BACKGROUND/AIMS: Intraductal ultrasonography (IDUS) has been performed as an adjunct to endoscopic retrograde cholangiography (ERC) during radiocontrast cholangiography (RC). Radiation exposure during RC poses a health risk to both patients and examiners. We evaluated the feasibility of IDUS without RC in various extrahepatic biliary diseases. METHODS: IDUS was performed with the insertion of an IDUS probe from the papilla of Vater to the confluent portion of the common hepatic duct without fluoroscopy. The technical success rate and procedure-related complications were evaluated retrospectively. RESULTS: Wire-guided IDUS without RC was performed in 105 patients. The mean age was 66.5 years, and 50 (47.6%) were male. The IDUS diagnoses included choledocholithiasis (73, 69.5%), benign biliary stricture (11, 10.5%), choledocholithiasis with biliary pancreatitis (9, 8.6%), bile duct cancer (5, 4.8%), pancreatic cancer (1, 0.9%), and others (6, 5.7%). After IDUS, 66 (62.8%) underwent stone removal, 19 (18.1%) underwent biliary drainage, and 7 (6.6%) underwent brush cytology and biopsy. No significant complications such as perforation or severe pancreatitis occurred. CONCLUSIONS: IDUS without RC was a feasible and safe approach in patients with various extrahepatic biliary diseases. We anticipate a potentially important role of IDUS in various ERC procedures because it lacks the hazards of RC.
Adult ; Aged ; Aged, 80 and over ; Bile Ducts, Extrahepatic/pathology/*ultrasonography ; Biliary Tract Diseases/*ultrasonography ; Cholangiopancreatography, Endoscopic Retrograde/adverse effects/*methods ; Contrast Media ; Drainage/methods ; Endosonography/*methods ; Female ; Humans ; Male ; Middle Aged ; Pancreatitis/ultrasonography ; Retrospective Studies ; Treatment Outcome ; Ultrasonography, Interventional/*methods

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.
Ampulla of Vater ; Bile Ducts, Extrahepatic* ; Cholangiocarcinoma ; Common Bile Duct ; Cystic Duct ; Gastric Emptying ; Humans ; Medical Records ; Neoplasms, Second Primary ; Pancreatic Fistula ; Pancreaticoduodenectomy* ; Pathology ; Reoperation ; Retrospective Studies ; Survival Rate

We report a case of small cell carcinoma of extrahepatic bile duct presenting with jaundice and hemobilia. A 59-year-old woman was admitted due to right upper quadrant pain and jaundice. An abdominal computed tomography revealed a 2 cm sized mass in the extrahepatic bile duct. Endoscopic retrograde cholangiopancreatography revealed bloody discharge coming out of the papillary orifice in endoscopic view and a dilated extrahepatic bile duct with multiple irregular filling defects in cholangiogram. A coronal T2-weighted image revealed a hyperintense mass at extrahepatic bile duct. Laparotomy was performed, and pathologic examination of resected specimen showed tumor cells having round to oval nuclei with coarsely granular chromatin and scanty cytoplasm, which were immunoreactive for synaptophysin and chromogranin A, compatible with the diagnosis of small cell carcinoma. The small cell carcinoma of bile duct, despite its rarity, should be considered in differential diagnosis of the causes for obstructive jaundice and hemobilia.
Bile Duct Neoplasms/*diagnosis/pathology/radiography ; Bile Ducts, Extrahepatic/*pathology/radiography ; Carcinoma, Small Cell/*diagnosis/pathology/radiography ; Cholangiopancreatography, Endoscopic Retrograde ; Chromogranin A/metabolism ; Female ; Hemobilia/complications/*diagnosis ; Humans ; Magnetic Resonance Imaging ; Middle Aged ; Synaptophysin/metabolism ; Tomography, X-Ray Computed

OBJECTIVETo observe the effect of targeted argon-helium cryoablation on portal region of the liver in dogs by observing the pathological changes in the first-order branches of the Glisson ductal system.

METHODSTwelve healthy dogs underwent percutaneous targeted argon-helium cryoablation of the liver and sacrificed at 3 and 28 days after the cryoablation to observe the pathological changes in target area for cryoablation and the first-order branches of the Glisson ductal system.

RESULTSNo obvious damage was not found in the vascular wall of the portal vein by gross or microscopic observation, but the liver tissue in the vicinity of the blood vessels showed total necrosis. In spite of the injuries of different degrees in the first-order bile duct system after argon-helium cryoablation, no severe damages such as perforation or full-thickness necrosis occurred in bile duct wall, and most of the injuries were temporary and reversible. The size of the ablated area on day 28 was significantly reduced as compared with that on day 3 following the cryoablation (P<0.05). In the acute stage after the cryoablation (1-3 days), ALT and AST levels increased significantly in (P<0.05) but recovered 1-4 weeks later (P>0.05). The cryoablated area was basically consistent with the pathological area that underwent necrosis (P>0.05).

CONCLUSIONTargeted argon-helium cryoablation can cause total destruction of the liver tissue around the blood vessel without damaging the vascular walls of the portal vein. Argon-helium cryoablation induces relatively minor injuries to the bile duct of hepatic portal section and does not obviously damage the liver function, and the scope of tissue necrosis can be estimated according to the size of frozen area observed. Argon-helium cryoablation is a safe and minimally invasive operation with reliable therapeutic effect.

Animals ; Argon ; Bile Ducts, Extrahepatic ; pathology ; Cryosurgery ; adverse effects ; methods ; Dogs ; Female ; Helium ; Liver Neoplasms, Experimental ; surgery ; Male ; Portal Vein ; pathology ; Random Allocation

OBJECTIVESTo investigate the expression of Survivin in patients with extrahepatic cholangiocarcinoma (EHCC) and its relationship with clinicopathological features of EHCC, and the correlation between the expression of Survivin and lymph node micrometastasis, tumor markers, and the prognosis of EHCC.

METHODSThe expression of Survivin protein in paraffin-embedded specimens of 59 patients with EHCC and their 20 para-carcinoma tissues were evaluated by S-P method of immunohistochemical staining. The correlation between the expression of Survivin and the lymph node micrometastasis, clinicopathological features of EHCC and the prognosis of EHCC were analyzed.

RESULTSThe positive expression rate of Survivin protein was 67.8% (40/59) in paraffin-embedded specimens of 59 patients with EHCC and was 20.0% (4/20) in para-carcinoma tissues, and difference between carcinoma tissues and para-carcinoma tissues was significant (P<0.01). Histological differentiation in EHCC had a negative correlation with the expression of Survivin protein, while the expression of Survivin protein in EHCC had a positive correlation with TNM of EHCC, lymphatic vessel infiltration, lymph node metastasis and perineural invasion (P<0.05). The serum CA19-9 levels in the positive group with expression of Survivin protein was (290,300+/-55 500) U/L and was obviously higher than that in the negative group [(113,300+/-31,400) U/L, P<0.05]. The mean survival time of the patients with negative expression of Survivin protein was higher than that of the patients with positive expression (43.5 vs. 21.1 months, P<0.01). Screened to significance univariate, the multivariate analysis through Cox proportional hazard model analysis showed that lymph node metastasis, residual tumor margins, and expression of Survivin protein were independent prognosis factors of the patients with EHCC (P<0.05, P<0.01, P<0.01).

CONCLUSIONSThe expression of Survivin protein in EHCC has a negative correlation with histological differentiation, while has a positive correlation with lymphatic vessel infiltration and serum CA19-9 concentrations. The expression of Survivin protein maybe an independent prognosis factor of the patients with EHCC.

Adult ; Aged ; Aged, 80 and over ; Bile Duct Neoplasms ; metabolism ; pathology ; Bile Ducts, Extrahepatic ; Cholangiocarcinoma ; metabolism ; pathology ; Female ; Follow-Up Studies ; Humans ; Inhibitor of Apoptosis Proteins ; metabolism ; Lymphatic Metastasis ; Male ; Middle Aged ; Prognosis

We report here on an extremely rare case of duplicated extrahepatic bile ducts that was associated with choledocholithiasis, and this malady was visualized by employing the minimum intensity projection images with using multi-detector row CT. The presence of duplicated extrahepatic bile ducts with a proximal communication, and the ducts were joined distally and they subsequently formed a single common bile duct, has not been previously reported.
Aged, 80 and over ; Bile Ducts, Extrahepatic/*abnormalities/pathology/radiography ; Choledocholithiasis/*complications/radiography ; Female ; Humans

Benign schwannomas arise in neural crest-derived Schwann cells. They can occur almost anywhere in the body, but their most common locations are the central nervous system, extremities, neck, mediastinum, and retroperitoneum. Schwannomas occurring in the biliary tract are extremely rare and mostly present with obstructive jaundice. We recently experienced a case of extrahepatic biliary schwannomas in a 64-yr-old female patient who presented with intra- and extrahepatic bile duct and gallbladder stones during a screening program. To the best of our knowledge, extrahepatic biliary schwannomas associated with bile duct stones have not been reported previously in the literature.
Adult ; Bile Ducts/pathology ; Bile Ducts, Extrahepatic/*metabolism/*pathology ; Central Nervous System/pathology ; Cholangiography/methods ; Endoscopy ; Female ; Humans ; Male ; Middle Aged ; Neurilemmoma/*diagnosis/*pathology ; Tomography, X-Ray Computed

We experienced one fatal case of biliary cast syndrome after cadaveric liver transplantation involving both intrahepatic ducts. A 58-year-old man underwent cadaveric liver transplantation because of hepatitis B virus related liver cirrhosis and concomitant hepatocellular carcinoma. Five weeks after the liver transplantation, postoperative course was complicated by development of acute cholangitis. Subsequent endoscopic retrograde cholangiography revealed diffuse intrahepatic bile duct strictures without filling defects. Percutaneous liver biopsy, which was done to exclude rejection, revealed biliary cast. Successful endoscopic removal was precluded due to its diffuse involvement. Because of the deterioration of patient's condition by refractory biliary obstruction and cholangitis, retransplantation from cadaveric donor was performed. Debridement of the biliary tree after graft removal yielded a near-complete cast of the intrahepatic ductal system. Biliary cast syndrome should be suspected when jaundice or cholangitis is associated with dilated ducts on abdominal imaging studies in cadaveric liver transplantation recipients. Initial therapeutic options include removal of biliary cast after endoscopic or percutaneous cholangiography. Although endoscopic retrieval of biliary cast by endoscopic retrograde cholangiopancreatography could be employed as a first-line management, other modalities such as endoscopic nasobiliary drainage, percutaneous transhepatic drainage, or retransplantation should be considered when complete removal is not feasible and the condition of the recipient deteriorates.
Bile Duct Diseases/*diagnosis/etiology/pathology ; Bile Ducts, Extrahepatic/pathology ; Bile Ducts, Intrahepatic/pathology ; Cholangiopancreatography, Endoscopic Retrograde ; Fatal Outcome ; Humans ; Jaundice, Obstructive/etiology ; *Liver Transplantation ; Male ; Middle Aged ; Postoperative Complications/*diagnosis/pathology/radiography ; Tomography, X-Ray Computed

Bile Duct Neoplasms ; genetics ; pathology ; Bile Ducts, Extrahepatic ; Cholangiocarcinoma ; genetics ; pathology ; Female ; GTP-Binding Protein gamma Subunits ; genetics ; Gene Expression Regulation, Neoplastic ; Humans ; Male ; Middle Aged ; Neoplasm Staging ; RNA, Messenger ; genetics ; metabolism ; Reverse Transcriptase Polymerase Chain Reaction

OBJECTIVETo explore the feasibility and outcome of combined hepatectomy, orthotopic liver transplantation and Whipple's pancreatoduodenectomy for radical excision of cholangiocarcinoma.

METHODSA 35-year-old female patient with unresectable cholangiocarcinoma underwent curative radical operation, which includes hepatectomy, orthotopic liver transplantation and pancreaticoduodenectomy of hilar bile duct carcinoma; immunosuppression followed an induction protocol with FK506 and steroids. Lamivudine and HBIg were used to prevent hepatitis B virus from infection again.

RESULTSPathologic examination revealed low differentiated cholangiocarcinoma and immunohistochemistry stains demonstrated positive expression of cytokeratin 9 and 17, carcinoembryonic antigen and the hepatocyte protein was negative. Neither the margins of resection nor the periductal lymph nodes were involved. The liver showed evidence of cholestasis and metastasis nod. The patient was hospitalized 32 days and came back to the previous work. He has been followed up for more than 14 months up to now and is currently alive without any evidence of recurrent cancer.

CONCLUSIONSFor some selected unresectable Klatskin's tumors, combined hepatectomy, pancreatoduodenectomy and orthotopic liver transplantation was justified. The radical methods maybe provide long-time survival and curative effect. Nevertheless, because of possible tumor recurrence and ethical controversy, the combined hepatectomy, pancreatoduodenectomy and orthotopic liver transplantation procedure has to be applied only with caution and indications.

Adult ; Bile Duct Neoplasms ; pathology ; surgery ; Bile Ducts, Extrahepatic ; surgery ; Cholangiocarcinoma ; pathology ; surgery ; Female ; Follow-Up Studies ; Hepatectomy ; Humans ; Liver Transplantation ; Pancreaticoduodenectomy ; Treatment Outcome