Natural history of metastatic biliary tract cancer (BTC) patients with good performance status (PS) who were treated with only best supportive care (BSC).

BACKGROUND: Although chemotherapy is widely recommended for patients with metastatic biliary tract cancer, the natural course of these patients, especially those with good performance status who are indicated for chemotherapy, is not known. METHODS: We retrospectively reviewed patients with metastatic or locally advanced biliary cancer who were diagnosed at six cancer centers. Patients were eligible if they had good performance (ECOG 0-2) and no history of any treatment for cancer. The primary objective was to evaluate the survival time of patients with advanced biliary cancer with good performance who were untreated. RESULTS: Of the 1677 patients, 204 met the inclusion criteria. The median age and overall survival were 72.0 years and 7.1 months. Overall survival (months) by location was 4.7 for intrahepatic, 9.7 for extrahepatic, 4.4 for gallbladder and 11.2 for ampulla of vater cancer. In subgroup analysis, overall survival of locally advanced biliary cancer was 13.8 months and that of patients with normal carcinoembryonic antigen/carbohydrate antigen 19-9 was 10.6 months. In multivariate analysis, variables that were associated with poor prognosis were metastatic biliary cancer [hazard ratio 2.19 (P = 0.001)], high baseline carcinoembryonic antigen level (defined as >4.0 ng/ml) [hazard ratio 1.51 (P = 0.024)] and high baseline carbohydrate antigen 19-9 level (defined as >100 U/ml) [hazard ratio 1.93 (P = 0.001)]. CONCLUSIONS: Advanced biliary tract cancer with good performance status showed modest survival without any treatment. Furthermore, subgroup analysis showed that patients with normal carbohydrate antigen 19-9 or carcinoembryonic antigen level or locally advanced status had favorable survival. Further studies comparing the outcome of chemotherapy with that of best supportive care in patients with unresectable biliary tract cancer are warranted.

Successful removal of remnant cystic duct stump stone using single-operator cholangioscopy-guided electrohydraulic lithotripsy: two case reports.

Cholecystectomy is the best method for treating gallstone diseases. However, 10%-30% of patients who undergo a cholecystectomy continue to complain of upper abdominal pain, dyspepsia, or jaundice-this is referred to as postcholecystectomy syndrome. Cystic duct stump stones are a troublesome cause of postcholecystectomy syndrome. Conventionally, surgery is mainly performed to remove cystic duct stump stones. However, repeated surgery can cause complications, such as postoperative bleeding, biliary injury, and wound infection. As an alternative method of surgery, endoscopic retrograde cholangiopancreatography is sometimes used to remove cystic duct stump stones, although the success rate is not high due to technical difficulties. Recently, peroral cholangioscopy, which can directly observe the bile duct, has been suggested as an alternative method. We report two cases in which a cystic duct stump stone was successfully removed via a single-operator cholangioscopy, after failure with an endoscopic retrograde cholangiopancreatography.

Endoscopic management of postoperative bleeding.

Postoperative gastrointestinal bleeding is a rare but serious complication that can lead to prolonged hospitalization and significant morbidity and mortality. It can be managed by reoperation, endoscopy, or radiological intervention. Although reoperation carries risks, particularly in critically ill postoperative patients, minimally invasive interventions, such as endoscopy or radiological intervention, confer advantages. Endoscopy allows localization of the bleeding focus and hemostatic management at the same time. Although there have been concerns regarding the potential risk of creating an anastomotic disruption or perforation during early postoperative endoscopy, endoscopic management has become more popular over time. However, there is currently no consensus on the best endoscopic management for postoperative gastrointestinal bleeding because most practices are based on retrospective case series. Furthermore, there is a wide range of individual complexities in anatomical and clinical settings after surgery. This review focused on the safety and effectiveness of endoscopic management in various surgical settings.

Hepatocellular carcinoma presenting as organized liver abscess: A case report.

BACKGROUND: Hepatocellular carcinoma (HCC) is difficult to treat and has a high mortality rate, emphasizing the importance of early diagnosis and treatment. If characteristic radiologic findings and underlying liver disease are present, a diagnosis can be made without a biopsy. However, when HCC is accompanied by a liver abscess, diagnosis might be delayed by atypical radiologic findings. This case report aims to assist in the diagnosis of HCC, which can manifest in various forms. CASE SUMMARY: A 75-year-old male presented to the Emergency Department with worsening fever and mental changes. He was diagnosed with liver cirrhosis six months earlier. Abdominal computed tomography (CT) raised our suspicion of an organized liver abscess. A follow-up CT scan after four weeks of antibiotic treatment showed a decrease in the liver lesion size. However, high fever recurred, and C-reactive protein increased to 14 mg/L. Aspiration of the liver lesion was performed, but no bacteria were identified. Blood culture revealed the presence of fungi. The patient received an additional four weeks of antibiotics and antifungal agents before being discharged. Approximately 10 mo later, a CT scan showed an increase in the lesion size, and biopsy was performed. The biopsy revealed an organized abscess with focal carcinomatous changes, for which surgery was performed. Postoperative histopathological examination revealed HCC, clear-cell variant. The nontumor liver tissue showed cirrhosis and an organized abscess. CONCLUSION: Even if a liver abscess is suspected in a patient with cirrhosis, the possibility of HCC should be considered.

Pulmonary Pneumatocele in a Pneumonia Patient Infected with Extended-Spectrum ß-Lactamase Producing Proteus mirabilis.

Pulmonary pneumatoceles are air-filled thin-walled spaces within the lung and are rare in adult cases of pneumonia. We report the case of a 74-year-old male who was admitted with a cough and sputum production. He had been treated with oral dexamethasone since a brain tumorectomy 6 months prior. Contrast-enhanced computed tomography (CT) of the chest revealed a large pneumatocele in the right middle lobe and peripheral pneumonic consolidation. Bronchoalveolar lavage was performed; cultures identified extended-spectrum ß-lactamase (ESBL) producing Proteus mirabilis. A 4-week course of intravenous ertapenem was administered, and the pneumatocele with pneumonia resolved on follow-up chest CT. To the best of our knowledge, this is the first reported case of pulmonary pneumatocele caused by ESBL-producing P. mirabilis associated with pneumonia.