Common Bile Duct Stricture Research Articles

CHOLEDOCHOLITHIASIS

Objectives: To determine the frequency of choleducholethiasis in patientswith symptomatic gall stone disease and evaluation of primary closure of common bile ductwithout T-Tube placement after open exploration as a treatment modality in its management.Study Design: Prospective (descriptive) study. Setting: Surgical Unit of Postgraduate MedicalInstitute, Lady Reading Hospital, Peshawar. Period: One year from 15-03-2013 to 15-03-2014. Subjects and methods: Total 0f 206 patients of symptomatic gallstones disease wereincluded in the study to find out frequency of choledcholithias and patients with common bileduct (CBD) stones were subjected to open choledochotomy and primary choledochorrhaphy,and follow up of patients was done to find out any post operative complication. Results: Atotal of 206 patients underwent open cholecystectomy during the study period. The age ofthe patients ranged from 17 to 70 years with mean of 44.24±1.23 years. Most of the patientswith symptomatic gall stones disease were female in the age range of 41-50 years. Frequencyof choledocholethiasis was 24 out of 206 constituting 11.65%. Among the patients with CBDstones 4 were male constituting 16.6% and 20 were female that is 83.33% with male to femaleratio of 1:4 respectively. Mean hospital stay of the patients in which open CBD explorationand primary repair was performed was 7.25±1.45 days. Complications developed in only 4patients constituting 16.66%. Complications were wound infection in 2 (8.33%) patients, intraabdominalpus collection in 1 (4.16%) patient and bile leak in 1 (4.16%). One patient lost fromfollow up. In none of the patients retained CBD stones and stricture observed. Conclusions:There should be low

Predictors of success of treatment of distal two thirds common bile duct strictures: A retrospective Cohort study over two years

BackgroundDistal biliary stricture is a challenging clinical condition that requires a co-ordinated multidisciplinary approach. The aim of this workwas to evaluate the predictors of success of different treatment modalities of distal two thirds CBD strictures. Patients and methodsData were retrieved retrospectively from the medical records of the patients with distal biliary strictures treated in the Main Alexandria University Hospital from June 2013 to June 2015. Patients were classified into three groups according to the intervention performed: (endoscopic, open surgical, and percutaneous). In addition to the forth group that was followed up without intervention. ResultsThe study included 282 patients. The mean age was 61.1 ± 10.8 years (25–78) years. The most frequent presenting symptom was jaundice. Pancreatic adenocarcinoma was the most common cause followed by fibrotic stricture secondary to stones. ConclusionIn univariate analysis, the success of treatment was significantly associated with the pathology of the stricture of the distal two thirds CBD. In the multivariate analysis, only two factors were affecting the success of the treatment; the stricture length and site.

Study of laparoscopic cholecystectomy in rural hospital

Background: Laparoscopic cholecystectomy is the preferred mode of treatment for gall stone diseases. This study is the audit of 125 laparoscopic cholecystectomy done in our institute between year 2013 to year 2014. In laparoscopic cholecystectomy common bile duct injuries were more common than open surgery. Objective of this study is to find out intra and postoperative complications in laparoscopic cholecystectomy and to find the reasons for conversion to open cholecystectomy. Methods: This is the retrospective study of standard four port laparoscopic cholecystectomy done during year 2013 to year 2014 in our institute. The result and complications of laparoscopic surgery were documented in audit form for each laparoscopic cholecystectomy and at the end the results are analyzed. Results: There were no common bile duct injury in our study of 125 cases and we had 5.6% conversion to open cholecystectomy due to various reasons discussed in the paper. There were no cases of postoperative abdominal abscess, port site hernia, common bile duct stricture or mortality in our study. One patient with cystic duct leak was managed successfully with post-operative endoscopic spincterotomy and stenting of common bile duct. Conclusions: Laparoscopic cholecystectomy as treatment of choice is associated with high success rate at our institute with added benefits of minimal invasive surgery. Our results are comparable to international standards. Critical view of safety is an essential prerequisite for prevention of bile duct injuries.

Results of Medium Seventeen Years' Follow-Up after Laparoscopic Choledochotomy for Ductal Stones.

Introduction. In a previously published article the authors reported the long-term follow-up results in 138 consecutive patients with gallstones and common bile duct (CBD) stones who underwent laparoscopic transverse choledochotomy (TC) with T-tube biliary drainage and laparoscopic cholecystectomy (LC). Aim of this study is to evaluate the results at up to 23 years of follow-up in the same series. Methods. One hundred twenty-one patients are the object of the present study. Patients were evaluated by clinical visit, blood assay, and abdominal ultrasound. Symptomatic patients underwent cholangio-MRI, followed by endoscopic retrograde cholangiopancreatography (ERCP) as required. Results. Out of 121 patients, 61 elderly patients died from unrelated causes. Fourteen patients were lost to follow-up. In the 46 remaining patients, ductal stone recurrence occurred in one case (2,1%) successfully managed by ERCP with endoscopic sphincterotomy. At a mean follow-up of 17.1 years no other patients showed signs of bile stasis and no patient showed any imaging evidence of CBD stricture at the site of choledochotomy. Conclusions. Laparoscopic transverse choledochotomy with routine T-tube biliary drainage during LC has proven to be safe and effective at up to 23 years of follow-up, with no evidence of CBD stricture when the procedure is performed with a correct technique.

The efficacy of endoscopic endosonography in diagnosis of benign and malignant stenoses of common bile duct

To define criteria and to estimate diagnostic significance of endosonography in differential diagnosis of benign and malignant stenoses of common bile duct. We presented the results of survey and treatment of 57 patients with benign and malignant stenoses of common bile duct. The technique of endosonography is described. We have formulated major criteria of differential diagnostics of tumoral and non-tumoral lesion of extrahepatic bile ducts. Comparative analysis of endosonography, ultrasound, computed tomography and magnetic resonance cholangiopancreatography was performed. Sensitivity, specificity and accuracy of endosonography in diagnosis of stenosis cause is 97.7%, 100% and 98.2% respectively. So it exceeds the efficacy of other diagnostic X-ray methods. In modern surgical clinic endosonography should be mandatory performed. It is necessary for final diagnostics of cause of common bile duct stenosis especially in case of its low location.

Idiopathic fibrosing pancreatitis associated with ulcerative colitis.

Idiopathic fibrosing pancreatitis has been associated with Sjögren's syndrome, primary biliary cirrhosis and primary sclerosing cholangitis. This condition frequently develops in childhood and youth, and has also been related to ulcerative colitis and pericholangitis. Pancreatic complications have been rarely described as systemic complications of ulcerative colitis. A 25-year-old man presented with epigastric pain and jaundice. Abdominal ultrasonography, computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) revealed a diffuse enlargement of the pancreas, filiform distal stenosis of the common bile duct and intrahepatic bile ducts, and pancreatic duct dilatation. At operation, a rock-hard and nodular pancreas was noted. Cholecystectomy and Roux-en-Y hepaticojejunostomy, with an access loop, was successfully performed. Idiopathic fibrosing pancreatitis should be considered in young patients with obstructive jaundice, especially those affected with chronic inflammatory or autoimmune diseases. Glucocorticoid therapy would be the first-line treatment, although many patients require operation.

Primary diffuse large B cell lymphoma of the common bile duct causing obstructive jaundice

We report a rare case of a diffuse large B-cell lymphoma (DLBCL) arising from the common bile duct (CBD). A 77-year old man presented with general fatigue and obstructive jaundice. Abdominal computed tomography revealed a well-circumscribed enhancing mass in the midportion of the CBD with proximal bile duct dilatation. Endoscopic retrograde cholangiopancreatography (ERCP) also showed a midportion of the CBD stricture. Direct peroral cholangioscopy revealed smooth mass in the midportion of the CBD, and narrow-band imaging (NBI) showed irregular tortuous microvessels. The brushing cytology of the CBD was performed, and it was diagnosed as suspicious for poorly differentiated adenocarcinoma or malignant lymphoma. We performed extrahepatic bile duct resection for accurate diagnosis. Histological and immunohistochemical examination of the resected specimen revealed DLBCL. Although systemic chemotherapy is the mainstay of treatment for DLBCL, he refused scheduled subsequent chemotherapy, and died of multiple liver metastases 6months after surgery.

Endoscopic Ultrasound-Guided Biliary Drainage: A Systematic Review and Meta-Analysis.

Variable success and adverse event rates have been reported for endoscopic ultrasound-guided biliary drainage (EUS-BD) utilizing either extrahepatic or intrahepatic approach. We aimed to conduct a proportion meta-analysis to evaluate the cumulative efficacy and safety of EUS-BD and to compare the two approaches and transluminal methods of EUS-BD. We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, ISI Web of Science, and Scopus from January 2001 through January 5, 2015, to identify studies reporting technical success and adverse events of EUS-BD. A sample size of more than 20 patients was a further criterion. Weighted pooled rate (WPR) for technical success and post-procedure complications was calculated for overall studies and predefined subgroups. Pooled odds ratios were calculated for technical success and adverse events for two approaches and transluminal methods of EUS-BD for distal common bile duct (CBD) strictures. The WPR with 95% confidence interval (CI) for technical success and post-procedure adverse events was 90% (86, 93%) and 17% (13, 22%), respectively, with considerable heterogeneity (I(2) = 77%). For high-quality studies, the WPR for technical success was 94% (91, 96 %), I(2) = 0% and WPR for post-procedure adverse event was 16% (12, 19%), I(2) = 39%. In meta-regression model, distal CBD stricture and transpapillary drainage were associated with higher technical success and intrahepatic access route was associated with higher adverse event rate. There was no difference in technical success using either approach OR 1.27 (0.52, 3.13), I(2) = 0% or transluminal method OR 1.32 (0.51, 3.38), I(2) = 0%. However, the extrahepatic approach appeared significantly safer as compared to the intrahepatic approach OR 0.35 (0.19, 0.67), I(2) = 27%. Likewise, choledochoduodenostomy was found to have less adverse events as compared to hepaticogastrostomy, OR 0.40 (0.18, 0.87), I (2) = 0%. In cases of failure of traditional ERC to achieve biliary drainage, EUS-BD appears to be an emerging therapeutic modality with a cumulative success rate of 90% and cumulative adverse events rate of 17%. Randomized controlled trials are required to further evaluate the efficacy and safety of the procedure along with the comparison to traditional modalities like percutaneous transhepatic biliary drainage.

Two Cases of a Unique Variant of Duplicated Extrahepatic Bile Ducts With Coexistence of Distal Klatskin Tumor Surgically Treated by Whipple Procedure and Hepaticojejunostomy

Duplication of the extrahepatic bile duct (DEHBD) is a rare anomalous of the biliary system. Here we report two unique cases of DEHBD coexistent with hilar cholangiocarcinoma (Klatskin tumor). The two cases were diagnosed preoperatively and treated with a modified surgical technique. Case 1: A 77-year-old female presented with obstructive jaundice. Abdominal computed tomography (CT) scan revealed diffuse bile duct dilatation (BDD). Magnetic resonance cholangiopancreatography (MRCP) showed diffuse BDD, stone in the extrahepatic duct with distal common bile duct (CBD) stricture. Endoscopic retrograde cholangiopancreatography (ERCP) was attempted at other hospital and reported diffuse BDD. The procedure was aborted due to suspected contrast extravasation and the patient was transferred to our facility for further evaluation. Repeated ERCP revealed EHBDD with single biliary drainage to the duodenum (Fig. 1A). Findings were consistent with type Va EHBDD (Fig. 2). Brushing cytology was done. Rapid on-site evaluation (ROSE) by cytopathologist was suggestive of cholangiocarcinoma.Figure 1Figure 2Case 2: A 78-year-old female presented with obstructive jaundice for one month. Abdominal CT showed diffuse BDD. MRCP showed diffuse BDD to the level below CD take off. The patient had ERCP at other facility that showed distal CBD stricture. The stricture was dilated and stented with a 10 French x 5 cm PS. Brush cytology was negative. Patient's jaundice persisted; so she was referred to our institution for further evaluation. Endoscopic ultrasound showed hypoechoic and well-demarcated mass of 21.3x17.2 mm at the neck of pancreas. Fine needle aspiration was done and ROSE by cytopathologist was suggetive of cholangiocarcinoma. Old stent was removed. ERCP was repeated and showed type Va EHBDD(Fig. 1C). The biliary hilum was obstructed by the mass mimicking Klatskin tumor (Fig. 1C). In both cases, biliary strictures were dilated and stented with 2 plastic stents placed up to the right and left main extrahepatic bile ducts (Fig. 1B&D). Both patients were referred for pylorus-preserving Whipple surgery with hepaticojejunostomy. Intra-operative evaluation and surgical pathology confirmed the diagnosis of type Va EHBDD with cholangiocarcinoma involving a distally located biliary hilum (Klatskin tumor) (Fig. 3A&B).Figure 3Preoperative diagnosis of type V EHBDD coexistent with distal hilar cholangiocarcinoma (Klatskin tumor) is challenging and necessitates surgical approach modification. Instead of major hepatic resection or traditional Whipple procedure; Whipple procedure with hepaticojejunostomy was used to manage those potentially resectable Klatskin tumors in the setting of this anomaly.

A Case of Cholangiocarcinoma Diagnosed by Skin Biopsy

A 72-year-old man presented to an outside hospital with abdominal pain, jaundice, and a 30 lb weight loss. CT showed choledocholithiasis and suspected cholecystitis. He underwent endoscopic retrograde cholangiopancreatography (ERCP) which revealed stones in the common bile duct (CBD). Sphincterotomy and stone extraction with stent placement was performed. A laparoscopic cholecystectomy was done, revealing a hydropic gallbladder (GB) that was pierced open, suctioned and subsequently removed in an endobag. A JP drain was left in the GB bed and pulled through a port site. The patient's jaundice did not improve and he was transferred to another facility where endoscopic ultrasound demonstrated a hilar mass with an associated CBD stricture. An ERCP with brush and biopsy of the CBD stricture was also done, and cytology returned showing only atypia. Both procedures were repeated two weeks later and results were again negative. In the interim, the patient underwent skin biopsy of an enlarging subcutaneous nodule located at a previous surgical port site and the results returned as metastatic adenocarcinoma. A GI pathologist re-examined the GB specimen obtained during the laparoscopic cholecystectomy and noted that there was evidence of cholangiocarcinoma (CCA) within the GB wall. CCA carries a dismal prognosis when detected in an advanced stage and early diagnosis is a challenge. The prevalence of incidental GB carcinoma is between 1% and 2% of all cholecystectomies performed with some studies reporting an incidence as high as 7.4%. Removal of unsuspected GB carcinoma laparoscopically can lead to seeding of tumor cells into the abdominal wall. Incidence of port site recurrence after laparoscopic cholecystectomy for unsuspected GB cancer can be as high as 14%. Intraoperative GB perforation can raise this rate of recurrence to 40%. Recurrences usually occur 6 to 16 months after the operation as was seen in this case. There are several proposed mechanisms of port site recurrence, the most popular of which include: direct wound contamination from laparoscopic instruments; the bile itself containing exfoliated tumor cells which can spread with bile spillage; and also, whether insufflation of the peritoneum can enhance wound metastases. In this case, JP drain placement along with GB perforation may also have been a route of seeding. Physicians should be aware of the risk of tumor seeding when CCA is a possibility in order to avoid the acceleration of metastatic disease.

Colon Cancer Metastatic to Biliary Duct

Metastasis of adenocarcinoma of the colon is commonly found in the lung, liver, or peritoneum. There are reports of tumors of the common bile duct (CBD) related to adenomas from Familial Adenomatous Polyposis and various organs metastasizing from outside of the gastrointestinal tract. We report a case of biliary colic due to metastatic adenocarcinoma of the colon to the CBD. A 57-year-old man with a history of metastatic rectosigmoid adenocarcinoma presented for evaluation of abdominal pain. He was diagnosed with rectosigmoid cancer in 2011 and had a lower anterior resection without chemotherapy or radiation. In 2013, he had local recurrence with metastasis to the liver. At that time he underwent several cycles of chemotherapy. At time of presentation, he was having pain associated with food intake for three weeks, which led to 30-pound weight loss. He had associated jaundice and was otherwise negative review of systems. On admission, liver function tests showed AST 115, ALT 51, alkaline phosphatase 714, and total bilirubin 2.0. Right upper quadrant ultrasound and showed gall bladder wall thickening with likely sludge and common bile duct 1cm. Computed Tomography of abdomen and pelvis showed probable pericholecystic sludge and a distended gallbladder as well as progression of liver metastasis. A pre-cholecystectomy endoscopic retrograde cholangiopancreatography (ERCP) revealed a main bile duct stricture and gallstones with sludge. A sphincterotomy was performed and stones were removed with retrieval balloon. Brush cytology and biopsies using cholangioscopy were obtained. Surgical pathology showed moderatelydiff erentiated adenocarcinoma consistent with colonic origin. One week later, a repeat ERCP was performed. Contrast was injected into the entire biliary tree, which showed a 4cm CBD stricture with proximal dilation. A 10mm, 6cm uncovered metal stent was placed. He was seen by oncology and resumed chemotherapy regimen. Usually, colon cancer metastasizes to the liver, which causes intrahepatic biliary tree obstruction and jaundice. Some patients have been identified to have extra-hepatic biliary obstruction caused by adenocarcinoma metastasis to lymph nodes adjacent to biliary structures. Obstructive jaundice with signs of acalculous cholecystitis on imaging in a patient with a history of colon cancer should raise suspicion for metastasis to CBD.Figure 1Figure 2

Post-ERCP pancreatitis and its related factors: A prospective study in Cipto Mangunkusumo National General Hospital

Abstract Objectives: Endoscopic retrograde cholangiopancreatography (ERCP) is a widely used procedure for the diagnosis and treatment of pancreatobiliary disease with post-ERCP pancreatitis (PEP) is the most common complication. The goal of this study was to comprehensively evaluate the potential patient- and procedure-related risk factors for PEP. Methods: A 25-variable database was compiled from information collected before, during, and 24-72 h after ERCP for 238 patients who underwent diagnostic or therapeutic ERCP in Cipto Mangunkusumo General National Hospital, Jakarta. The grading of acute pancreatitis was classified using the modified Glasgow (Imrie′s) severity criteria. Results: The average age was 51 years, and most patients were men and were overweight. Sixty-three patients (26.5%) were diagnosed with PEP, and 33 of these (52.4%) were classified as having severe pancreatitis. We applied univariate analysis to analyze the data contained in the 25-variable database to identify patient- and procedure-related predictors of PEP. We found significant correlations between PEP and the patient-related factor common bile duct stenosis (P < 0.05), and between PEP and the three procedure-related factors procedure time, cannulation time, and multiple cannulation attempts (P < 0.05). Multivariate analysis showed that multiple attempts at cannulations was the only significant risk factor for PEP. Conclusions: In our study, four variables were associated with PEP: Common bile duct stenosis, procedure time, cannulation time, and multiple attempts at cannulations. We conclude that, in patients undergoing ERCP who are at high risk of PEP, procedure-related factors should be monitored to reduce the risk of PEP. Multiple attempts at cannulation was the most significant risk factor in our study.

A Case of IgG4-Related Disease: A Unique Presentation of a Rare Entity

IgG4-related disease is a rare, systemic fibroinflammatory condition characterized by lymphoplasmacytic infiltrates and often times elevated serum IgG4 levels. Multiple organs are implicated in the disease and although the pathogenesis is not entirely understood, genetic risk factors and autoimmune dysregulation have been associated. Pathology from biopsied lesions is varied and can range from a dense lymphoplasmacytic infiltrate to fibrosis. Currently, there are limited reports of IgG4-related disease in the literature. A 69 year-old female with a past medical history significant for salivary gland tumor (s/p resection and radiation), rheumatoid arthritis (on Methotrexate), alcohol use (2-3 glasses of wine for several years) presented to hepatology clinic for evaluation of elevated liver function tests noted on routine blood work. ALP was 367 IU/L, ALT 162 IU/L and AST 67 IU/L. CA 19-9 was also elevated to 45 U/mL, however MRI and EUS were unremarkable. Liver biopsy showed portal fibrosis, lymphocytic, neutrophilic and eosinophilic portal and lobular hepatitis with bile ductular proliferation. After an unrevealing extensive workup for other causes of abnormal liver tests, it was thought the abnormal tests and biopsy finding may be secondary to ethanol abuse and methotrexate. Over the subsequent year, the patient continued to have elevated liver function tests, a thirty-five pound weight loss, jaundice and pruritus. MRI of the abdomen revealed an infiltrating peri-choledochal, peripancreatic, porta hepatic and retroperitoneal soft tissue mass, narrowing the common bile duct and multiple enlarged retroperitoneal and pericardial lymph nodes. EUS showed an irregular, 2.3 x 2.3 cm, poorly defined area within the region of the head of the pancreas, dilation of the pancreatic duct and distal common bile duct stricture. Biopsies were not performed, and cytology from FNA revealed only benign pancreatic acini. IgG4 levels were ordered to evaluate for IgG4 related autoimmune pancreatitis/sclerosing cholangitis and were elevated to 125 mg/dL. Given the elevated IgG4, and multiple organ dysfunction, a presumed diagnosis of IgG4-related disease was made. Although glucocorticosteroids are the mainstay of therapy, the patient has not since returned to clinic. IgG4-related disease is a rare yet potentially treatable entity that can mimic primary organ disease or malignancy, yet should always remain in the differential diagnosis. Close follow up and cognizance of this disease entity is critical as a lag in treatment can have significant implications.

Isolated Duodenal Varices Without Cirrhosis

A 61-year-old man with a remote history of idiopathic necrotizing pancreatitis complicated by need for multiple pancreatic necrosectomies and ultimately Roux-en-Y reconstruction presented with one day of epigastric pain radiating to the back and chills. He denied any recent trauma, alcohol ingestion, new medications, change in bowel habits, chest pain, palpitations, or dyspnea. On examination, vital signs were significant for a low-grade temperature of 37.6°C. He appeared in to be moderate distress secondary to acute abdominal pain which was worsened with palpitation. Physical exam revealed no stigmata of cirrhotic liver disease. Serum laboratory tests were notable for aspartate aminotransferase 99 U/L, alkaline phosphatase 570 U/L, bilirubin 0.5 mg/dL, and leukocyte count of 21.1x109/L; serum albumin and international normalized ratio were both normal. Computed tomography (CT) did not demonstrate any acute abdominal findings other than mild biliary ductal dilatation. Blood cultures revealed gram negative bacteremia, which in the context of the patient's history of pancreatobiliary disease and his current presentation, prompted referral for endoscopic retrograde cholangiopancreatography. During ERCP, gross pyobilia and a distal common bile duct stricture were found, necessitating biliary balloon dilation, sweeping, and stent placement. In addition, and intriguingly, there was an incidental finding of extensive and nearly circumferential isolated duodenal varices (IDVs; see Figure 1). On review of the patient's contrast-enhanced CT imaging, there was no evidence of cirrhosis or other varices (e.g. esophageal). In addition, abdominal ultrasound demonstrated normal hepatopedal flow in the portal vein. The patient was placed on a non-cardioselective beta blocker for variceal prophylaxis and was doing well at last follow-up six months later.Figure 1Discussion: IDVs are a rare manifestation of portal hypertension whose precise incidence and prevalence remain uncertain. Representing approximately 15% of all ectopic varices, duodenal varices may be subclinical or can present with acute hemorrhage with hematemesis and/or hematochezia and mortality rates approaching 40% per episode. IDVs are typically secondary to cirrhosis-associated portal hypertension, whereas here we report a case of cryptogenic IDVs which were likely consequent to extensive intra-abdominal surgeries resulting in impaired superior mesenteric venous outflow and development of noncirrhotic portal hypertension.

Clinical Vignettes/Case Reports - Biliary/Pancreas.

Groove pancreatitis is a rare type of segmental pancreatitis that can mimic the effects of a mass leading to gastric outlet obstruction. The clinical manifestations as well as the radiographic appearance make this entity a diagnostic challenge. A 61 year old male with a history of heavy alcohol use and multiple admissions for chronic pancreatitis presented with a four day history of nausea and vomiting. Nine months earlier he had been evaluated by his primary care doctor for a one month history of progressive jaundice. Initial workup was notable for a cholestatic elevation in liver enzymes and a direct bilirubinemia. MRCP suggested distal common bile duct stricture. ERCP confirmed this finding and suggested possible cholangiocarcinoma or pancreatic adenocarcinoma. Tumor markers including CA 19-9 and CEA were normal. A biliary stent was placed and jaundice resolved. Subsequent ERCP to exchange the stent revealed chronic calcified pancreatitis and adenopathy in the peripancreatic and porta-hepatis areas with persistent distal common bile duct stricture. Biopsies were taken from the pancreatic head which were suggestive of chronic pancreatitis but were negative for malignant cells. On admission, lab values were consistent with a severe metabolic alkalosis and a cholestatic pattern of hepatic enzyme elevations. Abdominal CT with oral contrast revealed partial gastric outlet obstruction. A nasogastric tube was placed to decompress the stomach. Repeat MRCP was notable for gastric outlet obstruction and a pancreatic head mass involving the second portion of the duodenum. Repeat ERCP showed partial obstruction in the duodenal cap with edematous folds. Biopsies were again taken from the pancreatic head, which were negative for malignancy. The patient underwent PEJ placement for nutrition and placement of a venting PEG tube for oral liquid intake. The patient was started on prednisone 40mg daily to reduce pancreatic inflammation and discharged. He was readmitted five days later with biliary sepsis, and severe gastric outlet obstruction. He was medically managed with antibiotics and hydration and subsequently transferred to the surgical service where he underwent gastrojejunostomy. At three month follow up he reported feeling well, resolved nasuea, and weight gain. A rare condition in the US, groove pancreatitis is associated with male gender and alcohol abuse. Pathogenesis likely involves increased viscocity of pancreatic secretions from alcohol use in susceptible patients, leading to stasis. inflammation, and obstruction of the minor papilla. Case series describing this condition suggest that definitive treatment is pancreatoduodenectomy, however this case demonstrates that pancreatic sparing surgical approaches may be feasible.Figure 1Figure 2Figure 2

A Case Report of IgG4-Related Autoimmune Cholangitis

Introduction: Autoimmune cholangitis is a biliary manifestation of IgG4 related disease (IgG4-RD) which can affect many organs and only rarely occurs in the absence of autoimmune pancreatitis. We present a case of IgG4 related cholangitis and discuss differential diagnosis and the role of clinical, laboratory and radiologic findings in establishing the diagnosis. Methods: N/A. Results: A 66 year old man was sent to the ED from his gastroenterologist's office for 3 weeks of jaundice, lower abdominal cramping, pale yellow stools 3-4 times daily, and dark orange urine. An outpatient abdominal ultrasound showed biliary obstruction and diffuse thickening of the common duct. In the ED, the patient appeared jaundiced but hemodynamically stable. Laboratory studies showed total bilirubin 11, direct bilirubin 8.9, AST 60, ALT 45, ALKP 265, amylase 65, and lipase 278. MRCP showed proximal and distal common bile duct strictures with intrahepatic and common duct dilation, circumferential biliary hyperenhancement, and bilateral striated heterogeneous nephrograms. The combination of these findings suggested the possibility of autoimmune cholangitis. ERCP was not initially performed due the location of the more proximal stricture and the possible risk of bacterial seeding of an obstructed biliary system. IgG4 levels were drawn and the patient was discharged on prednisone 40mg daily. Total IgG level and IgG4 returned elevated at 2641 and 459, respectively. Antinuclear antibody and anti-smooth muscle antibody were negative. After 2 weeks of steroid therapy, total bilirubin decreased to 2.4. Conclusion: IgG4 associated cholangitis was first described in the literature in 1995 and since then, there have been only a few case reports. IAC can further be classified into type 1 or 2; type 1 stenosis is exclusively located in the distal CBD, whereas type 2 stenosis is affects intra- and extrahepatic bile ducts. Diagnosis of biliary strictures with painless jaundice is also concerning for cholangiocarcinoma and pancreatic neoplasm, and these should be ruled out in the process of working up for an autoimmune cause. Steroid therapy is the initial treatment modality and many patients have good response. Changes in LFTs are best seen 5 and 10 days after therapy initiation and earlier initiation of therapy reduces risk of biliary cirrhosis. This case highlights the importance of laboratory and radiologic data in obtaining an accurate diagnosis.

Clinical observation of therapeutic endoscopic retrograde cholangiopancreatography in 1482 cases

Objective To analyze the clinical observation and incidences of complications of therapeutic postendoscopic retrograde cholangiopancreatography(ERCP). Methods The clinical information of 1 482 cases of therapeutic ERCP was analyzed retrospectively. Results Among them,468 cases had nasal biliary drainage,532 cases had pancreatic or bile duct stent after endoscopic procedure and the other 482 case hadn't.For the drainage group,there were 396 cases of biliary stone,36 cases of simple dilatation of common bile duct,8 cases of biliary cyst,6 cases of strictured papilla,18 cases of inflammatory stricture of common bile duct,2 cases of sclerosing cholangitis and 2 cases of autoimmune pancreatitis. For the pancreatic or bile duct stent group, there were 483 cases of malignant biliary obstruction,13 cases of biliary stone,28 cases of pancreatic duct stone,3 cases of sclerosing cholangitis and 5 cases of inflammatory stricture of common bile duct.And there were 385 cases of biliary stone,36 cases of simple dilatation of common bile duct,38 cases of inflammatory stricture of common bile duct,11 cases of strictured papilla,9 cases of pancreatic duct stone and 3 cases of biliary cyst for un-drainage group.The incidences of acute pancreatitis and acute cholangitis(4.4%,2.6%)were higher in un-drainage group than the nasal biliary drainage group(1.5%,0.6%,P 0.05)and the stent group(0.4%,0.8%,P>0.05). The incidences of 4 kinds of complications were not significantly different between the nasal biliary drainage group and the stent group. Conclusion Endoscopic nasal biliary drainage or stent can prevent and treat some of therapeutic ERCP complications effectively. Key words: Endoscopic retiograde cholangiopancreatgraphy; Nasal biliary drainage; Pancreatic or bile duct stent; Complication; Prevent and treat

Eleven years of primary closure of common bile duct after choledochotomy for choledocholithiasis.

The choice of surgical technique to extract stones from the common bile duct (CBD) depends on local experience, anatomical characteristics and also on the size, location and number of stones. Most authors consider choledochotomy an alternative to failed transcystic exploration, although some use it exclusively. Although the CBD is traditionally closed with T-tube drainage after choledochotomy, its use is associated with 11.3-27.5% morbidity. This study examined the efficacy of laparoscopic CBD exploration (LCBDE) with primary closure for the treatment of CBD stones using intraoperative cholangiography (IOC). Retrospective study of 160 patients who underwent LCBDE with primary closure after choledochotomy between January 2001 and December 2012. The diagnosis of choledocholithiasis was definitively made in all cases by IOC. The overall complication rate was 15% and the biliary complication rate was 7.5%. Bile leakage was reported in 11 patients (6.8%). In over half the cases (63.6%), no further action was required and the leak closed spontaneously. Six patients were reoperated (3.75%), two for bile peritonitis and four for haemoperitoneum. The success rate for stone clearance was 96.2%. The mortality rate and CBD stricture rate were 0%. Primary closure after choledochotomy to clear stones from the CBD is a safe technique that confers excellent results and allows one-stage treatment.

Drainage of a Pancreatic Pseudocyst via a Spontaneous Cyst Duodenostomy

51-year-old woman presented with 5 days of Aacute-onset severe epigastric and right upperquadrant pain associated with nausea and vomiting. Laboratory test results showed obstructive jaundice and acute pancreatitis. An abdominal ultrasound showed multiple stones within the gallbladder and a dilated common bile duct (CBD). A computed tomography (CT) scan showed evidence of severe necrotizing pancreatitis and the patient was started on intravenous fluids and antibiotics. Three days later, as a result of progressive obstructive jaundice and possible cholangitis, an endoscopic retrograde cholangiopancreatography was performed that showed a distal CBD stricture. Complete ductal clearance of stones could not be achieved and a plastic stent was placed. Symptoms improved and she was discharged home for elective cholecystectomy. Ten weeks later she returned with fevers, chills, and severe abdominal pain. The gallbladder and biliary stent were in place and liver function test results were normal. A CT scan of the abdomen now showed a 15 12.5 cm pancreatic pseudocyst (Figure A). Endoscopic cyst-gastrostomy was attempted 1 day after the CT scan. An esophagogastroduodenoscopy showed a large opening within the duodenal bulb leading into the pseudocyst cavity (Figure B). Minimal fluid was seen within the pseudocyst cavity along with trace amounts of adherent debris along the walls (Figure B). Endoscopic ultrasound confirmed a partially drained cystic collection. She returned 11 weeks later for endoscopic retrograde cholangiopancreatography, stent removal, and clearing of the CBD stones. The cyst-duodenostomy appeared well healed without evidence of a residual cyst cavity (Figure C); this was confirmed on CT scan (Figure D).

Operative management of hepatic artery aneurysms

Degenerative hepatic artery aneurysms (HAAs) are an uncommon pathologic process. The aim of this study was to evaluate the approach to and outcomes of operative management of HAA with open techniques (OTs) and endovascular techniques (ETs). Twenty-one patients who underwent intervention for HAA from January 1, 1992, to January 30, 2015, at a single institution were retrospectively reviewed. Patient presentation, risk factors, and operative approach were reviewed. The primary outcome was operative morbidity and mortality. Secondary outcomes included long-term survival, patency, and need for reintervention. Of the 21 patients, 14 (67%) were men. The mean age of all patients was 66 years (range, 30-85 years), with a mean HAA size of 45 ± 28 mm (12 common hepatic, 5 common and proper hepatic, 3 right hepatic, and 1 accessory left hepatic). Nine patients (43%) had connective tissue disorders. More than half of the patients (63%) had synchronous aneurysms (29% in the aorta, 24% in the splenic and iliac arteries, and 10% in the celiac arteries). Ten patients (48%) were asymptomatic. Right upper quadrant pain was the most common symptom at presentation (43%), followed by transaminitis (5%) and obstructive jaundice (5%). Five patients (24%) presented with rupture (size, 15-40 mm). OT was performed in 17 patients; 4 patients had ET. Fourteen patients (67%) underwent open reconstruction of the common hepatic (n = 10), the common and proper hepatic (n = 2), and the right and left accessory hepatic arteries (n = 1 each). Seven bypasses were performed with saphenous vein, six with Dacron, and one with polytetrafluoroethylene. Endoaneurysmorrhaphy alone, patch, and ligation were performed in one instance each. Postoperative complications occurred in six patients (29%), including hemorrhage, graft thrombosis, common bile duct stricture that required reoperation, duodenal perforation, and enterocutaneous fistula. ET was attempted in five patients; coil embolization was performed in four patients (two of the common and two of the right hepatic arteries). Overall mortality was 14% (6% after elective OT, 40% for emergency OT, 0% for ET). Mean follow-up was 32 ± 46 months. Overall survival was 86% at 5 years. Primary and secondary graft patency was 86% at 5 years. One patient underwent reintervention because of occlusion of saphenous vein graft. Open repair remains the mainstay treatment for degenerative HAA repairs to preserve arterial flow to the liver, with notable morbidity and mortality, particularly in the setting of rupture. However, coil embolization may be applied safely in select patients with aneurysms not involving the proper hepatic artery if adequate collateral circulation ensures hepatic perfusion.