End Of Common Bile Duct Research Articles

Common bile duct web: Managed with excision and primary anastomosis of bile duct over ERCP stent

Congenital biliary web formations are extremely rare, with only a few cases reported till date in the literature. We report a case of a four years old female child, presented to us for evaluation of jaundice and recurrent attacks of cholangitis. Intra-operatively, we found a nodular mass near the distal end of common bile duct causing extrinsic compression on extra-hepatic biliary tree. Biopsy revealed reactive lymphoid hyperplasia. Four weeks after the first surgery a second procedure was planned. The child then underwent exploratory laparotomy with resection of common bile duct web and anastomosis over an ERCP (Endoscopic retrograde cholangiopancreatography) stent. The reported treatment for biliary web commonly consists of Roux-en-Y hepatico-jejunostomy, excision of the diaphragm with t-tube insertion or excision of the web with a cholecystectomy. However, we performed excision of the web and primary anastomosis of CBD (Common Bile Duct) over an ERCP stent preserving native common bile duct.

Pay attention to endoscopic diagnosis and treatment for confluence disease of pancreaticobiliary ducts

The confluence of pancreaticobiliary ducts refers to the area between the end of common bile duct, the opening of main pancreatic duct and duodenal papilla. Those confluence diseases of pancreaticobiliary ducts will cause obstruction of biliary and pancreatic outflow tract, cholestasis, pancreatic juice deposition or pancreaticobiliary reflux, and thus induce gallstones, cholangitis, pancreatitis and other diseases. Endoscopic ampullary sphincterotomy is an important way to treat biliary and pancreatic diseases, but the length of incision is determined by the anatomy of Oddi sphincter. The endoscopic approach aims to relieve biliary and pancreatic outflow tract obstruction and pancreatic biliary reflux, and avoid enterobiliary reflux.

Clinical characteristics and risk factors of congenital choledochal cysts

Objective To investigate the clinical characteristics and risk factors of congenital choledochal cysts (CCC). Methods This retrospective study recruited 52 cases who were antenatally diagnosed with CCC and underwent surgical treatment after birth in Guangdong Women and Children Hospital from January 2013 to August 2018, with complete clinical data. According to the enlargement of cysts during pregnancy, they were divided into two groups: progressive group (≥15 mm, 22) and stable group (<15 mm, 30). Antenatal and postpartum ultrasound and MRI features of the two groups were analyzed. Clinical manifestations and biochemical examination results before and after operation were compared between the two groups. Other data, including amylase level in cyst fluid during operation, cholangiography findings, liver biopsy results, and post-operation follow-up, were also analyzed. Chi-square test, t (t') test, and Pearson correlations tests were performed for data analysis. Results (1) The average age of the 52 patients at operation was 46(7-822) d. The cysts of all cases were first detected during 19-21 weeks of gestation. The maximum diameter of the cyst in the progressive group was larger than that in the stable group after 34 weeks of pregnancy [31-34 weeks: (31.1±8.4) vs (23.1±6.6) mm, t=3.911; >34 weeks: (36.1±6.8) vs (27.1±7.3) mm, t=4.557; pre-operation: (51.8±18.0) vs (34.0±15.6) mm, t=3.809; all P<0.01]. (2) In the progressive group, the cysts were irregular in shape and enlarged after birth. The common hepatic duct and intrahepatic bile duct were dilated and gradually distended after birth, while the distal end of the common bile duct was narrowed, thus to form a cone-like duct. Deposits could be seen inside the cysts after delivery. Irregular cysts were also presented in the stable group, and five of them had dilatation of common hepatic duct and intrahepatic bile duct after birth. However, no cone-like formation was seen, the distal end of the common bile duct was visible, and deposits in cysts were occasionally found. (3) Twenty-five patients underwent laparotomy, and seven of them showed increased amylase level in cyst fluid including four with 2-5 times above the upper limit of normal value (one in the progressive group and three in the stable group). The other three cases were all in the stable group and their amylase levels in cyst fluid were more than ten times of the upper limit. The level of direct bilirubin in the progressive group was higher than that in the stable group before the operation [18.40(2.50-113.30) vs 8.70(0.00-16.80) μmol/L, u=2.400, P<0.05]. (4) Among the 52 cases, patients with type Ⅰ, Ⅳ and Ⅴ cyst accounted for 71.1% (37/52), 26.9% (14/52) and 2.0% (1/52), respectively. All cases were followed up regularly six months to one year after the operation. Liver function and bilirubin became normal and the growth and development of the babies were similar to those of the same age. (5) Different degrees of liver fibrosis and inflammation were shown in 46(88.5%) cases and more severe in older babies among those who underwent surgery in the progressive group. The time at operation was not associated with the severity of liver fibrosis and inflammation in the stable group. Hepatic fibrosis and inflammation were more serious in the progressive group than in the stable group (fibrosis grading: χ2=14.260, P=0.006; inflammatory activity grading: χ2=9.904, P=0.019). Conclusions Larger diameter (≥30 mm) in the initial prenatal examination or a significant increase in cystic diameter (≥15 mm) during pregnancy are risk factors for early stenosis or occlusion in the distal end of common bile duct requiring close follow-up after birth. When jaundice or abnormal liver function occur and stool color becomes light, early surgical treatment (one to two months after birth, generally within three months) for CCC is recommended to rule out the anomalous union of the pancreaticobiliary duct and hepatic disorders, as well as the cystic biliary atresia. Key words: Choledochal cyst; Ultrasonography, prenatal; Risk factors

Retraction: Small Intestinal Tumors: A Rare Case of Tubulovillous Adenoma in Duodenum.

[This retracts the article DOI: 10.7759/cureus.4671.].

胆总管探查改良自行脱落胆管支架引流与T管引流的比较

目的：探讨胆总管探查T管引流的替代方法。方法：胆总管结石患者采用开腹手术，进行胆总管切开探查取石后，通过导丝将蝴蝶结形可自行脱落支架管的远端置入十二指肠，胆总管切口一期缝合。结果：该法治疗31例患者，选择同期完成的放置T管引流30例患者作为对照组；术后平均住院时间分别为9.1 d和14.9 d (P < 0.05)，两组近期并发症及肝功能水平无明显差异。全部支架管自行脱落并随粪便排出，支架排出时间为(13.8 ± 2.91) d。结论：胆总管探查术中在胆总管下端放置蝴蝶结形可自行脱落支架管是T管引流的有效替代方法，可减少T管引流的相关并发症。 Objective: To explore the alternative methods of T-tube drainage in common bile duct exploration. Methods: Open common bile duct exploration (OCBDE) was done in patients with common bile duct (CBD) stones. After extraction of stones, the bowknot-liked stent was pushed into the distal part of the bile duct and lumen of the duodenum over a guide wire. The CBD incision was primarily closed. Results: This technique was used in 31 patients. While T-tube placement was performed in 30 patients of control group. The average postoperative hospital stay was 5.7 and 9.5 days (P < 0.05). There was no difference between the two groups on both the early postoperative complications and liver function. All the stents had been discharged with stool. The average time of the stent discharge was (13.8 ± 2.91) postoperative days. Conclusion: During OCBDE, it was an efficient alternative method to place the bowknot-liked stent at the lower end of common bile duct. It can reduce the complications related to T-tubes.

Successful removal of a giant hemolymphangioma of the duodenum and the head of pancreas in a 15-year-old male patient with pancreatoduodenectomy: a case report and literature review

Duodenum and pancreas hemolymphangioma is a type of rare benign neoplasm. Pancreatoduodenectomy (PD) is a procedure known to be associated with high risk of complication. A review of literature published before December 2015 found only five hemolymphangioma cases that were treated with PD. We presented a case of a hemolymphangioma in a 15 years old male patient with a tumor of 16×11×8 cm3 in size localized at the duodenum and pancreatic head. The patient had intermittent epigastric pain for 2 weeks before he was admitted to our hospital. Physical examination showed a huge mass in the right upper abdomen. Computed tomography (CT) indicated that the lower end of common bile duct and the second part of duodenum were extrinsically surrounded by a large retroperitoneal tumor. PD was performed and tumor was removed completely. Post-surgical diagnosis confirmed the tumor originated from duodenum and pancreas. There were no major complications in perioperative period, and the patient was discharged at the 14th day post-surgery. The patient was in good physical condition during follow-up visit 6 months after surgery. In conclusion, although PD is a procedure with high risk of postoperative complications, for some cases with benign lesions, it can still be a choice for a complete excision, which can significantly decrease the opportunity of recurrence and increase the rate of cure.

Laparoscopic management of antenatally detected choledochal cyst: a 10-year review.

The aim of this review was to study the characteristics and the outcome of children who underwent laparoscopic management of the antenatally detected choledochal cyst. A retrospective review was conducted for all children who underwent excision of antenatally detected choledochal cyst and hepaticojejunostomy from 2005 to 2015. Fourteen patients (11 females and 3 males) were included in this study. The mean diameter of the cyst was 5.0cm (range 2-12cm). The mean age at operation was 3.5months (range 11days to 9months). The mean body weight was 6.0kg (range 3.9-10.0kg). Five patients were symptomatic before operation. Laparoscopic excision of choledochal cyst was successful in all cases. The distal end of common bile duct (CBD) was cauterized in all but two cases. Conversion to open hepaticojejunostomy was required in two children. There was no intraoperative complication. Two patients had postoperative fever. One patient had minor bile leak that resolved on conservative management. The mean operative time was 286min (range 200-390min). The median hospital stay was 8days (range 6-25days). At a median follow-up of 46months (range 6-118months), all patients were freed from cholangitis or intestinal obstruction. Symptomatic patients had earlier operation (mean, 1.7 vs. 4.5months p=0.012) and were associated with postnatal increase in cyst size (p=0.023) but were not associated with increased risk of complication or conversion (p=1.000). Laparoscopic excision of choledochal cyst and hepaticojejunostomy could be safety performed in patients with the cyst detected antenatally. The distal CBD was usually small and stenotic. Symptomatic patients had earlier operation with no increase in morbidity.

Primary hydatid cyst of head of pancreas communicating with common bile duct containing stones

A 28 year female presented with dull pain in the upper abdomen for 1 year and distension/ fullness in abdomen and itching all over the body for 1 month. Examination showed icterus and a palpable gall bladder. Serum bilirubin was 4 mg/DL, serum alkaline phosphatase was 700 IU/L, Alanine transaminase was 103 IU/L and Aspartate transaminase was 201 IU/L. Magnetic Resonance Cholangio-Pancreaticography (MRCP) showed a thick walled cystic lesion with some solid component, measuring 8 X 7 X 6.1 cm at lower end of Common Bile Duct, with internal membranes and calcifications (Figure 1). Common Bile Duct (23mm), Common Hepatic Duct (13mm) and Intra Hepatic Biliary Radicals were dilated. Gall bladder showed multiple calculi. A provisional diagnosis of Hydatid cyst of head of pancreas was made. Hydatic serology was not done due to its non-availability. Patient was given 400 mg of Albendazole, once a day for 3 weeks and then was taken up for surgery.

Diagnosis and treatment of ectopic opening of the common bile duct in the duodenal bulb

Objective To investigate the diagnosis and treatment of ectopic opening of the common bile duct in the duodenal bulb. Methods The clinical data of 3 patients who were admitted to the Binzhou People's Hospital and 9 patients who were admitted to the Tianjin People's Hospital from January 2006 to December 2013 with ectopic opening of the common bile duct in the duodenal bulb were retrospectively analyzed. Seven patients had choledocholithiasis and 5 had stenosis at the end of common bile duct. The medical histories and clinical features in patients were analyzed and routine blood test and serum liver function test were done. All the patients received the endoscopic retrograde cholangiopancreatography (ERCP) examination and were cured. All the patients were followed up via outpatient examination and telephone interview up to August 2014. Results Six patients had histories of cholangitis recurrence and 2 had histories of duodenal ulcer recurrence. All the patients had pain in the right hypochondriac region of the abdomen. Seven patients had fever, chills, skin yellowing sclera and tenderness in the right hypochondriac region of the abdomen. The levels of alkaline phosphatase (ALP) and glutamyl-transpeptidase (GGT) in 11 patients, the levels of TBil and DBil in 8 patients and the count of WBC in 7 patients were increased. (1) The results of ERCP showed as follows: there was no papillar opening at the second and third segment of duodenum. The crack-like opening located at the duodenal post-bulb with rough and erosive mucosal surfaces and intermittent outflow of bile. Duodenal ulcer was detected in 5 patients and duodenal bulb metamorphosis in 3 patients. All the 12 patients received successfully intubations. (2) The results of retrograde cholangiography showed as follows: the end of common bile duct of 12 patients was taper and sickle-shaped. Intra-and extrahepatic bile duct dilation was detected in 10 patients, choledocholithiasis in 7 patients and clear findings for the pancreatic duct in 5 patients. Among the 12 patients, 8 received balloon dilation (5 with stenosis at the end of common bile duct , 3 with choledocholithiasis) , 3 received laparoscopic common bile duct exploration (LCBDE) combined with cholangioenterostomy due to diameter of stone more than 1. 5 cm and ectopic opening stenosis of the common bile duct in the duodenal bulb. One patient was treated by percutaneous transhepatic cholangiography (PTC) lithotomy of common bile duct after unsuccessful ERCP without bleeding and pancreatitis-related complications. The symptoms of cholangitis in 3 patients were alleviated after balloon dilation, 2 patients had recurrence of cholangitis and were cured by Roux-en-Y cholangioenterostomy. The mean open surgery time and mean duration of postoperative hospital stay in 5 patients were 85 minutes (range, 60-150 minutes) and 10 days (range, 8-14 days) , respectively. All the 12 patients were followed up with a median time of 38 months (range, 8-90 months) . During the follow-up, 10 patients survived well without recurrence of cholangitis and cholelithiasis. Two patients had recurrence of cholangitis at postoperative month 2 and month 14, including 1 patient with the recurrence of common bile duct sand-like stones, and they were readmitted to hospital and treated by Roux-en-Y cholangioenterostomy without recurrence by follow-up. Conclusions The clinical symptoms of ectopic opening of the common bile duct in the duodenal bulb included recurrence of cholangitis, duodenal ulcer history, pain in the right hypochondriac region of the abdomen, skin yellowing sclera, abnormal liver function, crack-like openings in the duodenal bulb by ERCP examination with outflow of bile, cholangiography-guided taper and sickle-shaped end of common bile duct. The treatment should be aimed at the concomitant diseases. Key words: Common bile duct ectopic opening; Duodenal bulb; Diagnosis; Therapy

Tuberculosis biliary stricture simulating as cholangiocarcinoma.

Tuberculosis (TB) is a rare cause of biliary stricture that is difficult to diagnose preoperatively. Patient present with obstructive jaundice, which may be confused with hepatobiliary malignancies. Suspicion of the disease with knowledge and awareness and establishing tissue diagnosis along with advent of image guided FNAC, endoscopic brush cytology and PCR testing of bile, diagnosis of hepatobiliary TB can be made without the need of laparotomy. Biliary TB is a potentially curable condition when diagnosed preoperatively requiring antituberculosis therapy & avoiding surgery [1]. Surgery is most often required for relief of biliary obstruction [2]. Failure to obtain preoperative tissue diagnosis may lead to histological diagnosis of biliary TB only after major surgery. TB of lower end of common bile duct (CBD) and periampullary region often forms pseudotumour and strictures mimicking cholangio carcinoma [3]. Hepatobiliary TB may be caused by three ways: (1) Spread of caseous material from the portal tracts into the bile ducts (most often), (2) Secondary inflammation-related tuberculous periportal lymphadenitis, (3) Spread of caseous material through the ampulla of Vater and ascending along the CBD [4]. Benign biliary strictures fall into two etiological groups: Traumatic (Post operative, Blunt, or Penetrating injury) and Nontraumatic (Sclerosing cholangitis, Recurrent pyogenic cholangitis, Chronic pancreatitis, Mirizzi syndrome) [5]. Various other benign conditions are Eosinophilic granuloma, Duodenal papillitis, Infestations due to Ascaris lumbricoides and Clonorchis sinensis. Tuberculous biliary stricture is due to the secondary endo luminal inflammatory process and scarring. Tuberculous biliary stricture involves all parts of the biliary tree, but commonly involving CBD [6]. We came across five cases of Tubercular biliary stricture in last six years. All the patients had no specific clinical findings & there was lack of constitutional symptoms of TB such as fever and night sweat, absence of past history of TB, negative tuberculin skin test, lack of radiological evidence of old or active TB. CBD was involved with either stricture or pseudo tumour [Table/Fig-1]. [Table/Fig-1]: Findings of five cases in present study The factors like (1) a past history of TB, (2) other systemic manifestations like pulmonary or generalized lymph node involvement, (3) associated involvement of other abdominal organs, (4) mild jaundice, (5) abdominal pain more than an abdominal mass, (6) image guided FNAC or biopsy in suspected cases, and (7) the geographic area where the patient resides might help in differentiating biliary TB from biliary tract malignancy [7]. Preoperative diagnosis of TB as the cause of obstructive jaundice is extremely difficult often compelling major resectional surgery such as whipples pancreatoduodenectomy. In most of the cases, final diagnosis is reached in the postoperative period by the histological finding of caseation necrosis and epitheloid granuloma formation and Langhans giant cells [1]. All the patients in our study were put on ATT. Patients without surgery showed improvement and are on regular follow up. My research review on various documented articles reflects the need to diagnose this disguising condition with various available investigations keeping TB in mind [Table/Fig-2]. [Table/Fig-2]: Comparison of various published literature with the present study There are several proposed investigations for preoperative diagnosis, for example, detection of acid fast bacilli (AFB) after staining or culture in the biliary fluid aspirate during ERCP, FNAC, and frozen section [18]. PCR technique for Mycobacterium TB from biliary fluid is helpful because of its sentivity [6]. The tubercular biliary stricture can be cured with antitubercular medications with excellent prognosis. In few reported cases, the biliary stricture does not resolve with medical therapy alone and requires surgical intervention and biliary metallic stent placement [1]. Whipples pancreastoduodenectomy is done for distal CBD stricture and choledochoduodenostomy is required in multiple strictures. Sequential placement of multiple plastic stents has been shown to be effective, as the stents both enable biliary drainage and act as dilators [17] . Although favourable results can be achieved by medical therapy and with repeated stenting of the bile ducts, long-term follow-up is required due to the risk of post-treatment cicatricial stenosis [5] . If preoperative diagnosis is established, major surgery can be avoided, which increases morbidity and mortality. Patients presenting with a short history with relatively good health from tuberculosis endemic country like India, tubercular biliary stricture should be kept in mind as a differential diagnosis. These benign lesions should be differentiated from malignant masquerade, equally keeping in mind not to mistake malignant lesions for benign lesions.

Pathologico-Anatomic Categories of Choledochal End-Piece Stenosis Due to Chronic Pancreatitis and Clinical Significance

Background: Chronic pancreatitis caused by common bile duct segment stenosis is a common complication. It often results in near side bile duct expansion, bile drain disorder, appearing serious obstructive jaundice, biliary cirrhosis, lifethreatening. However, chronic pancreatitis causes not bravery manager narrow some light, some heavy, and the clinical manifestation is different too. We think there may be different kinds of pathological anatomy. As a result, we carried out the research of this subject. Objective: To investigate the anatomicopathological classification of terminal stenosis of the common bile duct (CBD) caused by chronic pancreatitis (CP) and the treatment. Method: A retrospective analysis was made for the management of sympatomatic stenosis of the terminal end of CBD 47 CP cases. Autopsy was performed in 25 bodies to verify our classification. Result: By analyzing operation and postoperative follow-ups to 47 patients with obvious choledochal dilatations (diameter ≥ 15 mm) due to chronic pancreatitis, the authors have found that there exist three pathologico-anatomic categories of choledochal end-piece stenosis due to chronic pancreatitis. The stenosis of type I is the external-pressing annular stricture (59.6%); type II is front wall of choledochus being compressed one (31.9%); and type III is the pseudocystic oppression one (8.5%). Conclusion: The treatment of CP patients complicated with terminal stenosis of CBD need individual consideration. Clinical Significance: Type I should be treated with biliary-enterostomy owing to more serious stricture (only No.3 the Bake’s dilstors and smaller ones can be passed through its stenotic segment). Type II Could be managed with T-tube drainage because of its slighter stricture (Bake’s dilators bigger than No.6 and No.12 French urinary catheter can get through the Choledochal terminal). If there aren’t biliary and pancreatic complicated diseases, non-operative treatment can be carried out. Type III can undergo with the T-tube replacement between biliary tract and pseudocyst if pseudocystic decompression doesn’t lead to obvious stenosis (type IIIo and IIIb). If type III combines type I, the internal drainage should be performed in both ectatic bile duct and cyst.

Choledochal cyst: A review of 79 cases and the role of hepaticodochoduodenostomy.

Aim:To analyze our experience of choledochal cysts. The results of complete excision of cyst and hepaticodochoduodenostomy have been analyzed in particular.Material and Methods:Period of study: January 1993 to August 2010. Apart from basic investigations, we did ultrasonography (USG) of abdomen, contrast-enhanced computerized axial tomography scan (CECT), endoscopic retrograde cholangiopancreatography (ERCP), operative cholangiogram, hepatic isotope scan (HIDA), magnetic resonance cholangiopancreatogram (MRCP) and choledochoscopy. The patients were divided into six groups according to the management done and the results analyzed.Results:The total number of cases was 79 (Male : Female = 26 : 53). The mean age of presentationwas 5.18 years. The most common mode of presentation was abdominal pain in 86% cases. Types of cysts - Type I: 63; Type IV: 12; Forme fruste: 1; Caroli's disease: 1; Cyst with atresia in the lower end of common bile duct: 2. Two patients of group A (cyst excision and Roux-en-Y hepaticojejunostomy) had recurrent pain and cholangitis. One patient required revision for stricture. In group E (n=53) (excision of cyst and hepaticodochoduodenostomy), three patients developed occasional epigastric pain and they responded to omeprazole. One patient developed anastomotic stricture and was lost to follow up. One patient of cyst with biliary atresia with biliary cirrhosis died.Conclusions:In choledochal cyst, complete excision of cyst and good bilioenteric anastomosis with wide stoma should be done. Hepaticodochoduodenostomy with wide stoma is a simple, quick procedure with preservation of normal anatomy and physiology and minimum complications. It also avoids multiple intestinal anastomoses and so should be the preferred approach.

Clinical selection of surgical methods for pure stenosis at the end of common bile duct: a report of 43 cases

Objective To explore the clinical selection of surgical methods for pure stenosis at the end of the common bile duct.Methods The clinical data of 43 cases of pure stenosis at the end of the common bile duct treated in this hospital from October 2003 to June 2009 were retrospectively analyzed.Of the 43 cases, 12 underwent endoscopic sphincterotomy（EST）, 9 sphincteroplasty of Oddi, 5 pancreaticoduodenectomy,8 Roux-en-y choledochojejunostomy and 5 choledocoduodenostomy,4 underwent drainage of the T tube after exploration of the biliary passage.Results Among 37 patients did not undergo the radical pancreaticoduodenectomy,6 had space-occupying lesions 5-19 months postoperatively.Five of them received pancreaticoduodenectomy again.Conclusion Pure stenosis at the end of the common bile duct should be carefully managed. Key words: Common bile duct; Stenosis; Surgery

Endoscopic ultrasound in biliary fasciolosis

A 16-year-old woman presented with recurrent episodes of severe upper abdominal pain and vomiting of 3 years duration. Multiple upper gastrointestinal scopies and ultrasonographies (USG) were normal. CT scan of abdomen had revealed mild intrahepatic biliary radical dilatation up to the lower end of common bile duct (CBD), but no stones or mass lesion. Her amylase and lipase levels during attacks of pain were normal. She was labeled as suffering from depression and was on antidepressants. Her liver function tests were normal except deranged alkaline phosphatase (178 IU/L). Clinical examination was unremarkable. Endoscopic ultrasound (EUS) revealed dilated CBD with a 3–4 cm floating and moving structure in the mid CBD coming down into the lower CBD with appearance like fluke (Fig. 1a). A biliary sphincterotomy was performed and a leaf like live worm was extracted with balloon catheter (Fig. 1b). Microbiological examination revealed diagnosis of Fasciola gigantica. She received a course of antihelminths and is asymptomatic on follow up of 9 months. Conventional USG in biliary fasciolosis usually reveals biliary dilatation, irregular thickened walls and worms are seen as vermiform structures without acoustic shadowing. USG is believed to be helpful in diagnosis of biliary fasciolosis, it may miss distal CBD lesions. EUS is an accurate investigation for imaging the lower biliary tree. Its role in the diagnosis of biliary fasciolosis has been documented earlier [1].

Clinical and prognostic analysis of malignancies with multi-tumor factors in pancreas and periampullary region

Objective To investigate the biological features and treatment of malignancies with multi-tumor factors in the pancreas and periampullary region. Methods A retrospective clinical analy-sis was conducted on 18 cases of the malignancies admitted to our hospital during 2005.1-2007.5. The clinical features, imaging findings, therapeutic and pathological data were analyzed. Meanwhile, the prognosis of this kind of malignancies was compared with that of adenoductal cancer undergoing radical pancreateetomy and that of periampullary carcinoma receiving palliative operation. Results The ma-lignancies were found in 11 men and 7 women with a mean age of 62.4±11.7 years. Tumors were lo-cated in the pancreas,the lower end of common bile duct and the ampullary part of duodenum in 14 ca-ses, ampullary duodenum and common bile duct in 1, pancreas and gallbladder in 1, pancreas and common bile duct in 1 and papillary duodenum and beginning of duodenum in 1. Fifteen of them re-ceived pancreaticoduodeneetomy (PD), 2 resection of distal pancreas plus splenectomy and the others total pancreatectomy. Ten patients died of tumor recurrence or liver metastasis several months after operation. For the 8 patients who survived, the longest survival time was 18 months. The median sur-vival time for those patients was only 13.2 months, which was significantly shorter than 27 months for the adenoductal cancer receiving PD and 20.9 months for the periampullary carcinoma undergoing pal-liative therapy. Conclusion The malignancies with multi-tumor factors in the pancreas and periampul-lary region are located mainly in the head of pancreas and the lower part of common bile duet, among which combination of IPMC or adenoductal carcinoma with other rare types of malignancies were the most common histotypes. The prognosis of this kind of carcinoma is poor and needs further research. Key words: Pancreatic neoplasms; Multi-tumor factors

Diagnosis and treatment of iatrogenic injury in end of common bile duct

Objective To promote the recognition and effect of treatment of the iatrogenic injury in the end of common bile.Methods The clinical data of 12 cases of the iatrogenic injury in the end of common bile duct were retrospectively analyzed.Of the 12 patients with an age ranging from 45-65,6were mate and 6 female.All the 12 patients had the bile leakage after choledocholithotomy in combination with exploration.The injury was found during operation and managed immediately in 6 cases.In other 6 cases,there were fever and right upper local retroperitonitits and delayed diagnosis of the injury.Results Nine cases were cured and 3 died(mortality=25%).Conclusion Timely finding and management of the injury during operation are important.Meanwhile,postoperative finding and early management can promote the survival of patients.The delayed treatment will result in high mortality. Key words: Common bile duct injury; Diagnosis; Treatment

Carcinoma Arising from Villous Adenoma of the Ampullary Bile Duct: Report of a Case

Adenocarcinoma arising from the villous adenoma of the ampullary biliary epithelium is an extremely rare disorder. The preoperative diagnosis and treatment of the disease represent a major difficulty. A 67-year-old woman was admitted to the hospital with a chief complaint of jaundice. Preoperative investigations revealed obstructive type jaundice due to a 2-cm mass at the end of common bile duct. She was operated on and after undergoing a sphincterotomy, small, yellowish, grape-like particles fell down from the ampullar orifice. A frozen-section examination of these particles revealed villous adenoma. Next, a transduodenal resection of ampulla and reconstruction were performed. The frozen-section examination of the resected material also revealed a villous adenoma. The patient was discharged uneventfully. The histological examination revealed a villous adenoma arising from the biliary epithelium and some adenocarcinoma foci. The surgical margins were tumor free. Nevertheless, she developed hepatic metastases 15 months after surgery. This case shows the importance of surgeons to keep in mind the fact that frozen examinations may sometimes miss a malignancy and they therefore cannot be relied upon to rule out malignancy in villous adenoma of the ampullary bile duct.

Endoscopic Biliary Drainage by Nasobiliary Drain or by Stent Placement in Patients with Acute Cholangitis

Endoscopic biliary drainage is an established mode of treatment for acute cholangitis. We compared the safety and efficacy of nasobiliary drain (NBD) placement and stent placement for biliary drainage in patients with acute cholangitis. We recruited a total of 150 patients with severe cholangitis who required endoscopic biliary drainage. Patients were randomized to have either a 7-Fr NBD or a 7-Fr straight flap stent placed during endoscopy. Outcome measures included complications related to endoscopic retrograde cholangiopancreatography (ERCP) and the clinical outcome. Of the 150 patients, 75 were randomized to the NBD group and 75 to the stent group. The most common causes of biliary obstruction were common bile duct stones (n = 102) and biliopancreatic malignancies (n = 37). The site of the biliary obstruction was predominantly found to be the lower part of common bile duct in both the NBD group (n = 58) and the stent group (n = 59). Indications for biliary drainage were: a fever of > 100.4 degrees F (n = 140), hypotension (n = 23), peritonism (n = 40), impaired consciousness (n = 29), and failure to improve with conservative management (n = 45). Biliary drainage was achieved in 147 patients. Abdominal pain, fever, jaundice, hypotension, peritonism and altered sensorium improved after a median period of 2 days in both groups. Leukocyte counts became normal after a median time of 7 days in the NBD group and 6 days in the stent group. There were no ERCP-related complications. There were no instances of displacement or kinking of an NBD, occlusion of an NBD or stent, or of stent migration. Four patients died (two in the NBD group and two in the stent group) as a result of uncontrolled cholangitis after 1, 2, 4, and 6 days of biliary drainage. The success rates of biliary drainage in cholangitis were not affected by the type of endoprosthesis used (72/74 for NBD patients vs. 71/73 for stent patients), the etiology of the biliary obstruction (110/112 for benign obstruction vs. 33/35 for malignant obstruction), or the site of the biliary obstruction (28/30 for upper common bile duct obstruction vs. 115/117 for obstruction at the lower end of common bile duct). Biliary drainage by nasobiliary drain and drainage by stent are equally safe and effective treatments for patients with severe cholangitis.

Experience in diagnosis and treatment of benign stenosis at the end of common bile duct

目的 探讨胆总管末端良性狭窄的病因和诊断与治疗.方法回顾性总结我院1986年以来收治的24例胆总管末端良性狭窄的诊治资料.胆囊切除术后10例,胆囊切除、胆道探查术后7例,胆源性胰腺炎术后2例,慢性胰腺炎5例.作Oddi括约肌切开成形术11例,其中加作壶腹间隔切开成形术2例,胆肠内引流术9例,内窥镜下括约肌切开术(EST)2例,胰十二指肠切除术2例.结果术后并发十二指肠漏1例,胰漏2例,胆漏、胰漏1例.治愈23例,死亡1例.经1～15年随访20例.偶发胆管炎3例,频发较重胆管炎1例,其余效果满意.结论对有胆道手术史和慢性胰腺炎病人出现反复上腹或右上腹疼痛、黄疸等症状,应考虑有胆总管末端良性狭窄,影像学检查和内镜检查结合手术探查,必要时行术中活检是主要诊断手段.应根据狭窄的类型和程度选择合适的手术方式。

Hepatobiliary scintigraphy: An effective tool in the management of bile leak following laparoscopic cholecystectomy

Bile leaks and bile duct injury has been the major postoperative complications described after laparoscopic cholecystectomy. In this study, we evaluated the role of hepatobiliary scintigraphy (HBS) in patients who underwent laparoscopic cholecystectomy, and there was a clinical suspicion of bile leak in postoperative period. Method: Twenty-five patients (M/F=11:14, mean age 39±8 years; range 24−58 years) with suspected bile leak postlaparoscopic cholecystectomy underwent sequential HBS. Results: Thirteen patients had normal hepatobiliary scintigraphic studies. Five patients had small bile leak in gall bladder fossa with primary route of bile flow into the gut. All these 18 patients improved on conservative management alone. Significant bile leak from the cystic stump region was demonstrated in four patients. All of them were subjected to endoscopic cholangiography (ERCP), which confirmed the site of leak. All patients had stenting and sphincterotomy. One patient showed bile leak and obstruction at the lower end of common bile duct, he improved spontaneously. Another patient showed poor hepatocytes function and no excretion of radiotracer and underwent ERCP followed by hepaticojejunostomy for common hepatic duct ligation. One patient had frank bile leak in the right paracolic gutter and had to undergo hepaticojejunostomy. Conclusions: HBS is a valuable noninvasive method of investigating possible bile leaks or other biliary disruptions in postlaparoscopic cholecystectomy patients. Negative study for significant bile leak can assure the surgeon to manage the patient conservatively. However, it cannot be relied on absolutely when determining the need for reoperation for a significant bile leak in early postoperative period.