Branch Of Bile Duct Research Articles

Clinical application of prone position to suppress respiratory movement artifacts in supine position during magnetic resonance cholangiopancreatography/MRI.

To compare the image quality of magnetic resonance cholangiopancreatography (MRCP) in the supine position and prone position under the conditions of the same equipment, the same sequence (3D Navigator Triggered Sampling Perfection with Application-Optimized Contrast Using Different Flip-angle Evolutions, 3D-NT-SPACE) and the same patient, and to explore the clinical application value of prone position in MRCP examination to suppress respiratory motion artifacts. 53 participants who underwent MRCP in our hospital from April 2020 to August 2022 were prospectively collected. The 3D-NT-SPACE sequence was used in these patients. The visibility of the common bile duct, common hepatic duct, main pancreatic duct, and first- and second- and third-level branches of the intrahepatic bile duct and the comfort of the participants in two positions were subjective-evaluated. The Signal-to-noise ratio (SNR) and contrast-to-noise ratio were objective-evaluated. Statistical analysis was performed using Shapiro-Wilk, Levene's, Mann Whitney U test, Pearson chi-square test, and one-sample chi-square test. 53 patients (51.92years ± 2.02, 20 men) were evaluated. There were significant differences in the second- and third-level branches visibility score, the main pancreatic duct visibility score, the image quality score of the pancreaticobiliary tree, the blur and motion artifact score, the total image quality score, and SNR between the two positions (p < 0.05). The overall image quality of the prone position was better than that of the supine position. The prone position is a useful complement to the supine position.

Intrahepatic cholangiocarcinoma with extensive intraductal extension of high-grade biliary intraepithelial neoplasia: a case report

BackgroundIntrahepatic cholangiocarcinoma (ICC) is frequently associated with precursor lesions, and biliary intraepithelial neoplasia (BilIN) may play a significant role in the development of ICC. However, the exact sequence and progression of these lesions remain to be elucidated. We report a rare case of ICC that exhibited extensive longitudinal intraductal extension of high-grade BilIN in the posterior bile ducts and involved the hepatic hilum and the peripheral hepatic parenchyma.Case presentationA 70-year-old female presented with anorexia. Computed tomography (CT) revealed a 15 mm enhancing intrahepatic tumor extending to the right intrahepatic secondary confluence. This was associated with a 7 mm diameter cystic dilatation of the segment 6 bile duct (B6). Endoscopic retrograde cholangiopancreatography (ERCP) revealed stenosis at the bifurcation of the posterior bile duct branch. Bile cytology confirmed the diagnosis of adenocarcinoma cells. Therefore, the patient was diagnosed with an ICC involving the right glissonean pedicle and underwent a right hepatectomy and lymph node dissection. Histologic examination revealed the tumor consisted of moderately differentiated adenocarcinoma. In connection with this lesion, diffuse intraductal atypical epithelial cells, which were diagnosed as high-grade BilIN, was observed not only in the dilated B6 but in the entire posterior bile ducts, which measured approximately 120 mm in diameter. Furthermore, two distinct foci of adenocarcinomas were identified in the peripheral hepatic parenchyma. A lymph node metastasis was also present. The pathological diagnosis was ICC pT4N1M0 stage IVA. The patient underwent adjuvant chemotherapy and has shown no recurrence 5 years after surgery. Imaging modalities were unable to accurately assess the extent of the intraductal neoplastic lesions due to their low papillary or sessile intraductal tubular growth. No risk factors for BilIN development, which has the potential to predispose to cholangiocarcinoma, were identified in the present case.ConclusionsWe present a case of ICC involving the right hepatic hilum, accompanied by extensive longitudinal extensions of high-grade BilIN and multifocal microscopic invasions in peripheral hepatic parenchyma. Notably, the intraductal lesions involved the entire posterior intrahepatic bile ducts. The presence of biliary neoplasia with extensive intraductal extension, in conjunction with ICC, should be considered as a variant of BilIN.

Comparison of guidewires for successful cannulation of biliary stenosis and targeting of biliary branches in ERCP.

Background and study aims Guidewires play a crucial role in endoscopic retrograde cholangiopancreatography. The ability to pass through stenosis, and the ability to seek the desired biliary branch are particularly important. In this study, we aimed to compare these specific abilities in various guidewires by using a bile duct model. Patients and methods Seven 0.025-inch angle-type guidewires (VisiGlide2, Fielder 25, EndoSelector, NaviPro, Jagwire Plus, RevoWave DualMaster, and J-WIRE prologue ST) were evaluated. To compare these, a bile duct silicone model was prepared. The time from the entry of the guidewire into the common bile duct with the stenosis to the emergence of the guidewire from the common bile duct after reaching two target intrahepatic bile duct branches was measured. Results VisiGlide 2 and Fielder 25 were the fastest guidewires, whereas Jagwire Plus was the slowest. Conclusions In this study, a guidewire with a tip deflection height of approximately 9 mm and a hydrophilic coating length of 7 to 8 cm achieved the fastest completion time for the course. In clinical practice, it is important to consider the performance required in various scenarios and to select the most appropriate guidewire. The results of this model test, which focused on the time required to complete the course around the model, can serve as a foundation for guidewire selection. This method holds potential utility in future guidewire development.

Perspective of tumor heterogeneity for treatments of intrahepatic cholangiocarcinoma with intrahepatic lithiasis

The heterogeneity of tumors results in significantly distinct biological characteristics of intrahepatic cholangiocarcinoma (ICC) caused by different etiologies. Among them, ICC caused by intrahepatic lithiasis (IHL-ICC) presents challenges in early detection, tumor staging, and surgical treatment, and has the poorest prognosis among all etiologies of ICC patients. Thus, it is essential to focus on early assessment of the possibility of developing ICC, prompt intervention of intrahepatic lithiasis, anatomical resection of hepatic parenchyma corresponding to the branch of the intrahepatic bile duct undergoing cancerous transformation, and enhanced postoperative follow-up of hepatolithiasis and ICC for IHL-ICC patients. These interventions are crucial to improve the clinical outcomes and overall survival of IHL-ICC patients.

Zebrafish ppp1r21 mutant as a model for the study of primary biliary cholangitis

Primary biliary cholangitis (PBC) is an autoimmune cholestatic liver disease that progresses to fibrosis and cirrhosis, resulting from the gradual destruction of intrahepatic bile ducts. Exploring genetic variants associated with PBC is essential to understand the pathogenesis of PBC. Here we identify a zebrafish balloon dog (blg) mutant with intrahepatic bile duct branching defects, exhibiting several key pathological PBC-like features, including immunodominant autoantigen PDC-E2 production, cholangiocyte apoptosis, immune cell infiltration, inflammatory activation, and liver fibrosis. blg encodes the protein phosphatase 1 regulatory subunit 21 (Ppp1r21), which is enriched in the liver and its peripheral tissues and plays a vital role in the early intrahepatic bile duct formation stage. Further studies show an excessive activation of the PI3K/AKT/mTOR pathway in the hepatic tissues in the mutant, while treatment with the pathway inhibitor LY294002 and rapamycin partially rescues intrahepatic bile duct branching defects and alleviates the PBC-like symptoms. These findings implicate the potential role of the Ppp1r21-mediated PI3K/AKT/mTOR pathway in the pathophysiology of PBC.

Endoscopic Transpapillary Stenting for Malignant Hilar Biliary Stricture: Side-by-Side Placement versus Partial Stent-in-Stent Placement.

Endoscopic uncovered metal stent (UMS) placement has been widely performed for unresectable hilar malignant biliary stricture (UHMBS). Two stenting methods are used for the two bile duct branches: side-by-side placement (SBS) and partial stent-in-stent placement (PSIS). However, it remains controversial whether SBS or PSIS is superior. This study aimed to compare SBS and PSIS in UHMBS cases with UMS placement in two branches of the IHD. This retrospective study included 89 cases of UHMBS treated with UMS placement through the SBS or PSIS technique using endoscopic retrograde cholangiopancreatography at our institution. Patients were divided into two groups, SBS (n = 64) and PSIS (n = 25), and compared. Clinical success was achieved in 79.7% and 80.0% in the SBS and PSIS groups, respectively (p = 0.97). The adverse event rate was 20.3% and 12.0% in the SBS and PSIS groups, respectively (p = 0.36). The recurrent biliary obstruction (RBO) rate was 32.8% and 28.0% in the SBS and PSIS groups, respectively (p = 0.66). The median cumulative time to RBO was 224 and 178 days in the SBS and PSIS groups, respectively (p = 0.52). The median procedure time was 43 and 62 min in the SBS and PSIS groups, respectively, which was significantly longer in the PSIS group (p = 0.014). No significant differences were noted in the clinical success rate, adverse event rate, time to RBO, or overall survival between the SBS and PSIS groups, other than the significantly longer procedure time in the PSIS group.

Clinics in diagnostic imaging (216).

Clinics in diagnostic imaging (216).

Liver impaction technique improves technical success rate of guidewire insertion during EUS-guided hepaticogastrostomy (with video).

If the guidewire becomes kinked by the needle, guidewire manipulation may be difficult, and can cause complications such as guidewire shearing or injury during endoscopic ultrasound (EUS)-guided hepaticogastrostomy (HGS). To overcome this matter, we have previously described a technical tip for preventing guidewire injury, termed 'liver impaction technique'. However, its technical feasibility has been not reported in the setting of a large patient cohort. The aim of study was to evaluate the clinical usefulness of the liver impaction technique during EUS-HGS. Retrospective, single-center study. This retrospective study included consecutive patients who underwent EUS-HGS between April 2018 and September 2022. The primary outcome of this study was the technical success rate of guidewire insertion using the liver impaction technique. A total of 166 patients were enrolled in this study. Initial successful guidewire insertion without using liver impaction technique was obtained in 108 patients (65.1%). Among 58 patients in whom guidewire insertion failed initially, guidewire advancement into the periphery of the bile duct was observed in 32 patients (55.2%) and into a non-interest bile duct branch was observed in 26 patients (44.8%). Liver impaction technique contributed to increasing the technical success rate of guidewire insertion from 65.1% to 95.8%. Overall, adverse events were observed in 12 patients (7.2%; bile peritonitis n = 9, cholangitis n = 3), and these adverse events were Grade I. Among patients who underwent liver impaction technique (n = 58), adverse events were observed in two patients (3.4%; bile peritonitis). Also, guidewire sharing was not observed in any patients during liver impaction technique. In conclusion, the liver impaction technique may be helpful during EUS-HGS to obtain successful guidewire insertion into the biliary tract of interest.

Applied anatomical study and clinical application of the caudate lobe boundary and ductal system of the liver

Objective: To explore the relationship between the hepatic caudate lobe boundary and the ductal system so as to guide the identification of the anatomical relationship during liver surgery. Methods: The specific parts were observed and the liver parenchyma was removed according to 41 cadaveric liver autopsy specimens. The critical relationship between the hepatic caudate lobe and other ducts was observed to explore the reticular duct structure. Results: The plane formed by the hepatic hilar plate and Arantius ligament served as the boundary between the caudate lobe and other hepatic lobes. The caudate lobe hepatic portal vein was composed of numerous small branches from its left and right branches. The portal vein adjacent to the vena cava was mainly derived from the left branch, and to a lesser extent from the right branch. Blood was drained straight from the caudate lobe vein into the inferior vena cava via the short hepatic vein. There were three or four bile duct branches in the caudate lobe. The main source of arterial blood flow were the left and right branches of the hepatic artery. An avascular zone of loose connective tissue was found between the caudate lobe and the retrohepatic inferior vena cava. Conclusion: The hepatic caudate lobe is an independent lobe. During hepatic caudate lobe surgery, the plane formed by the hepatic hilar plate and Arantius ligament can serve as the boundary between the caudate lobe and other hepatic lobes and be used for anatomical site identification. The duct system of the caudate lobe's is complicated, but it also has its own distinct regularity.

S2502 Gastrointestinal Kaposi Sarcoma: A Case Report

Introduction: Kaposi sarcoma (KS) in the gastrointestinal (GI) tract is an uncommon entity specially without any cutaneous manifestation since the introduction of HAART therapy in HIV patients. Most of the gastrointestinal KS, remains undiagnosed as majority of KS is asymptomatic. Here we present a case of GI- KS in a HIV-AIDS patient. Case Description/Methods: A 21-year-old male with history of HIV-AIDS came in for nausea, vomiting and hematochezia for 1 month. Lab showed; total CD4 of 10, elevated ALP 435 U/L, AST, ALT, total and direct bilirubin, lipase was normal. There was periodic increase in ALP hence MRCP was done, which revealed multiple hepatic and intrabiliary lesions. On EGD and colonoscopy, a large infiltrative mass, with recent stigmata of bleeding was found in the duodenum (Figure) to the ileum causing a partial obstruction. The biopsy showed extensive spindle cell proliferation with immunostains positive for HHV8 , ERG which was consistent with Kaposi Sarcoma. A liver biopsy was also done which showed non caseating granuloma with lymphocytic infiltrate with portal ductal proliferation and edema. He underwent ERCP revealing multiple segmental moderate biliary strictures in the common bile duct (CBD), left and right intrahepatic branches. A biliary sphincterotomy and a plastic stent in CBD was performed. He was on HAART therapy and anthracycline based chemotherapy was considered, but the patient passed away due to multiorgan failure from sepsis. Discussion: GI- KS can present as multiple GI symptoms including nausea, vomiting, GI bleeding as in our case or abdominal pain, anemia. (1) However, most of the time gastrointestinal KS remains asymptomatic. (1) Clinician should have high suspicion for GI-KS especially in patients with HIV- AIDS, not in therapy. This will help in the earlier diagnosis and management of GI-KS.Figure 1.: Large infiltrative mass of Kaposi Sarcoma found in duodenum.

Right hepatectomy with preservation of the entire caudate lobe in patients with metastatic liver tumors: a case of a new hepatectomy technique and treatment strategy for patients with marginal liver function

BackgroundPerforming major hepatectomy for patients with marginal hepatic function is challenging. In some cases, the procedure is contraindicated owing to the threat of postoperative liver failure. In this case report, we present the first case of marginal liver function (indocyanine green clearance retention rate at 15 min [ICGR15]: 28%) successfully treated with right hepatectomy, resulting in total caudate lobe preservation.Case presentationA 71-year-old man was diagnosed with sigmoid colon cancer with three liver metastases (S5, S7, and S8). All of metastatic lesions shrunk after chemotherapy, but his ICGR15 and indocyanine green clearance rate (ICGK) were 21% and 0.12, respectively. Moreover, the remnant liver volume was only 39%. Therefore, portal venous embolism (PVE) of the right portal vein was suggested. Portography showed divergence of the considerably preserved right caudate lobe branch (PV1R) from the root of the right portal vein. The liver function was reevaluated 18 days after PVE was suggested. During this time, the ICGR15 (21–28%) and ICGK rate (0.12–0.10) deteriorated. The right caudate lobe was significantly enlarged; thus, a total caudate lobe-preserving hepatectomy (TCPRx) was performed. Patients eligible for TCPRx included those with (1) hepatocellular carcinoma or metastatic liver cancer, (2) no tumor in the caudate lobe, (3) marginal liver function (ICG Krem greater than 0.05 if TCPRx was adapted; otherwise, less than 0.05) and Child–Pugh classification category A, and (4) preserved PV1R and right caudate bile duct branch. The procedure was performed through (A) precise estimation of the remnant liver volume preoperatively, (B) repeated intraoperative cholangiography to confirm the biliary branch of the right caudate lobe (B1R) conservation, and (C) stapler division of posterior and anterior Glisson’s pedicles laterally to avoid injuries to the PV1R and B1R.ConclusionsRight hepatectomy with total caudate lobe preservation, following PVE, was a safe and viable surgical technique for patients with marginal liver function.

Synchronous Extrahepatic Cholangiocarcinoma and Gallbladder in Australian Patient Without an Abnormal Pancreatico-biliary Ductal Junction

Synchronous malignancies of bile duct and the gallbladder are rare. These cases are often associated with pancreatico-biliary maljunction which is characterised by a long-shared duct between the sphincter of Oddi, the branches of the common bile duct and the pancreatic duct. This predisposes the biliary epithelium to pancreatic enzyme reflux and makes the development of neoplasia more likely. We describe the case of a 64-year-old Australian female who presented with new jaundice and severe cholecystitis secondary to an impacted gallstone.

Recurrent intraductal papillary neoplasm of the bile duct due to intraductal dissemination: a case report and literature review

BackgroundIntraductal papillary neoplasm of the bile duct (IPNB) is a subtype of biliary tumor. The 5-year survival rate of patients with IPNB who underwent curative resection is 81%. However, IPNB is known to often recur in other parts of the bile duct. Nevertheless, its mechanism remains poorly understood. Herein, we report the case of a patient with recurrent IPNB, which was considered to be attributed to intraductal dissemination in the common bile duct at 12 months after curative resection. We also made a review of the existing literature.Case presentationA 69-year-old man was referred to our hospital for the evaluation and dilation of an intrahepatic bile duct (IHBD) mass. Computed tomography (CT) findings confirmed a mass in the left hepatic duct. Left trisectionectomy, extrahepatic bile duct resection with biliary reconstruction, and regional lymph node dissection were performed. Intraoperative examination of the resection margin at the common bile duct and posterior segmental branch of the hepatic duct was negative for the presence of malignant cells. Histologically, the tumor showed intraductal papillary growth of the mucinous epithelium and was diagnosed as non-invasive IPNB. It had a papillary structure with atypical epithelial cells lined up along the neoplastic fibrovascular stalks. Immunohistochemically, this was as a gastric-type lesion. At 12 postoperative months, CT revealed a 1.5-cm mass in the lower remnant common bile duct. We performed subtotal stomach-preserving pancreaticoduodenectomy. The tumor exhibited papillary growth and was microscopically and immunohistochemically similar to the first tumor. At approximately 16 months after the patient’s second discharge, CT showed an abdominal mass at the superior mesenteric plexus, which was diagnosed as recurrent IPNB. Chemotherapy is ongoing, and the patient is still alive. In this case, as described in many previous reports, IPNB recurred below the primary lesion in the bile duct.ConclusionBased on our review of previous reports on IPNB recurrence, intraductal dissemination was considered one of the mechanisms underlying recurrence after multicentric development. Considering the high frequency and oncological conversion of recurrence in IPNB, regular follow-up examination is essential to achieve better prognosis in patients with recurrent IPNB.

Intractable Biliary Strictures After Living Donor Liver Transplantation: A Case Series

Biliary stricture (BS) is a severe complication after liver transplantation. It is difficult to treat, especially after living donor liver transplantation (LDLT). We successfully treated 4 patients for intractable BS after LDLT. All patients had developed cholangitis with stenosis of bile ducts anastomosis. CASE 1: . A 65-year-old woman underwent LDLT with right lobe graft and duct-to-duct biliary reconstruction. Internal plastic stents inserted by endoscopic retrograde cholangiography (ERC) were changed quarterly for the next 2 years. CASE 2: A 55-year-old man underwent LDLT with right lobe graft and duct-to-duct biliary reconstruction. Insertion of internal plastic stents by ERC was attempted; however, the posterior bile duct branch showed complete obstruction. After percutaneous transhepatic biliary drainage (PTCD), the stents were inserted using the rendezvous technique of ERC and were changed by ERC quarterly for the next 3 years. CASE 3: A 22-year-old man underwent LDLT with left lobe graft and hepaticojejunostomy. An external drainage tube was inserted by PTCD, and stents were changed quarterly for the next 2 years. CASE 4: A 60-year-old man underwent LDLT with right lobe graft and hepaticojejunostomy. An external drainage tube was inserted by PTCD, and changed to a metallic stent after 1 year. Three months later the stent was extracted using the rendezvous technique of double balloon enteroscopy. BS of complete obstruction type after LDLT is difficult to treat. Appropriate procedures should be chosen based on the types of strictures and biliary reconstruction methods.

Microwave ablation for peribiliary hepatocellular carcinoma: propensity score analyses of long-term outcomes

Objective To compare the long-term outcomes of MWA as the first-line treatment for HCC in peribiliary versus non-peribiliary locations using propensity score matching analysis. Methods The study participants were recruited between April 2012 and October 2016. In total, 236 patients with HCC <5 cm who underwent ultrasonography-guided percutaneous MWA as the first-line treatment were enrolled. The patients were grouped into two according to tumor location: peribiliary (n = 74) and non-peribiliary (n = 162). The progression-free survival (PFS) and overall survival (OS) rates were compared before and after propensity score matching. Subgroup analyses were conducted for the peribiliary group according to the biliary grading. Results Propensity score matching yielded 63 matched pairs of patients. In the two matched groups, cumulative PFS rates were 29.0% and 14.0% in the peribiliary group, and 51.0% and 31.0% in the non-peribiliary group at 3 and 5 years, respectively. Corresponding OS rates were 51.0% and 49.0% in the peribiliary group, and 77.0% and 70.0% in the non-peribiliary group at 3 and 5 years, respectively. In addition, there were significant differences in major complication rates between the two groups (25.7% vs 8.0%; p < .001). In contrast to peribiliary HCCs adjacent to the second-degree branches of intrahepatic bile duct (67.1 ± 5.2 months), subgroup analysis indicated that the mean OS was significantly lower in peribiliary HCCs adjacent to the first-degree branches (51.2 ± 7.5 months) (p = .015). Conclusion The application of MWA for peribiliary HCC leads to a higher rate of complications and worse long-term tumor control than for non-peribiliary HCC. KEY POINTS The application of MWA for peribiliary HCC leads to a higher rate of complications than for non-peribiliary HCC. The application of MWA for peribiliary HCC leads to worse long-term tumor control than for non-peribiliary HCC. Abbreviations: Hepatocellular carcinoma (HCC); microwave ablation (MWA); α-fetoprotein (α-FP); local tumor progression (LTP); intrahepatic distal recurrence (IDR); progression-free survival (PFS); overall survival (OS).

Postsegmentectomy for a Local Recurrence of Hilar Cholangiocarcinoma after Central Bisegmentectomy and Caudal Lobectomy

Introduction: Surgical resection is the only curative treatment for hilar cholangiocarcinoma but the possibility of local recurrence is high. The standard treatment for recurrent hilar cholangiocarcinoma after operation is chemotherapy and repeated resection is rarely performed. We herein report a rare case that re-hepatectomy was done for a local recurrence of hilar cholangiocarcinoma after central bisegmentectomy and caudal lobectomy. Methods: A report of a case. Results: A 75-year-old woman developed hilar cholangiocarcinoma and underwent extrahepatic bile duct resection with concomitant central bisegmentectomy and caudal lobectomy. The histopathological examination confirmed that R-0 resection had been achieved. After 18 months of the operation, computed tomography(CT) showed a local recurrence of the tumor in the posterior segmental branch of the intrahepatic bile duct with the portal vein invasion. The recurrent tumor was localized only in the region and we decided to operate again. The tumor was resected with the posterior segment, the portal vein and the hepaticojejunosotomy. The patient had an uncomplicated postoperative recovery and was discharged home. Conclusion: We successfully performed re-hepatectomy for a local recurrence of hilar cholangiocarcinoma. As far as we know, such a case has not been reported. In the first operation, we chose not extended right hepatectomy nor extended left hepatectomy but central bisegmentectomy and as a result, remnant liver volume was spared. As a result, she could undergo curative major hepatectomy again.

An advanced intrahepatic cholangiocarcinoma treated with minimally invasive resection: case report

: Although reports for laparoscopic liver resection (LLR) on intrahepatic cholangiocarcinoma (ICC) are increasing, its major challenges are in lymph node (LN) dissection and bile duct reconstruction. Here we present a case report of advanced ICC, who underwent combined minimally invasive surgery. A 70-year-old man with a 9.5 cm mass and bile duct dilatation on the right liver was referred to our department. The findings of endoscopic retrograde cholangiography showed obstruction of the right branch of bile duct and stenosis on hilar portion of the main duct. Combined minimally invasive surgery of LLR and LN dissection and bile duct reconstruction through a small laparotomy was performed under the diagnosis of ICC. An 8-cm caudal-cranial incision on the right upper abdomen was placed. Through the incision, LN dissection and bile duct divisions were performed. After inserting a wound protector devise with a surgical glove to the incision, trocar ports and CO2-pneumoperitonium were introduced. Transection of the liver was performed on the Rex-Cantlie line exposing inferior vena cava (IVC) and the resected right liver was removed, both laparoscopically. Bile duct reconstruction with Roux-en-Y hepatico-jejunostomy was performed through the small laparotomy. The patient recovered uneventfully. He survived for 6.5 years, with the recurrence at 4 years, after the surgery and died of the disease. We believe this is one of the choices for advanced ICC, which has needs for LN dissection and bile duct reconstruction.

Advanced stent applications of material extrusion 3D printing for palliative treatment of unresectable malignant hilar biliary obstruction

Self-expanding metal stents (SEMSs) are preferred over plastic stents (PSs) in patients with life expectancy of >3 months. However, SEMSs for biliary application can become obstructed over time due to tumor overgrowth or ingrowth. Uncovered stents used for malignant obstructions in the biliary tree, especially in the hilar area, are prone to obstruction by tumor ingrowth. In comparison, full-covered stents may block bile duct branches and are at risk of migration. Moreover, metal stents merely promote biliary drainage and have no antitumor effect. In contrast, a drug-eluting self-expandable metallic stent (DES) may provide continuous tumor control and relief of malignant obstructive jaundice. In this study, a new design of SEMS was created and fabricated as advanced stent applications of material extrusion (ME) 3D printing for palliative treatment of unresectable malignant hilar biliary obstruction according to various paclitaxel (PTX)/poly ε-caprolactone (PCL) weight ratios. As a result, PTX-containing groups had significant effectiveness for inhibiting biliary tumor growth compared with the control group. The PTX-containing groups showed a controlled drug release profile, and its safety and efficacy were verified through in vivo testing. In conclusion, a new design of SEMS would be potential for palliative treatment of unresectable malignant hilar biliary obstruction.

Cholecystohepatic duct detected during laparoscopic cholecystectomy: a case report

BackgroundThe cholecystohepatic duct is a rare form of an aberrant hepatic duct that connects to the gallbladder. Although cholecystohepatic duct is reported to be a very rare anomaly, injury of cholecystohepatic duct during cholecystectomy may result in serious complications. Herein, we present a case of cholecystohepatic duct in the ventral branch of the right posterior inferior segmental bile duct detected during laparoscopic cholecystectomy.Case presentationA 77-year-old woman with cholecystolithiasis had been referred to our hospital for surgery. Drip infusion cholecystocholangiography-computed tomography revealed a bile duct branch without communication between the intra- and extrabiliary systems, although the existence of this aberrant hepatic duct was not suspected preoperatively. A 4-port laparoscopic cholecystectomy was performed. After critical view of safety was confirmed, the cystic artery and duct were divided after double clipping. During antegrade mobilization of the gallbladder from the gallbladder bed, a thin, white cord-like material connecting the gallbladder neck and bed was detected. After clipping and dividing it, a cholecystohepatic duct injury was recognized through rechecking the results of the preoperative examinations. Biliary reconstruction was considered unnecessary because of the lesion’s small drainage area. The postoperative course was uneventful, and an enhanced computed tomography performed 6 months after the surgery revealed a dilation in the ventral branch of the right posterior inferior segmental bile duct. The patient’s liver function remained normal, and she had no symptoms of cholangitis 42 months after the surgery.ConclusionsAlthough cholecystohepatic duct is a rare anomaly compared to other aberrant hepatic ducts, surgeons performing cholecystectomy should always keep its existence in mind to avoid serious postoperative complications. Ideally, preoperative detection of cholecystohepatic duct is preferable, but even if it is detected during surgery, the appropriate management according to the drainage area is also important.

Vasoactive Intestinal Peptide Derived From Liver Mesenchymal Cells Mediates Tight Junction Assembly in Mouse Intrahepatic Bile Ducts.

Formation of intrahepatic bile ducts (IHBDs) proceeds in accordance with their microenvironment. Particularly, mesenchymal cells around portal veins regulate the differentiation and ductular morphogenesis of cholangiocytes in the developing liver; however, further studies are needed to fully understand the arrangement of IHBDs into a continuous hierarchical network. This study aims to clarify the interaction between biliary and liver mesenchymal cells during IHBD formation. To identify candidate factors contributing to this cell–cell interaction, mesenchymal cells were isolated from embryonic day 16.5 matrix metalloproteinase 14 (MMP14)‐deficient (knockout [KO]) mice livers, in which IHBD formation is retarded, and compared with those of the wild type (WT). WT mesenchymal cells significantly facilitated the formation of luminal structures comprised of hepatoblast‐derived cholangiocytes (cholangiocytic cysts), whereas MMP14‐KO mesenchymal cells failed to promote cyst formation. Comprehensive analysis revealed that expression of vasoactive intestinal peptide (VIP) was significantly suppressed in MMP14‐KO mesenchymal cells. VIP and VIP receptor 1 (VIPR1) were mainly expressed in periportal mesenchymal cells and cholangiocytic progenitors during IHBD development, respectively, in vivo. VIP/VIPR1 signaling significantly encouraged cholangiocytic cyst formation and up‐regulated tight junction protein 1, cystic fibrosis transmembrane conductance regulator, and aquaporin 1, in vitro. VIP antagonist significantly suppressed the tight junction assembly and the up‐regulation of ion/water transporters during IHBD development in vivo. In a cholestatic injury model of adult mice, exogenous VIP administration promoted the restoration of damaged tight junctions in bile ducts and improved hyperbilirubinemia. Conclusion: VIP is produced by periportal mesenchymal cells during the perinatal stage. It supports bile duct development by establishing tight junctions and up‐regulating ion/water transporters in cholangiocytes. VIP contributes to prompt recovery from cholestatic damage through the establishment of tight junctions in the bile ducts.