Predictive factors in the differential diagnosis of benign and malignant causes in patients undergoing endoscopic retrograde cholangiopancreatography for extrahepatic cholestasis.

OBJECTIVE: Diagnosing benign vs. malignant extrahepatic cholestasis is challenging despite the currently available advanced imaging and endoscopic techniques. This study aims to determine the predictive accuracy of initial biochemical data and bile duct dilatation findings in transabdominal ultrasound (US) to differentiate between benign and malignant disease in patients with extrahepatic cholestasis. PATIENTS AND METHODS: We reviewed the case records of 814 patients who had undergone endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography (in cases of unsuccessful ERCP) for extrahepatic cholestasis. The etiology of biliary obstruction was determined based on ERCP, endoscopic ultrasonography, radiology, cytology, biopsy, and/or clinical follow-up at one year. The patients were divided into benign and malignant groups according to the underlying etiology of biliary obstruction. A complete biochemical profile, transabdominal ultrasonography at presentation, and other demographic data were recorded. RESULTS: Alkaline phosphatase (p = 0.002), aspartate aminotransferase (p = 0.038), and bilirubin levels were significantly higher in malignant patients. The mean age of patients with malignancy was 69.5 years, vs. 60.6 years in benign patients (p < 0.001). The likelihood of malignancy increased with the increased bilirubin levels (> 200 µmol/l: 30.0% sensitivity, 97.6% specificity). The total bilirubin level predicting malignancy as the best cut-off value was 111 mmol/L with optimum sensitivity and specificity (61.8% and 83.8%, respectively) and area under the curve = 0.756, (p < 0.001). Intrahepatic bile duct (IHBD) dilatation was significantly higher in malignant patients (p < 0.001). CONCLUSIONS: A serum bilirubin level of 111 µmol/L or higher and the detection of IHBD dilatation on abdominal ultrasonography are important predictors in the differential diagnosis of benign and malignant causes of extrahepatic cholestasis.

An unusual cause of extrahepatic cholestasis associated with solid liver lesions: a case report.

IgG4-related sclerosing cholangitis is a special type of cholangiopathy often associated with autoimmune pancreatitis. In this article, we report an unusual case of IgG4-SC limited to the common hepatic duct and associated with pseudo tumoral liver lesions, but without evidence of pancreatic involvement. Corticosteroid therapy was rapidly effective and allowed normalization of liver tests.

The morphological and histopathological assessment of Alagille syndrome with extrahepatic bile duct obstruction: the importance of the differential diagnosis with subgroup "o" biliary atresia.

PURPOSE: The differential diagnosis between Alagille syndrome (AGS) with extrahepatic bile duct obstruction (EHBDO) and biliary atresia (BA) is difficult. We report a case series of AGS with EHBDO with detailed validation of the morphological and histopathological features for the differential diagnosis of BA. METHODS: Six liver transplantations (LTs) were performed for AGS with EHBDO. All patients were diagnosed with BA at the referring institution and the diagnosis of AGS was then confirmed based on a genetic analysis before LT. We verified the morphological and histopathological findings of the porta hepatis and liver at the diagnosis of BA and at LT. RESULTS: All patients had acholic stool in the neonatal period and were diagnosed with BA by cholangiography. The gross liver findings included a smooth and soft surface, without any cirrhosis. The gross findings of the porta hepatis included aplasia of the proximal hepatic duct, or subgroup "o", in five patients. The histopathological examination of the EHBD also revealed obstruction/absence of the hepatic duct. There were no patients with aplasia of the common bile duct. CONCLUSIONS: Aplasia of the hepatic duct and the macroscopic liver findings may help in to differentiate between AGS with EHBDO and BA.

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.

Biliary stricture due to a migrated suture after laparoscopic distal gastrectomy.

Benign biliary strictures have a broad spectrum of etiologies. There have been no reported cases, however, of a biliary stricture secondary to a migrated suture after laparoscopic distal gastrectomy (LDG). Here, we report one such case. The patient was a 60-year-old man who underwent LDG with Roux-en-Y reconstruction for early gastric cancer. Pathology revealed early cancer (T1N0M0) with a curative resection. Two years after LDG, the patient was found to have elevated hepatobiliary enzymes. After further workup, the new diagnosis was invasive cholangiocarcinoma (T2N0M0), and the patient underwent pancreaticoduodenectomy. Intraoperatively, a monofilament nylon suture was found in the center of a biliary stricture; this suture was previously used for duodenal closure during LDG. Histologically, the bile duct with stricture showed chronic inflammation and fibrosis. Despite no evidence of invasive carcinoma on pathology, a small lesion of adenocarcinoma in situ was found in the superior common hepatic duct.

Endoscopic biodegradable biliary stents in the treatment of benign biliary strictures: First report of clinical use in patients.

The first clinical experience of endoscopically inserted polydioxanone biodegradable biliary stents (BDBS) in the treatment of benign biliary strictures is reported. Two patients with a benign common bile duct stricture were endoscopically treated with 8-mm-bore BDBS during endoscopic retrograde cholangiography. Both BDBS insertions were technically successful and without adverse events. At 6 months, the stricture resolution was excellent and BDBS degradation was predicted in repeated magnetic resonance imaging. The first experience with endoscopic BDBS seems promising in the treatment of benign biliary strictures. During 6 months of follow up, BDBS seemed sufficient for remodeling and resolution of strictures. Further studies are needed to confirm the effectiveness of biodegradable biliary stents in endoscopic management of benign biliary strictures.

Metal versus plastic stents for unresectable gallbladder cancer with hilar duct obstruction.

BACKGROUND AND AIM: Metal stents usually have a longer stent patency than plastic stents for malignant biliary obstruction. However, stent patency and patient survival may differ depending on the causative disease and stent type. There are no data regarding the selection of stents for unresectable gallbladder cancer (GC) with hilar duct obstruction. The aim of the present study was to evaluate the efficacy of metal versus plastic stents for unresectable GC with hilar duct obstruction. METHODS: Fifty-nine unresectable GC patients with jaundice were divided into metal stent group (MSG) and plastic stent group (PSG) depending on stent deployment. Clinical outcomes and approximate costs were assessed retrospectively. RESULTS: No significant difference was found between MSG (n = 28) and PSG (n = 31) for clinical success, early adverse events and later cholangitis. Median patency and survival were 119 and 112 days in MSG versus 93 and 118 days in PSG, respectively (P > 0.05). However, the overall cost was higher in MSG than in PSG (P = 0.00). Cox proportional hazards model analysis showed that the lower Bismuth type was associated with a longer stent patency (P = 0.046), whereas older age (P = 0.041) and lower TNM stage (P = 0.002) were associated with longer survival. CONCLUSION: Although metal and plastic stents have similar clinical efficacy, it seems reasonable to choose plastic stents as the treatment of choice for unresectable GC when cost-effectiveness is taken into account.

[Restoration and reconstruction of extrahepatic bile ducts in high strictures using enteric autotransplant of variable diameter].

AIM: To develop technique incorporating favorable aspects of gastroenterostomy in common hepatic duct anastomosis, providing bile drainage into duodenum and preventing duodenobiliary reflux. MATERIAL AND METHODS: It is presented developed operations for high strictures of extrahepatic bile ducts using enteric autotransplant of variable diameter. RESULTS: Good remote postoperative results were observed in 10 survived patients. There were no recurrence of stricture, cholangitis and normal biochemical parameters were observed. It has been proved that suggested methods may be alternative to Roux-en-Y hepaticojejunostomy.

Efficacy of diffusion-weighted magnetic resonance imaging in the evaluation of extrahepatic cholestasis-related hepatic fibrosis.

BACKGROUND/AIM: To investigate the efficacy of diffusion-weighted magnetic resonance imaging (DWI) in the diagnosis and staging of fibrosis induced by experimental bile duct ligation (BDL). MATERIALS AND METHODS: Twenty-four rats were divided randomly into four groups: control, BDL--3 days, BDL--2 weeks, and BDL--4 weeks. DWI was performed with b-values of 100 and 500 on the rats from control group at day zero, on the rats from the BDL--3 days group at the end of day 3, on the rats from the BDL--2 weeks group at the end of day 14, and on the rats from the BDL--4 weeks at the end of day 28. RESULTS: When fibrosis scores generated in all groups were evaluated together, a strong negative correlation was detected between fibrosis scores and apparent diffusion coefficient (ADC) values measured using b 100 and b 500. ADC values obtained using b 100 were found to be significantly higher compared to the fibrosis observed in both the BDL--2 weeks and BDL--4 weeks groups (P < 0.003 and P < 0.001, respectively). CONCLUSION: We think that DWI may be an alternative to liver biopsy for the diagnosis and staging of hepatic fibrosis with underlying extrahepatic cholestasis.

Jaundice as a Rare Indication for Aortic Aneurysm Repair.

Compression of adjacent anatomic structures by an abdominal aortic aneurysm (AAA) can result in a variety of symptoms. We describe the case of an 88-year-old Caucasian woman with jaundice, elevated laboratory parameters for extrahepatic and intrahepatic cholestasis, and concomitant juxtarenal AAA compressing the liver hilum. Following exclusion of other common causes for cholestasis, the patient was considered to have a symptomatic AAA. Open abdominal aortic surgery revealed a contained rupture and was repaired. Obstructive jaundice secondary to a compromising AAA is a rare condition and to the best of our knowledge has not been reported to date.