Amputation neuroma mimics common hepatic duct carcinoma.

Most amputation neuromas of the biliary tract occur in the cystic duct stump after cholecystectomy and are asymptomatic. However, when they arise in the main hepatic duct and are associated with obstructive jaundice, it is difficult to distinguish them from carcinoma. We describe a case in which preoperative differential diagnosis was difficult. A 60-year-old man was admitted to the Institute of Clinical Medicine, University of Tsukuba, with a chief complaint of jaundice. Cholangiography showed an irregularly elevated nodular lesion on the lateral wall of the common hepatic duct and multiple floating stones in the choledochus. Ultrasonography and computed tomography revealed one-sided regional thickening of the common hepatic duct associated with dilatation of the intrahepatic and extrahepatic bile ducts. Carbohydrate antigen 19-9 level was markedly elevated to 11,200 IU/mL in the bile juice, but was only 38 IU/mL in the serum, below the limit of abnormality. Cholangioscopy showed papillary tumor with coarse granular surface mimicking papillary carcinoma, but biopsy revealed no malignancy. The patient underwent hepaticocholedochus resection. Although the macroscopic finding from the surgical specimens was papillary carcinoma of the common hepatic duct penetrating to the hepatoduodenal ligament, histopathological examination revealed an amputation neuroma consisting of hypertrophic nerve tissues and giant cells containing foreign bodies, probably as a consequence of a previous cholecystectomy. The postoperative course was uneventful and the patient has been living well for the 5 years since the resection.

Traumatic neuroma as a cause of obstructive jaundice.

A 70-year-old man with previous cholecystectomy developed progressive obstructive jaundice, 3 months before hospitalization. Intraoperatively, a 2 x 2 x 1.5-cm mass in the distal part of the right hepatic duct was excised to release complete obstruction. It was verified as traumatic (amputation) neuroma. Despite rarity, traumatic neuroma of the bile duct should be considered in patients who have antecedent surgical procedure of the biliary tract with subsequent occurrence of extrahepatic biliary obstruction.

Clinicopathologic studies on perineural invasion of bile duct carcinoma.

To elucidate the clinical significance of perineural invasion on bile duct cancer, a clinicopathologic study was performed on 70 resected patients with bile duct carcinoma. The overall incidence of perineural invasion in the resected specimen was 81.4%. There seemed to be no correlation between perineural invasion and site, size of the tumor, and lymph node metastasis. A significant correlation was observed, however, between macroscopic type, microscopic type, depth of invasion, and perineural invasion. Perineural invasion index (PNI) was defined as the ratio between the number of nerve fibers invaded by cancer and the total number of nerve fibers with and without cancer invasion. Perineural invasion index was significantly higher at the center compared with the proximal and distal part of the tumor (p less than 0.001). The 5-year survival rate for patients with perineural invasion was significantly lower (p less than 0.05) than that for those without perineural invasion (67% versus 32%).

[Functional changes in the biliary system following extrahepatic biliary obstruction]. / Alterazioni funzionali del sistema biliare secondarie ad ostruzione biliare extraepatica.

To assess the potential structural changes of the biliary tree and liver in patients with extrahepatic biliary obstruction, the resected specimens of 20 patients operated for benign biliary stricture were evaluated by means of immunocytochemical and histological methods. Furthermore, liver biopsies were taken for the same purposes. The results showed that in the dilated segment of the hepatic duct proximal to the stricture, innervation was greatly reduced or completely absent with associated advanced morphological and histological changes and high intrabiliary pressure levels. Similar findings were observed in the liver biopsies, too. These biopsies showed advanced morphological and histological changes associated with reduced innervation. By contrast, the nondilated segment of the hepatic duct, distal to the obstruction, showed normal innervation, normal morphology and histology and normal levels of intrabiliary pressure. The present study provides evidence that in cases of extrahepatic biliary obstruction, there are advanced pathological changes in the biliary tree associated with innervation impairment. These structural changes are associated with functional changes in both the liver and the biliary tree. Such functional changes represent a threat to the patient, particularly if major surgery is required. Increased biliary pressure appears to be a major cause of the development of these changes. Biliary drainage, either surgical or endoscopic, is indicated as the only alternative to reduce intrabiliary pressure and to contribute to a reversal of these structural and functional changes.

[Development of the neural and tissue components of the excretory ducts of the liver, pancreas and Odd's sphincter in human embryogeny]. / Razvitie nervnykh i tkanevykh komponentov vyvodnykh protokov pecheni, podzheludochnoi zhelezy i sfinktera Oddi v émbriogeneze

The development of pancreatic, hepatic, cystic, common bile ducts, the Oddi's sphincter and their nervous apparatus were studied during prenatal human ontogenesis of fetuses and newborns. The process of formation of the nervous apparatus corresponds to the development of tissue structures of the ducts and the sphincter. The distinctions in the organization of nervous elements which are noted in adult humans are laid in the process of embryogenesis. These distinctions are especially pronounced in the structure of nervous plexuses and receptory endings. The nervous apparatus of the Oddi's sphincter region has a complex arrangement. This is the site of concentration of nerve nodules and receptory endings as well as abundant nervous connections between plexuses of the pancreatic head, duodenum and orifice zones of the both ducts. The receptors in nerve nodules and pericellular apparatuses on the bodies of ganglionic neurons were revealed.