Value of extrahepatic bile duct and main pancreatic duct segment patterns on MRCP to differentiate the periampullary carcinoma / 中华肝胆外科杂志

Objective:To investigate the value of the extrahepatic bile duct and main pancreatic duct segment patterns on magnetic resonance cholangiopancreatography (MRCP) for differentiating the periampullary carcinoma (PAC).Methods:The clinicopathologic data of 125 patients with PAC who were admitted to Wuxi No.2 People’s Hospital from June 2013 to December 2021 were retrospectively analyzed, including 72 males and 53 females, aged (64.9±8.6) years. According to its anatomy, the extrahepatic bile duct (B) was divided into suprapancreatic and intrapancreatic (including ampullary) segments, and the main pancreatic duct (P) was divided into tail-body and head segments. MRCP patterns: i. the extrahepatic bile duct or main pancreatic duct visible without dilatation, ii. cutoff of the distal extrahepatic bile duct or main pancreatic duct with upstream dilatation, iii. cutoff of the intrapancreatic or head segment with upstream dilatation and remnant intrapancreatic or head segments invisible, iv. cutoff of the intrapancreatic or head segment with upstream dilatation and nondilated remnant intrapancreatic or head segments, were represented as 0, 1, 2, and 3, respectively. Segment patterns of B1/P0+ B1/P1, B0/P2+ B0/P3+ B2/P2+ B2/P3+ B3/P3, B3/P0, and B0/P0+ B2/P0 on MRCP were compared in PAC patients.Results:Of the 125 patients, there were 57 (45.6%) with pancreatic head carcinoma, 36 (28.8%) with ampullary carcinoma, 20 (16.0%) with distal cholangiocarcinoma, and 12 (9.6%) with periampullary duodenal carcinoma. Segment patterns of B0/P2+ B0/P3+ B2/P2+ B2/P3+ B3/P3 were found in 52 patients with pancreatic head carcinoma (91.2%, 52/57), with a significant difference between PAC (χ 2=110.66, P<0.001). Segment patterns of B1/P0+ B1/P1were found in 36 patients with ampullary carcinoma (100.0%, 36/36), fallowed by 11 (91.7%, 11/12) with periampullary duodenal carcinoma, with a significant difference between PAC (χ 2=129.95, P<0.001). Segment pattern of B3/P0 presented in 16 patients with distal cholangiocarcinoma (80.0%, 16/20), with a significant difference between PAC (χ 2=62.45, P<0.001). The segment patterns of B0/P0+ B2/P0 were only seen in 3 of 57(5.3%) patients with pancreatic head carcinoma. Conclusion:On MRCP, cutoff of the head segment with upstream dilatation and remnant head segment invisible or nondilated indicates the pancreatic head carcinoma. Cutoff of the intrapancreatic segment with upstream dilatation, remnant intrapancreatic segment visible, and main pancreatic duct nondilated, indicates the distal cholangiocarcinoma. And cutoff of the distal extrahepatic segment with upstream dilatation and main pancreatic duct dilatation or not, indicates the ampullary or periampullary duodenal carcinoma.

Morphometric study of extra-hepatic biliary pathways: study in human corpses / Estudio morfométrico de las vías biliares extrahepáticas: estudio en cadáveres humanos

SUMMARY: Adverse events (AE) contribute significantly to postoperative morbidities and comorbidities. Many AEs occur due to a lack of anatomical knowledge and its variants. Latrogenic bile duct injuries, for instance, represent a serious surgical complication of laparoscopic cholecystectomy. Anatomical knowledge for the identification and adequate drainage of all ducts is relevant and fundamental in order to avoid future errors. The objective of the study was to morphometrically analyze the bile ducts in adult human corpses. 13 livers were extracted from adult human corpses to obtain the ducts: choledochal, common hepatic and cystic. After morphological analysis, duct measurements (length and diameter) were continued using a digital caliper. The data obtained were tabulated in SPSS 21 program, performing descriptive analysis with mean and standard deviation. The averages of bile ducts were 61.05 (± 16.43) mm in length and 3.86 (± 0.72) mm in diameter. The cystic duct length and diameter averages were 33.59 (± 12.29) mm and 3.40 (± 0.79) mm, respectively. The common hepatic ducts had an average of 30.02 (± 7.19) mm in length and 3.74 (± 1.18) mm in diameter. The analyzed samples presented different values ?? from those already described in the literature, where the length of the cystic ducts was greater, while the length of the common hepatic ducts was numerically smaller. This work is very significant, as the morphometric variability of the bile ducts allows for varying morphological situations that can compromise the hepatobiliar physiology.

RESUMEN: Los eventos adversos (EA) contribuyen significativamente a las morbilidades y comorbilidades postoperatorias. Muchos EA se deben a la falta de conocimiento de la anatomía y sus variaciones. Por ejemplo, las lesiones iatrogénicas de las vías biliares representan una complicación quirúrgica grave de la colecistectomía laparoscópica. El conocimiento anatómico para la identificación y drenaje adecuado de todos los conductos es relevante y fundamental para evitar futuros errores. El objetivo del estudio fue analizar morfométricamente las vías biliares en cadáveres humanos adultos. Se extrajeron 13 hígados de cadáveres humanos adultos y se retiraron los conductos: colédoco, hepático común y cístico. Después del análisis morfológico, se continuó con las mediciones de los conductos (longitud y diámetro) utilizando un calibrador digital. Los datos fueron tabulados en el programa SPSS 21, mediante análisis descriptivos con media y desviación estándar. Los promedios de las vías biliares fueron de 61,05 (± 16,43) mm de longitud y 3,86 (± 0,72) mm de diámetro. Los promedios de longitud y diámetro del conducto cístico fueron 33,59 (± 12,29) mm y 3,40 (± 0,79) mm, respectivamente. Los conductos hepáticos comunes tenían un promedio de 30,02 (± 7,19) mm de longitud y 3,74 (± 1,18) mm de diámetro. Las muestras analizadas presentaron valores diferentes a los ya descritos en la literatura, donde la longitud de los conductos císticos era mayor, mientras que la longitud de los conductos hepáticos comunes fue numéricamente menor. Este trabajo es significativo, debido a que la variabilidad morfométrica de las vías biliares y permite identificar situaciones morfológicas que pueden comprometer la fisiología hapatobiliar.

Clinical value of preferred endoscopic ultrasound-guided antegrade surgery in the treatment of extrahepatic bile duct malignant obstruction

ABSTRACT Objectives: To explore the clinical value of preferred ultrasound endoscopic guided biliary drainage in patients with extrahepatic biliary obstruction with intrahepatic biliary ectasis. Methods: A total of 58 patients with malignant obstruction and intrahepatic bile duct expansion, including 32 males, 26 females and median age 65 (58-81) were selected. A prospective randomized controlled study was randomized into EUS-AG and ERCP-BD, with 28 patients in EUS-AG and 30 in ERCP-BD. The efficacy of the two treatments, operation success rate, operation time, the incidence of complications, hospitalization days, cost, unimpeded stent duration, and survival time were compared. Results: 1) The surgical success rate in group EUS-AG was 100%, and in group, ERCP-BD was 96.67%. There was no statistical difference in surgical success rate in the two groups (p>0.05). 2) Average operating time in EUS-AG was (23.69±11.57) min, and in ERCP-BD was (36.75±17.69) min. The difference between the two groups has statistical significance (p<0.05). 3) The clinical symptoms of successful patients were significantly relieved. Compared with the preoperative procedure, the differences in group levels had statistical significance (p<0.05); TBIL, ALP, WBC and CRP levels, no statistical significance difference in groups (p>0.05). Conclusion: EUS-AG operation has short time, low incidence of complications, safe, effective, and can be used as the preferred treatment plan for patients with extrahepatic biliary duct malignant obstruction associated with intrahepatic biliary duct expansion; EUS-AG operation has more unique clinical advantages for patients with altered gastrointestinal anatomy or upper gastrointestinal obstruction.

Analysis of the incidence and epidemic trend of gallbladder cancer in China / 中华消化外科杂志

Many clinicians have the following 4 misconceptions about the incidence and epedemil trend of gallbladder cancer.(1) The incidence of gallbladder cancer and extrahepatic bile duct carcinoma is considered as the incidence of gallbladder cancer.(2) The gallbladder cancer is the common malignant tumor of the digestive system.(3) The gallbladder cancer is the most common malignant tumor of biliary tract system.(4) The incidence of gallbladder cancer is increasing year by year.Based on the latest annual report of the 2016 Chinese Cancer Registry Annual Report,published by the National Cancer Center (NCCR),combined with previous annual reports and the data of the incidence of gallbladder and extrahepatic bile duct cancer in the related articles,supplemented by clinical data,the author points out that the incidence of gallbladder cancer in China is about 1.00-1.30 per 100 000.It is pointed out that gallbladder cancer is not the most common cancer in the digestive and biliary systems.The incidence of gallbladder cancer has not been significantly increased in recent years,and its 5-year relative survival rate has been reduced by 0.9％ since 2003.Although the incidence of gallbladder cancer is low,the malignant degree is high and the prognosis is poor.It highlights the lack of effective treatment for the disease,and further hints that we should strengthen the necessity of early diagnosis and treatment of gallbladder cancer.

Biliary tract in trident, an anatomical variation between the cystic duct and its union to the common hepatic duct: a rare case report / Tracto biliar en tridente, una variación anatómica entre el conducto cístico y su unión al conducto hepático común: un caso raro

SUMMARY: Given that the gallbladder and the biliary tract are subject to multiple anatomical variants, detailed knowledge of embryology and its anatomical variants is essential for the recognition of the surgical field when the gallbladder is removed laparoscopically or by laparotomy, even when radiology procedures are performed. During a necropsy procedure, when performing the dissection of the bile duct is a rare anatomical variant of the bile duct, in this case the cystic duct joins at the confluence of the right and left hepatic ducts giving an appearance of trident. This rare anatomical variant in the formation of common bile duct is found during the exploration of the bile duct during a necropsy procedure, it is clear that the wrong ligation of a common hepatic duct can cause a great morbi-mortality in the postsurgical of biliary surgery. This rare anatomical variant not previously described is put in consideration to the scientific community. Anatomical variants of the biliary tract are associated with high rates of morbidity and mortality, causing serious bile duct injuries. Only the surgical skill of the surgeon and his open mind to the possibilities of abnormalities make the performance of cholecystectomy a safe procedure.

RESUMEN: Dado que la vesícula biliar y el tracto biliar están sujetos a múltiples variantes anatómicas, el conocimiento detallado de la embriología y sus variantes anatómicas es esencial para el reconocimiento del campo quirúrgico cuando la vesícula biliar se extirpa laparoscópicamente o por laparotomía, incluso cuando se realizan procedimientos de radiología. Durante un procedimiento de necropsia, se realiza la disección del conducto biliar y se observa una variante anatómica inusual del conducto biliar; en este caso, el conducto cístico se une a la confluencia de los conductos hepáticos derecho e izquierdo dando una apariencia de tridente. Esta rara variante anatómica en la formación del conducto biliar común puede causar una gran morbimortalidad en la cirugía biliar asociado a una ligadura incorrecta. Esta extraña variante anatómica no descrita anteriormente se reporta a la comunidad científica, debido a que las variantes anatómicas del tracto biliar se asocian con altas tasas de morbilidad y mortalidad, al causar lesiones graves en el conducto biliar. Solo la habilidad quirúrgica del cirujano y su mente abierta a las posibilidades de variaciones anatómicas hacen que la realización de la colecistectomía sea un procedimiento seguro.

Extrahepatic bile duct resection in patients with hepatocellular carcinoma with bile duct tumor thrombi / 中华肝胆外科杂志

Objective To review the role of extrahepatic bile duct resection in patients with hepatocellular carcinoma with bile duct tumor thrombi.Methods The Pubmed,Wan Fang and China Science and Technology Journal Database were reviewed systematically.Any case reports or studies involving treatment of hepatocellular carcinoma with bile duct tumor thrombi were included in this literature search.Two authors independently assessed the studies for inclusion and extracted the data.Univariate analysis was used to compare the baseline characteristics and the Kaplan-Meier method was used for analyzing survival and diseasefree survival outcomes.Results Using predetermined inclusion criteria,16 studies which included 170 patients entered into this study.All these patients underwent surgical resection of hepatocellular carcinoma and bile duct tumor thrombi.Based on the Satoh classification,45 patients were type Ⅰ,107 patients type Ⅱ and 18 patients type Ⅲ.Twenty-four patients underwent liver resection combined with extrahepatic bile duct resection.The remaining 146 patients underwent liver resection combined with thrombectomy.The 1-,3-,and 5-year survival rates of all the patients were 73.4％,41.5％ and 21.8％,and the corresponding recurrences free survival rates were 62.5％,29.2％ and 13.1％,respectively.On Kaplan-Meier analysis,there were no significant differences in the survival outcomes between the 2 groups of patients,(P ＞ 0.05).The 1-,3-,and 5-year survival rates of the extrahepatic bile duct resection group were 66.7％,41.7％ and 12.5％,and those of the thrombectomy group were 74.6％,41.3％ and 23.8％,respectively.On subgroup analysis (Satoh type Ⅱ and Ⅲ),no significant differences were observed between the two groups (P ＞0.05).The 1-,3-,and 5-year survival rates of the extrahepatic bile duct resection group were 65.2％,38.0％ and 13.0％,and those of the thrombectomy group were 72.8％,39.5％ and 20.9％,respectively.Conclusion Extrahepatic bile duct resection did not improve the overall survival of patients with hepatocellular carcinoma with bile duct tumor thrombi.

Laparoscopic assisted small incision biliary tract exploration in treatment of recurrent extrahepatic bile duct stones / 中华肝胆外科杂志

Objective To compare the clinical results between laparoscopic assisted small incision biliary duct exploration with traditional biliary exploration for patients with recurrent extrahepatic bile duct stones who had undergone biliary surgery for ≥2 times.Methods The clinical data of patients with recurrent extrahepatic bile duct stones who had undergone biliary surgery for ≥2 times,and underwent laparoscopic assisted small incision biliary duct exploration or traditional biliary exploration from September 2011 to June 2016 were retrospectively studied.Results 23 patients underwent laparoscopic assisted small incision biliary duct exploration (Group A),and 24 patients underwent traditional biliary exploration (Group B).The time spent on abdominal adhesion separation in group A and group B was (74.7 ± 20.5) min and (90.8 ± 20.3) min (P ＜ 0.05),respectively.The amount of intraoperative blood loss were (67.4 ± 35.6)ml and (107.4±31.5) ml (P ＜0.05).The number of patients with intestinal injury were 0 and 4.The postoperative time to first pass flatus was (26.9 ± 3.8) h and (35.5 ± 6.5) h (P ＜ 0.05).The durations of postoperative hospital stay were (8.1 ± 1.4) d and (12.8 ± 2.9) d,respectively,(P ＜ 0.05).The numbers of patients who required postoperative analgesics were 10 and 19 cases (P ＜ 0.05).The number of patients with postoperative incisional wound infection were 1 and 6.There was no significant difference in the time spent on biliary exploration,incidences of biliary leakage,pulmonary infection rate,hospitalization cost and liver function status between the two groups of patients (P ＞ 0.05).Conclusions Laparoscopic assisted small incision biliary duct exploration was safe and effective for patients with recurrent extrahepatic bile duct stones who had undergone biliary surgery for ≥2 times.This operation can be used as a preferred procedure.

Planned hepatectomy for the "central type" intrahepatic and extrahepatic choledochal cysts / 中华肝胆外科杂志

Objective To retrospectively study the clinical value and the advantages in " planned hepatectomy" for the "central type" intrahepatic and extrahepatic choledochal cysts.Methods The clinical data of 7 patients with the "central type" of intrahepatic and extrahepatic choledochal cysts which were treated with "planned hepatectomy" from January 2014 through April 2017 at the Department of Biliary Tract Surgery of the Eastern Hepatobiliary Surgery Hospital,Second Military Medical University were retrospectively analyzed.Results All the patients completed radical resection of the intrahepatic and extrahepatic choledochal cysts in accordance with the " planned hepatectomy".The operations included 6 patients who were treated with percutaneous transhepatic cholangial drainage (PTCD) and 5 patients with portal vein embolization (PVE) prior to the surgical excision.Combined right liver resection was performed in 6 patients,and combined left liver resection in one patient.All the 7 patients had a history of chronic cholangitis.Liver volume tests demonstrated that the hemiliver volume to be removed (the embolized hemiliver) significantly decreased after PVE,whereas the hemilivers to be persevered were remarkably enlarged.No complication associated with PTCD and PVE occurred.The mean postoperative hospitalization was 12 days.Liver function tests suggested all the patients recovered well.No postoperative complication of bleeding,infection or liver function failure was observed,except in one patient who experienced pleural and abdominal effusion.Conclusions Combined subtotal hepatectomy may increase the risk of complications associated with the "central type" intrahepatic and extrahepatic choledochal cysts.The surgical strategy in planned hepatectomy can be used effectively to treat the "central type" of intrahepatic and extrahepatic choledochal cysts,with improved surgical safety,decrease in incidences of postoperative liver function failure and residual choledochal cysts.

Analysis of small-middle endoscopic sphincterotomy combined with endoscopic papillary balloon dilation for patients with extrahepatic bile duct stone / 中国内镜杂志

Objective To evaluate the efficacy and safety of small-middle endoscopic sphincterotomy combined with endoscopic papillary balloon dilation for patients with extrahepatic bile duct stone. Methods The patients with special duodenal papilla included 38 cases, and those with normal duodenal papilla 143 cases. 38 patients had received SEST + EPBD, 143 had received MEST + EPBD. Results 181 patients had received SMEST + EPBD in our hospital and the related data were retrospectively analyzed. All 181 patients were successfully removed, the success rate was 100.00 %. There was no perforation occurred postoperatively, but mild acute pancreatitis occurred in 8 patients (4.42 %, 8/181) and bleeding occurred in 9 patients. The three major early complications rate were 9.93 %(17/181), which was cured by the conservative management. Conclusion SMEST plus EPBD is a safe and effective treatment for extrahepatic bile duct stone, with retaining the feature of sphincter of duodenal papilla, especially for patients with special duodenal papilla.

Clinical observation of early laparoscopic common bile duct exploration continue to failed endoscopic bile duct stone extraction / 中国内镜杂志

Objective To discuss the treatment method and opportunity for patients with gallbladder stones and extrahepatic bile duct stones who failed endoscopic removal of common bile duct stones by endoscopic retrograde cholangiopancreaticography (ERCP). Methods 12 patients, with gallbladder stones and extrahepatic bile duct stones, failed endoscopic stone extraction (ESE), underwent emergency one-stage laparoscopic cholecystectomy (LC) and Laparoscopic common bile duct exploration (LCBDE). Results All of the patients were successfully completed LC +LCBDE and stones were completely removed. Hyperamylasemia occurred in 3 cases and there was no bile leakage, intestinal leakage, cholangitis, pancreatitis, biliary bleeding and other complications. Conclusions Emergency LCBDE has been shown to be a safe and effective salvage procedure for failed ESE.

Analysis of clinical efficacy of LTCBDE in patients with secondary extrahepatic bile duct stones / 实用医学杂志

Objective To investigate the effect of laparoscopic cholecystectomy (LTCBDE) in treatment of patients with secondary extrahepatic bile duct stones. Methods Eighty-seven cases of our hospital patients with secondary to extrahepatic bile duct stones were randomly divided into the laparoscopic bile duct exploration and T tube drainage surgery (LCBDE) treatment group and the laparoscopic transcystic duct exploration of common bile duct lithotomy (ltcbde) treatment group. The observation focused on the operation time, bleeding volume , postoperative transfusion , postoperative drainage time , postoperative hospitalization time , cost of hospitalization, postoperative recovery time and complications compared clinical efficacies. Results LTCBDE group of patients in operation time (2.1 ± 0.5) was longer than that of the control group (1.6 ± 0.4), (P <0.001), while the bleeding volume, postoperative fluid volume, postoperative drainage time, postoperative hospitalization time, hospitalization expenses and postoperative recovery time were (17.4 ± 5.4), (6 550.4 ± 1 076.9), (3.5. 1.6), (4.1 ± 1.7), (12 243.5 ± 2 379.6), (11.3 ± 3.5) were lower than that of the group LCBDE (22.1 ± 7.5), (8 304.2 ± 1 394.8), (32.9 ± 10.4), (6.4 ± 2.4), (14 098.1 ± 2 897.3), (16.1 ± 5.7) P, respectively (P values were defined as 0.001, 0, 0, 0.015, 0.001, 0 individually); LTCBDE group of patients with bile leakage, acute peritonitis rates were 1/46,1/46,in which those were lower than the corresponding LCBDE in 6/41, 7/41 (P values were 0.033, 0.016, separately). Conclusion According to indications, LTCBD surgery has the advantages of less injury, less cost, less complications and so on. It has important significance to improve the condition of patients with secondary extrahepatic bile duct stones.

Surgery Alone Versus Surgery Followed by Chemotherapy and Radiotherapy in Resected Extrahepatic Bile Duct Cancer: Treatment Outcome Analysis of 336 Patients / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: This study analyzed the outcomes of patients with resected extrahepatic bile duct cancer (EHBDC) in order to clarify the role of adjuvant treatments in these patients. MATERIALS AND METHODS: A total of 336 patients with EHBDC who underwent curative resection between 2001 and 2010 were analyzed retrospectively. The treatment types were as follows: surgery alone (n=168), surgery with chemotherapy (CTx, n=90), surgery with radiotherapy (RT) alone (n=29), and surgery with chemoradiotherapy (CRT, n=49). RESULTS: The median follow-up period was 63 months. The 5-year rates of locoregional failure-free survival (LRFFS), distant metastasis-free survival (DMFS), progression-free survival (PFS), and overall survival (OS) for all patients were 56.5%, 59.7%, 36.6%, and 42.0%, respectively. In multivariate analysis, surgery with RT and CRT was a significant prognostic factor for LRFFS, and surgery with CTx was a significant prognostic factor for DMFS, and surgery with CTx, RT, and CRT was a significant prognostic factor for PFS (p < 0.05). Surgery with CTx and CRT showed association with superior OS (p < 0.05), and surgery with RT had marginal significance (p=0.078). In multivariate analysis of the R1 resection patients, surgery with CRT showed significant association with OS (p < 0.05). CONCLUSION: Adjuvant RT and CTx may be helpful in improving clinical outcomes of patients with resected EHBDC who have a high risk of disease recurrence, particularly R1 resection patients. Conduct of additional prospective, larger-scale studies will be required in order to confirm the benefit of adjuvant RT and CTx in these patients.

Postoperative radiotherapy appeared to improve the disease free survival rate of patients with extrahepatic bile duct cancer at high risk of loco-regional recurrence

PURPOSE: To investigate the outcomes of postoperative radiotherapy (RT), in patients with extrahepatic bile duct (EHBD) cancer by comparing the survival rate between patients undergoing surgery alone or surgery plus postoperative RT, and to identify the prognostic factors affecting survival. MATERIALS AND METHODS: Between 2000 and 2013, 52 patients with EHBD cancer underwent surgical resection. Of these, 33 patients did not receive postoperative RT (group I), and 19 patients did (group II). R1 resection was significantly more frequent in group II. The median radiation dose was 5,040 cGy. RESULTS: The 3-year overall survival (OS) rate for group I and group II was 38% and 56%, respectively (p = 0.274). The 3-year disease free survival (DFS) rate for group I and group II was 20% and 31%, respectively (p = 0.049), and the 3-year loco-regional recurrence free survival (LRFS) rates were 19% and 58%, respectively (p = 0.002). Multivariate analyses showed that postoperative RT and lymphovascular invasion were independent prognostic factors for DFS and LRFS. Overall, 42 patients (80%) experienced treatment failure. Distant metastasis was the predominant pattern of failure in group II. CONCLUSION: Postoperative RT after surgical resection appeared to improve the loco-regional control and DFS rate. More effort is needed to reduce distant metastasis, the major pattern of failure, in patients who receive postoperative RT.

Evaluation on clinical diagnosis value of colour ultrasound used in extrahepatic bile duct / 中国医学装备

Objective:To evaluate the ultrasound diagnostic value of extrahepatic bile duct diseases and misdiagnosis reasons for leakage.Methods: For the diagnosis of 399 cases of extrahepatic bile duct diseases were retrospectively analyzed, analysis of the ultrasonic diagnosis. Results: Three hundred and ninty-nine cases of extrahepatic bile duct disease, ultrasonic diagnosis diagnosis coincidence rate 93.2% (372/399). With extrahepatic bile duct stones coincidence rate 94.5%, extrahepatic bile duct carcinoma (89.3%, 86.0%, biliary ascariasis bile duct cystic expansion 100%, 27 cases of misdiagnosis.Conclusion: Ultrasound in the diagnosis of extrahepatic bile duct diseases with high value.

Pancreaticoduodenectomy for secondary periampullary cancer following extrahepatic bile duct cancer resection

PURPOSE: This study addressed the feasibility and effect of surgical treatment of metachronous periampullary carcinoma after resection of the primary extrahepatic bile duct cancer. The performance of this secondary curative surgery is not well-documented. METHODS: We reviewed, retrospectively, the medical records of 10 patients who underwent pancreaticoduodenectomy (PD) for secondary periampullary cancer following extrahepatic bileduct cancer resection from 1995 to 2011. RESULTS: The mean age of the 10 patients at the second operation was 61 years (range, 45-70 years). The primary cancers were 7 hilar cholangiocarcinomas, 2 middle common bile duct cancers, and one cystic duct cancer. The secondary cancers were 8 distal common bile duct cancers and 2 carcinomas of the ampulla of Vater. The second operations were 6 Whipple procedures and 4 pylorus-preserving pancreaticoduodenectomies. The mean interval between primary treatment and metachronous periampullary cancer was 20.6 months (range, 3.4-36.6 months). The distal resection margin after primary resection was positive for high grade dysplasia in one patient. Metachronous tumor was confirmed by periampullary pathology in all cases. Four of the 10 patients had delayed gastric emptying (n = 2) or pancreatic fistula (n = 2) after reoperation. There were no perioperative deaths. Median survival after PD was 44.6 months (range, 8.5-120.5 months). CONCLUSION: Based on the postoperative survival rate, PD may provide an acceptable protocol for resection in patients with metachronous periampullary cancer after resection of the extrahepatic bile duct cancer.

Diagnosis and treatment of tubular adenoma in the extrahepatic bile duct / 中华消化外科杂志

Objective To study the clinical manifestations,diagnosis and surgical treatment of tubular adenoma in the extrahepatic bile duct.Methods The clinical data of 3 patients with tubular adenoma in the extrahepatic bile duct who were admitted to the Affiliated Hospital of Inner Mongolia Medical University from July 2010 to February 2012 were retrospectively analyzed.Results The tumors were located at the middle and lower part of the common bile duct.All the 3 patients received resection of the common bile duct and Roux-en-Y cholangioenterostomy,and recovered well.The results of pathological examination showed that all the patients were with tubular adenoma,and 2 patients had moderate atypical hyperplasia.Conclusions Tubular adenoma in the extrahepatic bile duct could be diagnosed by pathological examination.Radical resection and rerouting of the bile duct can get a better outcome.

Effect analysis on combination of laparoscopy and duodenoscopy treatment for calculus of extrahepatic bile duct / 国际外科学杂志

Objetive To study the medical value of the combined treatment of laparoscopy and duodenoscopy treatment for calculus of extrahepatic bile duct.Methods Retrospectivly analyzed the clinical data of 72 cases with combination of laparoscopy and duodenoscopy treatment for calculus of extrahepatic bile duct between March 2006 and October 2011.There were 11 cases of choledocholithiasis and 61 cases of choledocholithiasis and cholecystolithiasis.Results Three cases of severe abdominal adhesion converted to laparotomy and other 69 cases were cured.The cure rate was 95.83％.There were no complications such as infection,bile duct injury,bile leakage,intraabdominal hemorrhage,bile reflux cholangitis,pancreatitis and cicatrical stenosis of papilary.The examination after operation showed that there weren't any residual bile duct stones.Conclusions The combination of laparoscopy and duodenoscopy treatment for calculus of extrabepatic bile duct has less traumatic,few intercurrent disease,and was safe and reliable with well postoperative recovery.It can be regarded as the preference treatment for calculus of extrahepatic bile duct.

Theraneutic effects of endoscopic sphincterotomy and endoscopic papillary balloon dilation for extrahepatic bile duct stones / 中华消化内镜杂志

Objective To study the safety and efficacy of endoscopic sphincterotomy (EST) and endoscopic papillary balloon dilation (EPBD) in the treatment for extrahepatic bile duct stones.Methods A total of 164 patients underwent endoscopic treatment for extrahepatic bile duct stones.Seventy eight underwent EST and EPBD (the EST + EPBD group),86 others underwent EST only (the EST group).The complication rate,complete stone clearance rate and gravel incidence rate were compared between the two groups.Results Hyperamylasemia occurred in 3 cases,mild acute pancreatitis in 2 cases of the EST and EPBD group,while hyperamylasemia occurred in 5 cases,mild acute pancreatitis in 3 and hemorrhage in 2 of the EST group.There were no severe complications like severe acute pancreatitis or intestinal perforation.The complication rate of the EST + EPBD group ( 6.4％,5/78 ) was slightly lower than that of the EST group ( 11.6％,10/86),(x2 =1.340,P =0.288),so was gravel incidence (33.3％ vs.60.5％,x2 =12.073,P =0.001 ).While complete stone clearance rate of this group was obviously higher than that of the EST group (100.0％ vs.93.0％ ),(x2 =5.649,P=0.030).Conclusion EST combined with EPBD is safe and effective for extrahepatic bile duct stone removal,especially for large stones or poor duodenal papilla.

Management of Spontaneous Perforation of the Bile Duct in an Infant in a Semi-Urban Setup: A Case Report

Spontaneous perforation of the extrahepatic bile duct leading to biliary peritonitis is a rare occurrence once other causes of biliary peritonitis, such as trauma, choledochal cyst, stone diseases, and distal atresia of the bile duct, are ruled out. A 7-month-old male infant was brought to the hospital in critical condition with distension of the abdomen. He had a history of vomiting and diarrhoea, low-grade fever, and refusal to feed for 2 days. Signs of peritonitis were found upon examination. Due to the poor general condition of the patient, the case was taken up for laparotomy, and a diagnosis of spontaneous extrahepatic bile duct perforation was made intra-operatively. In the present case, the cause was idiopathic. An external drain was placed near the site of the leak for 2 weeks. The patient recovered well and was discharged on post-operative day 16. Disease awareness for correct pre-operative diagnosis and interventional planning is required to reduce mortality, morbidity, and complications in spontaneous perforation of the common bile duct.

Extent of resection for T2N0 gallbladder carcinoma regarding concurrent extrahepatic bile duct resection

BACKGROUNDS/AIMS: Gallbladder carcinoma (GBCa) T2 lesions are considered to be advanced tumors showing diverse features in tumor extent. When this T2 lesion does not involve the cystic duct and there is no evidence of lymph node metastasis, we have to consider what is the most reasonable extent of resection - that is, whether to perform concurrent extra-hepatic bile duct resection (EHBD) resection or not. This study intends to evaluate the adequacy of EHBD resection in patients undergoing resection for T2N0 GBCa. METHODS: From our institutional database of GBCa, 48 cases of T2N0 GBCa who underwent R0 resection during November 1995 and August 2008 were selected. Patients who underwent prior laparoscopic cholecystectomy were excluded. Their medical records were reviewed retrospectively. RESULTS: Their mean age was 63.2+/-83.3 years and females were 25. The mean serum CA19-9 level was 37.3+/-89.3 ng/ml. The extents of liver resection were wedge resection (n=36) and segment 4a+5 resection (n=12). Concurrent EHBD resection was performed in 16 (33.3%) patients. No fatal surgical complication occurred. The majority of tumor pathology was adenocarcinoma (n=42), with additional unusual types as papillary (n=3), saromatoid (n=1), signet ring cell (n=1) and adenosquamous (n=1) cancers. The overall survival rate was 87.1% at 1 year, 69.5% at 3 years and 61.7% at 5 years. After exclusion of mortalities not related to cancer, the overall patient survival rate was 89.6% at 1 year, 72.9% at 3 years and 64.7% at 5 years, with 3-year survival rates of 72% in the EHBD resection group and 69.2% in the non-resection group (p=0.661). CONCLUSIONS: The results of this study indicate that concurrent EHBD resection did not improve patient survival when R0 resection was achieved in patients with T2N0 GBCa. Therefore, routine EHBD resection may not be indicated for T2N0 GBCa unless the tumor is close to the cystic duct.