Common Hepatic Duct Stricture Research Articles

Erdheim-Chester disease associated with an aggressive form of sclerosing cholangitis

BackgroundErdheim-Chester disease (ECD) is a rare histiocytic disorder recently recognized as a neoplasm due to the discovery of activating MAPK pathway mutations. Hepatic involvement by ECD is extremely rare.Case presentationWe describe a case of a 64-year-old male who presented with pruritis, weight loss, and cholestatic liver function tests. Magnetic resonance imaging of the abdomen showed beaded appearance of the intrahepatic biliary tree. A liver biopsy was suggestive of primary or secondary sclerosing cholangitis. Computerized tomography (CT) of the abdomen showed perinephric and periaortic soft tissue stranding suggestive of ECD. 18F-fluorodeoxyglucose positron emission/computerized tomography scan showed a mediastinal hilar mass which turned out to be follicular lymphoma. Histopathology of molluscum-like skin lesions showed CD68 + , Factor XIIIa + , and CD1a-foamy histiocytes with multiple giant cells suggestive of ECD. The patient developed recurrent episodes of ascending cholangitis and his hyperbilirubinemia continued to worsen despite stenting of a common hepatic duct stricture found on endoscopic retrograde cholangiopancreatography.ConclusionsThe absence of associated inflammatory bowel disease and anti-neutrophil cytoplasmic antibody, as well as the rapidity of disease progression, makes us consider the possibility of hepatic involvement by ECD or an overlap syndrome. We want to highlight that negative histopathology should not delay the diagnosis of ECD as effective and potentially lifesaving therapies with BRAF or MEK pathway inhibitors are now available for these patients.

Endoscopic treatment of a refractory benign biliary stricture using cholangioscopy-guided thulium laser stricturoplasty.

Video 1Details regarding the patient's clinical presentation and prior endoscopic treatments for common hepatic duct stricture are first described in the video. Next, the video features footage from subsequent ERCP demonstrating the common hepatic duct stricture both fluoroscopically and endoscopically via cholangioscopy, followed by treatment with thulium laser stricturoplasty/dissection. The immediate post-treatment images of the stricture are displayed which demonstrated marked improvement in the stricture. Finally, the patient's ensuing clinical course is displayed in which the stricture recurred and was retreated with laser stricturoplasty/dissection and stent upsizing.

Disposable digital percutaneous cholangioscope-aided retrieval of a plastic biliary stent after failed retrieval at ERCP.

Video 1Cholangioscopy, fluoroscopy, and endoscopy of the percutaneous retrieval of a biliary stent across an iatrogenic common hepatic duct stricture due to surgical staples.

EUS-guided choledochoduodenostomy as a rescue after failed ERCP and percutaneous transhepatic biliary drainage in the management of postoperative benign biliary stricture.

A 34-year-old woman presented with a 4-month history of obstructive jaundice. She had undergone complicated cholecystectomy and common bile duct exploration 5 years earlier. She underwent surgical choledochoduodenostomy (CDS) for recurrent biliary obstruction 5 months after the first surgery. She was asymptomatic until 4 months earlier, when she presented with obstructive jaundice and cholangitis. Magnetic resonance cholangiopancreatography showed a smooth common hepatic duct stricture, intrahepatic stones and bilateral intrahepatic biliary radicle (IHBR) dilatation.

S2326 Grasping for Straws: A Rare and Challenging Complication of Biliary Stenting

INTRODUCTION: Proximal (cephalad) migration of a biliary stent (PMBS) may be associated with severe complications. Prompt recognition and retrieval is important, but may be quite difficult. We present a challenging case of proximal migration of a plastic CBD stent, highlighting techniques used for successful retrieval. CASE DESCRIPTION/METHODS: A 73-year-old F with an indeterminate proximal CBD and common hepatic duct (CHD) stricture undergoing biliary endotherapy presented for a scheduled ERCP. Due to inadequate drainage via retrograde approach, a percutaneous biliary drain (PBD) was placed 9 months ago and patient had undergone multiple biliary drain exchanges and one liver biopsy. Surgical resection was not pursued due to underlying comorbidities. Two weeks prior to presentation, ERCP for internalization of PBD revealed that a previously placed 7Fr x 12cm straight plastic stent had migrated proximally within the anterior RHD (Figure 1). Attempts to retrieve the migrated stent with balloon and snare were unsuccessful, so a 10Fr x 10cm stent was placed and PBD was pulled. On repeat ERCP, direct visualization with Spyglass cholangioscopy revealed the stent to be embedded within the bile duct sidewall at the stricture level (Figure 2). Multiple tools, including balloon catheter, snare and pediatric biopsy forceps failed to remove the stent. Even the cholangioscope biopsy forceps could not grasp stent sufficiently to enable traction and removal. After multiple failed attempts, the stent was successfully retrieved using a small rat tooth forceps via direct grasping of its distal end within the CHD under fluoroscopy. Repeat cholangiogram showed stable findings and no perforation and a 10Fr x 12cm straight plastic stent was replaced. DISCUSSION: PMBS is rare and endoscopic retrieval can be challenging. Risk factors of PMBS include malignant stricture, large stent diameter and shorter stent length. Retrieval of PMBS is critical to avoid complications such as hepatic/ductal perforation and fistula. Endoscopic retrieval methods include Soehendra retriever, basket, lasso technique, balloon and forceps. Cholangioscopy can also be used but was not helpful in this case. Fluoroscopic positioning of rat tooth forceps enabled stent retrieval in our case. We postulate that multiple biliary drain exchanges may have caused proximal migration of the biliary stent. Knowledge of the various tools and techniques to retrieve proximally migrated biliary stents is essential to successfully manage these technically challenging cases.Figure 1.: Fluoroscopic visualization of proximally migrated straight biliary stent appearing as an upside down “V”.Figure 2.: Direct visualization of the embedded distal end of the proximally migrated straight biliary stent using Spyglass cholangioscopy.

S2379 A Unique Approach in Selective Guidewire Cannulation of a Complex Malignant Biliary Stricture

INTRODUCTION: Digital single-operator cholangioscopy (D-SOC), such as Spyglass DS, represents newer technology that can improve the diagnostic and therapeutic capabilities of ERCP. In the case below, we present how the use of Spyglass aided in the decompression of a complex malignant biliary stricture. CASE DESCRIPTION/METHODS: 52 year old male presented with epigastric pain, and obstructive jaundice. Patient has known portal vein thrombosis, and metastatic adenocarcinoma to the liver and lungs. The primary is suspected to be of upper GI or pancreatobiliary origin.CBC, PT INR, and BMP were within normal limits. T Bili is 17 mg/dL, D Bili 12.5 mg/dL, Alk Phos 1441 units/L, AST 300 units/L, ALT 251 units/L, AFP 11.5 ng/mL, CEA 249.8 ng/mL, and CA 19–9 113,888 units/mL. MRCP: Abrupt cut off of the distal common hepatic duct with intrahepatic bile duct dilatation.ERCP found 2 high grade biliary strictures. Conventional guidewire cannulation of the strictures were unsuccessful.A second ERCP was performed with the aid of Spyglass DS. Under direct visualization from Spyglass and fluoroscopy, guidewire cannulation of the high-grade common bile duct and hepatic duct strictures were achieved. A fully covered 10 Fr x 80mm metal stent was advanced over the guidewire and deployed across both strictures. Then, the waist of the stent was balloon dilated to 6 mm. Biliary drainage was confirmed upon scope retraction. Patients bilirubin downtrended and he was discharged with oncology follow up. DISCUSSION: The incidence of malignancy related biliary obstruction is increasing. The majority of these patients will benefit from biliary decompression in order to improve quality of life. Given the complications associated with percutaneous transhepatic biliary drains and stenting of biliary strictures, therapeutic ERCP is the favored approach. However, even the most experienced endoscopists fail to cannulate malignant strictures 5-10% of the time with conventional ERCP. Based on our experience, the utility of Spyglass DS might be of benefit when managing difficult malignant biliary strictures. Upon our literature review, the use of D-SOC guided cannulation of these strictures were found in only 11 patients, with 64% having cholangiocarcinoma. With the aid of D-SOC, the success rate of cannulation was 46%. Given limited literature, more research for this procedural indication should be considered as D-SOC could be a viable approach in improving the effectiveness of endoscopic management of these complex malignant strictures.

3022 Metastatic Colon Adenocarcinoma Presenting as a Hilar Obstructing Lesion Diagnosed With EUS-FNB

INTRODUCTION: Bile duct obstruction from periportal masses has a broad differential diagnosis.1 Cross-sectional abdominal imaging can help to detect periportal masses, but have low sensitivity in the diagnosis of proximal biliary and hilar lesions.2 Endoscopic ultrasound (EUS) allows for evaluation of periportal and biliary lesions and enables tissue diagnosis via fine needle biopsy (FNB). We present a case of a young patient who was presumed to have primary metastatic ovarian cancer; with EUS and ERCP guided sampling we arrived at a specific diagnosis of metastatic adenocarcinoma of colonic origin. CASE DESCRIPTION/METHODS: A 41-year-old female with a history of ovarian cancer s/p TAH and BSO and jejunal resection presented with painless jaundice, hematochezia, and high fever. Abdominopelvic CT scan showed a 2 cm mass in the region of the porta hepatis invading the portal vein and diffuse thickening of the rectosigmoid colon (Figure 1). Colonoscopy from a year prior was unremarkable, and subsequent colonoscopy was significant for hemorrhoids and hyperplastic polyps. Due to clinical suspicion for cholangitis, an ERCP was performed primarily for biliary drainage; a common hepatic duct (CHD) stricture and right hepatic duct dilation were found (Figure 2). Two 7 French 12 cm plastic stents were deployed across the common bile duct (CBD) stricture with their proximal end within the dilated right main hepatic duct. EUS showed a 2 cm lesion adjacent to the hilum that was invading the CHD and biliary bifurcation extending 1-2 cm distal and proximal to the bifurcation, portal, and hepatic artery. EUS-FNB demonstrated adenocarcinoma of jejunal origin based on cytokeratin markers (Figure 3). DISCUSSION: Specific diagnosis of periportal lesions involving the hilum of the liver is a limitation of cross-sectional imaging. EUS offers better visualization of the periportal region and enables tissue sampling for cytological or histological diagnosis. EUS-FNB has high sensitivity for diagnosis of lesions involving the common hepatic duct. It also enables assessment of vascular invasion and loco-regional staging, which is essential prior to therapy. Our case highlights, how EUS-FNB of a periportal lesion offered a specific diagnosis of metastatic colonic adenocarcinoma to the common hepatic duct. ERCP at the same session enabled biliary drainage that was essential prior to appropriate chemotherapy. The EUS FNB and ERCP with stent placement made a significant impact on the management of our patient.

1368 Hilar Inflammation Mimicking a Klatskin Tumor

INTRODUCTION: Hilar cholangiocarcinomas or Klatskin tumors (KT) pose significant diagnostic challenges; 15% of resections for KT prove to be non-malignant. Inflammatory, infectious, and other etiologies mimic radiological features of KT. A high index of suspicion is needed to avoid hepatic resection and associated morbidities while aggressively excluding KT. CASE DESCRIPTION/METHODS: A 64-year-old male who presented with jaundice, unintentional 50 lb weight loss, and fatigue was found to have bile duct dilation on ultrasound. A CT confirmed severe right and left hepatic duct dilatation with abrupt cutoff due to a 4 cm infiltrative hilar mass involving the right and left hepatic ducts, and extending into the common hepatic duct. Work-up for causes of jaundice (autoimmune hepatitis, hemochromatosis, alpha-1 antitrypsin deficiency, viral hepatitis, celiac sprue, autoimmune cholangiopathy) via ANA, AMA, F-actin, IgG, IgG4, HFE mutation, TIBC, ferritin, A1AT, tTG, hepatitis serologies was negative. Over 12 weeks, 3 ERCPs failed to confirm KT via biopsies, cytology, and fluorescence in situ hybridization (FISH). A severe proximal common hepatic duct stricture was found on initial ERCP, which was dilated and stented. ERCP with Spyscope showed hepatic bifurcation stricture improvement. This stricture was biopsied and again brushed, dilated and stented. A third ERCP showed further improvement in stricture and otherwise normal intra- and extra-hepatic ducts. Dilation to 8 mm was performed without further stenting. Cytology and FISH were negative for KT. Two CT guided biopsies of the mass were also negative for KT and failed to show biliary ductal thickening or clear evidence of the prior noted hilar mass. Two MRCPs, 7 months apart, showed significant improvement of right and left bile duct confluence stricturing, felt to represent fibrous tissue and scarring. DISCUSSION: Despite improvement in cross sectional imaging, advances in interventional radiologic and endoscopic modalities, differentiation between benign and malignant hilar biliary stenoses remains a major challenge. Up to 20% of hilar resection show chronic fibrosing inflammation without evidence of KT. We aggressively pursued this concern with 3 ERCPs (cytology, FISH, biopsy with Spyscope), and 2 CT guided biopsies. CT and MR showed radiologic improvement of the mass and lack of evidence of KT. Exclusion of autoimmune disease or other etiologies allowed a diagnosis of idiopathic inflammation, thus avoiding surgery.

Common Hepatic Duct Stricture Due to Surgical Clip

Common Hepatic Duct Stricture Due to Surgical Clip

Heterotopic Gastric Mucosa in a Duplication Cyst of the Common Hepatic Duct Mimicking Cholangiocarcinoma

Heterotopic gastric mucosa in biliary tract is a congenital anomaly that can prove significant clinical dilemmas. Here we report the case of a 28-year-old female patient presenting with jaundice, pruritus, and altered liver tests, with predominant cholestasis. Liver biopsy revealed histological changes suggesting large bile duct obstruction with advanced fibrosis. At imaging, common hepatic duct stricture due to an intraluminal enhancing mass was observed. Endoscopic retrograde cholangiopancreatography and upper echoendoscopy revealed a firm mass of the common hepatic duct with a complete obstruction, suspicious for cholangiocarcinoma. Fine-needle aspiration biopsy performed under echoendoscopic guidance revealed fundic type gastric mucosa. Despite histological result, radiological suspicion of malignancy together with advanced fibrosis prompted a segmental resection of biliary tract. At macroscopic examination, the common hepatic duct presented a focal pseudocystic appearance with a firm zone of subtotal stenosis. Histology revealed a duplication cyst lined by heterotopic fundic gastric mucosa. Heterotopic gastric mucosa of the biliary tract should be suspected in young patients without know risk factors for hepatobiliary malignancies. Imaging and careful histological examination are mandatory for optimal management. Liver fibrosis, secondary to chronic biliary obstruction may be a significant late complication.

Hepatic resection for bile duct injury: A case report

Background: Bile duct injury is a serious complication following both open and laparoscopic cholecystectomy. The extent of injury may be severe enough to consider biliary reconstruction procedures like Roux-en-Y hepaticojejunostomy or even hepatectomy in rare instances for the definitive management.Case: A 56 year old female, who underwent open cholecystectomy and detected bile duct injury intraoperatively. Small feeding tube was placed in the bile duct, exteriorized and patient was referred to our center for further management. Liver function tests at presentation revealed cholestatic patterns of liver derangement but the patient did not show any signs suggestive of sepsis. Endoscopic Retrograde Cholangiopancreatography revealed complete stricture of common hepatic duct. Magnetic Resonance Cholangiopancreatography revealed Bismuth type 4 bile duct stricture. The plan was to perform a bilateral hepaticojejunostomy, however, because of the very difficult anatomy and failure to identify the right duct, right hepatectomy with left duct hepaticojejunostomy was performed as a definitive management for her type IV bile duct injury. The patient had an uneventful post-operative course.Conclusion: Infrequently, liver resection remains an important therapeutic option in cases of complicated and major forms of bile duct injuries where the bilateral biliary reconstruction is not feasible.

Hepatic Artery Pseudoaneurysm Masquerading as Malignant Jaundice

Introduction: Visceral artery aneurysms and pseudoaneurysms (PSAs) are rare conditions with a reported incidence of 0.1 to 0.2%. The etiology of most PSAs are abdominal trauma, iatrogenic or pancreatico-biliary procedures. Hepatic artery PSAs are often asymptomatic or can present with abdominal pain, nausea, hemobilia, and rarely jaundice. Case Report: A 74-year-old man presented with jaundice, pruritus, and malaise that progressively worsened over a 2 week period. On admission the total bilirubin (TB) levels was 7.6, direct bilirubin (DB) 4.9, aspartate aminotransferase (AST) 39, alanine aminotransferase (ALT) 35, alkaline phosphatase (ALP) 214, Ca 19-9 79.4, and CEA 1.1. A contrast-enhanced computerized tomography (CT) scan was performed which showed significantly distended intrahepatic bile ducts, a common hepatic duct (CHD) stricture and a 2.6 x 3.8 cm contrast-filled lobulated stricture consistent with a PSA of the right hepatic artery (RHA) (Figure 1). Endoscopic retrograde cholangiopancreatography (ERCP) was attempted, however cannulation was unsuccessful. A percutaneous transhepatic cholangiogram was therefore performed identifying a severe stricture in the common hepatic duct. Bilateral percutaneous transhepatic biliary drains were placed, and brushings of the bile duct were performed. Cytology brushing were unremarkable, and there remained concern for cholangiocarcinoma. Eight days after percutaneous transhepatic cholangiography and drainage (PTCD), the patient presented with bloody drainage in his right hepatic drain. The patient underwent a PTCD which revealed a complex communication between the CHD and the RHA (Figure 2). The PSA was successfully embolized. An ERCP (Figure 2) was then performed with digital cholangioscopy (Figure 3). No tumor was visualized and a CHD stricture was confirmed due to extrinsic compression. The patient was managed conservatively and during outpatient clinic follow-up he was asymptomatic and his liver enzymes had normalized.Figure 1Figure 2Figure 3Discussion: Our case represents a spontaneous hepatic artery psudoaneurysm causing obstructive jaundice. In rare situations PSAs may develop from atherosclerosis. ERCP with digital cholangioscopy was crucial in our case to demonstrate an absence of a tumor and correctly identify extrinsic compression from the PSA.

Infundibulinės laparoskopinės cholecistektomijos metodika turi kokybiškai atsinaujinti: 18 metų 13 274 cholecistektomijų analizė, 45 jatrogeninių tulžies latakų sužalojimų aptarimas ir įvertinimas

ĮžangaAtliktas Respublikinės Vilniaus universitetinės ligoninės 1996–2013 metų tulžies pūslės chirurgijos retrospektyvusis auditas, apibendrinantis 18 metų operacijų patirtį. Svarbiausias tyrimo tikslas – apibūdinti su laparoskopine cholecistektomija (LC) siejamą tulžies latakų sužalojimo riziką.MetodaiLC metu, siekdami identifikuoti tulžies pūslės lataką ir jos arteriją, laikėmės infundibulinės metodikos principų. Jatrogeniniai tulžies latakų sužalojimai susisteminti į penkias klases pagal Bismutho ir Strasbergo klasifikaciją. Siekdami nustatyti Lietuvos gydytojų publikacijas, kuriose analizuojamos laparoskopinės cholecistektomijos komplikacijos, naudojomės http://scholar.google.co.uk paieškos sistema. Taikyti standartiniai vienfaktoriai ir daugiafaktoriai statistinės analizės būdai.RezultataiAtliktos 13 274 cholecistektomijos, iš jų LC – 11 189 kartus (84,29 %). 5241 (39,48 %) pacientas laparoskopiškai operuotas dėl ūminio, 8033 (60,52 %) – dėl lėtinio cholecistito. Tulžies latakai sužaloti 45 ligoniams, iš jų 42 sužalojimai siejami su LC. Laparoskopinės operacijos metu tulžies latakai buvo sužaloti 2,7 karto dažniau nei per atvirąją (0,38 % vs 0,14 %, ŠS = 2,6149, 95 % PI 0,8097–8,4442, z = 1,607, p = 0,1080). Operuojant pacientus dėl ūminio cholecistito, jatrogeninių tulžies latakų sužalojimų pasitaikė du kartus dažniau (0,5 % vs 0,24 %, ŠS = 2,1029, 95 % PI 1,1627–3,8034, z = 2,459, p = 0,0140). Su LC siejamų jatrogeninių tulžies latakų sužalojimų rizika yra 1:261. 2010–2013 metais jų padaugėjo. Tulžies pūslės latako nesandarumo rizika po LC yra 1:323 (tai didele dalimi atspindi specifinę technologijos problemą). Pagrindinių šoninių tulžies latakų sužalojimų rizika yra 1:247 (tai chirurginės technikos problema). E klasės sužalojimo rizika 1:1243. 2000–2013 metais su LC siejama 40 % (17/42) jatrogeninių tulžies latakų sužalojimų. Hospitalinis mirštamumas nuo tulžies latakų sužalojimo buvo 11 % (5/45).IšvadosJatrogeniniai tulžies latakų sužalojimai yra nedažni, bet pavojingi. Tyrimas išryškino koncepcinius, sisteminius ir techninius LC trūkumus. Kadangi laparoskopinės cholecistektomijos kultūra prasideda nuo operacijai tinkamų pacientų atrankos, išsamiai infomuoto paciento sutikimo, šiuolaikinių pripažintų technologinių ir techninių priklausinių bei racionalių, pacientų saugumą užtikrinančių sprendimų, ji turi keistis. Ir ne tik įstaigoje, kurioje buvo atliktas šis klinikinis tyrimas, bet ir visose kitose geografinio regiono gydymo įstaigose, jeigu jose praktikuojama tokia pati arba metodologiškai panaši tulžies pūslės chirurgija.

Intraductal radiofrequency ablation under direct vision of choledochoscopy for the treatment of malignant common hepatic duct stricture

Novel intraductal radiofrequency ablation for malignant biliary stricture indicated good therapeutic prospect. In traditional intraductal radiofrequency ablation, the radiofrequency catheter was placed through endoscopic retrograde cholangiography or percutaneous transhepatic cholangiogram under the supervision of X-ray. In February 2014, a patient with intrahepatic adenocarcinoma of the bile duct and malignant common hepatic duct stricture was admitted to the Shenzhen People′s Hospital. The patient received cholecystectomy + choledocholithotomy + T tube drainage 3 months prior to the admission. The results of histopathological examination indicated reactive hyperplasia. The patient recovered uneventfully after the operation. One week before the admission, the patient had jaundice and umber urine and received choledochoscopy + common bile duct dilatation + histopathological examination + biliary stent placement. The results of pathological examination confirmed that the patient had intrahepatic adenocarcinoma of the bile duct. The patient received intraductal radiofrequency ablation through T-tube fistula under direct vision of choledochoscopy, and recovered well after the operation. Intraductal radiofrequency ablation under direct vision of choledochoscopy not only has the advantages of accurate positioning and real-time monitoring, but also facilitate cyclical repeat treatment. Key words: Malignant biliary stricture; Radiofre-quency ablation; Choledochoscopy

Malignant obstructive jaundice in situs inversus: demonstration of precut and biliary drainage

A 68-year-old man with situs inversus was admitted to our hospital with obstructive jaundice. An MRCP revealed intrahepatic biliary dilation with a long segment stricture of the common hepatic duct and abnormal signal within the hepatic parenchyma near the hilum (Fig. 1) . The patient underwent ERCP in the supine position (Video 1, available online at www.giejournal.org). Repeated attempts to cannulate the bile duct were unsuccessful. Initial engagement was possible, but the guidewire could could only be advanced into the pancreatic duct. A pancreatic precut sphincterotomy was performed in the opposite orientation at the 1 o’clock position in an attempt to expose the bile duct. Cannulation of the bile duct was still unsuccessful, so a needle-knife precut was performed in a 1 to 2 o’clock orientation. Cannulation of the bile duct was then achieved, and a biliary sphincterotomy was performed. Cholangiogram confirmed a common hepatic duct stricture with proximal upstream dilation. Brushings of the biliary stricture were performed over a guidewire. A 5F × 15 cm single pigtail plastic stent was deployed over a guidewire into the pancreatic duct. A 10 × 60 mm fully covered, self-expanding metal stent was deployed across the biliary stricture with successful biliary drainage post-deployment. Pathology from the biliary brushings revealed cholangiocarcinoma. Magnetic resonance angiography showed no vessel involvement and no distant metastases. The patient is currently awaiting surgical resection by the liver transplant surgical team.

Neuroendocrine tumor of common hepatic duct

Extrahepatic bile ducts (EHBD) remain one of the rarest primary sites for neuroendocrine tumors (NETs) accounting for 0.1 % to 0.2 % of all NETs of the gastrointestinal tract. We present one such case, a 28-year-old female with vague abdominal symptoms and periportal lymph node enlargement on radiological examination. Endoscopic retrograde cholangiopancreaticography revealed 1.5 cms long common hepatic duct stricture and brush cytology showed no malignant cells. Endoscopic ultrasound guided fine needle aspiration cytology from the lymph nodes reported malignant cells. Roux-en-Y hepaticojejunostomy with excision of the extrahepatic biliary tree and radical lymphadenectomy was done. The diagnosis of well-differentiated neuroendocrine carcinoma was confirmed on histological and immunohistochemical studies. NETs of biliary tract are difficult to diagnose preoperatively. The aggressive use of curative and cytoreductive surgery is the frontline of treatment. But the rare alternative diagnosis of NETs should be kept in mind by the surgeon for proper timely management.

Mo1312 Fluoroscopy-Guided Endobiliary Biopsy (FGEB) is Highly Accurate in Diagnosing Malignant Proximal Biliary Strictures

The sensitivity of FGEB in diagnosing biliary cancer is reported to be 30-55%. The yield in diagnosing proximal (common hepatic and intrahepatic) duct strictures (PS) is presumed to be more dismal because of technical difficulty.

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Congenital biliary dilatation may consist of 2 disease entities

Background/Purpose This study aims to establish the possible mechanisms of pathogenesis of congenital biliary dilatation and to classify the disease accordingly. Methods Radiologic features of congenital biliary dilatation and pancreaticobiliary malunion in 107 affected children were examined and correlated with laboratory results. Relative lengths/diameters were calculated to provide comparison between children of different ages. Intraluminal pressures of common bile duct (CBD) were measured intraoperatively. Results The minimal relative diameters of distal CBD negatively correlated with the maximal relative diameters/lengths of dilated CBD, the maximal relative diameters of common hepatic duct, and left/right hepatic ducts. The intraluminal pressure in patients with a stenotic distal CBD (stenotic group) was significantly higher than that in patients with a nonstenotic distal CBD (nonstenotic group). The narrower the distal CBD, the more deranged the liver function. Conversely, serum/bile amylase levels were more elevated in the nonstenotic group. Common channel protein plugs were only found in the nonstenotic group, whereas common hepatic duct strictures, intrahepatic duct dilatations, and calculi were detected more frequently in the stenotic group. Conclusion We propose to categorize congenital biliary dilatation into 2 subgroups: (1) cystic type with stenotic distal CBD associated with deranged liver function and common hepatic duct stricture and (2) fusiform type with nonstenotic distal CBD associated with pancreatitis and common channel protein plugs. Different underlying pathologies of each group require different operative strategies.

Comparison of Abdominal Ultrasound and ERCP in Determining the Etiology of Obstructive Jaundice

Purpose: ERCP remains the gold standard for diagnosis and initial treatment of patients with obstructive jaundice. Accuracy of ultrasound in such patients and its concordance with ERCP has not been studied in our part of the world. Objective: To compare the efficacy of abdominal ultrasound and ERCP in determining the etiology of obstructive jaundice Methods: Study was carried out at a tertiary care referral center in Lahore, Pakistan from August 2006 to May 2007. Patients undergoing ERCP for provisional diagnosis of obstructive jaundice were included. Abdominal ultrasonographic examination was conducted before ERCP and all patients underwent ERCP under conscious sedation. Diagnosis on ultrasound and ERCP was compared using cross tabulation. Results: A total of 54 patients (male: female ratio of 0.6 (22/32)) with a mean age of 47.22 (±14.94) were included in the study. Jaundice and Abdominal pain were the predominant presenting symptoms in 48 (88.9%) and 42 (77.8%) patients respectively whereas pruritis and fever were present in 27 (50%) and 11 (20.4%) patients respectively. Choledocholithiasis/sludge was accurately diagnosed in 8 out of nine patients. Ultrasound only diagnosed 50% of the patients with Peri-ampullary tumors and pancreatic carcinoma accurately; sonographic finding of a distal CBD stricture without any definitive diagnoses were noted in the rest of the patients. Ultrasound was very accurate in determining the etiology of various proximal CBD lesions. In the 4 patients with mid-CBD strictures on ultraosound, 2 were found to have gall bladder carcinoma, 1 common hepatic duct stricture and 1 acute pancreatitis- diagnoses which are not usually possible on ERCP. Of the 3 patients with Cholangiocarcinoma, 2 cases had been suspected to have this diagnosis on ERCP and ultrasound alike while the third one had a mid-CBD stricture on ultrasound. Ultrasound findings had complete concordance with the ERCP diagnoses in cases of post-cholecystectomy strictures, fistulas and CBD ligation. Conclusion: Ultrasound was very accurate in determining the etiology of various proximal CBD lesions. The accuracy of Ultrasound in determining the etiology of distal biliary obstructive processes is significantly lower but is useful as inital investigation. Abdominal ultrasound and ERCP are complementary investigations in patients with obstructive jaundice.