Common Bile Duct Lesions Research Articles

S367 Endoscopic Eversion and Stent-Assisted Strangulation for the Management of an Intraductal Papillary Neoplasm of the Bile Duct: A Minimally Invasive Technique for Non-Surgical Candidates

Introduction: Intraductal papillary neoplasms of the bile duct (IPNB) are uncommon lesions that may accompany risk for malignancy. Management is often surgical and may be associated with significant postoperative morbidity and mortality. Case Description/Methods: An 80-year-old female with a history of hepatocellular carcinoma (HCC) presented for management of jaundice and sepsis after microwave ablation of HCC. Computed tomography (CT) imaging demonstrated intra and extrahepatic biliary ductal dilation with a 19 mm soft tissue density in the distal common bile duct (CBD). Index labs depicted leukocytosis, hyperbilirubinemia, and elevated lactate. Endoscopic ultrasound (EUS) delineated a round, hypoechoic intraductal CBD lesion. The pancreas and ampulla were normal. Endoscopic retrograde cholangiopancreatography (ERCP) confirmed a distal CBD filling defect. Biliary sphincterotomy was performed and balloon sweeping revealed a frond-like partially protruding polypoid lesion suggestive of an IPNB. Due to non-surgical candidacy, we decided to perform a complete eversion with subsequent full prolapse of the lesion by using a biliary extraction balloon. This was followed by the placement of a biliary plastic stent to assist with strangulation of the base of the lesion. Biopsies were consistent with a papillary neoplasm with intestinal differentiation, confirming our findings of an IPNB, without accompanying high-grade dysplasia or carcinoma. Interval surveillance ERCP 3 months later revealed no protruding lesion from the major papilla, no residual filling defects on cholangiogram, and sweeping of the biliary tree uncovered no contents. Cholangioscopy demonstrated segmental mucosal irregularity with mild granular tissue in the mid/distal bile duct wall; however, cholangioscopy-guided intraductal biopsies and brushings showed benign reactive tissue and no recurrent IPNB. At 5 months of follow-up, the patient continues to do well. Discussion: IPNB is a rare biliary lesion. Radical surgical resection has been the mainstay of curative treatment. However, a few recent cases have described endoluminal radiofrequency ablation as an alternative therapy. To the best of our knowledge, this is the first reported case of balloon-assisted eversion combined with stent-assisted strangulation of an IPNB leading to spontaneous removal. In non-surgical candidates, this technique may be advantageous to minimize adverse operative outcomes, improve patient tolerance, and decrease cost. Watch the video at https://tinyurl.com/ACGAbstractS367

UNUSUAL CAUSE OF BILIARY OBSTRUCTION IN AN ASYMPTOMATIC PATIENT

Benign tumors arising from the extra hepatic biliary tree are very rare, and are reported to occupy 6% of all tumors of the bile ducts. In benign tumors, adenoma and papilloma are the most common ones. Adenomas of the extra hepatic biliary tree usually present clinically with features of obstructive jaundice or chronic right upper quadrant pain. Herein, we report a case of a 77-year-old woman with right lower limb weakness secondary to left subdural hemorrhage being diagnosed incidentally with extra and intrahepatic biliary obstruction secondary to distal common bile duct lesion on radiological examination. It was initially misinterpreted as a common bile duct calculus. This diagnosis was of utmost importance because of the malignant potential of these benign tumors. Our study sheds light on the common pitfall in radiological diagnosis in such case between calculus and mass lesion and how to avoid it.

Values of Contrast-Enhanced Ultrasound in Classification and Diagnosis of Common Bile Duct and Superficial Organ Lesions under Compression Algorithm.

This work aimed to investigate values of contrast-enhanced ultrasound (CEUS) under DEFLATE in the classification and diagnosis of the common bile duct and superficial lymphoid lesions. 88 patients with lower common bile duct lesions and 126 patients with superficial lymphoid lesions were selected as the subjects investigated and examined by CEUS under DEFLATE to compare characteristics and diagnostic efficiency of CEUS in different types of lesions. The time-intensity curve (TIC) was for quantitative analysis on CEUS results. The results showed that there were statistically significant differences in the comparison of time to peak (TTP), area under the curve (AUC), and gradient (Grad) of common bile duct walls in patients from the malignant group (P < 0.05), while the comparison of three indicators of patients in the benign group was not statistically remarkable (P > 0.05). In addition, there were statistically great differences in TTP, AUC, and Grad among patients in the benign and malignant groups (P < 0.05). The sensitivity, specificity, accuracy, and positive/negative predictive value of CEUS + ultrasound (US) in the diagnosis of benign and malignant lymph nodes were 92.83%, 87.14%, 89.54%, 91.23%, and 86.43%, respectively. The values of maximal intensity (Imax) in the reactive hyperplasia group (group A), lymphoma group (group B), and metastatic lymph nodes group (group C) were compared, showing statistical differences (P < 0.05). The TTP and AUC of group B were higher than those of groups A and C, respectively (P < 0.05), and the base-to-peak ascending slope (KUP) and the absolute value of the semidescending slope (KDOWN) in group C increased hugely compared to group A (P < 0.05). It indicated that CEUS examination under DEFLATE could be applied in the qualitative diagnosis of lower common bile duct lesions and superficial lymphoid lesions, which was worthy of clinical application.

Common bile duct lesions - how cholangioscopy helps rule out intraductal papillary neoplasms of the bile duct: A case report

BACKGROUNDIntraductal papillary neoplasm of the bile duct (IPNB) is a rare variant of bile duct tumors, characterized by an exophytic growth exhibiting a papillary mass within the bile duct lumen and it can be localized anywhere along the biliary tree, with morphological variations and occasional invasion.CASE SUMMARYWe present a patient with obstructive jaundice who was diagnosed with IPNB using cholangioscopy during endoscopic retrograde cholangio-pancreatography. Using the SpyGlass DS II technology, we were able to define tumor extension and obtain targeted Spy-byte biopsies. After multidisciplinary evaluation, the patient was scheduled for surgical resection of the tumor, which was radically removed.CONCLUSIONCholangioscopy appears to be crucial for the rapid and clear diagnosis of lesions in the bile duct to achieve radical surgical resection.

S1571 A Case of Cholangiocarcinoma Causing Severe Hyperlipidemia That Improved With Biliary Decompression

INTRODUCTION: Cholestasis causes disturbances to cholesterol homeostasis in the epithelium of the biliary tract and also to the composition and metabolism of plasma lipoproteins, which can manifest as hyperlipidemia. However extreme degree of hyperlipidemia with high levels of lipoprotein-X is unusual outside the setting of primary biliary cholangitis. We present a patient with cholangiocarcinoma (CCA) who was noted to have severe hyperlipidemia that resolved with biliary stenting. CASE DESCRIPTION/METHODS: A 70 year-old man with a past medical history of hypertension and diabetes mellitus presented with abdominal pain, jaundice, and pruritus. Computed tomography (CT) scan revealed severe intrahepatic biliary ductal dilatation with abrupt cut-off at the level of the common hepatic duct (CHD). In addition to markedly elevated liver tests with a total bilirubin of 26.2 mg/dL, his labs revealed severe hyperlipidemia with low-density lipoprotein (LDL) > 1600 mg/dL. The patient underwent endoscopic ultrasound (EUS)/endoscopic retrograde cholangiopancreatography (ERCP) and was found to have two distinct biliary strictures, one at the distal common bile duct (CBD) and another at the CHD, without any pancreatic mass. A plastic biliary stent was placed. Biliary brushings were positive for malignant cells and the patient was deemed fit for surgical resection based on imaging criteria. Endocrinology was consulted to optimize lipids and for consideration of plasmapheresis prior to surgery. A lipoprotein electrophoresis was sent to confirm the diagnosis. The patient subsequently underwent cardiac work-up, including stress testing, which was normal. He required an additional plastic stent placement 7 days after the initial ERCP and his lipid levels improved rapidly with biliary stenting over a span of 2 weeks. Later at exploratory laparotomy, his disease was found to be more extensive and unsuitable for complete resection. The patient is currently receiving chemotherapy and is in stable condition with plans to reassess for resection following treatment. DISCUSSION: Hyperlipidemia may occur in the setting of cholestasis and is often secondary to the accumulation of abnormal lipoprotein particles such as lipoprotein-X. Such particles are unlikely to be atherogenic and seldom require therapy other than treatment of the underlying cholestatic condition. In our case, a patient with cholangiocarcinoma had dramatic improvement in his cholesterol upon biliary decompression coinciding with a decrease in his cholestasis and pruritus.Figure 1.: CT showing ill-defined partially cystic CBD lesion, and stricture of the common hepatic duct.Figure 2.: Decrease in total bilirubin and LDL after stents placed on April 28 and May 5.Figure 3.: Cholangiogram showing biliary strictures (arrows).

Complications in pediatric laparoscopic cholecystectomy: systematic review.

Laparoscopic cholecystectomy (LC) is the gold standard for surgical management in symptomatic children, but it is not without complications, bile duct injury being among the most feared. This study reviewed the complications of LC in children. MEDLINE/PubMed, CENTRAL and Lilacs were reviewed for LC. Studies in patients ≤ 18years of age published in English, Portuguese or Spanish were selected by two independent reviewers. Data were collected for patients' characteristics, surgical information, complications, mortality and follow-up. Twenty-four papers were identified and offered 2783 patients. Mean age was 11years (3months-18years). In the 93/2783 (3.3%) complications, single-port procedures were associated with seven (7.5%), 3/4-port with 81 (87.1%) and the number of ports were not specified in five. Routine cholangiography was not part of the protocol in any of the reports. Complications included wound issues (n = 24), perforation (n = 14), bleeds (n = 13), biliary tree complications (n = 9), sickle cell crisis (n = 8), fever (n = 6), leaks (n = 4), pain (n = 3), nausea/emesis (n = 3) and others (n = 9). Two of these patients had a history of obesity and cholecystitis and only two biliary tree lesions were diagnosed intra-operatively. Seventeen cases (18.3%) required re-intervention: 15 surgical and two endoscopic. Issues related to biliary tree included: common bile duct lesion (n = 6), biliary fistula (n = 3), clip dislocation from cystic duct (n = 1), cholangitis (n = 1) and calculus (n = 1). There was no mortality, and the mean follow-up period was 10.3months (1month-5years). LC is safe in children and, although most complications are minor, almost 1/5 complications require interventions, mostly due to bleeding and biliary tree complications. Mortality has not been reported in pediatric LC.

Fundus first as the standard technique for laparoscopic cholecystectomy

In previous studies the fundus first technique (FF) has been a cost-effective way to simplify the laparoscopic cholecystectomy (LC) and facilitate patient rehabilitation. The feasibility and safety profile when introducing FF as the standard technique were aimed in this study. Between 2004–2014, 29 surgeons performed 1425 LC with FF and 320 with a conventional technique. During the first year 56% were with FF and 98% during the last four years. More females, ultrasonic shears, urgent operations, daycare operations and a shorter operation time were found with FF. 63 (3.6%) complications occurred: 10 (0.6%) bleedings, 33 (1.9%) infections and 12 (0.7%) bile leakages. Leakage from cystic duct occurred in 4/112 (3.6%) when closed with ultrasonic shears and in 4/1633 (0.2%) with clips (p 0.008). A common bile duct lesion occurred in 1/1425 (0.07%) with FF and in 3/320 (0.9%) with the conventional approach (p 0.003). In a multivariate regression model, the conventional technique was a risk factor for bile duct injury with an odds ratio of 20.8 (95% CI 1.6–259.2). In conclusion FF was effectively established as the standard procedure and associated with lower rates of bile duct injuries. Clipless closure of the cystic duct increased the rate of leakage.

1265 Endoscopic Ultrasound an Excellent Tool for Diagnosis of Early Stages of Cholangiocarcinoma

INTRODUCTION: Cholangiocarcinoma (CC) is a biliary tract malignancy with a poor prognosis and 3-year survival rate of 95%.1 Due to late onset of symptoms, patients often present with metastatic disease. Data suggest that endoscopic ultrasound (EUS) is an excellent tool to diagnose cholangiocarcinoma with a sensitivity varying from 60 to 89%.2–5 CASE DESCRIPTION/METHODS: Case 1 An 80-year-old man with a 3-week history of weight loss, jaundice, and generalized pruritus underwent both ultrasound and abdominopelvic CT scan which demonstrated dilatation of the intra and extrahepatic ducts and no masses. MR with MRCP revealed a common bile duct (CBD) measuring 18 mm and a biliary stricture at the head of the pancreas; masses were not noted in the pancreas or bile duct. He subsequently underwent EUS-guided fine needle aspiration (FNA) that revealed a 9 × 6 mm hypoechoic distal CBD lesion and normal pancreatic head; FNA cytology revealed adenocarcinoma consistent with biliary origin. Based on the EUS impression and cytology, the patient was diagnosed with T1N0M0 extrahepatic cholangiocarcinoma. Case 2 A 69-year-old male with history of weight loss, jaundice, and acholic stools was found to have several pancreatic cysts clustered together, 18 mm in conglomerate with a dilated CBD to 11 mm and no masses on MR of the abdomen. A subsequent EUS showed a normal pancreas, a 1 × 1.2 cm distal CBD lesion without evidence of invasion into the pancreatic head and a 1.2 cm peripancreatic lymph node with equivocal EUS features for malignancy. FNA cytology of lymph nodes was negative for malignancy. ERCP showed a distal CBD stricture of 2 cm suspicious for malignancy; brushings showed adenocarcinoma. EUS findings were consistent with T1N0M0 extrahepatic cholangiocarcinoma. DISCUSSION: EUS-FNA is an established, minimally invasive diagnostic modality for pancreatico-biliary tumors with high sensitivity to diagnose tumors less than 3 cm.6 EUS has demonstrated benefit in the diagnosis and staging of extrahepatic cholangiocarcinoma, as compared to other modalities such as MRI.7 While ERCP is primarily a therapeutic modality, it can also be used for diagnosis of CC via ERCP guided forceps biopsy, brush cytology or cholangioscopic biopsy.7 Our cases highlights the utility of EUS in diagnosing early stage cholangiocarcinoma, while other imaging modalities are indeterminate. The second case also illustrates how ERCP guided brush cytology complements EUS imaging in the diagnosis of T1 extrahepatic cholangiocarcinoma.

Pancreatic Cancer With Metastasis to Liver: Report of a Case

Pancreatic adenocarcinoma is a malignant neoplasm of pancreas. It is the fourth leading cause of the cancer-associated deaths in the United States with only 6% survival rate within next 5 years of diagnosis and 45% of patients diagnosed with metastatic disease. It does not cause any symptoms in the early stage, and later symptoms are nonspecific, thus the disease is usually diagnosed when already advanced. We present a case of 60-year-old male patient presented to our department with complain of pain in abdomen, anorexia, malaise, scleral icterus and weight loss since 6 months. The patient never smoked, and has no past history of alcohol or drug abuse. On physical examination patient was in good health with scleral icterus. On palpation the abdomen was soft. No costovertebral tenderness was elicited. The bowel sounds were normal. Vital Signs were HR 88/min, BP 110/70 mm Hg, RR 18/min, Temp 98.8 F. Lab investigations were Hemoglobin, 13 g/dl; White blood cell, 9,800 cells/uL; Platelet, 205,000/mm3; total bilirubin, 11 mg/dl; direct bilirubin, 7 mg/dl; ALP 255 IU/L; ALT, 100 IU/L; AST, 80 IU/L. Viral markers were negative. Tumor marker were AFP 55 ng/ml (normal 0-8.5), CEA was 4.6 ng/ml and CA 19-9 was 55,000 U/ml (normal 0-37). Ultrasonography showed a hypoechoic mass in the head of pancreas. Pancreatic Cancer was the suspected diagnosis. An abdominal CT scan was done and it showed a mass in head of pancreas. It also showed dilated intra and extrahepatic biliary tree with stenosis of common bile duct and multiple round lesions on liver. A diagnostic and therapeutic ERCP was performed and a stent was placed in the common bile duct. ERCP resulted in a failure and jaundice did not get any better. The tumor was found to be inoperable because of liver metastasis. Pathohistological diagnosis confirmed the clinical diagnosis. The patient was referred to a cancer hospital and chemotherapy was started with Gemcitabine. CT with contrast after two treatment cycles showed shrinkage of the pancreatic lesion and liver nodules. This case an example of common, late-stage diagnosis of pancreatic cancer with a compromised biliary system and metastatic liver lesions. Metastatic pancreatic cancer patients should be offered more aggressive chemotherapy options, although chemotherapy is integrated in treatment protocols of different stages of disease progression. Gemcitabine monotherapy can be used for metastatic pancreatic cancer with liver and biliary tract involvement.

Diagnosing common bile duct obstruction: comparison of image quality and diagnostic performance of three-dimensional magnetic resonance cholangiopancreatography with and without compressed sensing.

This study aimed to evaluate image quality and diagnostic performance of a recently developed navigated three-dimensional magnetic resonance cholangiopancreatography (3D-MRCP) with compressed sensing (CS) based on parallel imaging (PI) and conventional 3D-MRCP with PI only in patients with abnormal bile duct dilatation. This institutional review board-approved study included 45 consecutive patients [non-malignant common bile duct lesions (n=21) and malignant common bile duct lesions (n=24)] who underwent MRCP of the abdomen to evaluate bile duct dilatation. All patients were imaged at 3T (MR 750, GE Healthcare, Waukesha, WI) including two kinds of 3D-MRCP using 352×288 matrices with and without CS based on PI. Two radiologists independently and blindly assessed randomized images. CS acceleration reduced the acquisition time on average 5min and 6s to a total of 2min and 56s. The all CS cine image quality was significantly higher than standard cine MR image for all quantitative measurements. Diagnostic accuracy for benign and malignant lesions is statistically different between standard and CS 3D-MRCP. Total image quality and diagnostic accuracy at biliary obstruction evaluation demonstrates that CS-accelerated 3D-MRCP sequences can provide superior quality of diagnostic information in 42.5% less time. This has the potential to reduce motion-related artifacts and improve diagnostic efficacy.

Duct-to-duct Biliary Reconstruction in Living-donor Liver Transplantation for Primary Sclerosing Cholangitis: Report of a Case

Although Roux-en Y hepaticojejunostomy was previously recommended for the biliary reconstruction in liver transplantation for primary sclerosing cholangitis (PSC), some recent reports showed no difference in the graft survival between Roux-en Y and duct-to-duct anastomosis in deceased-donor liver transplantation. On the other hand, considering the risk of recurrence and the short length of the bile duct of the graft, duct-to-duct biliary anastomosis has never been reported in a patient undergoing living-donor liver transplantation (LDLT) for PSC. A 45 year-old male underwent LDLT using a left-lobe graft donated from his brother. Cholangiography showed no lesion in his common bile duct and duct-to-duct anastomosis was chosen for him. Fifteen months later, he suffered cholangitis due to PSC recurrence and endoscopic retrograde cholangiography was performed. The stents were inserted into his B2 and B3, and he remains well. Because of the ability to easily manage biliary complication, duct-to-duct biliary reconstruction may become the first choice in LDLT for PSC without common bile duct lesions.

Brachytherapy in the treatment of bile duct cancer - a tough challenge.

The majority of patients with bile duct cancer are diagnosed with clinically advanced disease. Most of these patients have a short life expectancy and are treated with palliative aim. Most patients present with locally advanced or metastatic disease, which is not amenable to surgical resection, resulting in poor survival. Adjuvant or definitive radiotherapy, with or without chemotherapy, is therefore used in many centers worldwide for better local control, and with the expectation that it will have a favorable effect on survival. However, the lack of appropriate prospective trials, as well as the small size of the published series and their retrospective nature, has produced insufficient evidence for the best treatment for these patients. Intraluminal brachytherapy is an important component in the multimodality approach to bile duct cancers. The objective of this treatment is to deliver a high local dose of radiation to the tumor while sparing surrounding healthy tissues. The treatment can be safely adapted for right and left hepatic duct, and for common bile duct lesions. Brachytherapy plays a limited but specific role in definitive treatment with curative intent in selected cases of early disease, as well as in the postoperative treatment of small residual disease. Depending on the location of the lesion, in some cases, brachytherapy is a treatment of choice. Clinical indications, different techniques, results, and complications are discussed in this work.

Endoscopic ultrasound-guided fine needle aspiration as a primary diagnostic modsality in patients with unresectable proximal biliary strictures: A large single-center study

Background:Diagnostic yield of the current available techniques in patients with upper end common bile duct (CBD) block is low; endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) may be an alternative to evaluate the upper end CBD block.Objectives:To report the outcome of EUS FNA for the evaluation of unresectable proximal biliary strictures.Setting:The study was conducted in a tertiary care center at New Delhi, India.Design:This was a prospective cohort study.Intervention:EUS FNA of unresectable proximal biliary lesion or the suspicious metastatic nodes.Outcome:Performance of EUS FNA in the evaluation of unresectable proximal biliary hilar lesions.Results:A total of 123 patients underwent EUS for the evaluation of upper end CBD block. Eighty-three patients were suspected to have unresectable upper end CBD lesion, and EUS FNA was attempted in these patients. Final diagnosis was based on positive cytology, surgical specimen, and at least 1-year follow-up. Final diagnosis was malignancy in 75 patients and benign stricture in eight patients. EUS FNA was positive for malignancy in 68 out of 75 patients, and none of the patients with benign stricture showed malignancy in FNA specimen (sensitivity 90.66%, specificity 100%, positive predictive value 100%, and negative predictive value 53.33%).Strength:Large sample size.Limitation:Inclusion of both cholangiocarcinoma and gall bladder cancer patients.Conclusion:EUS FNA is highly sensitive tool for malignant lesions involving the upper CBD; low negative predictive value suggests that negative lesions need further evaluation.

Liver Microabscesses Due to Choledocholithiasis Masquerading as Metastatic Liver Lesions

A 56 year-old man with a past medical history of HTN presented with 2.5 weeks of right upper quadrant abdominal pian and a 20lb weight loss. Reported fevers, chills, jaundice, and tea colored urine. Laboratory findings were significant for an elevated total bilirubin of 2.1 mg/dl and an alkaline phosphatase of 918 IU/L. A CT scan of the abdomen and pelvis with IV contrast showed multiple irregularly shaped hypoattenuating masses disseminated throughout the liver with the largest measuring 3.1 cm and a lamellated soft tissue mass within the common bile duct extending into the right and left intrahepatic bile ducts. A subsequent MRI showed several filling defects throughout the biliary tract with ductal dilation. An ERCP was performed which revealed large grape like gallstones filling the common bile duct. While performing cholangioscopy, the stones were fragmented using the holmium laser and removed with balloon sweeps. Brushings of the biliary tree did not reveal any evidence of malignancy. The patient was discharged on intravenous antibiotics. On subsequent follow up, the patient was asymptomatic and his liver was normal appearing on MRI, with no evidence of biliary obstruction, choledocholithiasis, or malignancy. There are 3 major etiologies for a liver abscess: pyogenic (80%), amebic (10%) and fungal (< 10%). A pyogenic liver abscess usually arises from the biliary tract due to the obstruction of bile flow. Typically, a patient will present with continuous or intermittent fever, right upper quadrant pain, weight loss, nausea and vomiting. Jaundice may be present in 25% of patients associated with biliary tract disease. A CT Scan with IV contrast remains the diagnostic modality of choice and can be used for guiding percutaneous aspiration and drainage, when needed. In this case, the patient presented with chronic intermittent fever, right upper quadrant pain, weight loss with no elevation in his white blood count. The CT scan finding of a lamellated mass in the common bile duct and multiple hypoattenuation liver lesions, gave the appearance of an intraductal cholangiocarcinoma, rather than choledocholithiasis which is a rare presentation of liver abscess masquerading malignancy. Because the liver abscesses were caused by the obstruction of bile flow from choledocholithiasis, the patient was treated with broad spectrum antibiotics and ERCP with cholangioscopy, lithotripsy, and stone extraction rather than percutaneous drainage of the liver abscesses.Figure 1Figure 2Figure 2

Value of iterative reconstruction technique combined with biliary reconstruction in diagnosis of common bile duct lesions

Value of iterative reconstruction technique combined with biliary reconstruction in diagnosis of common bile duct lesions

Minilaparoscopic cholecystectomy - the new non-visible scars technique. Preliminary report of first series.

IntroductionSurgery without scars is the dream of many patients and surgeons as well. It includes many new laparoscopic techniques (LESS, SILS, hybrid NOTES), but data concerning common bile duct (CBD) lesions are unavailable.AimTo establish the new technique of minilaparoscopic cholecystectomy (MCh): non-visible scar intervention without increasing the risk of CBD lesions.Material and methodsForty consecutive patients with symptomatic gallbladder lithiasis were qualified for elective laparoscopic cholecystectomy (LCh) using one 10/11 mm umbilical port, one 5 mm right suprapubic port and two minilaparoscopic, disposable, no-port graspers. There were 26 women and 14 men, with the mean age 56 (17–72) years and with the average body mass index 28 (18–33) kg/m2. CO2 Veress 15 mm Hg pneumoperitoneum was performed after transumbilical incision, and the first 10/11 mm port was inserted at the beginning for the 5 mm laparoscope and finally for typical instruments. Next under camera control, a 5 mm trocar was inserted in the right ‘bikini line’. To this port the laparoscope was relocated from the umbilicus, and under its control two minilaparoscopic, disposable, non-port graspers were introduced after small, 2 mm skin incisions in the right anterior axillary line and in the right mesogastrium to catch the gallbladder. Next through the umbilical port, using typical instruments, the cystic duct and artery were dissected, clipped and cut. The gallbladder was removed through the umbilical port whole.ResultsThere was no conversion to open cholecystectomy. In 5 cases drainage of the gallbladder lodge was necessary through a 5 mm port in the right bikini line. The time of the intervention ranged from 90 min during the introduction of the new method to 50 min for the last procedures. No postoperative complications were observed, and all patients were discharged at the same time as after conventional LCh.ConclusionsTwo-port laparoscopic cholecystectomy performed with two minilaparoscopic no-port graspers does not increase the risk of CBD lesions. It provides an excellent cosmetic effect and is very convenient for the surgeon like typical LCh.

An unusual presentation of a carcinoid tumor of the common bile duct.

Carcinoid tumors arising from the bile ducts account for only a small fraction of biliary tract cancers. We report herein a 42-year-old man with a carcinoid tumor of the common bile duct. He presented with abdominal pain, bloating and dyspepsia. Clinicolaboratory and imaging studies suggested a probable obstructive common bile duct lesion. The patient underwent an endoscopic retrograde cholangiopancreatography with a stent placement in view of common bile duct decompression. Persistence of symptoms prompted a laparotomy and pancreaticoduodenectomy that revealed a well-differentiated carcinoid tumor originating in the common bile duct. Clinician's familiarity with the unusual sites of origin of neuroendocrine tumors and/or atypical presentation of such tumors may facilitate their early recognition and allow for a timely intervention.

FDG PET/CT Findings of Common Bile Duct Tuberculosis

Common bile duct (CBD) tuberculosis is rare. A 39-year-old woman was referred because of a 5-month history of abdominal pain. Abdominal enhanced MRI and CT showed dilatation of the distal CBD with irregularly thickened wall. Enhanced CT revealed enlarged retroperitoneal lymph nodes. FDG PET/CT showed increased FDG uptake of the CBD lesion and several retroperitoneal lymph nodes with slight FDG uptake. CBD cholangiocarcinoma with retroperitoneal lymph node metastasis was suspected. CBD tuberculosis was confirmed by endoluminal biopsy. Tuberculosis should be considered in the differential diagnosis of abnormal biliary FDG accumulation, particularly in tuberculosis endemic areas.

The Role of Direct Peroral Cholangioscopy Using an Ultraslim Endoscope for Biliary Lesions: Indications, Limitations, and Complications

Advantages of direct peroral cholangioscopy (POC) using an ultraslim endoscope include use of conventional endoscopy equipment, operation by a single endoscopist, and superior image quality of the biliary tree with easy application of enhanced endoscopy and a large working channel. The major diagnostic indications of this system are an evaluation of biliary strictures, filling defects, or unclear findings on cholangiogram or other imaging studies. Therapeutic application using a direct POC system can be broadened by a larger working channel. However, direct POC is difficult to apply in patients with a narrow diameter bile duct, far distal common bile duct lesion, or failed anchoring of the scope with accessories. An air embolism is a rare complication of direct POC but can be a fatal problem. Cholangitis can also occur during or after the procedure. Use of a CO2 system instead of room air during the POC procedure and administration of antibiotics before and after the procedure are strongly recommended. Continuous development of specialized endoscopes and accessories is expected to facilitate the diagnostic and therapeutic roles of direct POC.

Laparoscopic cholecystectomy – review over 20 years with attention on acute cholecystitis and conversion*

BACKGROUND: The first laparoscopic cholecystectomy (LC) in Austria was performed on March 22nd, 1990 at the General Hospital Linz. As the experience increased during time the scope of contraindications has been narrowed and the rate of conversion has been decreased. However, acute cholecystitis still leads to a higher conversion rate. METHODS: We retrospectively analysed all cholecystectomies from 1990 till 2010. All acute cholecystectomies have been carried out with regard to conversion, risk factors for conversion, morbidity and mortality. RESULTS: We performed 7541 cholecystectomies. 701 (9.3%) patients had primary open cholecystectomy (OC) and 452 (6%) had concomitant CHE without further evaluation for this study. From the remaining 6139 patients with LC 1775 (male 885 [36%], female 890 [21%]) have been operated due to acute cholecystitis. 141 (7.9%, 78 male, 63 female, median age 66 years, range 20–94) of them led to conversion. The acute inflammation itself including difficulties in Calot's triangle was the most common cause for conversion (56%) followed by adhesions (19.1%). Two patients have been converted due to common bile duct lesion (1.4%) In case of acute operation and conversion the mortality was 5%, morbidity was 20%. Out of the 4364 patients with elective LC 200 had to be converted (4.6%). The overall conversion rate was 5.5%. The Reoperation rate after conversion was 6.3% (n = 9). CONCLUSIONS: Acute cholecystitis leads significantly more often to conversion as in elective LC. Male patients present at the clinic more frequent than female with acute cholecystitis, but in the acute situation the conversion rate is equal.