Intraand Extrahepatic Bile Ducts Research Articles

Comparative study of the effect of U100 laser and pneumatic ballistic combined with percutaneous transhepatic cholangioscopic lithotomy in the treatment of intra-and extrahepatic bile duct stones and its effect on liver function.

Objectives:To compare the efficiency of U100 laser and pneumatic ballistics combined with percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) in the treatment of intra-and extrahepatic bile duct stones and their effects on liver function.Methods:Medical records of 97 patients with intra-and extrahepatic bile duct stones treated in our hospital from May 2020 to May 2021 were selected for retrospective analysis. Of them, forty-three patients received pneumatic ballistic lithotripsy combined with PTCSL (Group-I), and 54 patients received U100 laser lithotripsy combined with PTCSL (Group-II). The therapeutic effects of the treatment in two groups and its effect on liver function were compared and analyzed.Results:There was no significant difference in the operation time and intraoperative bleeding (P>0.05) between the two groups. The postoperative pain duration and hospital stay of patients treated with U100 laser lithotripsy combined with PTCSL (Group-II) were shorter than those treated with pneumatic ballistic lithotripsy combined with PTCSL (Group-I), P<0.05. The biliary bleeding rate of patients in Group-II was lower (3.70%) than those in Group-I (16.27%, P<0.05), and the stone residue rate of patients in Group-II was also lower (1.85%) than those in Group-I (11.63%, P<0.05). The levels of total bilirubin (TBIL), alanine aminotransferase (ALT) and albumin (ALB) in Group-II patients were higher than in patients in Group-I.(P<0.05).Conclusion:Compared with pneumatic ballistics, U100 laser lithotripsy combined with PTCSL in the treatment of intra and extrahepatic bile duct stones has the advantages of less postoperative pain, shorter hospital stay, less biliary bleeding and stone residue, and less damage to liver function.

Caudate lobe as the sole remnant liver following anatomical hepatectomy for the treatment of hepatolithiasis

Objective To investigate the safety and short-term effect of anatomical hepatectomy for the treatment of hepatolithiasis with the caudate lobe as the sole remnant liver. Methods The clinical data of 1 patient with hepatolithiasis combined with liver atrophy-hypertrophy syndrome who was admitted to the Hunan Provincial People's Hospital in April 2014 were retrospectively analyzed.The stones were located in the left and right liver, the involved liver became fibroatrophy, and the hepatic caudate lobe not containing stones became hypertrophy.The body surface area of the patient was 1.65 m2, standard total liver volume was 1 167.63 mL. According to the result of CT, expected residual liver volume after hepatectomy was 706.12 mL, and the ratio of residual liver volume over the standard total liver was 60.47%.The radio of residual liver volume over the body mass index was 1. 21%.The patient received the second exploration of common bile ducts, hepatectomy with the caudate lobe as the sole remnant liver and T tube drainage.The follow-up including recurrence of calculus was performed by outpatient examination and telephone interview up to April 2015. Results The patient underwent caudate lobe as the sole remnant liver following anatomical hepatectomy successfully without blood transfusion.The operation time and volume of intraoperative blood loss were 380 minutes and 350 mL.The peritoneal drainage tube was removed at postoperative day 2 and the patient was discharged at postoperative day 8 with a good recovery of liver function.The postoperative pathological examination showed that there were focal biliary epithelial papillary hyperplasia combined with light-medium atypical hyperplasia and no canceration.The T tube cholangiography two month later showed that there were unobstructed lower bile duct and no residual intra-and extra-hepatic stones. The liver function was normal.Then T tube was removed and patient resumed normal life.During the 1-year follow-up, no chills and fever, jaundice and abdominal pain occurred, no calculus was detected by Bultrasonography, and computed tomography reexamination showed that remnant liver volume was increased and no intra-and extra-hepatic bile duct stones were detected. Conclusion Anatomical hepatectomy for the treatment of hepatolithiasis with the caudate lobe as the sole remnant liver is safe and feasible, with a good curative effect. Key words: Hepatolithiasis; Anatomical hepatectomy; Surgical procedures, operative

Pyogenic Liver Abscess after Bile Duct Exploration Drained with Endoscopic Techniques

Background: Pyogenic liver abscess (PLA) after surgery may lead to sepsis.Endoscopic techniques provide an alternative choice for PLA drainage. Methods: We describe a 49-year-old woman who developed a right PLA after left lobe hepatectomy and common bile duct (CBD) exploration due to intra-and extra-hepatic bile duct stones. Results: The patient suffered from persistent high fever and hyperbilirubinemia with unknown reason after surgery despite amount of antibiotic applied until a liver abscess in right lobe was found .It was treated with ultrasound-guided percutaneous transhepatic drainage(PTD). However, outcome of the PTD was worse because of no fluid collected in abscess cavity at that time. T-tube drainage suddenly stop work after post-operative day 4. Emergent Endoscopic Retrograde Cholangiopancreatography (ERCP) and Endoscopic Nasobiliary Drainage (ENBD) was performed. The patient recovered rapidly a week later. Conclusions: PLA induced by regional closed-loop biliary obstruction is an important reason of abdominal infection after surgery.Endoscopic techniques with ERCP and ENBD can resolve PLA in early stage especially when PTD inadequently drained.

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

Analysis of the causes of reoperation and countermeasures of intra-and extrahepatic bile duct stones after op-eration

Objective To explore the extrahepatic bile duct stones after reoperation cause analysis and coun-termeasures.Methods Clinical data of 150 patients with liver surgery gallstone surgery again were retrospectively analyzed,according to the first reason for liver from gallstone surgery will be divided into the three groups：group hepa-tolithiasis （ group A,100 cases） ,gallstones group （ group B,30 patients） ,common bile duct stones group （ group C, 20 cases） .The reasons for reoperation were analyzed.Results In intrahepatic bile duct stones reoperation patients, the recurrence of liver gallstones was 98 cases（65.3%）,common bile duct cysts and Caroli disease was 35 cases （23.3%）,anastomotic stenosis in 17 cases（11.3%）;The postoperative complication rate of group A（44.0%） was significantly higher than that of group B（13.3%） and group C（15.0%）（χ2 =9.32,5.88,all P〈0.05）;The sec-ondary and post-operative inflammation stone recurrence within 5 years of group A was 32.0%,which was significant-ly higher than 6.7%of group B and 10.0%of group C（χ2 =7.67,3.97,all P〈0.05）.Conclusion The intrahe-patic bile duct stones are the main types of reoperation after liver gallstones,gallstones and liver recurrence is the main cause of its secondary surgery.It should be make clear the disease cause of preoperation, take a different surgical options for patients with different types of stones,prevention,and avoid the occurrence of postoperative complications, which can effectively reduce the risk of secondary surgery to alleviate the suffering of patients. Key words: Calculi Bile Ducts; Intrahepatic Bile Ducts; Extrahepatic Reoperation

Cephalic Duodeno-Pancreatectomy with Pancreatic-Gastric Anastomosis with Double Purse String, in Patient with Lithiasis and Tumoral Jaundice - Case Report

Abstract Introduction: One of the most feared complications after cephalic duodeno-pancreatectomy remains pancreatic fistula. In recent years, various methods of pancreatico-digestive reconstruction were performed in order to reduce the rate of pancreatic fistula. One of these methods is pancreatico-gastric reconstruction by using two purse string threads. Case report: We present in this article a patient with jaundice with mixed etiology: tumoral and lithiasic. Subjectively, the patient accused sclerose-skin-jaundice, right upper quadrant and epigastric pain, nausea and vomiting. Computed tomography revealed dilatation of intraand extrahepatic bile ducts, a dilated Wirsung duct and a tumor at the biliopancreatic confluence, leading to a suspicion of vaterian ampulom. Upper endoscopy revealed a tumor protruding in the descending duodenal segment. Intraoperatively a tumor suggestive of vaterian ampulom and duct stones was shown. Surgical treatment consisted of coledocolitotomy, cephalic duodeno-pancreatectomy with pancreatic-gastric anastomosis, performed by using two purse string threads. The postoperative evolution was favorable. Conclusion: Pancreatico-gastric anastomosis using two purse string threads is a simple, safe and quick procedure, avoiding the application of sutures through the pancreatic parenchyma and thus reducing the rate of pancreatic fistula.

761 Zebrafish Studies Show That Add3, Not Xpnpep1, Is a Biliary Atresia Risk Gene

Biliary atresia (BA) is a progressive fibro-inflammatory cholangiopathy affecting the intraand extrahepatic bile ducts of neonates. Although BA is the most common identifiable cause of obstructive jaundice in infants, and is the leading indication for pediatric liver transplantation, the etiology remains elusive. We investigated the importance of genes identified in genome-wide association studies (GWAS) of BA patients using zebrafish. The Matthews's lab has demonstrated the utility of the zebrafish system to test the functionality of genes identified in GWAS of BA by demonstrating that knockdown of gpc1 leads to biliary defects. A prior GWAS examined single-nucleotide polymorphisms in 200 Han Chinese BA patients and 481 ethnically matched controls. The strongest association was found for a region located between the XPNPEP1 and ADD3 genes on 10q24.2. Our genetic analysis confirmed the importance of this region in a separate cohort of patients. To determine whether loss of xpnpep1 and/or add3a leads to biliary defects we performed knockdown studies of the respective genes using morpholino antisense oligonucleotides (MO). We then examined their biliary function using the lipid reporter PED6, biliary development using cytokeratin immunostaining, and gene expression using quantitative PCR. We confirmed that xpnpep1 and add3a are expressed in the developing zebrafish liver. Knockdown of add3a led to decreased biliary function by PED6 screening, while xpnpep1 knockdown had only a mild effect. There were developmental biliary defects in the add3a morphants, as demonstrated by cytokeratin immunostaining. The transcription factor vhnf1, implicated in biliary development, was significantly downregulated in add3a morphants but not xpnpep1 morphants. add3a morphants also demonstrated increased expression of gli2a, a Hedgehog target, which is consistent with prior studies of BA patients and of zebrafish models of BA such as gpc1 knockdown. Interestingly, knockdown of both add3a and gpc1 resulted in a synergistic disruptive effect on biliary development. While GWAS identified ADD3 and XPNPEP1 as potential BA susceptibility genes, our results suggest that ADD3 is likely the more important gene in this regard. Like gpc1, add3a acts via Hedgehog signaling, supporting a role for this important pathway in BA pathogenesis.

762 Control of Microenvironmental Cues Enables the Differentiation of Pluripotent Stem Cell Derived Hepatocyte-Like Cells to an Adult Phenotype

Biliary atresia (BA) is a progressive fibro-inflammatory cholangiopathy affecting the intraand extrahepatic bile ducts of neonates. Although BA is the most common identifiable cause of obstructive jaundice in infants, and is the leading indication for pediatric liver transplantation, the etiology remains elusive. We investigated the importance of genes identified in genome-wide association studies (GWAS) of BA patients using zebrafish. The Matthews's lab has demonstrated the utility of the zebrafish system to test the functionality of genes identified in GWAS of BA by demonstrating that knockdown of gpc1 leads to biliary defects. A prior GWAS examined single-nucleotide polymorphisms in 200 Han Chinese BA patients and 481 ethnically matched controls. The strongest association was found for a region located between the XPNPEP1 and ADD3 genes on 10q24.2. Our genetic analysis confirmed the importance of this region in a separate cohort of patients. To determine whether loss of xpnpep1 and/or add3a leads to biliary defects we performed knockdown studies of the respective genes using morpholino antisense oligonucleotides (MO). We then examined their biliary function using the lipid reporter PED6, biliary development using cytokeratin immunostaining, and gene expression using quantitative PCR. We confirmed that xpnpep1 and add3a are expressed in the developing zebrafish liver. Knockdown of add3a led to decreased biliary function by PED6 screening, while xpnpep1 knockdown had only a mild effect. There were developmental biliary defects in the add3a morphants, as demonstrated by cytokeratin immunostaining. The transcription factor vhnf1, implicated in biliary development, was significantly downregulated in add3a morphants but not xpnpep1 morphants. add3a morphants also demonstrated increased expression of gli2a, a Hedgehog target, which is consistent with prior studies of BA patients and of zebrafish models of BA such as gpc1 knockdown. Interestingly, knockdown of both add3a and gpc1 resulted in a synergistic disruptive effect on biliary development. While GWAS identified ADD3 and XPNPEP1 as potential BA susceptibility genes, our results suggest that ADD3 is likely the more important gene in this regard. Like gpc1, add3a acts via Hedgehog signaling, supporting a role for this important pathway in BA pathogenesis.

O56 SOFOSBUVIR/LEDIPASVIR WITH AND WITHOUT RIBAVIRIN FOR 8 WEEKS COMPARED TO SOFOSBUVIR/LEDIPASVIR FOR 12 WEEKS IN TREATMENT-NAÏVE NON-CIRRHOTIC GENOTYPE-1 HCV-INFECTED PATIENTS: THE PHASE 3 ION-3 STUDY

Biliary atresia (BA) is a progressive fibro-inflammatory cholangiopathy affecting the intraand extrahepatic bile ducts of neonates. Although BA is the most common identifiable cause of obstructive jaundice in infants, and is the leading indication for pediatric liver transplantation, the etiology remains elusive. We investigated the importance of genes identified in genome-wide association studies (GWAS) of BA patients using zebrafish. The Matthews's lab has demonstrated the utility of the zebrafish system to test the functionality of genes identified in GWAS of BA by demonstrating that knockdown of gpc1 leads to biliary defects. A prior GWAS examined single-nucleotide polymorphisms in 200 Han Chinese BA patients and 481 ethnically matched controls. The strongest association was found for a region located between the XPNPEP1 and ADD3 genes on 10q24.2. Our genetic analysis confirmed the importance of this region in a separate cohort of patients. To determine whether loss of xpnpep1 and/or add3a leads to biliary defects we performed knockdown studies of the respective genes using morpholino antisense oligonucleotides (MO). We then examined their biliary function using the lipid reporter PED6, biliary development using cytokeratin immunostaining, and gene expression using quantitative PCR. We confirmed that xpnpep1 and add3a are expressed in the developing zebrafish liver. Knockdown of add3a led to decreased biliary function by PED6 screening, while xpnpep1 knockdown had only a mild effect. There were developmental biliary defects in the add3a morphants, as demonstrated by cytokeratin immunostaining. The transcription factor vhnf1, implicated in biliary development, was significantly downregulated in add3a morphants but not xpnpep1 morphants. add3a morphants also demonstrated increased expression of gli2a, a Hedgehog target, which is consistent with prior studies of BA patients and of zebrafish models of BA such as gpc1 knockdown. Interestingly, knockdown of both add3a and gpc1 resulted in a synergistic disruptive effect on biliary development. While GWAS identified ADD3 and XPNPEP1 as potential BA susceptibility genes, our results suggest that ADD3 is likely the more important gene in this regard. Like gpc1, add3a acts via Hedgehog signaling, supporting a role for this important pathway in BA pathogenesis.

P1163 ALL-ORAL THERAPY WITH DACLATASVIR IN COMBINATION WITH ASUNAPREVIR AND BMS-791325 FOR TREATMENT-NAIVE PATIENTS WITH CHRONIC HCV GENOTYPE 4 INFECTION

Biliary atresia (BA) is a progressive fibro-inflammatory cholangiopathy affecting the intraand extrahepatic bile ducts of neonates. Although BA is the most common identifiable cause of obstructive jaundice in infants, and is the leading indication for pediatric liver transplantation, the etiology remains elusive. We investigated the importance of genes identified in genome-wide association studies (GWAS) of BA patients using zebrafish. The Matthews's lab has demonstrated the utility of the zebrafish system to test the functionality of genes identified in GWAS of BA by demonstrating that knockdown of gpc1 leads to biliary defects. A prior GWAS examined single-nucleotide polymorphisms in 200 Han Chinese BA patients and 481 ethnically matched controls. The strongest association was found for a region located between the XPNPEP1 and ADD3 genes on 10q24.2. Our genetic analysis confirmed the importance of this region in a separate cohort of patients. To determine whether loss of xpnpep1 and/or add3a leads to biliary defects we performed knockdown studies of the respective genes using morpholino antisense oligonucleotides (MO). We then examined their biliary function using the lipid reporter PED6, biliary development using cytokeratin immunostaining, and gene expression using quantitative PCR. We confirmed that xpnpep1 and add3a are expressed in the developing zebrafish liver. Knockdown of add3a led to decreased biliary function by PED6 screening, while xpnpep1 knockdown had only a mild effect. There were developmental biliary defects in the add3a morphants, as demonstrated by cytokeratin immunostaining. The transcription factor vhnf1, implicated in biliary development, was significantly downregulated in add3a morphants but not xpnpep1 morphants. add3a morphants also demonstrated increased expression of gli2a, a Hedgehog target, which is consistent with prior studies of BA patients and of zebrafish models of BA such as gpc1 knockdown. Interestingly, knockdown of both add3a and gpc1 resulted in a synergistic disruptive effect on biliary development. While GWAS identified ADD3 and XPNPEP1 as potential BA susceptibility genes, our results suggest that ADD3 is likely the more important gene in this regard. Like gpc1, add3a acts via Hedgehog signaling, supporting a role for this important pathway in BA pathogenesis.

Isolated Pancreatic Tuberculosis Mimicking Inoperable Pancreatic Cancer: A Diagnostic Challenge Resolved by Endoscopic Ultrasound-Guided Fine-Needle Aspiration

1Department of Gastroenterology, Strasbourg University, Strasbourg; 2Department of Hematology, University of Nice, Nice, France Correspondence: Dr Adrien Sportes, Department of Gastroenterology, Strasbourg University, 1 place de l’hopital, 67000 Strasbourg, France. Telephone 0-33-369-55-1008, fax 0-336-955-0315, e-mail adrien.sportes@chru-strasbourg.fr Received for publication March 14, 2013. Accepted May 6, 2013 Case presentation In December 2010, a 52-year-old man was admitted to hospital for febrile cholestatic jaundice. The patient was of Algerian origin and had immigrated to Alsace (France) two years previously. He was a construction worker with no medical or surgical history, nor was there history of contact with tuberculosis. The clinical history began one month previously, with diffuse abdominal pain, weight loss and jaundice. Physical examination on admission revealed a temperature of 38.5°C, epigastric abdominal pain associated with scleral jaundice and no lymphadenopathy. The remainder of the physical examination was unremarkable. The patient’s initial laboratory analysis revealed a leukocyte count of 7.07×109/L, a hemoglobin level of 97 g/L and a platelet count of 259×109/L. Cholestasis was demonstrated by increased serum levels of gamma-glutamyltransferase (336 U/L; normal range 11 U/L to 82 U/L), alkaline phosphatase (177 U/L; normal range 41 U/L to 117 U/L) and total bilirubin (30 μmol/L; normal range 1.7 μmol/L to 21 μmol/L), with a direct bilirubin level of 20 μmol/L (normal range 1 μmol/L to 10 μmol/L) and alanine aminotransferase level of 120 U/L (normal range 10 U/L to 49 U/L). Acute phase reactants increased, with a C-reactive protein level of 63 mg/L (normal <4 mg/L). Tests for HIV 1 and 2, and hepatitis B and C were negative. Computed tomography (CT) showed a heterogeneous mass in the head of the pancreas 3.5 cm × 4.5 cm in size, causing a compression of the bile duct, with dilation of the intraand extrahepatic bile ducts. The tumour was in contact with the superior mesenteric vein and artery. In addition, many peripancreatic lymph nodes were present (Figure 1). Magnetic resonance cholangiopancreatography was performed and revealed dilation of the intraand extrahepatic bile ducts upstream of a cephalic pancreatic mass, with dilation of the duct of Wirsung (Figure 2). The initial differential diagnosis was cholangitis secondary to a malignant tumour of the pancreatic head without knowledge of the histological type. Given the septic context and the presence of a locally advanced tumour (invasion of the superior mesenteric artery and vein), it was decided to perform endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) of the mass of the head of the pancreas, along with placement of a metal biliary stent. EUS revealed a large tumour in the head region of the pancreas compressing the bile duct, and many peripancreatic lymph nodes and some ascites (Figure 3). Cytology demonstrated granuloma with caseous necrosis and the presence of an aspect of diffuse necrosis, the absence of tumour cells and tuberculosis bacterium. The assessment was completed using a CT scan-guided transmural biopsy of the peripancreatic lymphadenopathy. Pathological examination revealed caseous necrosis with the presence of acid-fast bacilli; Ziehl-Neelsen stain staining was positive. Additionally, bacteriological samples returned positive for Mycobacterium tuberculosis with polymerase chain reaction DNA. Positron emission CT was used to search for other sites of tuberculosis infection. Examination revealed hyperintense metabolism characterizing the large swelling of the head of the pancreas associated with multiple gastric lymph nodes and perihepatic hilum (Figure 4). The final diagnosis was isolated pancreatic tuberculosis complicated by cholangitis. Antituberculous therapy was initiated, leading to clinical, biological and radiological improvement (Figure 5). The metal biliary stent was replaced with a plastic stent. It was replaced once again before its final removal in September 2011.

Mucin-producing gallbladder carcinoma.

A 54-year-old Japanese woman presented with epigastralgia. Physical examination revealed tenderness in the epigastrium. Laboratory test results showed elevated levels of AST (103 mU/ml), ALT (203 mU/ml), gamma GTP (642 mU/ml), and ALP (2,132 mU/ml). Ultrasonography (US) using a SSD-5500 (Aloka, Tokyo, Japan) showed a hyperechoic protrusion in the fundus of the gallbladder, with diffuse and mild wall thickening (Fig. 1). Spotty and linear hyperechoic contents were seen in the enlarged gallbladder lumen and intraand extrahepatic bile ducts (Fig. 2). Contrast-enhanced CT depicted a papilla-like protrusion with mild enhancement (Fig. 3). Dilatation of the intraand extrahepatic bile ducts was observed. Endoscopic retrograde cholangiopancreatography showed variable filling defects in the gallbladder and common bile duct, suggesting the presence of mucin, and pancreaticobiliary maljunction (Fig. 4). Cytological examination of the bile showed the presence of malignancy. Carcinoma of the gallbladder being diagnosed, gallbladder and bile duct resection, as well as lymph node dissection, was performed. The resected gallbladder contained a massive amount of mucin together with the tumor, which showed a papillary growth pattern. Histopathological examination using immunostaining revealed a papillary tumor consisting of an adenoendocrine cell carcinoma containing mucus. The postoperative course in this patient was uneventful.

Treatment of intra-and extrahepatic bile duct stone with laparoscopy and endoscopy

Objective To investigate the application of laparoscope,duodenoscope and choledochoscope in the treatment of intra-and extrahepatic bile duct stone.Methods The clinical data of 3 16 patients with intraand extrahepatic bile duct stone who were admitted to the Bethune First Hospital from April 2007 to August 2010were retrospectively analyzed.There were 269 patients with cholecystolithiasis and choledocholithiasis,10 patients with cholesystolithiasis,choledocholithiasis and hepatolithiagis,and 37 patients with choledocholithiasis.Laparoscopic cholecystectomy(LC)+laparoscopic common bile duct exploration(LCBDE)+choledochoscopy was applied to patients with hepatolithiasis or with the diameter of common bile duct≥10 mm;endoscopic sphincterotomy (EST)+LC or LC+EST was applied to patients with the diameter of common bile duct between 10 mm and 5 mm and the diameter of cystic duct<5 mm;LC+laparoscopic transcystic common bile duct exploration(TC-CBDE)+choledochoscopy wag applied to patients with the diameter of common bile duct≤5 mm and the diameter of cystic duct≥5 mm.Results The success rate of operation was 96.8%(306/316).A total of 163 patients received LC +LCBDE+T-tube drainage+choledochoscopy,and the mean operation time,expense,duration of hospital stay were 93.6 minutes,2.8×104 yuan and 9.8 days,respectively,and 5 patients had complications postoperatively.Fifty-four patients received EST+LC,and the mean operation time,expense,duration of hospital stay were 45.0minutes,6.6 days,2.3×104yuan,respectively,and 1 patient had complication postoperatively.Sixty-seven patients received LC+EST,and the mean operation time,expense and duration of hospital stay were 40.0minutes,6.1 days,2.4×104 yuan,respectively,and 2 patients had complication postoperatively.Thirty-two patients received one-stage repair of common bile duct and LC+TC-CBDE+choledochoscopy,and the mean operation time,expense and duration of hospital stay were 97.3 minutes,7.3 days and 2.5×104yuan,respectively,and 1 patient had complication postoperatively.A total of 272 patients were followed up for 12 months,except for 6 patients with recurrence of common bile duct stone,no residual stone or biliary stricture was etected.Conclusion Combined application of laparoscope,duodenoscope and choledochoscope has advantages of less trauma,quick ecovery and fewer complications in the treatment of intra-and extrahepatic bile duct stone. Key words: Cholelithiasis; Laparoscopy; Duodenoscopy; Choledochoscopy

Severe obstructive jaundice in a young patient with IgG4-negative autoimmun pancreatitis – treatment without invasive procedures

Introduction: Autoimmun pancreatitis should be a differenzial diagnosis from other form of chronic pancreatitis and pancreas malignancies in jaundice, abdominal pain, weight loss with pancreas enlargement, narrowing of the bile duct and abnormal immunserological tests. Here we report a 28-year-old previously healthy male with ANA, IgG4- negative autoimmun pancreatitis according to the findings of serum biochemistry, CT and ERCP. Our patient presented with a 1 month history of obstructive jaundice, epigastrial pain, weight loss after using itraconazol for skin mycosis. His serum bilirubin and ALP were highly elevated on admission. The transaminase levels were only mildly elevated and serum amylase was in normal range. Abdominal US showed a dilated common bile duct (CBD) and intrahepatic biliary radicals, the head and body of the pancreas was bulky. There were no gallstones, CBD stones or any mass lesions in the CBD. The CT scan of the abdomen showed the enlargement of the head and body with dilated intra-and extrahepatic bile ducts. Hypergammaglobulinaemia, autoantibodies and elevated serum IgG4 levels were not detected. CA 19–9, CEA were in normal range. Fine needle aspiration of the pancreas was done, malignancy was not observed. During ERCP diffuse narrowing of pancreatic duct and intrapancreatic part of the CBD were found, papillotomy and biliary drainage were not performed. Biopsy was taken from the papilla of Vateri, IgG4 positive cells were not detected. Diabetes mellitus appeared, needing just diet. Oral prednisolon therapy was started. After a few weeks, the diffuse enlargement of the pancreas on CT reverted to normal. Dilation of the bile ducts and elevated liver enzymes normalized. Paralelly clinical improvement was observed, abdominal pain, weigt loss and jaundice resolved, serum blood glucose levels normalized on diet. Conclusion: AIP was diagnosed based on clinical symptoms and ERCP pictures. Early initiation of corticostreoid therapy may prevent invasive endoscopic procedures in the management of obstructive jaundice.

Sarcoma primario pancreático

A 53-year-old woman with a past medical history of appendectomy and neurinoma on the left side of the neck in 1986 was admitted for asthenia and itching of recent onset, with absence of abdominal pain or any alterations on physical examination. A blood test showed: alkaline phosphatase, 1,499 IU/L, gamma-glutamyl transpeptidase, 1,163 IU/L, total bilirubin, 1.62 mg/dl, and CA-19.9, 533 IU/ml (normal value < 37 IU/ml). Doppler-US and abdominal CT scans were performed, which revealed a mass measuring 6 cm in diameter located in the head of the pancreas, with dilated intraand extra-hepatic bile ducts. The lesion had cystic areas with solid septa and papillary epithelium, some of which stained very brightly (Figs. 1 and 2); no evidence of vascular invasion or adenopathies was observed. With a diagnostic impression of resectable cystic neoplasm of the pancreas with no surgical contraindications a cephalic duodenopancreatectomy was performed. In the surgically removed tissue a solid mass of whitish color and elastic consistency was observed. The mass was located in the head of the pancreas. Although not encapsulated, it showed well-defined borders and was easily removed from the adjacent pancreas. An immunohistochemical study showed that it was positive for vimentin marker, and negative for cytokeratins (AE1-AE3), S-100, chromogranin, CD 34, C-KIT, and actin. Furthermore, a low cell proliferation index (MIB-I) was also observed (Fig. 3). These data from the histological study suggested the presence of a low-malignancy-grade fusocellular sarcoma. After a 2-year follow-up, the patient remained asymptomatic and without recurrent disease.

Combination of endoscopy and laparoscopic hepatectomy in the treatment of intra- and extrahepatic bile duct stones.

Objective To study the approach of the combination of endoscopy and laparoscopic hepatectomy in the treatment of intra-and extrahepatic bile duct stones.Methods Eighty-one patients with intra-and extrahepatic bile duct stones who had been admitted to Nankai Hospital from July 2004 to March 2008 were divided by random number table into 2 groups.Twenty patients in group A underwent open hepatectomy+biliary exploration.Sixty-one patients in group B received duodenoscopy first,and patients with successful clearance of stones in the extrahepatic bile duct underwent total laparoscopic hepatectomy or hand-assisted laparoscopic hepateetomy according to the location of the stones in the liver;patients with residual stones in the extrahepatic bile duct underwent hand-assisted laparoscopie hepateetomy+biliary exploration.The changes of the indexes during perioperative period of the 2 groups were analyzed by t test.Results Minimally invasive surgeries were successfully carried out in group B.Satisfactory outcomes were obtained,and no severe complication was observed.The gastrointestinal function recovery time of patients who underwent hand-assisted laparoscopic hepatectomy+biliary exploration in group B was significantly shorter than in group A(t:3.062,P＜0.05),but there was no significant difference in operation time and perioperative blood loss between the 2 groups(t=0.953,0.911,P＞0.05).Compared with patients who underwent hand-assisted laparoscopic hepateetomy,the operation time was significantly longer,hut the gastrointestinal function recovery time was significantly shorter in patients who underwent total laparoscopic hepatectomy(t:2.046,2.316,P＜0.05),there was no significant difference in operation time between the 2 groups(t=0.874,P＞0.05).Conclusion Endoscopy+laparoscopic hepatectomy is safe and effective,and can decrease the trauma to the minimum for patients with intra-and extrahepatic bile duct stones. Key words: Endoscopes; Laparoscopy; Hepatectomy; Intra-and extrahepatic bile duct stone

Role of color Doppler flow imaging in predicting difficulties of laparoscopic cholecystectomy

Objective To evaluate the color Doppler flow imaging (CDFI) findings in predicting possible difficulties of laparoscopic cholecystectomy (LC). Methods A total of 99 patients with acute cholecystitis received CDFI examination, and were divided into easy LC group (n=67) and difficult LC group (n=32) according to the indexes including the volume of gallbladder, the thickness of gallbladder wall, the condition of arterial flow in the gallbladder wall, the condition of gallbladder cavity and fossa, and of the intra-and extra-hepatic bile duct. After LC, all the patients were redivided into easy LC group and difficult LC group according to a difficulty scoring system of LC. The relationship among imaging results, operation difficulties and operation findings was investigated. Results According to the final score of difficulty scoring system of LC, the number of patients in easy LC group and difficult group was 61 and 38, respectively. Compared with easy LC group, patients in difficult LC group had bigger gallbladder volume [(39.5±13.2)am3 vs(32.6±10.4)cm3], thicker gallbladder wall [(10.1±4.0)mm vs(3.8±0.9)mm], more stone incarceration in the neck of gallbladder, abundant color blood flow signal of the gallbladder wall and more severe adhesion of gallbladder to the adjacent tissues, with statistical difference between the 2 groups (t=-2.820,-12.318,-3.952,x2=33.548,19.461,P<0.05). Using gallbladder volume, the thickness of gallbladder wall, infarction of stones in the neck of gallbladder and adhesion of gallbladder to the adjacent tissues as prediction indexes, the accuracy of CDFI in predicting the possible difficulties of LC was 94% (93/99). Conclusion Preoperative CDFI is helpful in predicting difficulties of LC for acute cholecystitis. Key words: Color Doppler flow imaging; Cholecystitis; Laparoscopic cholecystectomy; Prediction

Feasibility of Percutaneous Transhepato-Cholecystic Biliary Interventions After Failed Endoscopic Attempt

Background: Biliary interventions using percutaneous transhepato-cholecystic access (PTHCA) after failed endoscopic attempts have been found to be useful in selected cases, however, the feasibility of this technique has not been fully elucidated. Aim: To evaluate our experience of PTHCA to the common bile duct. Patients and Methods: PTHCA was conducted for those patients of cholangitis who did not have intra-and extrahepatic bile duct dilatation, after failed endoscopic and/or percutaneous transhepatic attempts at our institute. The procedure for PTHCA was as follows: 1) Transhepatic fistula formation after percutaneous transhepatic gallbladder drainage (PTGBD) was evaluated by fluoroscopy after about two weeks, and the PTGBD drainage tube was changed to a seeking catheter (6.5Fr). 2) A hydrocoated guidewire (0.035inch) was inserted from the gallbladder to the common bile duct through the cystic duct. 3) Access to the cystic duct was obtained from the gallbladder to the common bile duct via the PTGBD route using the hydrocoated guidewire and spheroid-seeking catheter under fluoroscopic control. Results: Six patients underwent PTCHA. The success rate of PTHCA was 83.3% (5/6). The indications for PTCHA included cholangitis due to Lemmel' syndrome (n = 1), bile duct carcinoma (n = 1), pancreatic carcinoma (n = 1) and choledocholithiasis (n = 3). PTGBD was performed in all to evaluate the shape and diameter of the cystic duct. The diameter of the cystic duct was > 4 mm in 5/6 patients. A double-pigtail stent (7.2Fr) was successfully placed in the patient with recurrent cholecystitis due to Lemmel' syndrome. The rendez-vous method was successfully employed in two of the three cases in which it was attempted, one in which an endoscopic metallic stent was placed for pancreatic carcinoma, and the other in which endoscopic mechanical lithopripsy was performed. The remote afterloading system (RALS) was employed for a patient with carcinoma of the lower part of the bile duct who was not a candidate for surgical operation. The tumor diminished markedly in size after the RALS. Rendez-vous with endoscopic therapy was performed for pancreatic head carcinoma (n = 1) and choledochlithiasis (n = 2) after PTCHA. The procedure was successful in two of the three cases. Failure of PTCHA due to cystic duct obstruction was encountered in one patient with choledocholithiasis. No post-procedure complications were recognized. Conclusions: Our results indicate that percutaneous transhepato-cholecystic biliary interventions are technically feasible in selected cases without bile duct dilatation, after failed conventional percutaneous transhepatic and endoscopic attempts.

Abdominal ultrasonogram of autoimmune pancreatitis: Five cases of pancreatic lesions accompanied by Sjögren syndrome.

The concept of autoimmune pancreatitis has recently been established, and ultrasonographic findings we obtained from five cases consistent with autoimmune pancreatitis are reported here. Case 1, a 77-year-old man, was admitted complaining of loss of body weight. Serum hepatobiliary enzymes and γ-globulin levels were elevated, and antinuclear antibody was positive, Abdominal ultrasonography showed dilatation of the intrahepatic bile duct, wall thickening of the common bile duct and hypoechoic swelling of the pancreatic head and body. ERCP revealed multiple stenosis of the intra-and extra-hepatic bile ducts, and diffuse irregular narrowing of the main pancreatic duct. The patient complained of thirst, and the minor salivary gland was examined histologically. Our diagnosis was Sjögren syndrome accompanied by sclerosing cholangitis and a pancreatic lesion. Obstructive jaundice also developed, and PTCD was therefore performed. Both the pancreatic swelling and multiple stenosis of the bile duct improved after steroids were administered. Case 2, a 71-year-old man, was admitted with jaundice. Abdominal ultrasonography showed hypoechoic swelling of the pancreas. ERCP showed stenosis of the common bile duct in the pancreatic head region and diffuse irregular narrowing of the main pancreatic duct. Histological examination of the minor salivary gland suggested Sjögren syndrome. Steroids were therefore administered because the presence of both hyper-γ-globulinemia and positive antinuclear antibody suggested involvement of the autoimmune mechanism. Steroid therapy improved the jaundice as well as the findings from the cholangiograms and pancreatograms. We also encountered three similar cases, all consistent with the concept of autoimmune pancreatitis. The ultrasonographic findings of the pancreatic lesion (1) showed them as homogeneous and markedly hypoechoic areas and, (2) visualized the main pancreatic duct in the lesion, which facilitated a differential diagnosis of the neoplastic lesions. (3) Steroid therapy effectively decreased the hypoechoic area; in some cases, however, a hypoechoic area remained around the main pancreatic duct.

Primary sclerosing cholangitis: challenges of a new millenium

K. M. Boberg is a syndrome of unknown aetiology, characterized by fibrosis and inflammation of the intraand extrahepatic bile ducts. The term “primary” is used to distinguish this entity from cholangitis secondary to infection, choledocholithiasis, congenital abnormality of the biliary tract, or choledochal surgery. PSC is an increasingly important chronic liver disease. Until effective conservative treatment is obtained, PSC will remain a major indication for liver transplantation in certain areas 2. Although several aspects of PSC remain to be clarified, this Editorial will focus on only two: the diagnosis and prognosis of PSC.