Bile Duct Excision Research Articles

Simple prophylactic cholecystectomy without excision of the common bile duct (CBD) for pancreaticobiliary maljunction (PBM) without bile duct dilatation: is it justified？

Simple prophylactic cholecystectomy without excision of the common bile duct (CBD) for pancreaticobiliary maljunction (PBM) without bile duct dilatation: is it justified？

Effects of Cystic Duct Margin Involvement on the Survival Rates of Patients With Gallbladder Cancer: A Propensity Score-Matched Case-Control Study.

Background In gallbladder cancer (GBC), extrahepatic bile duct (EHBD) resection is selectively performed if gross direct extension or microscopic involvement of the cystic duct margin (CDM) is detected. Although CDMis usually sent for frozen biopsy intraoperatively in most centers, there are no studies regarding the routine use of CDM frozen biopsy irrespective of the tumor location and paucity of literature regarding the impact ofCDM status on recurrence-free and overall survival inGBC. The presence of obstructive jaundice in GBC usually indicates the involvement of EHBD or cystic duct-bile duct junction. The present study aimed to analyze the necessity of routineCDM frozen biopsy inpatients with resectable GBC withoutjaundice, regardless of the tumor location. The impact of positive CDM on survival was also evaluated. Methods This retrospective observational case-control study was conducted from May 2009 to March 2021 and included 105 patients with resectable GBC without macroscopic EHBD infiltration andjaundice. Patients were divided into CDM-negative (n=91) and CDM-positive (n=14) groups. Propensity score matchingwas performed for variables such asperformance status, tumor size, tumor-node-metastasis (TNM) stage, and adjuvant chemotherapy. After propensity score matching, 27 patients (CDM-negative=13, CDM-positive=14) were included. The primary outcome was to analyze the role of routine CDM frozen biopsy regardless of tumor location, and secondary outcomes were to study the impact of positive CDM status on survival andevaluate predictive factors for CDM positivity. A subgroup analysis was conducted to assess clinicopathologic characteristics and outcomes of the anatomical location of the tumor. Results Of 105 patients, 91 had negative CDM, and 14 had positive CDM. Among 14 patients with positive CDM, only one patient had a tumor in the fundus/body, and the remaining had a tumor involving the neck. All CDM-positive patients underwent bile duct excision with hepaticojejunostomy. Common bile duct (CBD) involvement was present in 50% of patients with positive CDM in the final histopathological examination. In the matched population, patients with positive CDM had a significantly higher rate of neck tumors (p=0.001). Recurrence-free survival (24 vs. 12 months, p=0.30) and overall survival (24.5 vs. 20 months, p=0.417) were comparable between CDM-negative and CDM-positive groups, respectively. On multivariate analysis, preoperative and intraoperative tumor location were independent predictive factors for CDM positivity. On subgroup analysis, 30 patients had tumor involving the neck of the gallbladder, and the remaining 75 had at the fundus and body of the gallbladder. Neck tumors had inferior recurrence-free survival (17 vs. 30 months, p=0.012) and overall survival (24 vs. 36 months, p=0.048) compared to non-neck tumors. Conclusions Routine use of CDM frozen analysis in patients with resectable GBC without jaundice, regardless of tumor location, can be avoided. Itcan be selectively preferred in patients with GBC involving the neck since tumor location is found to be an independent predictive factorfor CDM positivity. Positive CDM has comparable survival outcomes to negative CDM, providing a similarR0 resection rate and tumor stage.However, neck tumors have aworse prognosis than non-neck tumors.

A choledochal cyst type IVa in a child treated with Roux-en-Y hepaticojejunostomy.

A choledochal cyst is a bile duct anomaly that disrupts the transportation of bile from the liver to the gallbladder and small intestine. Choledochal cysts are rare, occurring in approximately one out of every 100,000 to 150,000 children in Western countries, with a girls-to-boys ratio of 4:1. Immediate surgery to excise the cyst and construct a biliary-enteric continuity is necessary to treat this condition. This case-report aimed to present a child with choledochal cyst type IVa who underwent a Roux-en-Y hepaticojejunostomy. A 3-year-11-month-old girl with an abdominal mass experienced jaundice, nausea, and vomiting over the past two years, which worsened in the last month. Abdominal ultrasonography indicated intrahepatic biliary dilatation. Abdominal computed tomography scan results confirmed a choledochal cyst type IVa, characterized by fusiform cyst dilatation at the bilateral intrahepatic bile duct, common hepatic duct, cystic duct, and common bile duct. The cyst exerted pressure on the pancreas and small intestine. Before the surgery, the patient was treated with ceftriaxone 100 mg/kg/day and gentamicin 5 mg/kg/day. Roux-en-Y hepaticojejunostomy was performed, involving the complete excision of the extrahepatic bile duct to reconstruct the biliary system. During the surgery, a retroperitoneal cyst measuring 20 cm x 10 cm with a volume of 200 ml was discovered. Following the surgery, the patient showed clinical improvement. Patient follow-ups indicated that no complications such as wound infection, acute pancreatitis, and the formation of pancreatic or biliary fistula occurred. This case highlights that Roux-en-Y hepaticojejunostomy proves to be an effective surgical approach for managing choledochal cyst type IVa in children, helping to prevent further complications.

Survival analysis of extrahepatic cholangiocarcinoma based on surveillance, epidemiology, and end results database.

Cholangiocarcinoma (CCA) can be classified as intrahepatic CCA or extrahepatic CCA (eCCA). We intended to analyze and reports the survival outcomes for eCCA. Surveillance, epidemiology, and end results (SEER) registry, site recode C24.0, was used to select cases of eCCA from 2000 to 2018. Patients with incomplete data or ages <18 years were excluded. Male (52.69%) and White race (77.99%) predominated. Compared with 2000-2006, survival increased in 2013 (adjusted hazard ratio [HRadj]: 0.68, 95% confidence interval [CI] 0.58-0.70; p < 0.01). Surgery with chemoradiotherapy (HRadj: 0.69, 95% CI 0.60-0.7; p < 0.01) and surgery with chemotherapy (HRadj: 0.72, 95% CI 0.62-0.83; p < 0.01) improved survival over surgery alone. Compared with surgery without lymph node (LN) removal, surgery of four or more regional LN reduced the risk of death by 58% (HRadj: 0.42, 95% CI 0.36-0.51; p < 0.01). Compared with patients without surgery, patients who underwent bile duct excision (HRadj: 0.82, 95% CI 0.72-0.94; p < 0.01), simple or extended lobectomy (HRadj: 0.85, 95% CI 0.75-0.95; p = 0.009), and hepatectomy (HRadj: 0.80, 95% CI 0.72-0.88; p < 0.01) significantly improved survival. Patients with distal CCA had a 17% higher survival than perihilar CCA (HRadj: 0.83, 95% CI 0.74-0.92; p < 0.01) and LN dissection was equally beneficial for both subgroups (p < 0.01). Surgery with chemoradiotherapy has a proven increase in the 5-year survival of the eCCA. LN resection, bile duct excision, lobectomy, and hepatectomy have better outcomes.

Intrahepatic cholangiocarcinoma with bile duct tumour thrombus: a case for complete resection

Intrahepatic cholangiocarcinoma (ICC), which is ordinarily a very invasive tumor and often takes a rapid and fatal course, sometimes shows macroscopic intra bile duct extension. We present a case of a 45-year-old Indian gentleman who presented with jaundice. Further evaluation with contrast enhanced computed tomography (CECT) and magnetic resonance imaging (MRI) abdomen revealed mass lesion in segment 4 of liver with extension into the bile duct. A formal left hepatectomy with gall bladder and bile duct tumour thrombus extraction with bile duct excision followed by a Roux-en-Y hepaticojejunostomy was performed. Intra bile duct growth of ICC may reflect indolent biological behavior and thus warrants an aggressive surgical approach, which appears to give a good prognosis.

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.

Does Timing of Completion Radical Cholecystectomy Determine the Survival Outcome in Incidental Carcinoma Gallbladder: A Single-Center Retrospective Analysis.

IntroductionIncidental discovery of gallbladder cancer (GBC) on postoperative histopathology or intra-operative suspicion is becoming increasingly frequent since laparoscopic cholecystectomy became the standard of care for gallstone disease. Incidental GBC (IGBC) portends a better survival than primarily detected GBC. Various factors affect the outcome of re-resection with the timing of re-intervention an important determinant of survival.MethodsAll patients of IGBC who underwent curative resection from January 2009 to December 2018 were considered for analysis. Details of demographic profile, index surgery, and operative findings on re-resection, histopathology and follow-up were retrieved from the prospectively maintained database. Patients were evaluated in three groups based on the interval between index cholecystectomy and re-resection: Early (<4 weeks), Intermediate (4-12 weeks) and Late (>12 weeks), using appropriate statistical tests.ResultsNinety-one patients were admitted with IGBC during the study period of which 48 underwent re-resection with curative intent. The median age of presentation was 55 years (31-77 years). The median duration of follow-up was 40.6 months (Range: 1.2-130.6 months). Overall and disease-free survival among the above-mentioned three groups was the best in the early group (104 and 102 months) as compared to the intermediate (84 and 83 months) and late groups (75 and 73 months), though the difference failed to achieve statistical significance (p=0.588 and 0.581). On univariate analysis, factors associated with poor outcome were node metastasis, need for common bile duct (CBD) excision and high-grade tumor. However, on multivariate analysis, poor differentiation was the only independent factor affecting survival.ConclusionEarly surgery, preferably within four weeks, possibly entails better survival in incidentally detected GBC. The grade of a tumor, however, is the most important determinant of survival in IGBC.

Anomaly of the biliopancreatic junction with associated hepatic duct anomaly – a rare case report

Pancreaticobiliary maljunction (PBM) or anomaly is defined as an anatomical maljunction of the biliary duct and pancreatic duct outside of the duodenal wall beyond the influence of the sphincter of Oddi. Children with this anomaly can present with choledochal cyst with recurrent attacks of acute pancreatitis, and condition can be worse when not treated appropriately. Pancreaticobiliary maljunction or anomaly is considered to be a major risk factor for biliary tract cancer. In patients with this anomaly, free reflux of pancreatic juice into biliary tract may cause biliary tract damage, resulting biliary malignancy can occur. Therefore, in this condition total excision of the extrahepatic bile duct with hepaticojejunostomy is recommended. Early diagnosis of this condition and early surgical treatment is the mainstay to prevent further complications. Proper follow-up is necessary to detect biliary tract malignancy in early post-operative period, especially in patients demonstrating post-operative complications. Here we are describing a young boy with an abnormal pancreaticobiliary junction (PBM) with choledochal cyst associated with hepatic duct anomaly and biliary and pancreatic stones causing recurrent attack of acute pancreatitis.

Ectopic gallbladder with congenital biliary dilatation: a pediatric case report

BackgroundAn ectopic gallbladder is a rare anomaly and can result in the misinterpretation of imaging findings and clinical confusion. Knowledge of such anomalies facilitates accurate diagnoses and prompt management. We report a pediatric case of an ectopic gallbladder concomitant with congenital biliary dilatation (CBD).Case presentationA 9-year-old girl was referred to our hospital for elevated liver enzyme levels. Following physical examination and a review of medical imaging findings, she was diagnosed with Todani type IV-A CBD. We could not visualize the gallbladder by abdominal ultrasonography, CT, and MRI scans; therefore, we suspected gallbladder agenesis. A laparoscopic excision of the extrahepatic bile duct was performed to treat the CBD. Neither a gallbladder nor a cystic duct were revealed on the liver undersurface. Therefore, gallbladder agenesis was considered as a diagnosis based on preoperative imaging and intraoperative findings. However, during dissection of the hepatic hilum, a cyst-like structure was found on the ventral side of the common hepatic duct, slightly to the right, and a small additional duct that originated from the cystic structure was found. Upon incision, a small amount of bile was drained from the small duct. Thus, the cystic structure was diagnosed as an ectopic gallbladder with hypoplasia. Following the removal of the ectopic gallbladder, the extrahepatic bile duct was excised. Subsequently, laparoscopic Roux-en-Y hepaticojejunostomy was performed without any complications. Postoperative histopathological evaluations of the resected specimen revealed Rokitansky–Aschoff sinuses in the resected cystic lesion. The pathological investigations confirmed the diagnosis of an ectopic gallbladder. Following an uneventful postoperative course, the patient was discharged on day nine.ConclusionsTo our knowledge, this is the first pediatric case report describing an ectopic gallbladder concomitant with CBD. If the gallbladder cannot be detected in a preoperative imaging examination, it is important to consider the possibility of an ectopic gallbladder.

Laparoscopic definitive surgery for congenital biliary dilatation with aggressive hilar bile ductoplasty and complete resection of the intrapancreatic bile duct in pediatric patients is safe and effective, comparable to open surgery.

After surgery for congenital biliary dilatation (CBD), hilar and hepatic bile duct stenosis and intrapancreatic bile duct remnants can cause many postoperative complications. We investigated the efficacy of laparoscopic surgery with aggressive bile ductoplasty and complete excision of the intrapancreatic bile duct in CBD patients compared to open surgery. Pediatric patients who underwent surgery for CBD at our institution between 2006 and 2020 were divided into two groups: laparoscopic surgery (Lap group) and open surgery (Op group). Surgical outcomes were compared between the two groups. We enrolled 160 patients (85 in the Lap group and 75 in the Op group). Hilar bile ductoplasty was performed in 52 (61%) patients from the Lap group and 40 (53%) patients from the Op group. The operative time was significantly longer, the amount of blood loss was significantly lower, and the length of hospital stay was significantly shorter in the Lap group than in the Op group. Postoperative early and late complications occurred at a similarly low rate in both groups. When the surgical outcomes were compared between the group who underwent laparoscopic bile ductoplasty and the group that did not, postoperative early and late complications occurred similarly in both groups. Laparoscopic surgery for CBD with aggressive hilar bile ductoplasty and complete excision of the intrapancreatic bile duct is safe and effective, comparable to open surgery. However, it is necessary to verify whether long-term occurrence of hepatolithiasis similar to open definitive surgery can be obtained in the future.

Differences in post-operative complications after reconstruction for congenital biliary dilatation in a single institution-Roux-en-Y hepaticojejunostomy versus hepaticoduodenostomy -

The standard surgical procedure for congenital biliary dilatation (CBD) consists of excision of extrahepatic bile duct and Roux-en-Y hepaticojejunostomy (HJ). However, alternative reconstructive operations for CBD includes hepaticoduodenostomy (HD). We compared postoperative complications and therapeutic outcomes of these two operations at our institution. From 1981 to 2009, there were 23 traceable patients who underwent operation for CBD, They were divided into an HJ Group (n = 15) and an HD Group (n = 8). Demographic and outcome data were compared. There were no significant differences in postoperative complications(cholangitis, pancreatitis, and anastomotic stenosis) and current blood test data (AST, ALT, Total Bilirubin, Direct Bilirubin, Amylase) between the two groups. Current abdominal pain and carcinogenesis were not observed in either group. Intrahepatic stones occurred in one patient in each group, both > 25years post-operation. HD is considered to be an acceptable reconstruction method compared to HJ, based on our results. There has been a suggestion that inadequate diversion in HD might increase the risk of cholangiocarcinoma. To date, in this series, that has not happened.

Differences in Clinicopathological Factors and Outcomes after Major Liver Resection and Bile Duct Resection for Biliary Tract Cancers

Purpose: The surgical treatment of perihilar cholangiocarcinoma (PHC), intrahepatic cholangiocarcinoma (ICC) and gallbladder cancer (GBC) can be similar in case of hilar tumor infiltration. The aim of the present study was to investigate short- and long-term outcomes between these cancers operated with a major liver resection (≥3 Couinaud’s segments) and extrahepatic bile duct resection. Methods: All patients subjected to a major liver resection and bile duct excision for PHC, ICC and GBC at a single center between 2012-2019 were included. Clinicopathological factors and survival were compared between groups. Results: In total, 81 patients were included (52 PHC, 9 ICC, 20 GBC). Tumor size was 30, 67 and 48 mm for PHC, ICC, and GBC (P<0.001). Percentage node positivity and peritoneal invasion were 52, 67 and 85% (P=0.033) and 31, 44 and 50% (P=0.046), for PHC, ICC, and GBC. Mortality within 90 days was 4, 0 and 35% for PHC, ICC, and GBC (P=0.002). Median survival and 5-year survival excluding perioperative mortality were 31, 21 and 18 months, and 42, 13 and 20% for PHC, ICC, and GBC, respectively (P=0.197). Conclusion: PHC, ICC and GBC necessitating a major liver resection and bile duct resection for tumor clearance display differences in pathological features. Survival for GBC was low.

Different rotations: does it have an impact on confidence of future HBP surgeons to perform complicated procedures

Presenter: Salah Abdel Jalil MD | Grand Strand Regional Medical Center Background: The pursuit of a fellowship has become increasingly popular over the past several years with >90% of graduating general surgical residents continuing their education in further subspecialties (1). The goal of the HPB fellowship is to provide the fellow with the necessary skills and expertise to be able to perform complicated procedures, which is variable between programs. Our goal of the survey is to investigate the strength and weakness areas upon participating in different rotations including Surgical Oncology, Hepatobiliary Surgery and Transplant Surgery rotation. Methods: This is a retrospective survey using an anonymous online survey of hepato-pancreato-biliary fellowship (HPB) program fellows and physicians. Statistical analysis was performed to calculate how many respondents were needed to achieve a 95% confidence level for p <0.05, as there is 220 HBP graduates since 2012. Thirty percent was the response rate needed to achieve the that power. The survey underwent face validation process with expert physicians. Also, cognitive interview was done by fellows outside of the HBP field. Respondents were asked to answer 18 questions to judge the effect of different rotations on the HBP physician’s confidence in doing complicated HBP procedures. No incentives were offered to the fellows at any stage in the study in exchange for survey completion other than the satisfaction of participating in the acquisition of knowledge and benefits of future HBP fellow’s education. The survey was posted online using Monkey survey software that allows fellow to access through the link that was distributed. Results: eight fellows responded, Our survey showed that half of the fellows completed both Transplant and HBP rotations during their fellowship, while only 25% completed surgical oncology rotations, also about 42% found that surgical oncology and Transplant rotation’s duration was about the right length, and non-thought it’s too long for both rotations, while for HBP rotation slightly more than half the reposnders found it’s about the right length while 42% responds as its too short. Slightly more than half of the fellows were comfortable performing complex bile duct excision and reconstruction, and 42% were comfortable performing hemi-hepatectomy, and complex bile duct excision and reconstruction on the other side more than 80% did not feel comfortable performing HPB-related vascular reconstruction. Conclusion: Our survey shows that most of the recently graduated fellows in HBP surgeons were not comfortable in performing HPB-related vascular reconstruction after graduation. We believe increasing the length of transplant and HBP rotations should have a positive impact on the surgeon’s ability and self-confidence to perform such procedures.

Mucinous cystic neoplasm of the liver with biliary communication: case report and surgical therapeutic option

BackgroundMucinous cyst neoplasm of the liver (MCN-L) comprise less than 5% of all cystic liver lesions and is characterized by the presence of ovarian stroma and absence of bile duct communication.Case presentationHere, we discuss a 45-year-old woman who presented with symptomatic liver mass. Diagnostic workup detected a 4.2 × 3.6 cm septate cyst located in segments I, V, and VIII of the liver in communication with the right hepatic duct. An open right liver resection with total bile duct excision and hilar lymphadenectomy was performed. Pathology revealed a multiloculated cyst with lined mucinous epithelium and ovarian-like stroma, consistent with low-grade MCN-L.ConclusionsThis case shows that unusual location and bile duct communication can be present in MCN-L.

Interventional radiology in the prevention of bile duct anastomotic stricture during reconstructive surgery for the iatrogenic bile duct injury (one center experience)

Aim . To study the possibility of using radiological interventions in the staged treatment of intraoperative bile ducts injury and the prevention of biliodigestive anastomotic stricture. Materials and methods . A retrospective analysis of the treatment of 20 patients with “large” (classes B—E) iatrogenic damage to the extrahepatic biliary tract was performed. In all cases, percutaneous transhepatic cholangiostomy was performed before reconstructive Roux-en-Y hepatico- or bighepaticojejunostomy. Biliary drains installed before surgery were retained to control the anastomosis in the early postoperative period, as well as for 6 months for possible correction of the forming narrowing. Preoperatively established biliary drains were retained to control the anastomosis in the early postoperative period, as well as for 6 months for possible correction of the anastomotic stricture. Results . In 2 cases with a B-class injury, it was possible to restore the patency of the common hepatic duct by balloon dilatation without subsequent reconstructive surgery. Roux-en-Y hepatic or (bihepatico)-jejunostomy was performed in 18 patients. In 10 cases antegrade interventional radiological reconstruction of the common bile duct was performed on the external-internal drainage, including 4 cases with partial excision of the common bile duct (class E). Temporary (6 months) antegrade stenting of the partially excised right lobe duct and the confluence zone was performed in 2 cases with trauma classes D and E. There were no lethal outcomes or complications of interventional radiological surgery. Narrowing of the anastomosis was avoided in all patients. The follow-up period varied from 6 months to 13 years. Conclusion . Regardless of the period of detection of biliary tract injury in the postoperative period, tactics of stage treatment, involving the drainage of the biliary tree, with subsequent endoscopic or radiologic intervention, are advisable. Percutaneous biliary drainage in case of “large” iatrogenic injuries of the bile ducts in the postoperative period makes it possible to control biliodigestive anastomosis, timely detect and adequately correct its stricture.

Intraductal papillary neoplasm in common bile duct opening into the stomach

AbstractEctopic bile duct openings are uncommonly encountered and due to limited reports, the incidence and work up are not well delineated. We therefore present our experience in the assessment and management of one such case. A 62‐year‐old lady presented with obstructive jaundice. Final investigation results revealed intraductal papillary neoplasm of the bile duct (IPNB) in an ectopic common bile duct (CBD) inserting ectopically into the lesser curve of the stomach with a normal pancreatic duct opening into the duodenum. Anatomical delineation and staging was done using computer tomography (CT) scan and endoscopic cholangiopancreatography (ERCP). Robotic distal gastrectomy, extrahepatic bile duct excision with porta lymph node dissection, and hepaticojejunostomy with Roux‐en‐Y reconstruction was performed. The blood loss and operation time were 200 mL and 301 minutes, respectively. Pathology showed IPNB with high grade dysplasia and clear margins. After transient gastroparesis, the patient recovered and was disease‐free at 1 year postoperatively. Ectopic biliary drainage into the stomach is extremely rare, but its recognition may help identify the cause of certain clinical conditions and prevent bile duct injury during surgery if required.

AB171. Biliary duct tumour thrombosis with hepatocellular carcinoma—a case report

: Jaundice in hepatocellular carcinoma (HCC) is an unusual presentation and may be multifactorial. A rare cause of obstructive jaundice in HCC is biliary metastasis, known as bile duct tumour thrombosis (BDTT). BDTT can be challenging to diagnose but has characteristic histopathological features. There is considerable uncertainty regarding optimal surgical management of BDTT and its contribution to HCC-related morbidity and mortality. We present the case of an eighty-year-old gentleman diagnosed with BDTT. We discuss jaundice in HCC, the diagnosis and management of BDTT and finally provide some learning points for future. The patient initially presented with obstructive jaundice and was diagnosed with both gallstones and fasciola hepatica. After jaundice persisted, an Endoscopic retrograde cholangiopancreatography (ERCP) was undertaken and four separate histopathologists identified hepatocellular tissue in the bile duct samples. No fasciola was proven. A repeat computed tomography (CT) revealed a segment intravenous (IV) HCC and the patient was formally diagnosed with BDTT. He was not considered suitable for a surgical intervention but to his medical comorbidities and age and was managed conservatively before being discharged home. BDTT is rare and can be difficult to diagnose. There was considerable diagnostic uncertainty in our patient until the histology had been reported. BDTT is often associated with vascular invasion, and suspected mechanism of spread likely involves direct tumour extension and haemobilia, leading to poorer outcomes. While surgery is recommended, the role of a thrombectomy is contested, with most surgeons advocating bile duct excision. Obstructive jaundice in the presence a liver lesion should alert clinicians to the possibility of BDTT. Where possible a liver resection and bile duct excision should be attempted as this seems to offer the best outcome. Lastly, further clarity is needed on whether BDTT has an adverse effect on HCC survival and recurrence, and whether or not a bile duct excision is preferable to a thrombectomy.

Endoscopic retrograde cholangiopancreatography in children with symptomatic pancreaticobiliary maljunction: A retrospective multicenter study.

Endoscopic retrograde cholangiopancreatography (ERCP) has been widely used in pediatric patients with cholangiopancreatic diseases. To evaluate the efficacy, safety, and long-term follow-up results of ERCP in symptomatic pancreaticobiliary maljunction (PBM). A multicenter, retrospective study was conducted on 75 pediatric patients who were diagnosed with PBM and underwent therapeutic ERCP at three endoscopy centers between January 2008 and March 2019. They were divided into four PBM groups based on the fluoroscopy in ERCP. Their clinical characteristics, specific ERCP procedures, adverse events, and long-term follow-up results were retrospectively reviewed. Totally, 112 ERCPs were performed on the 75 children with symptomatic PBM. Clinical manifestations included abdominal pain (62/75, 82.7%), vomiting (35/75, 46.7%), acholic stool (4/75, 5.3%), fever (3/75, 4.0%), acute pancreatitis (47/75, 62.7%), hyperbilirubinemia (13/75, 17.3%), and elevated liver enzymes (22/75, 29.3%). ERCP interventions included endoscopic sphincterotomy, endoscopic retrograde biliary or pancreatic drainage, stone extraction, etc. Procedure-related complications were observed in 12 patients and included post-ERCP pancreatitis (9/75, 12.0%), gastrointestinal bleeding (1/75, 1.3%), and infection (2/75, 2.7%). During a mean follow-up period of 46 mo (range: 2 to 134 mo), ERCP therapy alleviated the biliary obstruction and reduced the incidence of pancreatitis. The overall effective rate of ERCP therapy was 82.4%; seven patients (9.3%) were lost to follow-up, eight (11.8%) re-experienced pancreatitis, and eleven (16.2%) underwent radical surgery, known as prophylactic excision of the extrahepatic bile duct and hepaticojejunostomy. ERCP is a safe and effective treatment option to relieve biliary or pancreatic obstruction in symptomatic PBM, with the characteristics of minor trauma, fewer complications, and repeatability.

1331 Choledochal Cyst in an Adult Female

INTRODUCTION: The incidence of biliary cyst (BC) is 1:100,00 to 150,000 making it a rare medical condition. BC are most commonly diagnosed in the pediatric population but can occasionally present in adults. A multi-disciplinary team approach including a gastroenterologist and a hepatobiliary surgeon is ideal in treating patients with this diagnosis. CASE DESCRIPTION/METHODS: We present a case of a 38-year-old female with past medical history significant for gastroesophageal reflex disease and migraine who was admitted for evaluation of worsening epigastric pain. Patient was noted to be one week after a total abdominal hysterectomy with bilateral salpingo-oophorectomy. A comprehensive metabolic panel was ordered on admission displaying liver chemistries elevated with AST of 258 IU/L (Ref: 9-45 IU/L), ALT of 260 IU/L (Ref: 17-63 IU/L), alkaline phosphatase of 230 IU/L (45-117 IU/L) and total bilirubin of 3.2 mg/dl (Ref: 0.2-1.0 mg/dl). The patient obtained a RUQUS, which did not show any gallbladder stones or sludge. Patient was still having pain throughout her admission, so a magnetic resonance cholangio-pancreatography (MRCP) was ordered for further evaluation. The MRCP revealed a fusiform dilation of proximal half of the common bile duct (CBD) with a diameter of 15 mm and normal intrahepatic ducts. The pancreatic duct could not be visualized on MRCP and hence unable to comment on length of common channel. There was no evidence of stone or stricture in the CBD. At this point, the patient was diagnosed with Type I choledochal cyst. Patient then underwent a laparoscopic extrahepatic bile duct excision with Roux-en-Y hepatico-jejunostomy and cholecystectomy. On follow up evaluation, the patient had been doing well with normal liver chemistries. DISCUSSION: Although rare, choledochal cysts can cause many complications and need to be treated as soon as possible. These complications are due to bile stasis and/or reflux of pancreatic enzymes into the CBD resulting in recurrent cholangitis and other problems including CBD strictures, rupture, stones and secondary biliary cirrhosis. Additionally, there is an overall 10-30% risk for cholangiocarcinoma in patient's with this diagnosis. This case is a good example of successful treatment of a choledochal cyst in a young female.

Signet Ring Cell Carcinoma of the Extrahepatic Bile Duct: A Case Report

Abstract Introduction Signet ring cell carcinoma (SRCC) of the biliary system is extremely rare and its clinicopathological features and impact on prognosis are not well known. We report the extremely rare case of SRCC originating from the extrahepatic bile duct. Case Report We present a 76-year-old female who had elevated liver enzymes noted on routine laboratory test. Abdominal imaging revealed a polypoid mass within the central bile duct, located above the level of pancreatic head with proximal intrahepatic duct dilatation with no significant lymphadenopathy or ascites. Total bilirubin was normal, alanine transaminase level was 163 IU/L, and aspartate aminotransferase was 55 IU/L. The patient underwent common bile duct excision with cholecystectomy. The specimen showed a 3.3-cm centrally located tan polypoid lesion in the common bile duct with adjacent firm lymph node. Microscopic examination of the lesion revealed sheets of tumors cells with signet ring cell morphology underlying benign biliary epithelium. The lymph node was completely replaced by neoplastic cells. The neoplastic cells were diffusely positive for CDX2 and focally positive for CK7 and CK20. The histomorphology and immunophenotype are consistent with poorly differentiated adenocarcinoma with signet ring cell type. Conclusion SRCC of the extrahepatic bile duct is a histologically distinct entity classified by the World Health Organization, but it is very rare. To best of our knowledge, only five cases of SRCC of the extrahepatic bile duct have been reported in the English literature.