Common Hepatic Bile Duct Research Articles

Morphological expression of the extrahepatic bile duct. A study in a sample of Colombian mestizo population


 Background: The great variability of the extrahepatic bile duct (EBD) has clinical-surgical implications. The objective of this study was to characterize the morphological expressions of EBD.
 Methods and findings
 This descriptive study, done by injecting a semi-synthetic (Palatal GP40L 85%; styrene 15%) impregnated with mineral green dye into the gallbladder, to determine the anatomical characteristics and the biometrics of EBD in 33 blocks formed from the supra-mesocolic floor.The gallbladder presented a length of 66.9 ± 1.7 mm. The Hartmann´s Pouch was observed in 16 specimens (50%). The lengths of the cystic duct (CD), common hepatic duct (CHD) and common bile duct (choledoch duct) were 27.8 ± 1.6 mm, 28.6 ± 11.39 mm and 60.6 ± 11.6 mm respectively.
 The presence of accessory hepatic ducts (AHD) was found in three samples (9.1%). In 29 specimens (87.9%) the cystic duct presented medium length, while in 4 cases (12.1%) the CD was long (P < 0, 05). The trajectory of the lateral oblique of CD was present in 23 cases (69.7%), with statistically significant differences in relation to the other trajectories of the CD (P <0, 05). In 18 samples (55%) the cystic-hepatic union appeared at the level of the middle third of the EBD, while in 15 (45%) cases the union of the CD was low (P<0,05).
 Conclusions
 The mathematical distribution of the segments of the EBD, carried out in this study, provides reliability to the assessment of the cystic-hepatic junction level. The presence of CHA and the level of the cysto-hepatic junction are important anatomical references, especially in emergency room procedures.

Fluorescence cholangiography for the evaluation of extrahepatic bile ducts patency. The first experience

The aim — to study the possibility of fluorescent cholangiography application to assess extrahepatic bile ducts patency.Materials and methods. The results of the fluorescent cholangiography for evaluation of extrahepatic bile ducts patency were analyzed. A video system for fluorescent cholangiography by Karl Storz (Germany) and indocyanine green were used.Results and discussion. The fluorescence cholangiography in laparoscopic cholecystectomy for the technically complicated acute destructive cholecystitis made it possible to detect cystic duct, common hepatic and common bile duct in laparoscopic cholecystectomy for transient choledocholithiasis suspicion to visualize a free passage of bile into the duodenum and did not allow to visualize the passage of bile in extrahepatic bile ducts during open operation for tumor obstruction.Conclusions. The first experience of fluorescence cholangiography in laparoscopic cholecystectomy showed the technical simplicity of the technique, the possibility of a clear visualization of extrahepatic bile ducts. Assume that fluorescence cholangiography can be used to evaluate the bile ducts patency instead of intraoperative cholangiography or other intraoperative audit methods in certain cases. Evaluation of extrahepatic bile ducts patency in a complete tumor block using fluorescence cholangiography is ineffective.

3:00 PM Abstract No. 160 Obstructive cholangiocarcinoma: hilar location as an indication for initial percutaneous management

The best initial therapy for hilar biliary obstruction is unclear: endoscopic retrograde cholangio-pancreatography (ERCP) is utilized by many clinicians, despite evidence suggesting that percutaneous transhepatic biliary drainage (PTBD) may be more appropriate in this setting [1]. The purpose of this study is to identify the influence of cholangiocarcinoma location on therapy outcomes. Records of 122 patients with newly diagnosed cholangiocarcinoma requiring biliary decompression from 2007 to 2016 were retrospectively reviewed. Preprocedural MRI was used to classify tumor location for 84% of patients. When this was not available, fluoroscopic procedural images were used. Hilar cholangiocarcinoma (Klatskin tumor) was present in 74 patients, and 41 had tumor involving the common hepatic and/or common bile ducts but not the hilum. PTBD was the initial therapy for 57 patients, and 65 were initially treated by ERCP. Therapeutic success was defined as resolution of hyperbilirubinemia to below 2.5 mg/dL, a level at which systemic chemotherapy can be safely administered. Of the group receiving initial ERCP treatment, 18/33 (55%) patients with hilar cholangiocarcinoma required conversion to PTBD within 30 days, compared to 4/28 (14%) with cholangiocarcinoma of the common hepatic or common bile ducts. Patients with hilar tumors are therefore over three times more likely to fail endoscopic management (p = 0.001). Immediately apparent technical failure of ERCP stent placement occurred in 9/33 (27%) patients with hilar tumors. The ERCP and PTBD treatment groups had average pretreatment serum total bilirubin concentrations of 17.5 and 17.4 mg/dl, respectively. In both treatment groups, half of the patients reached therapeutic success within the period of available follow-up data. The PTBD group had a shorter mean time to therapeutic success of 33 days vs. 41 days for the ERCP group. Hilar location of cholangiocarcinoma is a strong predictor of failure of endoscopic management. PTBD as the first-line therapy for these patients could minimize the number of procedures performed and the associated complication risks. MRI is useful to determine which treatment best suits a patient.

Intraoperative endoscopic treatment of Mirizzi syndrome in a pediatric patient

Abstract Mirizzi syndrome occurs when an impacted gallstone, together with an associated inflammatory response, causes external obstruction of the common hepatic duct or common bile duct. Patients classically present with obstructive jaundice, right upper quadrant pain, and sometimes with fever. Mirizzi syndrome is a rare presentation of complicated gallstone disease and is even more rare in the pediatric population. However, as the number of obese pediatric patients increases, so does the incidence of gallstone-related disease. We present a case of Mirizzi syndrome treated by open cholecystectomy and cystic duct stone extraction in a pediatric patient. Recognition and awareness of Mirizzi syndrome is important, even in the pediatric population, to aid in safe operative intervention and to avoid intraoperative bile duct injury.

Pancreatic hemangioendothelioma, an extremely rare vascular anomaly in children: A case report and literature review.

The current study presents the case of a female infant with pancreatic hemangioendothelioma (HE) and discusses this rare disease in terms of the clinical features, treatment principle and prognosis. An 8-month-old female with pancreatic HE was admitted to the Department of General Surgery in The Children's Hospital (Zhejiang University School of Medicine, Hangzhou, Zhejiang, China) on January 3, 2011, due to yellow skin and sclera that had been apparent for 1 week. Magnetic resonance imaging (MRI) showed dilatation in the left and right hepatic, common hepatic and common bile ducts, a pancreatic head mass of ~4.7×5.2 cm with a strong signal, and close linkage of the portal vein and mesenteric vessels to the mass. Laparotomy was performed on January 11, 2011. An intraoperative frozen specimen showed a benign tumor. Finally, Whipple surgery retaining the tumor was chosen. The patient was treated by fasting, gastrointestinal decompression, antibiotics and supportive treatment post-surgery. Jaundice disappeared rapidly following the surgery. The patient started eating at 1 week post-surgery and was discharged 1 week later. From the pathological results, a diagnosis of pancreatic HE was made, with no tumor invasion of the hepatic lymph nodes. During the follow-up visit at 28 months post-surgery, the child showed good growth and development. MRI showed that the mass size was ~2.4×2.0×1.5 cm, which was a significantly decrease from previously. Additionally, a literature search showed that from 1973 to the present date, only 9 studies on children with HE of the pancreas have been reported. Childhood pancreatic HE is a rare form of pancreatic vascular anomaly, mainly occurring in infants. If the tumor oppresses the duodenum and invades the mesenteric vessels, Whipple surgery retaining the tumor could be performed.

Application values of computer-assisted preoperative planning of hilar cholangiocarcinoma

To explore the application value of computer-assisted preoperative planning of hilar cholangiocarcinoma. Retrospective analyses were conducted for the clinical data of 47 patients with hilar cholangiocarcinoma undergoing radical resection plus hemihepatectomy from January to December 2013. According to whether computer-assisted preoperative planning was used, they were divided two groups of computer-assisted surgical planning (CASP) and without computer-assisted surgical planning (WCASP). Then we analyzed the data including preoperative examinations, preoperative planning, intraoperative findings and postoperative complications. There were 31 cases of hilar vascular invasion by tumor. Among 29 cases of CASP, left hepatic artery originated from left gastric artery (n = 6), right posterior bile duct drained into left hepatic bile duct (n = 1) and right posterior bile duct run into common hepatic bile duct (n = 2). The mean operative duration of CASP was (6.5 ± 1.3) h and the mean volume of intraoperative bleeding (672.0 ± 214.3) ml; while the mean operative duration of WCASP was (7.9 ± 2.9) h and the mean volume of intraoperative bleeding (870.0 ± 330.1) ml. By statistical analysis, the inter-group differences of mean operative duration had statistical difference (P = 0.028) and the inter-group differences of mean volume of intraoperative bleeding had statistical difference (P = 0.016). The ratio of first negative test in group CASP was higher than that of group WCASP and the inter-group differences had statistical significance (P = 0.043). But the inter-group rate of postoperative complications had no significant difference (P = 0.419). The computer-assisted surgical planning system provides accurate information so that an optimal surgical protocol may be designed by surgeons. And it has great application values in preoperative surgical planning for hilar cholangiocarcinoma and enjoys wide prospects in precise liver surgery.

Bendrojo kepenų latako jatrogeninio E2 klasės sužalojimo atliekant laparoskopinę cholecistektomiją gydymas endoskopinio stentavimo būdu: klinikinis atvejis

ĮžangaAprašome bendrojo kepenų latako jatrogeninio E2 klasės sužalojimo endoradiologinės diagnostikos ir nestandartinio sėkmingo gydymo tulžies latako stentavimu atvejį. Klinikinis atvejisLigoniui, 81 metų vyrui, dėl ūminio perforacinio kalkulinio cholecistito ir subhepatinio pūlinio atlikta laparoskopinė cho­lecistektomija ir pokepeninio tarpo drenavimas. Po operacijos buvo iki 700 ml tulžies nuotėkis pro dreną. Endoskopinės cholangiopankreatografijos metu diagnozavus bendrojo kepenų latako E2 klasės sužalojimą, tulžies latakai buvo stentuoti plastikiniu stentu. Vėliau susidariusi 1 cm ilgio striktūra buvo panaikinta metaliniu savaime išsiplečiančiu ir antimigracinį me­chanizmą turinčiu Hanarostent BCT-10-080-180 stentu. Praėjus pusei metų nuo šios procedūros ligonis jautėsi visiškai paten­kinamai. Cholangito simptomų nebuvo.IšvadosTulžies latakų stentavimas yra efektyvi alternatyva atviroms tulžies latakų operacijoms esant bendrojo kepenų latako jatro­geninės kilmės didelės apimties perforaciniam sužalojimui ir vėliau susidariusiai striktūrai (E2 ir potencialiai E1 sužalojimų klasės). Jis yra ypač svarbus vyresnio amžiaus ligoniams, turintiems mažą fiziologinį rezervą.

Acute cholecystitis of a duplicated gallbladder with double cystic duct in a 10 year old boy.

A 10 year-old boy was referred to the children’s emergency service with complaints of jaundice, vomiting, fever and right upper quadrant abdominal pain. He had Murphy’s sign during his physical examination, and a history of thalassemia minor. Laboratory data revealed acute cholecystitis with significant elevations of cholestatic liver enzymes. An abdominal ultra-sound (US) (ACUSON Antares Siemens Medical Systems, Erlangen, Germany) showed two hydropic gallbladders which had thickened echogenic separated walls containing millimetric gallstones and sludge formation with two cystic ducts entering the common bile duct (Figure 1). The common hepatic duct and common bile duct were enlarged. Magnetic resonance cholangiopancreatography (MRCP) (AERA 1.5T Siemens Medical Systems, Erlangen, Germany) showed a normal liver with two gallbladders with wall inflammations, two cystic ducts and dilated common bile and hepatic duct due to gallstones (Figure 2, ​,3).3). The patient underwent a percutanous transhepatic cholangiography (PTC) for the management of obstructive cholestasis (Figure 4). The gallstones in the common bile duct were successfully removed into the duodenum. Biliary drainage was maintained. After the laparoscopic cholecystectomy, the patient recovered. FIG. 1. Double gallbladders with double cystic ducts (white arrows) with inflamed walls (red arrows), sludge formation (stars) and stone (small black arrow) are shown on coronal ultrasound image FIG. 2. Axial T2 HASTE image of MRCP shows two hydropic gallbladders with separated-inflamed walls (stars) FIG. 3. 3D Coronal MIP image of MRCP demonstrates duplication of gallbladder (stars) with two cystic ducts (arrow heads) FIG. 4. Stones (white arrows) in enlarged common hepatic and common bile duct are demonstrated on PTC. Duplication of gallbladders (stars) with double cystic ducts (arrow heads) are shown Gallbladder duplication is an uncommon anomaly of the biliary tree in the paediatric population. Duplicated gallbladders are classified into subgroups based on the anatomy of the gall-bladder and biliary ducts. “Ductular” type, in which cystic ducts are separately joined to the common bile duct, is the commonest variant of the gallbladder (1). Acute or chronic cholecystitis is observed due to stone or sludge formation; also, fistulas, torsion, papilloma or carcinoma may occur (2). US is the first line imaging technique for diagnosing the duplication anomalies (2). MRCP is a non-invasive imaging modality without X-ray exposure which can give an accurate diagnosis of duplication anomaly both in adults and children (3–5). PTC is a therapeutic invasive technique where stones or sludge formation can be removed to the duodenum or extracted in order to maintain biliary drainage in the same session (5). Surgical resection of duplicated gallbladders should be considered in symptomatic and complicated patients. In conclusion, a multimodality approach including PTC should also be considered to establish the diagnosis preoperatively and to maintain biliary drainage in obstructive cholestasis in children.

Gastroduodenal Signet-Ring Cell Carcinoma Presenting as IgG4-Related Sclerosing Cholangitis: Not Everything That Glitters Is Gold

Introduction: IgG4-related sclerosing cholangitis (IgG4-SC) is a new entity of cholangiopathy and IgG4-related disease, described as dense infiltration of IgG4-positive plasma cells and extensive fibrosis in the bile duct wall. We presented a case of signet-ring cell carcinoma of the duodenum with initial presentation of IgG4-SC. A 75-year-old male presented with gradual-onset painless jaundice and right upper quadrant pain for 3 weeks. He was afebrile, with mild right upper quadrant tenderness, without Murphy’s sign. Labs were pertinent for AST of 142 U/L, ALT of 142 U/L, alkaline phosphatase of 461 U/L, and direct/total bilirubin of 3.5/9.3 mg/dL. MRCP showed intrahepatic biliary dilatation with right hepatic duct strictures and non-visualization of the proximal common hepatic and central common bile ducts, replaced with vague enhancement. Further investigations were significant for negative CA 19-9, CA-125 of 125 U/mL (0-30), and normal gamma immunoglobulin subclasses. EUS showed marked thickening of the extrahepatic bile duct up to the hilum without definite mass lesion. He underwent ERCP for biliary sphincterotomy and biliary stenting. Biopsies of the ampulla and the bile duct showed frequent IgG4-positive plasma cells (30 cells/highpower field). Steroid was initiated for possible IgG4-SC. At 10 days after the index ERCP, he had worsening nausea and vomiting without worsening labs. ERCP for biliary stent exchange showed narrowing of the duodenal bulb and the proximal second portion of the duodenum. Biopsies of the duodenum and the bile duct showed nonspecific inflammatory changes without evidence of malignancy. Over a 4-week follow-up after the index ERCP, he developed worsening clinical gastric outlet obstruction. Repeat ERCP/EUS revealed thickening of the pre-pyloric antrum and proximal duodenum without obvious mass, and diffuse sclerosis of the bile duct, especially the right hepatic duct, and markedly dilated left duct. Duodenal biopsies eventually revealed poorly differentiated signet-ring cell carcinoma. At 2 months, he developed new-onset symptomatic pleural effusion and ascites. Cytology analysis of the fluids showed adenocarcinoma. He died under hospice care at 2 months after initial presentation. IgG4-SC is a new challenging disease that clinicians should consider in the differential diagnosis of cholangiopathy (e.g., cholangiocarcinoma and primary sclerosing cholangitis). This case represents an example of signet-ring cell carcinoma of the stomach and duodenum that presented as IgG4-SC. These could represent separate concurrent disease processes; the latter could result from immune dysregulation secondary to occult malignancy, or represent a nonspecific change.

The Value of Cholangiography through Jackson-Pratt Drains in the Management of Postoperative Biliary Injuries

Iatrogenic biliary injury is the most significant complication after laparoscopic cholecystectomy. We present our experience with an alternative diagnostic approach using transcatheter cholangiography (TCC) through a Jackson-Pratt (JP) drain and discuss potential benefits and limitations of the technique. From March 2002 to February 2012, 40 patients with major postoperative biliary injury underwent biliary reconstruction at our institution. Mean age was 51.7 ± 18.1 years (range, 19 to 86 years) with 30 (75%) females. Seventeen (42.5%) injuries were detected intraoperatively and in 13 (32.5%) cases, JP drains were placed for biliary drainage. Lesions were classified according to Bismuth grade: I (10 patients [25%]), II (10 patients [25%]), III (six patients [15%]), IV (10 patients [25%]), and V (four patients [10%]). TCC was performed in seven patients with JP drains (53.8%). It fully defined the injury site in three cases of limited magnetic resonance cholangiopancreatography (MRCP) such as common hepatic duct and common bile duct leaks and in four cases (57.1%) that endoscopic retrograde cholangiopancreatography (ERCP) was limited as a result of clipping of the distal common bile duct. TCC showed promising results in cases of limited MRCP and ERCP such as fistulous orifices or leakage. It may represent an alternative adjunct in the diagnostic armamentarium of complex biliary injuries.

Heterotopic gastric mucosa in the hilar bile duct mimicking hilar cholangiocarcinoma: report of a case

We herein report a case of heterotopic gastric mucosa in the hilar bile duct. An asymptomatic 58-year-old male was noted to have mild liver dysfunction in March 2009 during the follow-up for angina pectoris. Abdominal-enhanced CT revealed wall thickening from the upper common hepatic bile duct to the left hepatic bile duct. Endoscopic retrograde cholangiopancreatography (ERCP) showed stenosis at the junction of the left hepatic bile duct. Although the patient's serum tumor markers were all within the normal ranges, the possibility of malignant disease of the biliary tree could not be ruled out. Left hepatectomy with the caudate lobe and resection of the extrahepatic bile duct were performed. Histopathologically, the resected specimen showed a polypoid lesion measuring 2 × 2 cm in size that projected into the lumen of the left hepatic bile duct. Microscopic examination revealed this polypoid lesion to be composed of mucous glands resembling gastric fundic glands, with parietal and chief cells. We also review eight other reports of heterotopic gastric mucosa in the biliary tree previously published in the English literature.

‘Steinstrasse’ in biliary tree - MRCP appearance

A sixty-year-old man presented with obstructive jaundice and was evaluated by magnetic resonance cholangiopancreatography (MRCP). MRCP (Fig. 1) showed numerous calculi all along the entire biliary tree—the gallbladder, cystic duct, left hepatic, common hepatic and common bile ducts. ‘Steinstrasse’ is street of stones in German. It has been described in the urinary tract usually after fragmentation of renal pelvi-calyceal calculi by lithotripsy [1] and occasionally spontaneously [2].

Endoscopic management of biliary injuries and leaks

AbstractBile duct injuries and subsequent leaks can occur following laparoscopic and open cholecystectomies and also during other hepatobiliary surgeries. Various patient related and technical factors are implicated in the causation of biliary injuries. Over a period of twenty five years managing such patients of biliary injuries our team has found a practical approach to assess the cause of biliary injuries based on the symptoms, clinical examination and imaging. Bismuth classification is helpful in most of the cases. Immediate referral to a centre experienced in the management of bile duct injury and timely intervention is associated with improved outcomes. Resuscitation, correcting dyselectrolytemia, aspiration of undrained biloma and antibiotics take the priority in the management. The goal is to restore the bile conduit, and to prevent short and longterm complications such as biliary fistula, intra-abdominal abscess, biliary stricture, recurrent cholangitis and secondary biliary cirrhosis. Endoscopic therapy by reducing the transpapillary pressure gradient helps in reducing the leak. Endoscopic therapy with biliary sphincterotomy alone or with additional placement of a biliary stent/nasobiliary drainage is advocated. In our tertiary care referral unit, we found endoscopic interventions are useful in situations where there is leak with associated CBD calculus or a foreign body, peripheral bile duct injury, cystic duct stump leak and partial bile duct injury with leak/narrowing of the lumen. Endotherapy is not useful in case of complete transection (total cut off) and complete stricture involving common hepatic or common bile ducts. In conclusion, endoscopic treatment can be considered a highly effective therapy and should be the first-line therapy in such patients. Though less successful, an endoscopic attempt is warranted in patients suffering from central bile duct leakages failing which surgical management is recommended.

Magnetic resonance demonstration of gall bladder ascariasis

A 40-year-old man presented with right hypochondrial and epigastric pain and tenderness. There was no history of jaundice or vomiting. Serum alkaline phosphatase was mildly elevated (170 IU/L). His ultrasound was suggestive of gall bladder worms or stones. MRI revealed curvilinear hypointense structure in the gall bladder (Fig. 1); this suggested the diagnosis of gall bladder ascariasis. Common hepatic and bile ducts were normal. Stool examination revealed ova of Ascaris lumbricoides. The patient was given analgesics and albendazole (400 mg single dose). Three days later, he reported relief of symptoms and passage of worm in the stools. Ultrasound done 4 days later showed no worm in the gall bladder. The adult worm of ascariasis usually resides in the small bowel. It can occasionally migrate into biliary system. Involvement of gall bladder is rare because of the small size of cystic duct [1]. Ultrasound is the usual imaging modality for diagnosing gall bladder ascariasis which demonstrates it as curvilinear echogenic structure [1]. In cases which are inconclusive on sonography, MRI may show curvilinear hypointense structure in the gall bladder lumen, while gall stones typically appear as rounded objects of signal void [2]. MRI also allows simultaneous visualization of common hepatic and common bile ducts. Gall bladder ascariasis is usually treated by surgery and endoscopy. Occasionally, medical therapy may lead to spontaneous passage of worm, as happened in our case.

Immunoglobulin G4-associated Cholangitis in a Patient with Ulcerative Colitis: Learning to Think Beyond Cholangiocarcinoma and Primary Sclerosing Cholangitis

Purpose: Immunoglobulin G4 (IgG4)-associated cholangitis (IAC) is a rare steroid responsive biliary disease characterized by dense infiltration of IgG4 plasma cells in the bile ducts, pancreas, or other affected organs. IAC is often difficult to distinguish from more common entities such as cholangiocarcinoma and primary sclerosing cholangitis (PSC). We report a case of IAC in a patient with UC that was eventually diagnosed after he was presumed to have both cholangiocarcinoma and PSC. Methods: A 64-year-old male with well-controlled UC on mesalamine diagnosed over 10 years prior presented in December 2008 with acute onset of obstructive jaundice. The patient underwent an endoscopic retrograde cholangiopancreatography (ERCP) that revealed a long biliary stricture involving both the common hepatic and common bile ducts (CBD) with associated mild diffuse intrahepatic ductal dilation. Cytology from the endoscopically obtained brushings of the biliary stricture returned with dysplasia. The cholangiographic appearance of the stricture as well as the pathology results were highly suspicious for cholangiocarcinoma, therefore the patient underwent Whipple's procedure. Histopathologic examination of the tissue revealed, an increase in the number of plasma cells and upon consultation with Armed Forces Institute of Pathology plasma cells were noted to have significant IgG4 reactivity consistent with IAC. For the next two years patient continued to be symptomatic without any treatment due to unknown reasons. Results: When the patient presented to us with continued symptoms the patient was immediately started on oral corticosteroids with improvement of his alkaline phosphatase and abdominal pain though the biliary dilation remains present on imaging. He is currently undergoing gradual corticosteroid taper with close observation for relapse. Conclusion: The diagnosis of IAC requires a high index of suspicion as its clinical manifestations can be misinterpreted as cholangiocarcinoma or PSC, however there are several characteristics that can aid in prompt recognition. IAC tends to have an abrupt clinical presentation with obstructive jaundice, as with our patient, while PSC is a more chronic and progressive disease. Cholangiograghically, IAC more often has long strictures in the distal CBD where as a band-like or beaded appearance is seen in PSC. In the case of our patient, his existing diagnosis of UC led to the presumption that the clinical and cholangiographic findings were due to malignancy and then PSC, rather than pursuing alternative etiologies. Despite its relatively low prevalence, IAC should be considered in patients with biliary strictures, especially considering its good response to corticosteroid therapy.

Anatomopathologie des cholangiocarcinomes

Cholangiocarcinomas (CC) are tumors that arise from the epithelial cell of the biliary tract. They represent the second most frequent primitive liver malignancy after hepatocellular carcinoma. Recent epidemiological data show an increase incidence of CC independently of the increased incidence of cirrhosis. According to their location in the biliary tract, we distinguish intrahepatic, hilar (Klastkin tumors) and extrahepatic CC. In literature, confusion exists around hilar CC that are included, according series, to intrahepatic or extrahepatic CC. However, hilar CC share common clinical, morphological and therapeutic features with extrahepatic CC. So, OMS classification of digestive tumors defined two groups of CC: intrahepatic or peripheral CC which develop from small intrahepatic biliary duct beyond the second segmentation, and extrahepatic CC comprising hilar CC and tumors from common hepatic bile duct. In this chapter, we will describe the different gross features and histological characteristic of CC and will detail the major histopronostic criteria of these tumors.

Mirizzi syndrome-rare cause of major biliary complications. /Case Report/

Mirizzi syndrome is a rarely observed complication of gallstone disease, causing major biliary problems, if not diagnosed previously. It was described in 1948 by P. L. Mirizzi and presents unusual lodged gallstone in either the cystic duct or most frequently in Hartmann pouch of the gallbladder. Impaction, acute obstruction and wall ischemia are causative for inflammation and abscess formation. External common hepatic bile duct compression and obstruction result in clinical presentation of intermittent or constant jaundice. We report 57-year-old male with extensive mechanical icter, fever, nausea and vomiting, and upper abdominal pain in epigastria from five days. Abdominal US evaluation showed 17mm stone localized in infundibulum and shrunk of gallbladder. MRCT revealed impacted stone, chronic tissue inflammation, involved common hepatic duct with stricture. Mirizzi syndrome was diagnosed. Intraoperatively was found an impacted gallstone in the Hartmann pouch, extensive fibrosis of hepatoduodenal ligament and abscess cavity formation in the Callot’s triangle with engagement of common hepatic bile duct wall. Antegrade cholecystectomy was made and T drain was placed. Second operation and Roux-Y limb anastomosis was performed after unsuccessful tentative for recanalization of distal CBD with clamping of T drain.

Acute Myeloid Leukemia Presenting as Obstructive Jaundice Caused by Granulocytic Sarcoma

We report a rare case of granulocytic sarcoma infiltrating the bile duct in a patient with acute myeloid leukemia. A 23-year-old man presented with jaundice and weight loss. A peripheral blood smear revealed blast cells, and the results of an examination of bone marrow aspirate were consistent with acute myeloid leukemia. The bilirubin level increased gradually after induction chemotherapy with cytarabine. Magnetic resonance cholangiopancreatography (MRCP) revealed dilatation of the intrahepatic bile ducts and smooth tapering off at the level of the common hepatic bile duct. Endoscopic retrograde cholangiopancreatography (ERCP) also revealed diffuse narrowing of the proximal common hepatic bile duct. Obstructive jaundice resolved after endoscopic nasobiliary drainage. Remission induction chemotherapy with cytarabine and idarubicin was administered, and the patient remained complete hematological remission with normal liver function tests.

Adenomyoma of the Common Hepatic Duct Mimicking Bile Duct Cancer: Report of a Case

We report an unusual case of adenomyoma of the common hepatic duct mimicking bile duct cancer. A 50-year-old woman was referred to our hospital for the investigation of general fatigue. Laboratory data showed abnormal liver test results and computed tomography showed a mass lesion in the hepatic hilum and dilatation of the intrahepatic bile ducts. These findings led to a preoperative diagnosis of hilar bile duct carcinoma, and we performed a left lobectomy with resection of the extrahepatic bile duct. Macroscopically, an elevated lesion was found in the common hepatic duct, which was confirmed histologically to be an adenomyoma. Bile duct strictures are rarely caused by benign tumors of the biliary tract, such as adenomyoma. Surgical resection of the bile duct should be considered for all bile duct strictures because it is often difficult to differentiate malignant from benign lesions in this location preoperatively, and malignant cells may be present in the lesion.

Pigmented neuroendocrine carcinoma of the hepatic duct: a case report

Results A pigmented tumor measuring 2.9 cm was located in the common hepatic bile duct with lumen stenosis reaching to the bifurcation of the hepatic ducts. The preoperative cytology showed atypical and single pleomorphic tumor cells with pigment granules and an immunocytological positive reaction for cytokeratin. The histological examination revealed an unencapsulated neoplasm infiltrating the biliary wall including the mucosa. The neoplastic cells were organized in solid, trabecular structures or cords in a condensed stroma. They were argyrophil in the Grimelius and non-argentaffin in the Fontana-Masson silver impregnation, while the pigment granules were argentaffin. The tumor cells exhibited a diffuse strong staining for chromogranin A, neuron-specific-enolase, a lesser staining for synaptophysin and neurofilament, and a weak nuclear reaction for S-100 protein. Cytokeratin was positive and HMB45 completely negative. No S-100 positive sustentacular cells could be found. The proliferation-index Ki-67 (MIB1) was low (2%). The electron microscopy revealed electron-dense neuroendocrine granules.