Duct Stricture Research Articles

Balloon Dilation and Triple Catheter Placement Technique for Treatment of Proximal Biliary Stenosis

Introduction: Post-surgical bile duct lesions occurred in approximately 0.5% of cholecystectomies and are associated with high mortality. These lesions include leaks, stenosis, removal of part of the duct and arterial injury. Percutaneous and endoscopic approaches can definitely treat biliary lesions. Objective: To present the experience of a clinical case where percutaneous interventional treatment of a bile duct stenosis with cholangioplasty and placement of tutors was performed in a single time. Methods: 79-year-old male with a history of high blood pressure, left cerebrovascular accident, open cholecystectomy 20 years ago and bile duct stenosis. tomography with contrast that showed proximal extrahepatic bile duct stenosis Bismuth II. An endoscopic cholangiopancreatography is performed that identifies the bile duct stenosis and an attempt is made to place a stent while passing a guide, but the catheter device cannot be placed through the diameter of the stenosis. Interventional radiology performs a percutaneous cholangiophraphy identifying the stenosis and performs balloon expansion of the same and inserts a biliary silicone drain along with two 8 fr and 10 fr tutors handcrafted from multipurpose drainage catheters (Cook medical) in parallel at the level of stenosis (maximum diameter 20 Fr) Outcome: patient presented a favorable evolution after the procedure, presented as a minor complication an acute renal injury that resolved with observation Conclusion: Percutaneous treatment with balloon dilation and the use of tutors at the level of stenosis was safe and successful in our patient.

Treatment with Everolimus for Bile Duct Stenosis after Liver Transplantation

Background: Treatment of antibody mediated rejection (AMR) in post-liver transplant management has not been established at present. In some cases, it has been reported that everolimus (EVR) inhibits worsening of chronic rejection, and there is great expectation for the efficacy of EVR for chronic rejection.

Primary endoscopic bile duct stone removal for severe acute cholangitis: a retrospective study.

Introduction:While the Tokyo Guidelines 2018 suggest primary stone removal for mild to moderate cholangitis, a guideline for severe acute cholangitis is not mentioned. We, therefore, investigated the clinical outcomes of patients with severe acute cholangitis to confirm the usefulness and safety of primary stone removal.Method:This study included 104 severe acute cholangitis patients without gallstone pancreatitis diagnosed at our institution between January 2014 and December 2020. Patients with percutaneous transhepatic biliary drainage as the primary drainage, bile duct stenosis, and endoscopically unidentified bile duct stones were excluded from this study. The clinical results of 14 patients with primary stone removal (primary group) and 23 patients with elective stone removal (elective group) were then retrospectively examined (excluding abnormal values due to underlying diseases).Results:Upon comparing the patient characteristics between groups, the elective group had significantly higher cardiovascular dysfunction (57% vs 7%; p = 0.004), septic shock (39% vs 0%; p = 0.006), disseminated intravascular coagulation treatment (57% vs 14%; p = 0.016), and positive blood cultures (91% vs 43%; p = 0.006) than those in the primary group. Endoscopic sphincterotomy for naïve papilla (90% vs 21%; p = 0.01) and endoscopic nasobiliary drainage (50% vs 9%; p = 0.014) were higher in the primary group, while endoscopic biliary stenting (7% vs 87%; p < 0.001) was lower than that in the elective group.Discussion:There were no significant differences in adverse events or complete stone removal rates between the two groups. In the primary group, the period from the first endoscopic retrograde cholangiopancreatography to stone removal (0 days vs 12 days; p < 0.001) and hospitalization period (12 days vs 26 days; p = 0.012) were significantly shorter and the hospitalization cost ($7731 vs $18758; p < 0.001) was significantly lower than those in the elective group.Conclusion:If patients are appropriately selected, bile duct stones may be safely removed for the treatment of severe acute cholangitis.

Diagnosis and treatment modalities of hilar biliary duct stricture in hepatic cystic echinococcosis after endocystectomy.

Aim: Hilar biliary duct stricture may occur in hepatic cystic echinococcosis (CE) patients after endocystectomy. This study aimed to explore diagnosis and treatment modalities. Methods: Clinical data of 26 hepatic CE patients undergoing endocystectomy who developed postoperative hilar biliary duct stricture were retrospectively analyzed and were classified into three types: type A, type B, and type C. Postoperative complications and survival time were successfully followed up. Results: Imaging showed biliary duct stenosis, atrophy of ipsilateral hepatic lobe, reactive hyperplasia, hepatic hilum calcification, and dilation or discontinuity of intrahepatic biliary duct. All patients received partial hepatectomy to resect residual cyst cavity and atrophic liver tissue, and anastomosis of hepatic duct with jejunum or common bile duct exploration was applied to handle hilar biliary duct stricture. Twenty-five patients were successfully followed up. Among type A patients, one patient died of organ failure, and upper gastrointestinal bleeding and liver abscess occurred in one patient. Moreover, calculus of intrahepatic duct was found in one type B and type C patient. Conclusion: Long-term biliary fistula, infection of residual cavity or obstructive jaundice in hepatic CE patients after endocystectomy are possible indicators of hilar bile duct stricture. Individualized and comprehensive treatment measures, especially effective treatment of residual cavity and biliary fistula, are optimal to avoid serious hilar bile duct stricture.

Palliative surgical treatment of patients, suffering proximal tumoral affection of biliary ducts and the jaundice syndrome

Objective. To compare the efficacy of methods of miniinvasive palliative treatment of malignant hilar strictures with the jaundice syndrome.&#x0D; Materials and methods. Into the investigation 71 patients, suffering proximal obturation jaundice of tumoral genesis, were included. The patients were divided into three Groups: Group I - 26 patients, to whom external-internal suprapapillary cholangiostomy was done; Group II - 28 patients, in whom transcutaneous transhepatic antegrade endobiliary stenting was performed; Group III -17 patients, to whom endoscopic retrograde biliary stenting was accomplished.&#x0D; Results. Technical success in all the Groups have constituted 100%; clinical one - in 94.0%: in Group I - 96.2%, in Group II - 89.3%, and in group III - 82.4% (p&gt;0.05). In Group I general rate of morbidity was lesser, including cholangitis and pancreatitis. The duration of cholangitis was lesser as well. Cumulative survival were the highest in Group of patients, to whom external-internal suprapapillary cholangiostomy was performed (135 days at average), while the least one - in Group of the patients, in whom endoscopic retrograde biliary stenting was done (90,6 days). In Group of patients, to whom transcutaneous transhepatic antegrade endobiliary stenting was performed, this index have constitited 101.2 days.&#x0D; Conclusion. In proximal strictures of biliary ducts of tumoral genesis on background of jaundice the priority method of palliative treatment must be external-internal suprapapillary cholangiostomy, while the second-line of surgical treatment must constitute transcutaneous transhepatic antegrade endobiliary stenting. Endoscopic retrograde biliary stenting owes the lowest priority.

Primary Two-Layered Closure of the Common Bile Duct Reduces Postoperative Bile Leakage After Laparoscopic Common Bile Duct Exploration.

Objective: The effectiveness and feasibility of the primary closure after laparoscopic common bile duct exploration (LCBDE) have been well demonstrated, however, the incidence of postoperative bile leakage after LCBDE remains high. The current study aimed at investigating whether our new suturing method could reduce the risk of bile leakage after LCBDE. Materials and Methods: This retrospective study included 81 patients who underwent primary two-layered closure or traditional primary closure of the common bile duct (CBD) after LCBDE, and the related clinical data were compared and analyzed. Results: The primary two-layered closure group had a lower rate of bile leakage compared with the traditional primary closure group (P < .05). There were no significant differences in additional parameters, such as operative time, estimated blood loss, postoperative stay duration, time to drain removal, postoperative pancreatitis, stone recurrence, and overall morbidity. No patients developed bile duct stenosis during the follow-up period. Conclusions: Primary two-layered closure of CBD can reduce the postoperative bile leakage after LCBDE. Moreover, it is a safe and effective therapeutic option for patients with choledocholithiasis.

Endoscopic Ultrasonography Diagnosis of Early Pancreatic Cancer.

Early diagnosis of pancreatic cancer (PC) can improve patients’ prognosis. We aimed to investigate the utility of endoscopic ultrasonography (EUS) for the early diagnosis of PC. This study included 64 patients with PC at an early stage treated at Onomichi General Hospital between January 2007 and January 2020. Diagnostic procedures included contrast computed tomography (CT), magnetic resonance cholangiopancreatography, EUS fine-needle aspiration, and endoscopic retrograde cholangiopancreatography (ERCP) for pancreatic juice cytology. The mean age was 71.3 years. In all, 32 patients were stage 0, and 32 were stage I. As for image findings, the main pancreatic duct (MPD) stenosis was detected in several cases, although CT and MRCP seldom detected tumors. EUS had a high detection rate for stage 0 tumor lesions. The median observation period was 3.9 years. In cases with stage 0, the 1 year and 5 year survival rates were 100% and 78.9%, respectively. In cases with stage I, the 1 year and 5 year survival rates were 96.4% and 66.7%, respectively. EUS has the highest sensitivity among all imaging modalities for detecting small pancreatic tumors. Cases with MPD dilation or stenosis, especially with tumors that cannot be identified on CT and MRI, should have EUS performed. In some cases, EUS was not able to detect any tumor lesions, and ERCP-based pancreatic juice cytology should be useful for pathological diagnosis.

Complications of Laparoscopic Choledochotomy and Lithotomy for Primary Suture

Objective: To explore the non-placement of “T�?tube after laparoscopic choledochotomy. feasibility and complication analysis of primary suture bile duct. Methods: Retrospective analysis of January 2013~ December 2016, Laparoscopic choledocholithotomy for primary bile duct suture in 87 cases, Combined with literature, the indications, methods and complications of the operation were summarized and analyzed. Results: There was no operative death in the whole group, Postoperative complications occurred in 5 cases (5.7%), 1 case with jaundice, gradually subsided after 4 days of conservative treatment. Two cases had postoperative bile leakage, to prolong the drainage time of the peritoneal drainage tube and stop by itself. In 1 case, bile duct stenosis occurred. 1 case of residual common bile duct stones. The average postoperative hospitalization was 9 days. Conclusion: Select the right case strictly, Patient and delicate operation, Laparoscopic choledochotomy is safe and feasible.

Risk factors for development of endocrine insufficiency in chronic pancreatitis

Endocrine insufficiency is a common and frequent complication of chronic pancreatitis. Identifying the role of pancreatic damage in the development of diabetes is important for early identification and appropriate management. MethodsAll consecutive CP patients between January 2019 and May 2020 were retrospectively studied. Relevant statistical tests were performed. A two sided p value < 0.05 was considered statistically significant. ResultsTotal 587 chronic pancreatitis patients were included of which 118 (20.1%) patients developed diabetes with duration of 12 (IQR 4–48) months. Older age (OR 1.079; 95% CI 1.045–1.113; p < 0.001), presence of pancreatic parenchymal (OR 2.284; 95% CI 1.036–5.038; p = 0.041) and ductal (OR 2.351; 95% CI 1.062–5.207; p = 0.035) calcifications, exocrine insufficiency (OR 6.287; 95% CI 2.258–17.504; p < 0.001), and pancreatic duct stricture (OR 3.358; 95% CI 1.138–9.912; p = 0.028) were independently associated with development of diabetes mellitus in chronic pancreatitis patients. On cox-regression analysis, smoking (HR 2.370; 95% CI 1.290–4.354; p = 0.005) and pancreatic ductal calcification (HR 2.033; 95% CI 1.286–3.212; p = 0.002) were independently associated with earlier onset of diabetes mellitus in patients with chronic pancreatitis. ConclusionPancreatic calcification, pancreatic duct stricture and pancreatic exocrine insufficiency are associated with development of diabetes mellitus in chronic pancreatitis indicating disease progression. Smoking is the modifiable risk factors associated with early onset of diabetes mellitus in CP patients.

The holmium:YAG laser lithotripsy-a non-invasive tool for removal of midsize stones of major salivary glands.

Incorporeal lithotripsy by using holmium:YAG laser has been recently successfully spread and used in the treatment of urolithiasis. Although this method is not as common in salivary gland surgery, it is also recommended for endoscopic treatment of sialolithiasis. In this study, we decided to analyse effectiveness of holmium:YAG laser method among patients with midsize stones as the treatment in this particular population is still not determined and remains in dispute. Thus, the primary aim of the study is a prospective, complex analysis of incorporeal holmium:YAG laser lithotripsy effectiveness and safety in patients suffering from sialolithiasis. The examined group consisted of 32 consecutive patients, 17 female (53%) and 15 male (47%). The average age was 42 (age range 22-70). In our series, sialoendoscopy with intraductal lithotripsy was performed in patients with wide range of stone's diameter (3 to 10mm). The calculi were removed with foreign body forceps or retrieval basket, after stone fragmentation with holmium:YAG laser. The power of the laser during surgery was set at 2.5 to 3.5W. One shot energy equalled 0.5-0.7J with frequency of 5Hz. The bivariate Pearson Correlation and a point-biserial correlation were used to analyse the data. Total success rate of holmium:YAG laser lithotripsy in this consecutive group was equal to 90% and efficacy in the group with excluded cases when endoscopic approach difficulties were experienced (stone not visible) reached 93%. The long-term follow-up revealed that in 26 patients (84%), complete recovery was achieved. Two patients developed Wharton's duct stenosis and one Stensen's duct orifice stenosis (9.5%), of whom one required reoperation. Two patients eventually underwent total excision of submandibular gland. Sialoendoscopy combined with incorporeal laser-assisted lithotripsy proved to be effective and safe method for treatment of sialothiasis with midsize stones (4-8mm) in population of clinic. Even taking into account the prevalence of complications associated with holmium:YAG laser, it is still safer alternative compared to open surgery where there is a significant risk of the bleeding, wound infection or injury of the facial nerve.

Sialographic Analysis of Radioiodine-Associated Chronic Sialadenitis.

To apply a novel sialography classification system to identify parotid and submandibular ductal findings following I-131 therapy and to assess correlates to dose and duration of symptoms. Retrospective single-center case series. Patients who underwent sialography between February 2008 and February 2019 after previously receiving I-131 treatment were identified via a retrospective chart review. Their sialograms were systematically evaluated and scored by applying the Iowa parotid sialogram scale to also include submandibular gland analysis. From 337 sialograms, 30 (five submandibular, 25 parotid) underwent analysis. Ductal stenosis was identified in all sialograms and was graded as moderate (>50%-75%) in 7/30 cases and severe (>75%) in 15/30 cases. The distal (main) duct was narrowed in 23/30 cases. No association was identified between degree of ductal stenosis and I-131 dose (P = .39), age (P = .81), or time from I-131 therapy to sialogram (P = .97). The Iowa parotid sialogram scale was successfully applied to report abnormalities of the parotid and submandibular ductal system. The most common manifestation of I-131-associated sialadenitis was a severe stenosis within the distal salivary duct. No statistically significant association was found between degree of ductal stenosis and dose of I-131, age, or duration of symptoms. 4 Laryngoscope, 131:E1450-E1456, 2021.

Identification Of Liver Fluke Eggs In Bile Duct Brush Cytology In An 82 Year Old Man With A Hepatic Mass: Report Of A Case

Abstract Introduction/Objective Clonorchis sinensis infects the liver, gallbladder, and bile ducts in humans. It is acquired via consumption of raw/undercooked fish, crabs, or crayfish in endemic areas. Though majority are asymptomatic, long lasting infections may cause severe disease. Without treatment, human infections may persist for the parasite lifespan (25–30 years). Diagnosis in cytology is challenging with a potentially acellular sample with miniscule eggs that can be overlooked as an artifact. Here we reported a rare case of liver fluke eggs diagnosed in bile duct brush cytology. Methods An 82 year old man who emigrated from China 20 years prior presented to the hospital with worsening jaundice for 2 weeks. Abdominal CT revealed a 4.8 x 2.9 cm central right hepatic lobe mass extending to the hilum, obstructing the bile ducts, resulting in severe intrahepatic ductal dilatation and stricture and focal occlusion of the right anterior portal vein. His CBC revealed eosinophilia. Bile duct brushing was submitted for cytology. Results ThinPrep and cell block showed oval-shaped parasite eggs measuring 10-24 µm. There was no other cellular matter. Eggs had a convex operculum resting on “shoulders” at the smaller end of the egg. At the opposite (abopercular) end, a small knob or hook-like protrusion was often visible. Wet mounts revealed visible miracidium inside the eggs. These findings were compatible with liver fluke eggs. Conclusion Cytologic microbiologic features of fluke eggs confirmed the findings. The most important features are the shape and size of the eggs; The seated operculum with its prominent “shoulders”, a small knob at the abopercular end, which can distinguish them from acellular artifact or a human cell. The cytologic and microbiologic features combined with the travel history and clinical presentation can aid in achieving the diagnosis.

Role of Sialendoscopy in Non-neoplastic Parotid Diseases: A Prospective Study of 241 Patients in Indian Population.

To assess the role of sialendoscopy as a diagnostic modality and in managing cases of non-neoplastic parotid gland diseases. Secondly, to provide descriptive analysis of intraoperative findings. The patients of chronic parotid sialadenitis who presented with complaints of recurrent unilateral or bilateral parotid swelling and pain were included in the study. All patients underwent sialendoscopy, and the findings were noted. Intervention was carried out in the same sitting like dilatation of stenosis, stone removal by basket, combined approach, flushing of mucoid flakes, etc. Failed cases were worked up with radiological investigation and managed accordingly. Two hundred and forty-one cases of parotid sialadenitis who underwent sialendoscopy between 2012 and 2018 were included. Diagnostic sialendoscopy was achieved in 100% cases, while intervention was successful in 96.7% (233/241) cases after the first procedure. On diagnostic sialendoscopy, ductal stenosis was the most common pathology present in 177 (73.4%) patients followed by stones (12%) and debris (11.6%). All cases of stenosis were serially dilated with increasing sizes of sialendoscopes followed by stenting in 75% of the cases. The diagnosis of juvenile recurrent parotitis was confirmed in 17 children (mean age 5.6years) with consistent clinical history and sialendoscopic findings of stenosis along with pale ductal mucosa. There were 18 cases where ductal perforation was seen. One case showed multiple hyperdense foci in bilateral parotid gland along with multiple strictures that underwent repeat sialendoscopy, but the symptoms did not resolve, and finally the patient underwent bilateral superficial parotidectomy. Sialendoscopy is a safe and highly effective modality in managing non-neoplastic parotid gland disorders with low complication rates and resulted in gland preservation in the vast majority of patients. Therefore, it can be concluded that sialendoscopy is the diagnostic and therapeutic modality of choice for parotid obstructive sialadenitis.

Performance of digital single-operator cholangiopancreatoscope for biliopancreatic diseases in real life: results from a prospective multicenter study

Objectives Peroralcholangio-pancreatoscopy (POCP) is used for diagnosis and treatment of biliopancreatic disease when standard endoscopy (ERCP) or pre-operative imaging workup failed. We aimed to evaluate the diagnostic and therapeutic performance of POCP in complex biliary and pancreatic diseases. Materials and methods Patients with indeterminate biliary or pancreatic duct (PD) strictures, and patients with failure of complex biliary or pancreatic stones removal, were enrolled (six centers). The primary endpoint evaluated malignancy diagnostic performances (accuracy, sensitivity, specificity) and therapeutic performances (biliary or pancreatic stones extraction). Secondary endpoints evaluated: technical success in lesion visualization, ease of maneuvering, image quality and 30-days complications. Results From November 2016 to March 2018, 66 patients were included: 29/37 women/men, median age (IQR): 73 (64–82). Fifty-three patients had diagnostic POCP and 13 patients therapeutic POCP. One endoscopist with one or two endoscopy nurses performed 94% of the POCP. The ‘POCP visual impression’ of malignancy showed 92.0% sensitivity, 92.9 % specificity and 92.5 % overall accuracy compared with the final diagnosis. ‘POCP-guided samples histological analysis’ showed 75.0 % sensitivity and 91.6% specificity. The technical success for lesion visualization was 98.5%. The median VAS scores for insertions in bile and PD were respectively 9.0 (8.1–9.6) and 9.0 (8.8–10.0). Median VAS score for access to the lesion and image quality were respectively 9.0 (7.7–9.6) and 9.0 (7.9–9.7). Only three 30-day minor complications occurred without any major complications. Conclusions POCP was an effective, safe and easy-to-use tool in routine clinical practice for the management of complex diagnostic and therapeutic biliary and pancreatic diseases (NCT03190343).

Efficacy of probing adjunctive with low-dose mitomycin-C irrigation for the treatment of epiphora in adults with nasolacrimal duct stenosis.

PURPOSE:The purpose of the study was to investigate the efficacy of adjunctive low-dose mitomycin-C (MMC) during successful lacrimal duct probing in adults with nasolacrimal ducts (NLDs) stenosis.MATERIALS AND METHODS:This is a prospective case–control study on patients with NLD stenosis who were randomized into two groups. All patients underwent probing without or with an application of MMC. Former group received 0.2 mg/ml MMC irrigation for 5 min. The main outcome measures were objective evaluation of patency with irrigation, as well as patients' subjective assessment of improvement.RESULTS:There were 73 eyes in 58 consecutive patients; patient mean age ranged from 19 to 78 years (mean 44 years). Female included larger group of patients (63%) and mean duration of the symptoms was 26.1 months (range, 2–120 months). After mean follow-up of 11 months (range, 9–14 months), 23 (60%) of the 38 eyes in the MMC groups and 8 (22%) of the 35 eyes in control group had complete response and remained symptom free. This difference was statistically significant (P = 0.005). According to the patient's satisfaction, epiphora was partially improved in 6 (17%) eyes of control group and 4 (10%) eyes in MMC group. Application of MMC has a better outcome in patients with severe stenosis (P = 0.007); patients who had symptoms more than 12 months (P = 0.02) and patients with constant epiphora were compared with intermittent symptoms (P = 0.001). No complications were detected during patients follow-up.CONCLUSION:This study suggests acceptable long-term results for probing adjunctive with MMC irrigation for adults with NLD stenosis that can be recommended as a simple and effective procedure for these patients.

Transpapillary tissue sampling of biliary strictures: balloon dilatation prior to forceps biopsy improves sensitivity and accuracy

The early and definitive diagnosis of malignant bile duct stenoses is essential for a timely and adequate therapy. However, tissue sampling with transpapillary brush cytology (BC) or forceps biopsy (FB) remains challenging. With this study, we aimed to compare the effectiveness and safety of different tissue sampling modalities (BC, FB without/after previous balloon dilatation). Standardized database research identified all patients, who underwent endoscopic retrograde cholangiography with BC and/or FB for indeterminate bile duct stenosis between January 2010 and April 2018 and with a definitive diagnosis. 218 patients were enrolled (149 cases with malignant and 69 with benign disease). FB had a significant higher sensitivity than BC (43% vs. 16%, p < 0.01). Prior balloon dilatation of the stenosis improved the sensitivity of FB from 41 to 71% (p = 0.03), the NPV from 36 to 81% (p < 0.01) and the accuracy from 55 to 87% (p < 0.01). The complication rates did not differ significantly between the modalities. In our center FB turned out to be the diagnostically more effective procedure. Balloon dilatation of the stenosis before FB had a significant diagnostic benefit and was not associated with a higher complication rate.

S1525 Bilothorax: A Rare Complication of Transarterial Chemoembolization of Hepatocellular Carcinoma

INTRODUCTION: A Bronchobiliary fistula (BBF) is an abnormal communication between the bronchial system and the biliary tree. When this occurs, the direct flow of bile from the biliary system to the pleural space can lead to increased lung parenchymal irritation and subsequent inflammatory response with coughing up of bile, also known as bilioptysis. CASE DESCRIPTION/METHODS: A 71-year-old man presented with a five-day history of coughing up greenish watery fluid. He was diagnosed with Hepatocellular Carcinoma years prior and underwent transarterial chemoembolization a month prior. Work up revealed polymicrobial bacteremia and computed tomography (CT) of the chest revealed right lower lobe patchy consolidations. He had minimal improvement with aggressive antibiotics thus repeat CT was done which revealed a right lower lobe abscess immediately adjacent to the hepatic tumor along the liver (Figure 1). Subsequent hepatobiliary iminodiacetic acid scan then confirmed a communication between the biliary tract and lungs as evidenced by leakage of the radiotracer in the bronchi and trachea (Figure 2). Symptoms resolved after targeted antibiotic therapy, fistula resection, adhesiolysis, and intraabdominal abscess drainage. Repeat Imaging showed resolution of bilothorax (Figure 3). DISCUSSION: Bronchobiliary fistula is the most reported cause of Bilothorax. The mechanism of BBF remains unclear however, biliary obstruction and adhesions may be contributing factors. In our case, the common bile duct and pancreatic duct were likely dilated due to a mechanical effect from a mass in the head of the pancreas or ductal strictures from radioablative therapy. Local inflammation causes adhesions from multiple TACE procedures which promotes recurrent sub-diaphragmatic collections. The increased intraluminal pressure in the biliary system with an adjacent hepatic abscess may have caused diaphragmatic invasion with rupture into the pleural space and subsequent erosion into the bronchial tree causing bilothorax and eventual bilioptysis. Resection of the tumor and fistula tract is recommended but it is associated with a high mortality rate. Decompression of the biliary system can be achieved by endoscopic placement of biliary stents, percutaneous transhepatic biliary drainage or percutaneous drainage of hepatic collections. In cases of recurrent BBF despite non-surgical interventions, percutaneous bronchial embolization shows promise with closure of the distal bronchi near abscess.Figure 1.: Computed tomography of the chest: Right lower lobe pneumonia with air fluid levels indicating an abscess (arrow) immediately adjacent to a hepatic tumor with abscess (arrowhead) along the dome of the liver.Figure 2.: Hepatobiliary iminodiacetic acid scan showing radiotracer uptake in the bronchi and trachea. This is consistent with a fistula between the hepatic and pulmonary abscess.Figure 3.: Computed tomography of the chest demonstrating radiologic resolution of findings after surgical intervention.

Drenaje biliar guiado por ultrasonografía endoscópica en la obstrucción biliar maligna, experiencia inicial en un centro de Argentina. Serie de casos

When endoscopic retrograde cholangiopancreatography (ERCP) fails or is not feasible for drainage of the bile duct, endoscopic ultrasound-guided biliary drainage (EUS-BD) is a viable option. This technique of drainage has a lower complication rate and a better quality of life concerning percutaneous or surgical drainage. The aim of this work is to show our initial experience in this technique, in patients with malignant bile duct stenosis, in a referral centre. We performed a descriptive study of case series. Five patients with obstructive jaundice of neoplastic origin, in whom ERCP drainage was not feasible, were included EUS-BD was performed. Technical success of 100% was achieved in all cases and clinical success in four cases (80%). Post-procedural bleeding occurred in one patient, and two late complications: infection and prosthetic migration, all of which were resolved with conservative treatment. No serious adverse events were recorded. EUS-BD is a feasible and effective treatment option in selected cases particularly in cases of malignant biliary obstruction, with high technical and clinical success rates. Complications are usually mild and resolve conservatively.

Colon cancer metastasis mimicking a hilar cholangiocarcinoma: a case report and literature review

BackgroundAn accurate diagnosis of the primary cancer or metastatic tumor is quite important because misdiagnosis may lead to the selection of incorrect adjuvant therapy and worse long-term outcomes after surgery. Here, we present a rare case with an unusual metastatic pattern mimicking a hilar cholangiocarcinoma originated from colon cancerCase presentationA 69-year-old man was referred to our hospital because of an upper bile duct stenosis. He had the past history of the sigmoidectomy for the primary colon cancer and the partial hepatectomy with radiofrequency ablation (RFA) for synchronous liver metastases 4 years ago. After 2 years from the initial operation, he had experienced the local recurrence of post-RFA lesion and had undergone a partial hepatectomy. According to the radiological findings of the bile duct stenosis, we diagnosed a hilar cholangiocarcinoma (Bismuth type II), and then he underwent the extended right hepatectomy with extrahepatic bile duct resection. Histological findings including the immune-histochemical examinations (CK7−, CK20+, CDX2+ and SATB2+) uncovered the metastatic tumor into extrahepatic bile duct originated from the primary colon cancer.ConclusionWe experienced an extremely rare case with a colon cancer metastasis mimicking a hilar cholangiocarcinoma. In this case with a past history of colon cancer, an immunohistochemical staining led us to distinguish the primary hilar cholangiocarcinoma and the mimicking tumor.

Real-world Evidence of Diffusion-weighted Imaging Combined With Magnetic Resonance Cholangiopancreatography for Pancreatic Tumor Screening: A Cross-Sectional Diagnostic Accuracy Study.

The aim was to clarify the sensitivity and specificity of diffusion-weighted imaging, as well as of that in combination with magnetic resonance cholangiopancreatography for pancreatic tumor diagnosis in real-world clinical setting. Subjects were 217 consecutive patients who underwent both magnetic resonance imaging and contrast-enhanced ultrasound sonography. Cases positive for a pancreatic tumor were confirmed based on pathological diagnosis, whereas negative cases were defined when no solid pancreatic tumor was detected by contrast-enhanced ultrasound sonography or a solid mass was detected but the diagnosis was ultimately denied based on pathological results. Diffusion-weighted imaging-positive was defined as a case with high signals and magnetic resonance cholangiopancreatography-positive when localized main pancreatic duct stenosis with caudal dilation was detected.We calculated sensitivity and specificity of each modality and those in combination based on sequential use for pancreatic tumor diagnosis. Diffusion-weighted imaging showed a sensitivity of 94.4% and specificity of 94.5%, whereas those values for magnetic resonance cholangiopancreatography alone were 83.3% and 99.0%, respectively, and for the modalities in combination were 100% and 94.5%, respectively. Diffusion-weighted imaging was more sensitive than magnetic resonance cholangiopancreatography, whereas those used in combination resulted in increased sensitivity.