the diagnosis of choledocholithiasis without CBD dilatation. METHODS: A total of 66 patients with suspected choledocholithiasis without CBD dilatation were enrolled. EUS were performed in all cases within 48 hours after computed tomography (CT) or ultrasonography (US). Final diagnosis was obtained by ERCP or clinical course (minimum 6 months follow-up). We analyzed the accuracy of US, CT, and EUS, respectively. RESULTS: CT and US were performed in 51 and 15 cases, respectively. CBD stones were detected in 23 (35%) patients by ERCP. EUS showed 100% sensitivity, 95% specificity, 92% positive predictive value, and 100% negative predictive value for identifying CBD stones. CT or US showed 26%, 93%, 67%, and 70%, respectively. There were no EUS-related complications. CONCLUSIONS: EUS was more effective than CT or US and as accurate as ERCP for the diagnosis of small choledocholithiasis without CBD dilatation. Thus, EUS may help to avoid unnecessary diagnostic ERCP and its complication.

Parásitos de fasciola hepática intracoledociano / Common bile duct fasciolasis: report of one case

La fasciolasis es una enfermedad parasitaria producida por el tremátodo digeneo Fasciola hepática. Durante la fase crónica de la enfermedad los parásitos pueden entran en los conductos biliares, y ser causa de ictericia obstructiva, colangitis, pancreatitis y otras complicaciones. Se presenta el caso clínico de una paciente intervenida por sospecha de colelitiasis y colédocolitiasis, a la cual durante la exploración coledociana intraoperatoria le fueron extraídos múltiples parásitos adultos de Fasciola hepática. Este hallazgo sólo fue aclarado posteriormente en la biopsia diferida. Se realiza una revisión breve del tema, métodos de diagnóstico, tratamiento médico y alternativas quirúrgicas de tratamiento.

Fasciolasis is a zoonotic disease caused by the digenean trematode Fasciola hepatica. During the chronic phase of the disease the parasites invade the main biliary ducts, causing obstructive jaundice, cholangitis, pancreatitis and other complications. We report a 75 years old female, operated due to the suspicion of a choledocholithiasis. During the exploration of the choledochus, adult F. hepatica parasites were extracted. The pathology report of the parasites confirmed the diagnosis.

The Usefulness of Percutaneous Transhepatic Cholangioscopy for Identifying Malignancies in Distal Commom Bile Duct Strictures

The diagnostic accuracy of percutaneous transhepatic cholangioscopy (PTCS) was compared to that of three radiologic modalities in distal common bile duct (CBD) strictures for the evaluation of clinical application. Ninety-five patients who underwent PTCS for the evaluation of distal CBD strictures (35 malignant and 60 benign) whose masses were not obvious from radiologic imagings were included. Confirmative diagnosis could not be reached by endoscopic retrograde cholangiopancreatography (ERCP) or radiologic findings in all cases. Specific findings on the computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP) and direct cholangiography were analyzed among 68 (25 malignant and 43 benign) out of the 95 patients in order to determine the sensitivity and specificity of three radiologic studies for the diagnosis of malignant distal CBD strictures, and to compare those results with those by a combination of PTCS-guided biopsy and tumor vessel observation on cholangioscopy. The sensitivity/specificity of CT, MRCP and direct cholangiography including ERCP in diagnosing malignant distal CBD strictures were 42.9%/65.8%, 53.3%/58.3%, and 70.8%/47.6% respectively, while it was 96%/100% for the combination of PTCS-guided biopsy and tumor vessel. PTCS is a useful method for differential diagnosis of distal CBD strictures, particularly when it is difficult to distinguish benign from malignant strictures by radiologic studies and when peroral approach is not feasible.

Prevalence of sphincter of Oddi dysfunction in patients referred to endoscopic retrograde cholangiopancreatography

BACKGROUND: Sphincter of Oddi manometry is the gold-standard method for sphincter of Oddi dysfunction. The prevalence of sphincter of Oddi dysfunction among patients referred to endoscopic retrograde cholangiopancreatography is largely unknown. AIM: To evaluate prospectively the prevalence of biliary sphincter of Oddi dysfunction (B-SOD) among Brazilian patients referred to endoscopic retrograde cholangiopancreatography and to study the safety of sphincter of Oddi manometry in this setting. METHODS: Biliary sphincter of Oddi manometry was intended in 110 patients referred to endoscopic retrograde cholangiopancreatography. The number of attempts to obtain deep cannulation with the manometry catheter was recorded and patients were divided into two groups: up to 5 (easy cannulation) and >5 attempts (difficult cannulation). RESULTS: Sphincter of Oddi manometry was successful in 71/110 patients (64.5 percent). Sphincter of Oddi dysfunction was found in 18/71 patients (25 percent). Endoscopic retrograde cholangiopancreatography findings were: normal in 16, biliary stones in 39, malignant biliary strictures in 9 and benign biliary strictures in 7. There was no statistical difference in sphincter of Oddi dysfunction prevalence regarding disease, gender or difficulty of cannulation. Only 2/71 patients developed post-procedure mild pancreatitis. CONCLUSIONS: We have found a high prevalence of sphincter of Oddi dysfunction in patients referred to endoscopic retrograde cholangiopancreatography. Gender, nature of disease or difficulty of cannulation did not influence the prevalence of sphincter of Oddi dysfunction among these patients. Sphincter of Oddi manometry is a safe procedure for the evaluation of sphincter of Oddi dysfunction in patients referred to endoscopic retrograde cholangiopancreatography.

RACIONAL: Manometria do esfíncter de Oddi é o método padrão-ouro para o diagnóstico da disfunção do esfíncter de Oddi. Atualmente, a prevalência de disfunção do esfíncter de Oddi em pacientes encaminhados a colangiopancreatografia retrógrada endoscópica é desconhecida. OBJETIVOS: Avaliar prospectivamente a prevalência de disfunção do esfíncter de Oddi em pacientes encaminhados a colangiopancreatografia retrógrada endoscópica e estudar a segurança da manometria do esfíncter de Oddi nesses pacientes. MÉTODO: Neste estudo, 110 pacientes encaminhados à colangiopancreatografia retrógrada endoscópica foram submetidos a manometria do esfíncter de Oddi biliar. Com base no número de tentativas de canulação da papila os pacientes foram divididos em dois grupos: até cinco tentativas (canulação fácil) e mais de cinco tentativas (canulação difícil). RESULTADOS: Manometria do esfíncter de Oddi foi realizada com sucesso em 71/110 pacientes (64,5 por cento). Disfunção do esfíncter de Oddi foi encontrada em 18/71 pacientes (25 por cento). Os achados das colangiopancreatografia retrógrada endoscópica foram: estudo normal em 16, coledocolitíase em 39, estenose biliar maligna em 9 e estenose biliar benigna em 7. Não foi observada diferença estatística na prevalência de disfunção do esfíncter de Oddi considerando-se a natureza da doença, sexo ou a dificuldade de canulação. Somente 2/71 pacientes evoluíram com pancreatite pós-procedimento de leve intensidade. CONCLUSÃO: Encontrou-se alta prevalência de disfunção do esfíncter de Oddi em pacientes encaminhados a colangiopancreatografia retrógrada endoscópica. Sexo, natureza da doença ou dificuldade de canulação não mostraram influência na prevalência da disfunção nestes pacientes. Manometria do esfíncter de Oddi mostrou-se um procedimento seguro na pesquisa de disfunção do esfíncter de Oddi em pacientes encaminhados a colangiopancreatografia retrógrada endoscópica.

Ectopic pancreatic tissue mimicking ampullary tumor.

Ectopic pancreas is an anomaly in the fusion of the two pancreatic buds where an ectopic rest develops at a place away from the normal site. We report a 70-year-old lady who presented with obstructive jaundice; she was found to have an ampullary tumor highly suggestive of malignancy, for which she underwent pancreatico-duodenectomy. However, histology showed ectopic pancreatic tissue in the ampulla.

Benign obstruction of the common hepatic duct (Mirizzi syndrome): diagnosis and operative management

RACIONAL: A síndrome de Mirizzi, é complicação rara da colelitíase de longa duração, caracterizada pelo estreitamento do ducto hepático comum devido a mecanismo de compressão e/ou inflamação por cálculos biliares impactados no infundíbulo da vesícula biliar ou no ducto cístico. OBJETIVO: Descrever série de oito enfermos consecutivos com síndrome de Mirizzi de uma única instituição, submetidos ao tratamento cirúrgico e comentar seus aspectos com ênfase no diagnóstico e tratamento. MÉTODO: Quatro mulheres e quatro homens, com média de idade de 61,6 anos (42 a 82 anos), foram operados com síndrome de Mirizzi entre 1997 e 2003. Avaliaram-se a apresentação clínica, os resultados dos exames laboratoriais e de imagem, os achados operatórios, a presença de coledocolitíase, o tipo de síndrome de Mirizzi de acordo com a classificação de Csendes, a escolha do procedimento operatório e as complicações pós-operatórias. RESULTADOS: Os sintomas mais freqüentes foram dor abdominal (87,5%) e icterícia (87,5%). Todos os doentes apresentaram exames de função hepática alterados. O diagnóstico da síndrome de Mirizzi foi intra-operatório em sete (87,5%) doentes, e pré-operatório em um (12,5%). Observou-se fístula colecistocoledociana associada à coledocolitíase em três (37,5%) casos. A síndrome de Mirizzi foi classificada como tipo I em cinco (71,4%) doentes, tipo II em um (14,3%), tipo III em um (12,5%), e tipo IV em outro (12,5%). A colecistectomia, como procedimento cirúrgico isolado, foi realizada em quatro (50,0%) doentes. Um (12,5%) enfermo foi submetido a colecistectomia parcial e fechamento do orifício fistuloso com a região central do infundíbulo. Dois (25,0%) enfermos foram submetidos a colecistectomia e anastomose coledocoduodenal látero-lateral e outro (12,5%) a anastomose coledocoduodenal látero-lateral, deixando-se a vesícula biliar in situ. Sete (87,5%) doentes evoluíram sem complicações pós-operatórias e obtiveram alta hospitalar em boas condições. Um (12,5%) enfermo apresentou, no pós-operatório, sepse por abscesso sub-hepático, sendo re-operado. Não houve mortalidade operatória. CONCLUSÕES: O diagnóstico pré-operatório da síndrome de Mirizzi é difícil e é necessário elevado índice de suspeita para evitar lesões da árvore biliar. O problema pode se tornar evidente apenas no momento da operação na forma de aderências firmes ao redor do triângulo de Calot. O sucesso do tratamento está relacionado ao reconhecimento...

Spontaneous perforation of the common bile duct in pregnancy.

Spontaneous perforation of the bile duct is rare. Bile duct perforation occurring during pregnancy is even rarer. We report a 21-year-old primipara with sealed bile duct perforation at 28 weeks of amenorrhea.

Biliary Ascariasis: MR Cholangiography Findings in Two Cases

We describe the imaging features of two cases of biliary ascariasis. Ultrasonography and CT showed no specific abnormal findings, but MR cholangiography clearly demonstrated an intraductal linear filling defect that led to the correct diagnosis. MR cholangiography is thus a useful technique for the diagnosis of biliary ascariasis.