Extrahepatic Biliary Ducts Research Articles

Хірургічне лікування гострого біліарного панкреатиту

Introduction. Despite the widespread of associated damage of the biliary system and the pancreas, a lot of issues of treatment tactics remain unresolved. There is no doubt that an adequate treatment of this pathology should combine the surgical and conservative components which will be determined by the peculiarities of the course of pathological processes in the bile ducts and in the pancreas.Materials and methods. A clinical examination and treatment of 126 patients with acute biliary pancreatitis have been performed. Men were 32 (25.4%), women – 94 (74.6%). There was isolated cholecystolithiasis in 65 patients with acute biliary pancreatitis (group 1). 35 patients were diagnosed small concrements in different parts of the common bile duct, which did not cause obstruction of the common bile duct (group 2). 26 patients were diagnosed obturating concretions of the common bile duct, including – impacted into a large duodenal papilla (third group).Results and their discussion. Clinical symptomatology, biochemical blood count, elevation of α-amylase, lipase, pancreatic α-amylase, and positive ACTIM Pancreatitis test allowed us to establish a preliminary diagnosis of acute pancreatitis. Ultrasound examination evaluated changes in the pancreas, but did not always fully describe the state of extrahepatic bile ducts. Magnetic resonance imaging (MRI) was used to fully characterize the pathology of the common bile duct, which made it possible to clearly identify the genesis of acute biliary pancreatitis. At the first stage of treatment, all diagnostic-therapeutic measures were performed during 24 hours. The absence of pathological inclusions in the common bile duct was determined in 80.0% of patients of group 1 using ultrasound examination. MRI was performed for 20.0% of patients. 25.7% of patients of group 2 needed MRI, and 74.3% – transpacillary endoscopic radiography. The ultrasound examination was effective only in 7.7% of patients of group 3. Other patients in this group to verify the cause of acute biliary pancreatitis required the use of other methods of radiotherapy. During 24 hours, laparoscopic cholecystectomy (LCE) was performed in 49 patients (75.4%) of group 1. Patients of groups 2 and 3 were performed endoscopic diagnostics and revision of extrahepatic biliary ducts, followed by LCE during 24 hours. 12 (9.5%) patients had complications related to the unfavorable course of the inflammatory process in the pancreas and peripanecratic tissue. The formation of false pancreatic cysts was diagnosed in 2 patients of group 1, in 3 patients – group 2 and in 2 patients – group 3. Taking into account their favourable course and the absence of laboratory and clinical data for their infection, these patients were recommended to follow dynamic observation in the outpatient settings. Abscesses of retroperitoneal space developed in 5 patients (group 2 – in 3 patients and group 3 – in 2 patients).Conclusion. Diagnostic tactics in acute biliary pancreatitis should include: determination of the activity of lipase, α- amylase, pancreatic α-amylase, ACTIM Pancreatitis test and MRI. Active surgical tactics involving LCE should be used in patients with acute biliary pancreatitis in cholecystolithiasis, and also endoscopic transpasillary decompression of the common bile duct in choledocholithiasis, within 24 hours of patient’s stay in the surgical department.

Choledochoscopic Examination of a 3-Dimensional Printing Model Using Augmented Reality Techniques: A Preliminary Proof of Concept Study.

We applied augmented reality (AR) techniques to flexible choledochoscopy examinations. Enhanced computed tomography data of a patient with intrahepatic and extrahepatic biliary duct dilatation were collected to generate a hollow, 3-dimensional (3D) model of the biliary tree by 3D printing. The 3D printed model was placed in an opaque box. An electromagnetic (EM) sensor was internally installed in the choledochoscope instrument channel for tracking its movements through the passages of the 3D printed model, and an AR navigation platform was built using image overlay display. The porta hepatis was used as the reference marker with rigid image registration. The trajectories of the choledochoscope and the EM sensor were observed and recorded using the operator interface of the choledochoscope. Training choledochoscopy was performed on the 3D printed model. The choledochoscope was guided into the left and right hepatic ducts, the right anterior hepatic duct, the bile ducts of segment 8, the hepatic duct in subsegment 8, the right posterior hepatic duct, and the left and the right bile ducts of the caudate lobe. Although stability in tracking was less than ideal, the virtual choledochoscope images and EM sensor tracking were effective for navigation. AR techniques can be used to assist navigation in choledochoscopy examinations in bile duct models. Further research is needed to determine its benefits in clinical settings.

Effect of gene regulation in pathogenesis of biliary atresia

Biliary atresia (BA) is a common neonatal liver disease characterized by inflammation and fibrosis of the extrahepatic biliary ducts, leading to cholestasis and biliary cirrhosis.It is also a severe liver disease in infants.The pathogenesis of BA is associated with multiple genes and gene polymorphism, virus infections, epigenetic, immune abnormalities, and so on.With the development of genetic technology, it provides a new method to determine the susceptibility genes in BA.Now, more and more doctors pay attention to the change and regulation of genes in BA. Key words: Biliary atresia; Gene; Child

Glucocorticosteroids for infants with biliary atresia following Kasai portoenterostomy

Biliary atresia is a life-threatening disease characterised by progressive destruction of both intra- and extra-hepatic biliary ducts. The mainstay of treatment is Kasai portoenterostomy, as soon as the disease has been confirmed. Glucocorticosteroids are steroid hormones which act on the glucocorticoid receptor and have a range of metabolic and immunomodulatory effects. Glucocorticosteroids are used to improve the postoperative outcomes in infants who have undergone Kasai portoenterostomy. To assess the beneficial and harmful effects of glucocorticosteroid administration versus placebo or no intervention following Kasai portoenterostomy in infants with biliary atresia. We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE Ovid, Embase Ovid, Science Citation Index Expanded (Web of Science), and online trial registries (last search: 20 December 2017) for randomised controlled trials. We included randomised clinical trials which assessed glucocorticosteroids for infants who have undergone Kasai portoenterostomy. For harm, we also considered quasi-randomised studies, observational studies, and case-control studies that were identified amongst the search results. We used standard methodological procedures expected by Cochrane. We assessed the risk of bias for each trial according to prespecified domains. We analysed data using both random-effects and fixed-effect models. We performed the analyses using Review Manager 5.3 and Trial Sequental Analysis software. We considered a P value of 0.025 or less, two-tailed, as statistically significant. We planned to calculate risk ratios (RRs) for dichotomous outcomes, and the mean difference (MD) for continuous outcomes. For all association measures, we planned to use 95% confidence intervals (CIs) as well as Trial Sequential Analysis-adjusted CIs. We used Trial Sequential Analyisis to control the risks of random errors; however, we were often unable to implement this beyond calculating the required information size as there were few trials and data. We assessed the certainty of the evidence using GRADE. We found two randomised controlled trials fulfilling the inclusion criteria of our review. The trials provided data for meta-analysis. We judged the two trials as trials at low risk of bias. The two trials randomised a total of 213 infants to glucocorticosteroids versus placebo. In our Trial Sequential Analysis, the required information size (that is, the meta-analytic sample size) was not reached for any outcome. Trials were funded by charities, public organisations, and received support from private sector companies, none of which seemed to have an interest in the outcome of the respective trials. The effect of glucocorticosteroids after Kasai portoenterostomy on all-cause mortality is uncertain; the confidence interval is consistent with appreciable benefit and harm (RR 1.00; 95% CI 0.14 to 6.90; low-certainty evidence). The results showed little or no difference in adverse effects between the use of glucocorticosteroids or placebo after Kasai portoenterostomy, however this analysis was based on a single trial and we have low certainty in the result (RR 1.02; 95% CI 0.87 to 1.20;). Available data suggest that the proportions of infants who do not clear their jaundice at six months is similar between the two groups (RR 0.89; 95% CI 0.67 to 1.17; low-certainty evidence). All-cause mortality or liver transplantation did not differ at two years between the two groups (RR 1.00; 95% CI 0.72 to 1.39; low-certainty evidence). There were no data regarding health-related quality of life.Our searches also yielded 19 observational studies, some of them containing limited information on harmful effects of glucocorticosteroid treatment. We presented the extracted information narratively. We identified one further ongoing trial with no currently available results. The two meta-analysed randomised clinical trials present insufficient evidence to determine the effects of using glucocorticosteroids versus placebo after Kasai portoenterostomy in infants with biliary atresia on any of the primary or secondary review outcomes. There is insufficient evidence to support glucocorticosteroid use in the postoperative management of infants with biliary atresia for long-term outcomes of all-cause mortality or liver transplantation. It is also unclear if glucocorticosteroids are able to reduce the numbers of infants who did not clear their jaundice by six months. Further randomised, placebo-controlled trials are required to be able to determine if glucocorticosteroids may be of benefit in the postoperative management of infants with biliary atresia treated with Kasai portoenterostomy. Such trials need to be conducted as multicentre trials.

“Свіжі” пошкодження позапечінкових жовчних проток

У статті проведено аналіз клінічних спостережень (вітчизняних та закордонних) з початку 1990 років щодо причин, сприятливих обставин, факторів ризику, профілактики та лікування ятрогенних пошкоджень позапечінкових жовчних проток, в тому числі так званих “свіжих”. Наведено різні класифікації, фактори ризику цього ускладнення. Узагальнено можливості інструментальних методів діагностики (черезшкірна черезпечінкова холангіографія, ендоскопічна ретроградна панкреатохолангіографія, магнітно-резонансна томографія, комп’ютерна томографія, ультразвукове дослідження) та методів профілактики, особливості їх застосування. Також наведено способи та методи лікування інтраопераційних пошкоджень жовчних проток.Як свідчать отримані дані, ні тривалість захворювання, ні характер операційного втручання (планове чи ургентне), ні діаметр протоки, ні навіть професійний стаж хірурга не впливають на ймовірність пошкодження жовчних протоків.Вказані обставини вказують на необхідність подальшого удосконалення системного розгляду даної проблеми.

Surgical treatment of patients, suffering an acute biliary pancreatitis and biliary hypertension

Objective. To improve the results of treatment in patients, suffering an acute biliary pancreatitis with biliary hypertension, applying individual approach in choosing surgical procedure in early phase of the disease.
 Маterials and methods. The results of diagnosis and treatment of 140 patients, suffering an acute biliary pancreatitis, were analyzed. There were 33 men and 107 women, ageing 22 – 88 yrs, and median age – 57.6 yrs old. In all the patients biliary origin of pancreatitis was diagnosed in accordance to criteria, proposed by Holland’s Investigation Group for Pancreatitis Studying. The patients were divided into two groups, in accordance to periods for conduction of decompressive treatment procedures. Into Group 1 were included 70 patients, in whom decompressive surgical interventions were performed in the first 72 h after primary appearance of abdominal pain, independent from time of admittance to the clinic, and into Group 2 – 70 patients, in whom the wait–and–see tactics with conservative therapy was applied in accordance to the disease severity, decompressive methods were used later than 72 h after the disease beginning.
 Results. In patients of Group1 49 fibrogastroduodenoscopies (FGDS) with papillosphincterotomy and lithoextraction, 10 transcutaneous puncture drainages, 13 laparoscopic cholecystectomies with external draining of extrahepatic biliary ducts (in 5 patients laparoscopic choledochoscopy with lithoextraction) were performed. Necrotic forms of an acute pancreatitis were revealed in 26 (37.1%) patients, in 12 (46.2%) of them the infectioning have occurred. Average duration of treatment have constituted 15.48 days, and lethality – 8.57%. In patients of Group 2 22 FGDS with papillosphincterotomy and lithoextraction,5 transcutaneous puncture drainages, 6 cholecystectomies (of them 5 – with external draining of common biliary duct), 18 necrsequestrectomies (in 11 patients cholecystectomy was done additionally and in 7 – drainage of extrahepatic biliary ducts) were performed. Necrotic forms of an acute pancreatitis have developed in 38 (54.3%) patients, of them in 25 (65.8%) the infectioning have occurred. Average duration of treatment have constituted 22.2 days, and lethality – 17.14%.
 Conclusion. Application of decompressive operative interventions for elimination of biliary hypertension in patients, suffering an acute biliary pancreatitis in the first 72 h after the disease beginning, make possible to reduce the occurrence rate for necrotic and infected forms, the disease severity, the lethality level and the stationary state duration.

Visualization of biliary ducts while doing laparoscopy, using HEV LapVision

Objective. To determine efficacy of intraoperative visualization of biliary tree, using fluorescent cholangiography (FCH) and a high–energy visible laparoscopy vison (HEV LapVison) while laparoscopic cholecystectomy performance (LCHE).
 Маterials and methods. In 25 patients LCHE was performed. Preoperatively fluorescein was injected intravenously for guaranteeing of the FCH performance. HEV LapVison was applied for intraoperative visualization of fluorescence.
 Results. Visualization of the cystic duct and its inflow into common biliary duct was guaranteed in 90% patientsх. In 13 (52%) patients the anatomic picture was typical while in 7 (28%) some variants were observed: a parallel course of cystic duct and common biliary duct, and low level of the cystic duct inflow into hepaticocholedochus.
 Conclusion. FCH is a simple procedure for intraoperative navigation doing and guaranteeing of «critical view on security» while performance of LCHE. FCH together with HEV LapVison constitutes a new surgical procedure, making possible revealing of extrahepatic biliary ducts. This method may be applied as additional one while doing LCHE, preventing damage of biliary ducts.

MORPHOGENESIS OF HUMAN BILE DUCTS IN EMBRYONIC PERIOD

Numerous publications in scientific periodical press are indicative of an extraordinary interest of scientists in the issues of intrauterine morphogenesis. The study deals with the issue of prenatal morphogenesis of extrahepatic biliary ducts, since developmental defects of this segment of the digestive system constitute approximately 6-8 % out of all developmental defects. The objective of the study is to specify regularities of the spatial-temporal dynamics of the prenatal morphogenesis of the extrahepatic bile ducts. The investigation resulted in the following: the rudiment of the common bile duct in embryos of 4,0-5,0 mm of the parietococcygeal length is in the form of a hollow epithelial cord connecting the hepatic diverticulum with the ventral wall of the primary intestine. Physiological atresia of the common bile duct occurs in embryos of 8,5-11,0 mm of the parietococcygeal length due to intensive epithelial proliferation. Recanalization of the common bile duct is completed at the later stages of the intrauterine development.

Хірургічне лікування хворих з приводу хронічного панкреатиту з біліарною гіпертензією

Проаналізовані результати лікування 25 хворих з приводу фіброзно–дегенеративного хронічного панкреатиту (ХП) з біліарною гіпертензією (БГ), у яких виконана операція Фрея. У 13 (52%) хворих (група порівняння) здійснена класична операція Фрея з формуванням панкреатоєюноанастомозу (ПЄА) на петлі тонкої кишки, виключеній за Ру, у 4 (16%) – операція Фрея з накладанням гепатикоєюноанастомозу (ГЄА). У 8 (32%) хворих застосовано модифікацію операції Фрея, що передбачала формування ПЄА на ізольованому сегменті тонкої кишки, додаткового дуоденоєюноанастомозу з дистальним кінцем сегмента тонкої кишки, холецистектомію, фомування ГЄА бік у бік та міжкишкового анастомозу за Ру (основна група). Для інтраопераційного визначення тиску у позапечінкових жовчних протоках використовували оригінальну методику. Віддалені результати проаналізовані у 13 пацієнтів. В групі порівняння показник фізичного здоров’я (PHs) становив у середньому (42,9 ± 0,9) ум. од., психологічного здоров’я (MHs) – (57,6 ± 1,9) ум. од., вираженість больового синдрому (BP) – (60,3 ± 5,2) ум. од.; в основній групі PHs становив (47,1 ± 1,1) ум. од., MHs – (61,5 ± 1,5) ум. од., BP – (68,4 ± 4,2) ум. од. Запропонована модифікація хірургічного лікування фіброзно–дегенеративного ХП з БГ має переваги, обнадійливі віддалені результати і може бути застосована у лікуванні таких хворих.

Cancer screening and diagnosis in primary sclerosing cholangitis

Primary sclerosing cholangitis (PSC) is a progressive liver disease seen predominantly in patients who also have inflammatory bowel disease. PSC is characterised by inflammation and fibrosis of the intra- and extra-hepatic biliary ducts leading to progressive cholestasis, and it frequently leads to decompensated liver disease, necessitating liver transplantation. Patients with PSC and IBD have a predisposition to developing cancer, particularly in the colon and biliary tree. There are no available treatments for PSC; however, the efficacy of simtuzumab and obeticholic acid are being investigated. This article presents evidence and guidelines for screening and early detection of colorectal carcinoma, cholangiocarcinoma and gallbladder cancer, as well as other malignancies, including hepatocellular carcinoma and pancreatic cancer. Nurses have an important role in remaining vigilant for signs of cancer and helping patients make more informed decisions.

Endoscopic Ultrasound-guided Rendezvous Technique after Failed Endoscopic Retrograde Cholangiopancreatography: Which Approach Route Is the Best?

Objective The endoscopic ultrasound-guided rendezvous technique (EUS-RV) is a salvage method for failed selective biliary cannulation. Three puncture routes have been reported, with many comparisons between the intra-hepatic and extra-hepatic biliary ducts. We used the trans-esophagus (TE) and trans-jejunum (TJ) routes. In the present study, the utility of EUS-RV for biliary access was evaluated, focusing on the approach routes. Methods and Patients In 39 patients, 42 puncture routes were evaluated in detail. EUS-RV was performed between January 2010 and December 2014. The patients were prospectively enrolled, and their clinical data were retrospectively collected. Results The patients' median age was 71 (range 29-84) years. The indications for endoscopic retrograde cholangiopancreatography (ERCP) were malignant biliary obstruction in 24 patients and benign biliary disease in 15. The technical success rate was 78.6% (33/42) and was similar among approach routes (p=0.377). The overall complication rate was 16.7% (7/42) and was similar among approach routes (p=0.489). However, mediastinal emphysema occurred in 2 TE route EUS-RV patients. No EUS-RV-related deaths occurred. Conclusion EUS-RV proved reliable after failed ERCP. The selection of the appropriate route based on the patient's condition is crucial.

SVAP-1: a novel potential therapeutic target and marker for risk stratification in primary sclerosing cholangitis

Primary sclerosing cholangitis (PSC) is a chronic condition affecting the liver, targeting mainly intra- and extra-hepatic biliary ducts, potentially able to evolve to cirrhosis, biliary cancer and liver failure (1). Lack of understanding of its pathogenesis is likely to be one of the main reasons why there is still no effective treatment besides liver transplantation.

Changes in the Occurrence of Abdominal Complaints in Surgically Treated Patients due to Cholecystolithiasis

Introduction: The post cholecystectomy syndrome is defined as the maintenance or the occurrence of digestive tract symptoms after cholecystectomy due to extra hepatic biliary duct disorders. The introduction of a laparoscopic approach has revolutionized the procedure in the treatment of cholecystolithiasis. Laparoscopic cholecystectomy is less invasive for patients as compared to the classic surgical procedure. Aim: Determination of the frequency and the intensity of abdominal symptoms occurring after laparoscopic surgery and classic cholecystectomy related to the post cholecystectomy syndrome. Material and methods: The study group consisted of 105 patients of the Clinical Department of Surgery of the Regional Specialist Hospital in Tychy, Poland. Patients were divided into two groups: patients who underwent laparoscopic (n=83) or classic (n=22) cholecystectomy. The assessments were performed preoperatively, 1 month and 6 months postoperatively, using the “Gastric Symptom Questionnaire”. Results: The results were compared using statistical methods. Results: The symptoms of the syndrome were observed in 32 (30.5%) patients from the study group. Symptoms related to the post cholecystectomy syndrome included abdominal pain, flatulence, nausea, vomiting, movement difficulties, loss of appetite or diarrhea. These symptoms occurred more frequently after classic cholecystectomy as compared to the laparoscopic approach, 1 month and 6 months after cholecystectomy. Conclusions: The post cholecystectomy syndrome may occur in 1/3 of patients after cholecystectomy. The symptoms occur less frequently in laparoscopically treated patients. In a large number of patients the syndrome may be related to the treatment method.

A case of neuroendocrine carcinoma in the hepatic hilar lymph nodes concomitant with an adenocarcinoma of the gallbladder

BackgroundNeuroendocrine tumors (NETs) are rare especially in the gallbladder. They have not been elucidated in the pathogenesis, clinicopathological characteristics, and treatment options.Case presentationWe present a 76-year-old woman with a gallbladder tumor and hepatic hilar lymph node swelling. The lymph node biopsy demonstrated neuroendocrine carcinoma (NEC). We performed cholecystectomy, hepatic hilar lymphadenectomy, extrahepatic biliary duct resection, and hepaticojejunostomy prior to chemotherapy. Pathological examination revealed the gallbladder mass was an adenocarcinoma invading to the muscular layer without any NEC components, whereas the hepatic hilar lymph nodes were filled with high-grade NEC cells with negligible area of adenocarcinoma. The patient received general chemotherapy consisting of carboplatin and etoposide, but a recurrence in the para-aortic lymph nodes occurred 4 months after surgery.ConclusionsWe report a rare case of NEC of the hepatic hilar lymph nodes that were concomitant with an adenocarcinoma of the gallbladder. High-grade NEC generally has an aggressive behavior and an optimal treatment strategy should be chosen for each patient.

Biliary Tract IPMN Successfully Treated with Roux-en-Y Hepaticojejunostomy

A 72 year-old lady presented with complaints of jaundice, fatigue, pruritis and anorexia. Her medical history was notable for chronic abdominal pain, GERD and previous cholecystectomy. Admission lab studies revealed a total bilirubin of 7.4, alkaline phosphatase of 194 and an AST of 82. CT and MR imaging showed dilated intra and extrahepatic biliary ducts and suspicion for an ampullary mass. The pancreatic duct was radiographically normal. Initial ERCP revealed haziness in the CBD; two stents were placed after the duct was swept for gelatinous fluid which was cytologically negative for malignancy. She was discharged home but returned two weeks later with persistent complaints of refractory jaundice. Repeat serum studies yielded an increased total bilirubin of 14.1, an alkaline phosphatase of 342 and a stable AST of 84. She underwent repeat EUS/ERCP and intraductal cholangioscopy (with the Spyglass system) which showed a lesion at the hilar and right main hepatic duct suspicious for intraductal papillary mucinous neoplasm (IPMN). She had surgical resection of the extrahepatic bile duct with right hepatectomy, re-excision of the left hepatic duct margin and Roux-en-Y hepaticojejunostomy. The postoperative course was complicated by the development of ascites and septicemia which were successfully treated with diuretics and antibiotics. Excised tissue sent for pathology confirmed primary right hepatic duct IPMN consistent with carcinoma in situ and high grade dysplasia. Furthermore, right partial hepatectomy revealed extensive IPMN involving major and minor ducts and obstructive cholangiopathy of the liver adjacent to the bile duct. Compared to its pancreatic counterpart, biliary tract-IPMN (BT-IPMN) is an uncommon phenomenon and is even rarer when isolated to the intra and extra-hepatic hilar ducts. BT-IPMN is more often associated with invasive features compared to similar pancreatic neoplasms. Patients typically present with abdominal pain, jaundice and elevated total bilirubin and alkaline phosphatase. Historically, BT-IPMNs have been frequently misdiagnosed (as adenocarcinomas, cholangiocarcinomas and cystic neoplasms); there is an emergence of literature substantiating the need for clear diagnostic definitions for this rare diagnosis. BT-IPMN is defined as an intraluminal neoplasm with papillary cyto-architecture and mucin hypersecretion often leading to marked dilatation of affected bile ducts. Treatment is ultimately resection of the involved tissue.

Endoscopic Features and Management Strategies of Ampullary Carcinoids: A Case Series

Introduction: Although the gastrointestinal tract is the most common site for occurrence of carcinoids, particularly the small bowel and the appendix, ampullary carcinoids are rather rare, with less than 100 cases reported in literature, most of which are single case reports. We present our experience of managing three such cases, two by endoscopic ampullectomy and one requiring surgery. Case Presentation: The three patients presented with obstructive jaundice. Abdominal imaging suggested ampullary masses of varying sizes, between 1.2 to 1.8 cm, accompanied by both intra and extrahepatic biliary duct dilatation and pancreatic duct dilatation. On endoscopy the tumors were noted to be umbilicated and firm. On endoscopic ultrasound (EUS) the masses were hypoechoic and confined to the deep mucosa. No CBD involvement or periduodenal lymphadenopathy was noted in any of these cases. One patient elected for surgical treatment (Whipple's) and the tumor was successfully excised. The other two underwent successful endoscopic ampullectomy. The cut surface of the endoscopically resected lesions appeared yellow and granular. The tumor was confirmed on pathology to be well-differentiated low-grade carcinoid, confined to the deep mucosa. Both patients had an uneventful post-ampullectomy course with resolution of their jaundice. Surveillance endoscopy and biopsy showed no residual tumor. Discussion: Ampullary carcinoids are rare tumors, which were traditionally managed with pancreatoduodenectomy or local excision. EUS has changed this paradigm and gives discrete information including depth of tumor, ductal invasion, and lymph node involvement. Ampullary carcinoids can be identified endoscopically by the typical features described above and successfully managed by endoscopic ampullectomy.

P-244 Cholangiocarcinoma: a retrospective analysis of our experience in diagnosis, prognostic factors, staging and treatment

P-244 Cholangiocarcinoma: a retrospective analysis of our experience in diagnosis, prognostic factors, staging and treatment

The Use of the Gallbladder Wall for Reconstruction of the Extrahepatic Bile Ducts in a Case of Agenesis of the Common Bile Duct: A Case Report

Unexpected anomalies of the extrahepatic biliary ducts were found intraoperatively during open cholecystectomy in a 49-year-old male, with calcular obstructive jaundice. The patient had congenital absence of the common bile duct that appears to have been replaced by the cystic duct, which opened directly into the duodenum. The right and left hepatic ducts drained into the posterior wall of the gallbladder by a short common hepatic duct. Intraoperatively the gallbladder wall (with uncompromised nerve and blood supply) was used as a vital flap to reconstruct a tubular bridge across the defect in the biliary ducts, while retaining a functional sphincter of Oddi at the end of the original cystic duct. The patient showed uneventful recovery and had no further complaints at subsequent follow-up for nine years after surgery. Knowledge of such an anomaly is essential for hepatobiliary surgeons. Intraoperative assessment of the biliary ducts should be performed prior to excision of the gallbladder in order to allow repair of any anomalies in the duct system using the gallbladder wall while maintaining its cystic arterial supply.

Initial Presentation of a Pancreatic Mass

Question: A 55-year-old African American man with a medical history of chronic pancreatitis, pancreatic mass, alcohol abuse, hypertriglyceridemia, gastroesophageal reflux disease, and essential hypertension presented to the emergency department with severe abdominal pain radiating to his back that was associated with diaphoresis and weight loss. The initial workup demonstrated acute pancreatitis. Prior radiologic studies were reviewed to better characterize the pancreatic mass. More recent computed tomography and MRI scans demonstrated an enlarging, cystic and septated mass within the pancreatic head with marked dilatation of the patient’s pancreatic, and intrahepatic and extrahepatic biliary ducts (MRI; Figure A). Additionally, there was evidence of peripancreatic fat infiltration and multiple enlarged peripancreatic lymph nodes. Ultrasonography had also shown that the mass was displacing the patient’s duodenum.

Right Posterior Segmental Hepatic Duct: Role of Intraoperative Cholangiogram to Prevent Extrahepatic Biliary Duct Injuries

Extrahepatic bile ducts constitute a significant anatomic site for surgeons when performing hepatobiliary operations from minor procedure such as cholecystectomy to major operation such as hepatectomy. The challenges for surgeon in performing such cases increase when congenital variance of biliary tree occurs which may lead to unintentional bile duct injuries. We reported a case of a lady who presented with obstructive jaundice secondary to huge distal common bile duct stone. The presence of right posterior segmental hepatic duct, which rarely occurs, was discovered during intraoperative cholangiogram before common bile duct exploration. The operation was successful without incidence of biliary duct injury.