Detection of tumors of the ampulla of Vater, including ampullary adenoma, has been improved by routine screening endoscopic procedures and imaging modalities. Endoscopic resection by endoscopic papillectomy is rapidly replacing classic surgical resection and is a less invasive procedure. Endoscopic resection can have a role not only in the final histopathologic diagnosis but also as a definite therapeutic option. However, the indications for endoscopic resection are not fully established, and endoscopic procedures are not standardized. Significant complications, including severe pancreatitis, intractable bleeding and duodenal perforation, are rare but can occur, especially in less experienced hands. Severe pancreatitis is the most feared complication, but it can be prevented by pancreatic duct stent insertion in most cases. However, in some cases, pancreatic stenting can be challenging after resection. Incomplete resections are sometimes performed to avoid complications. Endoscopic surveillance is also important for identifying and managing remnant adenomatous tissue or recurrent lesions. Further technical development is needed to expand the indications for this procedure, minimize complications and ensure a high success rate.
Adenoma/pathology/*surgery ; Ampulla of Vater/pathology/*surgery ; Carcinoma/pathology/*surgery ; Common Bile Duct Neoplasms/pathology/*surgery ; Endoscopy, Digestive System ; Humans

Multiple synchronous malignancies are defined as the occurrence of two or more primary malignant tumors whose pathogenetic processes are believed to be independent or unrelated. Multiple synchronous biliary carcinomas are not frequently reported. The diagnosis is often made as a result of incidental intraoperative discovery of a gallbladder mass during surgical treatment of extrahepatic cholangiocarcinoma. We experienced a case of synchronous double primary cancer of the gallbladder and distal common bile duct confirmed by pathologic evaluation, and report the case with a review of the clinical literature.
Biliary Tract* ; Cholangiocarcinoma ; Common Bile Duct ; Diagnosis ; Gallbladder ; Gallbladder Neoplasms

OBJECTIVETo investigate the risk factors of gastroesophageal varices rebleeding after therapeutic endoscopy.

METHODSMedline,EMBASE and the China Biology Medicine Database were searched for literature published between January 2000 to May 2013 on topics related to risk factors of gastroesophageal varices rebleeding after therapeutic endoscopy. Data from each study that meet the requirements for analysis were extracted and subjected to meta-analysis.

RESULTSSixteen studies were collected for use in this meta-analysis. The odds ratio (OR) value of portal vein embolus was 7.88 (P<0.00001). The OR value of beta-blockers or nitrate medications was 0.53 (P=0.0008). The standardized mean difference (SMD) value of number of ligation points was 0.94 (P<0.01). The SMD value of albumin in the subgroup with follow-up time of less than or equal to 14 days was-0.89 (P<0.00001), while the SMD value of prothrombin time in the subgroup with follow-up time of less than or equal to 14 days was 1.78 (P<0.00001).

CONCLUSIONSPortal vein embolus, hepatocellular carcinoma, diameter of the portal vein, Child-Pugh classification C, moderate/excessive ascites, prothrombin time, and number of ligation points were risk factors of gastroesophageal varices early rebleeding after therapeutic endoscopy. Portal vein embolus, hepatocellular carcinoma, and diameter of the portal vein were risk factors of gastroesophageal varices long-term rebleeding after therapeutic endoscopy. Beta blockers or nitrate medications were protective factors of gastroesophageal varices rebleeding after therapeutic endoscopy.

Carcinoma, Hepatocellular ; China ; Endoscopy, Digestive System ; Esophageal and Gastric Varices ; Gastrointestinal Hemorrhage ; Humans ; Ligation ; Liver Neoplasms ; Portal Vein ; Risk Factors

Choledochal cysts are congenital lesions involving cystic dilatation of the bile ducts. The choledochocele, the rarest type of choledochal cyst, is a cystic dilatation of the distal common bile duct that protrudes into the duodenum. There have been few reports concerning malignancy in the biliary tree associated with choledochoceles. We recently experienced a case of a choledochocele with gallbladder cancer.
Bile Ducts ; Biliary Tract ; Choledochal Cyst ; Common Bile Duct ; Dilatation ; Duodenum ; Gallbladder ; Gallbladder Neoplasms

An ectopic opening of the common bile duct (CBD) into the duodenal bulb is a very rare congenital anomaly of the biliary system, which may cause recurrent duodenal ulcer or biliary diseases such as choledocholithiasis and cholangitis. Endoscopic retrograde cholangiopancreatography (ERCP) plays a major role in the diagnosis of this anomaly. We report two such cases: one in a 61-year-old man and the other in a 57-year-old man. In the first case, this anomaly caused acute cholangitis with multiple CBD stones, which were successfully treated by ERCP. In the second case, abdominal computed tomography showed pneumobilia, which was further evaluated using ERCP. Besides, this patient was diagnosed with an ectopic opening of the CBD associated with gallbladder cancer. We report these unusual cases and review the relevant medical literature.
Biliary Tract ; Cholangiopancreatography, Endoscopic Retrograde ; Cholangitis* ; Choledocholithiasis ; Common Bile Duct* ; Diagnosis ; Duodenal Ulcer ; Gallbladder Neoplasms* ; Humans ; Middle Aged

The diagnostic accuracy of percutaneous transhepatic cholangioscopy (PTCS) was compared to that of three radiologic modalities in distal common bile duct (CBD) strictures for the evaluation of clinical application. Ninety-five patients who underwent PTCS for the evaluation of distal CBD strictures (35 malignant and 60 benign) whose masses were not obvious from radiologic imagings were included. Confirmative diagnosis could not be reached by endoscopic retrograde cholangiopancreatography (ERCP) or radiologic findings in all cases. Specific findings on the computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP) and direct cholangiography were analyzed among 68 (25 malignant and 43 benign) out of the 95 patients in order to determine the sensitivity and specificity of three radiologic studies for the diagnosis of malignant distal CBD strictures, and to compare those results with those by a combination of PTCS-guided biopsy and tumor vessel observation on cholangioscopy. The sensitivity/specificity of CT, MRCP and direct cholangiography including ERCP in diagnosing malignant distal CBD strictures were 42.9%/65.8%, 53.3%/58.3%, and 70.8%/47.6% respectively, while it was 96%/100% for the combination of PTCS-guided biopsy and tumor vessel. PTCS is a useful method for differential diagnosis of distal CBD strictures, particularly when it is difficult to distinguish benign from malignant strictures by radiologic studies and when peroral approach is not feasible.
Aged ; Biopsy ; Cholangiopancreatography, Magnetic Resonance ; Common Bile Duct Diseases/*diagnosis/pathology ; Common Bile Duct Neoplasms/*diagnosis/pathology ; Constriction, Pathologic ; Endoscopy, Digestive System/*methods ; Endosonography ; Female ; Humans ; Male ; Middle Aged ; Retrospective Studies ; Sensitivity and Specificity

PURPOSE: From the early 1990s, operative mortality following pancreaticoduodenectomy have been decreased markedly. And severity of the postoperative complications also has been improved. Experienced hands in large volume hospitals and advances in supportive care have been considered as main reasons. Under this currency, indications for pancreaticoduodenectomy have been expanded, and extended pancreaticoduodenectomy has been tried more occasionally. METHODS: For 254 consecutive patients who underwent pancreaticoduodenectomy between Dec. 1998 and Mar. 2002, a retrospective analysis of operative mortality and postoperative complications was performed by reviewing of the medical records. RESULTS: Eighty-five patients were treated for common bile duct cancer, 58 patients for pancreatic cancer, 60 patients for ampulla of Vater cancer, 9 patients for duodenal cancer, 5 patients for advanced gastric cancer, 2 patient for gallbladder cancer, one patient for colon cancer and 34 patients for benign diseases or traumatic conditions. Standard pancreaticoduodecnectomies were performed in 169 patients, pylorus-preserving pancreaticoduodenectomies in 64 patients, total pancreatectomies in 15 patients and hepatopancreaticoduodenectomies in 6 patients. There was no postoperative 30-day or hospital mortality. Postoperative complications were occurred in 100 (39%) patients. The leading complication of this study is hemorrhage in 27 cases (11%) followed by pancreatic fistula in 17 cases (7%), delayed gastric emptying 16 cases (6%) and intraabdominal abscess in 11 cases (4%). There were no significant difference of the incidence of the complications between malignant diseases and benign, above 70-years old and below. Among them in 15 patients (15%) re-operative treatments were needed and in the remain conservative treatments were chosen. CONCLUSION: Operative mortality itself is no more limited factor for pancreaticoduodenectomy. Most of the complications following pancreaticoduodenectomy can be treated successfully and pancreaticoduodenectomy can be chosen as a safe and effective procedure not only in periampullary tumors but other benign diseases and even old age with same complication risk. But hemorrhagic complication and pancreatic fistula have been remained as serious problems on performing of pancreaticoduodenectomy.
Abscess ; Aged ; Ampulla of Vater ; Colonic Neoplasms ; Common Bile Duct ; Duodenal Neoplasms ; Gallbladder Neoplasms ; Gastric Emptying ; Hand ; Hemorrhage ; Hospital Mortality ; Humans ; Incidence ; Medical Records ; Mortality* ; Pancreatectomy ; Pancreatic Fistula ; Pancreatic Neoplasms ; Pancreaticoduodenectomy* ; Postoperative Complications ; Retrospective Studies ; Stomach Neoplasms

BACKGROUND/AIMS: Management of malignant gastrointestinal obstruction presents a significant challenge. Recently, self-expandable metal stent (SEMS) has emerged as an effective, safe, and less invasive alternative for the treatment of malignant intestinal obstruction. Accordingly, we reviewed our experience in SEMS insertion with hemoclip placement. METHODS: Between June 2004 and December 2005, a total of 40 SEMS were tried to place in 38 patients with malignant intestinal obstruction. Two stents were placed again due to recurrent obstruction and delayed stent migration after initial stent placement. We analyzed the technical and clinical success rates and complications. RESULTS: Total stent placement was successful in 38/40 (95%). In 2 cases, stent placement was failed due to complete obstruction. Twenty-eight stents for palliation of malignant intestinal stenosis, 9 stents for one-staged operation for malignant colonic obstruction, and 1 stent for management of tracheoesophageal fistula were placed. Stent migration occurred in 6/38 (15.8%). Early stent migration rate was significantly lower in the clipping group (0/19, 0%) than in the non-clipping group (5/19, 26.3%, p=0.04). Recurrent obstruction occurred in 2/38 (6.1%) due to tumor ingrowth and in 1/38 (2.6%) due to hard food materials. CONCLUSIONS: Application of the clips reduce early stent migration in patients with malignant gastrointestinal obstruction.
Adult ; Aged ; Aged, 80 and over ; Colonic Neoplasms/surgery ; Digestive System Surgical Procedures/instrumentation ; Esophageal Neoplasms/surgery ; Female ; Gastrointestinal Neoplasms/*surgery ; Humans ; Intestinal Obstruction/*surgery ; Male ; Middle Aged ; Prostheses and Implants ; Retrospective Studies ; *Stents ; Stomach Neoplasms/surgery

PURPOSE: Local recurrence, following a resection for cancer of the gallbladder (GB) and bile duct, is usually incurable; with 2nd curative surgery being almost impossible. To determine the feasibility and significance of 2nd curative surgery, our experiences are presented in this study. METHODS: The medical records and clinical outcomes of 4 patients that underwent a re-resection for recurrent cancer of the extrahepatic biliary tract were retrospectively reviewed. RESULTS: The mean age of the four patients was 51.5 years. One patient that had a recurrent disease at the intrahepatic and intrapancreatic bile duct, 66 months after a segmental resection of the bile duct for common bile duct (CBD) cancer, underwent a hepatopancreatoduodenectomy. The second patient had a recurrent tumor mass in the CBD originating from in a cystic duct, 11 months after a cholecystectomy, and underwent a segmental resection of the bile duct. The third patient had a recurrent disease in the distal CBD, 28 months after a right hepatectomy for a Klatskin tumor, and underwent a pylorus-preserving pancreatoduodenectomy. The gross type of the above 3 cases was a papillary tumor. The fourth patient had a recurrent tumor mass of the liver parenchyma, close to the previous resection margin, 16 months after a cholecystectomy and wedge resection of the GB bed at another hospital for GB cancer, and underwent a wider wedge resection of the GB bed. There were no operative mortalities or morbidities. All patient are still alive after 46, 63, 9 and 30 months, respectively, without recurrence after the reoperation. CONCLUSION: It is concluded that a surgical re-resection is possible in selected patients with recurrent bile duct cancer, mostly of the papillary type. A primary operation for bile duct cancer should be performed with a wide surgical margin, and secondary curative surgery should be considered whenever possible in cases of recurrence.
Bile Duct Neoplasms ; Bile Ducts ; Biliary Tract* ; Cholecystectomy ; Common Bile Duct ; Cystic Duct ; Gallbladder Neoplasms ; Hepatectomy ; Humans ; Klatskin's Tumor ; Liver ; Medical Records ; Mortality ; Pancreaticoduodenectomy ; Recurrence ; Reoperation* ; Retrospective Studies

PURPOSE: In order to study the patency, restenosis, efficacy, and complications of the metallic stent in the course of treatment of malignant biliary obstruction,the results of follow up of the dead patients after stent insertion were reviewed. MATERIALS AND METHODS: Self-expandable Gianturco metallic stent with 10-mm diameter was successfully inserted in 33 patients :10 with Klatskin tumor, 7 with common bile duct cancer, 7 with gallbladder cancer, 5 with pancreatic cancer, 2 with recurred stomach cancer, one with periampullary cancer, one with hepatocellular carcinoma. RESULTS: The overall duration of survival and patency of the stents in 33 patients were 5.2 months(1-12 months) and 4.9 months(1.14 months), respectively. Restenosis of metallic stents was found in 9 cases(27%), after 6.1 months in average. Causes of stent occlusion were overgrowing of tumor in 5, overgrowing and ingrowing of tumor in 3, extraductal dislodgement in one case. Two cases of symptomatic cholangitis after stent placement were successfully treated with percutaneous cholecystostomy. Three cases of destruction and migration of metallic stents were found after 6 months. CONCLUSION: On the basis of our experience, insertion of Gianturco metallic biliary stent is an acceptable treatment method in the malignant biliary obstruction, especially for whom short term survival is expected.
Carcinoma, Hepatocellular ; Cholangitis ; Cholecystostomy ; Common Bile Duct ; Follow-Up Studies* ; Gallbladder Neoplasms ; Humans ; Klatskin's Tumor ; Pancreatic Neoplasms ; Stents* ; Stomach Neoplasms