Choledochoduodenostomy combined with Billroth II procedure for extrahepatic biliary obstruction and duodenal perforation in a cat.

Case summary: A 5-year-old neutered Somali cat presented with a 2-week history of icterus. Diagnostic imaging revealed extrahepatic biliary obstruction (EHBO) due to a common bile duct (CBD) mass. During exploratory laparotomy, a duodenal perforation was discovered incidentally. Choledochoduodenostomy combined with the Billroth II procedure was performed after resection of the CBD mass and the proximal duodenum to treat the EHBO and duodenal perforation. Based on histological and immunohistochemical findings, the CBD mass was diagnosed as a neuroendocrine carcinoma with gastrin-producing cell differentiation. The cat recovered almost uneventfully and was discharged 11 days after surgery. The cat survived for nearly 100 days without recurrence of EHBO or duodenal perforation; however, intermittent vomiting and weight loss persisted despite supportive medications. Relevance and novel information: To the best of our knowledge, there is no detailed report on the application of choledochoduodenostomy combined with the Billroth II procedure in cats, as we used to treat the EHBO and duodenal perforation in the present case. As serum gastrin concentrations were elevated on the first day of hospitalisation, the CBD mass was diagnosed as a neuroendocrine carcinoma with gastrin-producing cell differentiation, which seemed to have caused not only EHBO but also duodenal perforation (Zollinger-Ellison syndrome). The cat survived for almost 100 days without any perioperative complications. However, this combined procedure might be considered as only a salvage option and not as a definitive treatment option in cats requiring simultaneous biliary and gastrointestinal reconstruction because postoperative supportive care could not improve the cat's condition or maintain its quality of life.

Duodenal Fibrosis Mimicking Neoplastic Obstructive Hepatopathy in the Setting of Lynch Syndrome.

Intestinal fibrosis is a rare complication of chronic inflammation resulting from various etiologies, including surgery, abdominal radiation, and inflammatory bowel disease. Consequences of intestinal fibrosis include intestinal dysmotility, malabsorption, and obstruction. Patients with Lynch syndrome are predisposed to developing intestinal adenocarcinoma including in the small intestines which typically require intra-abdominal procedures that expose them to fibrogenic triggers. Here, we present a rare case of duodenal fibrosis involving the sphincter of Oddi leading to malabsorption and gastrointestinal symptoms in a patient with Lynch syndrome requiring advanced endoscopy interventions.

Ultrasonographic evaluation of cholecystoduodenostomy sites in six cats.

CASE SERIES SUMMARY: This case series describes the postoperative ultrasonographic findings in six cats that underwent a cholecystoduodenostomy as treatment for extrahepatic biliary obstruction. The surgery site was identified in all six cats, most often within the right cranial abdomen as a thick-walled gall bladder, with a broad-based connection to the descending duodenum. Postoperatively, the biliary tree often remained distended, similar to its preoperative appearance. Recurrent extrahepatic biliary obstruction was suspected in three cats with worsening hyperbilirubinemia. Common bile duct distension was progressive in one of these cats and unchanged in another, but improved in the third. Intrahepatic bile duct distension resolved in one cat following surgery but reappeared with suspected recurrent biliary obstruction. In two cats, progressive echogenic biliary contents were associated with locally aggressive cholangiocarcinoma. Our findings suggest that in cats with cholecystoduodenostomy and progressive increases in hyperbilirubinemia following surgery, progressive or recurrent biliary distension and/or progressive echogenic biliary contents should prompt further investigation. RELEVANCE AND NOVEL INFORMATION: Biliary diversion surgery in cats is associated with high morbidity and mortality. The ultrasonographic appearance of a postoperative cholecystoduodenostomy site has not been described, making differentiation of the expected appearance from postoperative abnormalities difficult. The goal of this study was to determine the expected ultrasonographic appearance, in order to assist in managing cats with recurrent, persistent or worsening clinical signs and biochemical abnormalities following surgery.

Percutaneous Intraductal Microwave Ablation and Self-expandable Metallic Stenting: A New Treatment Method for Malignant Extrahepatic Biliary Obstruction.

PURPOSE: To evaluate the patency and clinical efficacy of percutaneous intraductal microwave ablation (PIMWA) and uncovered self-expandable metallic stents (USEMs) in inoperable malignant extrahepatic biliary obstruction. MATERIALS AND METHODS: The procedures to be performed on patients with malignant inoperable extrahepatic biliary obstruction were decided by a multidisciplinary team including an interventional radiologist. In our study, 141 patients were evaluated retrospectively. Twenty-one patients who underwent PIMWA + USEMs with the MedWaves AveCure microwave system (AveCure® Intelligent Controller and Super-Flex Smart Catheter) and met the inclusion criteria were included in the study. Complications related to the intervention, stent patency, survival time, serum bilirubin levels, and the general condition of the patients were noted. RESULTS: The median stent patency and the median survival time were 108 and 143 days, respectively. The rates of 30-day, 2-month, 6-month and 8-month survival were 95.2%, 85.7%, 38.1%, and 14.3%, respectively. CONCLUSION: The PIMWA + USEMs procedure is a safe, effective, and minimally invasive alternative palliative treatment method in patients with malignant inoperable extrahepatic biliary obstruction.

Follicular cholecystitis: clinicopathologic associations.

Follicular cholecystitis (FC) is a relatively rare entity with uncertain causal associations. In this study, we aimed to explore different clinicopathologic associations of FC, and to better characterize the entity. A retrospective review of archival hematoxylin and eosin slides and pertinent clinical information was undertaken for all cholecystectomy cases with a rendered diagnosis of "follicular cholecystitis," from 1991 to 2017. Concurrent conventional chronic cholecystitis (CC) and lymphocytic cholecystitis (LC) were documented. Forty-three consecutive patients were confirmed to have FC. The majority of the patients (88.4%) had at least one other histologic association in the gallbladder (LC, CC, or both). Remarkably, functional distal biliary obstruction (from choledocholithiasis, sclerosing cholangitis, distal biliary strictures, or malignancies of the pancreatic head or ampulla) was found in 76.7% of the patients, irrespective of the presence of other concurrent histologic findings. FC associated with CC was relatively more common in females (61%) and strongly associated with cholelithiasis (70%). However, those without CC were predominantly males (70%) and had a significant association with LC (75%). All four cases of FC without any other histologic associations who had clinical information available showed some form of distal biliary obstruction. FC cases without concurrent LC were often associated with CC (74%). FC is strongly associated with extrahepatic biliary obstruction distal to the gallbladder. Therefore, this finding at routine cholecystectomy may warrant further evaluation to rule out a cause for distal biliary tract obstruction. Additionally, it is commonly associated with other concomitant histologic abnormalities in the gallbladder such as CC and/or LC.

A prospective randomized study for efficacy of an uncovered double bare metal stent compared to a single bare metal stent in malignant biliary obstruction.

BACKGROUND AND AIMS: A biliary self-expandable metal stent (SEMS) is commonly used to relieve malignant biliary obstruction. The aim of this study was to compare the efficacy of a conventional uncovered SEMS with that of a newly developed uncovered double bare metal stent in reducing the risk of stent occlusion caused by tumor ingrowth. PATIENTS AND METHODS: We performed a prospective, open-labeled, randomized trial in 71 patients at Severance Hospital, Yonsei University College of Medicine from June 2013 to June 2014. Patients with inoperable malignant biliary obstruction were included and randomized to receive an uncovered single bare metal stent (SBSs; S&G Biotech Inc.), an uncovered single bare metal stent (SBSt; Taewoong Medical), or an uncovered double bare metal stent (DBS; S&G Biotech Inc.). RESULTS: The mean age was 66.6 years (range, 35-83), and 42 (59.2%) were male. The mean duration of stent patency was 212 days (±152) in the DBS group (n = 24) compared with 124 days (±98) in the SBSs group (n = 23; P = 0.022 for noninferiority) and 116 days (±79) in the SBSt group (n = 24; P = 0.010 for noninferiority). There were no differences in the incidences of early and delayed complications or migration. CONCLUSIONS: The newly developed DBS is noninferior to the conventional uncovered SEMSs on duration of stent patency and tumor ingrowth occurred less frequently in the DBS group. This might decrease the need for reintervention and offer a better quality of life. The trial is registered with Clinicaltrials.gov no: NCT01869894.

Ampullary carcinoid tumour presenting with extrahepatic biliary obstruction.

Carcinoid tumours are slow growing tumours, derived from enterochromaffin cells located in the crypts of Lieberkühn, which is part of neuroendocrine system. A 36-year-old female patient presented in surgical clinic with complaints of progressively increasing yellowish discolouration of her eyes and pruritis for 6 months. She was deeply jaundiced with a soft and non-tender abdomen. Diagnostic work-up revealed obstructive jaundice secondary to ampullary growth, while computed tomography revealed a small intraluminal lower common bile duct mass. Endoscopic ultrasound showed thickened duodenum at ampulla of Vater. Pancreaticoduodenectomy (Whipple's procedure) with pancreaticojejunostomy, hepaticojejunostomy and gastrojejunostomy was done. Pathological examination of the resected specimen revealed carcinoid tumour. Postoperative course of patient was unremarkable and she is doing well after surgery.

Gangliocytic Paraganglioma With Atypical Immunohistochemical Features Presenting as Extrahepatic Biliary Obstruction.

Gangliocytic paraganglioma is a rare benign tumor of upper gastrointestinal tract that most commonly involves the second part of duodenum. The tumor is detected incidentally on imaging in most of the cases. However, presentation with extrahepatic biliary obstruction is extremely rare. We recently encountered a 50-year-old male patient who was evaluated for extrahepatic biliary obstruction and was found to have a periampullary mass on imaging. The patient underwent pylorus-preserving pancreaticoduodenectomy along with liver biopsy and hepatoduodenal lymph node dissection. On histopathological examination, a tumor was detected in the periampullary region of duodenum, which was confirmed to be gangliocytic paraganglioma on immunohistochemistry along with atypical histological and immunohistochemical features.

A prospective, multicenter study of a double stent system for palliative treatment of malignant extrahepatic biliary obstructions.

BACKGROUND: A double stent system (covered stent in uncovered stent) was designed to provide long-term patency without tumor ingrowth or stent-related complications, such as stent migration, cholecystitis, or pancreatitis. PURPOSE: To investigate the safety and efficacy of double stents in patients with malignant extrahepatic biliary obstructions. MATERIAL AND METHODS: This prospective, nonrandomized, multicenter study enrolled 160 consecutive patients (102 men; mean age, 64 years; range, 33-91 years) with malignant extrahepatic biliary obstructions treated with a double stent system from January 2010 to March 2012. RESULTS: The technical success rate of the double stent placement was 100%. No stent migration was observed. Procedure-related minor (self-limiting hemobilia [n = 6] and cholangitis [n = 2]) and major (pancreatitis [n = 16], cholecystitis [n = 3], and hepatic abscess [n = 2]) complications occurred in a total of 29 patients. The mean serum bilirubin level, which was 8.9 ± 5.6 mg/dL before drainage, decreased to 2.2 ± 4.6 mg/dL 1 month after stent placement (P < 0.001). Successful internal drainage was achieved in 148 patients (92.5%). During the mean follow-up period of 205 days, acute cholecystitis (n = 3) and hepatic abscess (n = 2) occurred in five patients. The median patient survival and stent patency time were 135 days (95% confidence interval [CI], 96-160 days) and 114 days (95% CI, 83-131 days), respectively. Of 153 patients, 22 (14.4%) presented with stent dysfunction due to sludge incrustation (n = 17), tumor overgrowth (n = 4), or blood clot (n = 1), and required repeat intervention. Tumor ingrowth was not observed in any of these patients. CONCLUSION: Percutaneous treatment of malignant extrahepatic biliary obstruction using a double stent safely and effectively achieves internal biliary drainage.

Gall bladder carcinoma with ampullary carcinoma: a rare case of double malignancy.

Simultaneous double cancers in the biliary system are rare. Most are associated with pancreaticobiliary maljunction (PBM). However, it can occur in patients without PBM. Differentiation between these events is important since these two mechanistic origins imply different stages of disease, as well as different subsequent treatments and prognoses. Herein, we report a case of ampullary carcinoma associated with gall bladder carcinoma diagnosed nonoperatively and palliated with biliary metal stenting.

Ampullary neuroendocrine tumor presenting with biliary obstruction and gastric outlet obstruction.

Neuroendocrine tumors of the ampulla of Vater are extremely rare cause of extrahepatic biliary obstruction and further rarer cause of duodenal obstruction, and only a few cases have been reported in the literature. Herein we report a case of ampullary neuroendocrine tumor in a 75-year-old woman who presented with biliary obstruction and gastric outlet obstruction palliated with metal biliary and duodenal stenting with relief of jaundice and vomiting at 1 month of follow-up.

Hepatoma presenting as extrahepatic biliary obstruction due to hemobilia

A case of hepatoma presenting as extrahepatic biliary obstruction due to hemobilia is reported. The patient, a 49-year-old woman, developed jaundice of the obstructive type after a history of B-viral hepatitis. On laparotomy, the liver revealed macronodular cirrhosis without any noticeable mass. A 4-cm sized friable tissue and blood clots were identified within the distended left hepatic duct. Pathologic examination of this tissue confirmed the diagnosis of hepatocellular carcinoma extended in the hepatic duct.

Hepatoma presenting as extrahepatic biliary obstruction due to hemobilia

A case of hepatoma presenting as extrahepatic biliary obstruction due to hemobilia is reported. The patient, a 49-year-old woman, developed jaundice of the obstructive type after a history of B-viral hepatitis. On laparotomy, the liver revealed macronodular cirrhosis without any noticeable mass. A 4-cm sized friable tissue and blood clots were identified within the distended left hepatic duct. Pathologic examination of this tissue confirmed the diagnosis of hepatocellular carcinoma extended in the hepatic duct.