Left Biliary System Research Articles

An alternative method in the diagnosis of intrabiliary lesions: Percutaneous endobiliary brush biopsy.

Biliary strictures can occur as a result of various benign or malignant processes. The aim of this study is to evaluate the effectiveness and reliability of percutaneous endobiliary brush biopsy in the diagnosis of intrabiliary lesions. This retrospective, single-center study was conducted between January 2022 and April 2023, involving a total of 16 patients. Of the patients, 10 were male (62.5%), and 6 were female (37.5%). The average age of the patients was 68.1±8. All patients underwent the procedure using an endobiliary biopsy brush under ultrasound and fluoroscopic guidance. Technical success was achieved in all patients (100%). Cell detection was not observed in biopsy samples from 2 patients (12.5%), resulting in a diagnostic success rate of 87.5%. Access was made to the right biliary system in 14 patients (87.5%) and to the left biliary system in 2 patients (12.5%). Biopsy locations included the common bile duct in 12 patients (75%), hepatic hilum in 2 patients (12.5%), and bilioenteric anastomosis line in 2 patients (12.5%). The mean fluoroscopy time was 16.2±7.1 minutes. The average radiation dose was 660±370 mSv. Pathological diagnosis revealed malignancy in 8 patients (50%) and benign findings in 6 patients (37.5%). Liver abscess requiring drainage developed in 2 patients (12.5%). Percutaneous endobiliary brush biopsy performed under imaging guidance is an effective and reliable method for the diagnosis of biliary lesions.

Intraoperative digital single-operator cholangioscopy - extra-anatomical biliary access and insights into severe sclerosing cholangitis in a pediatric patient.

A 3-year-old boy with Downʼs syndrome, born prematurely with atrial septal defect type II and stenosis of the pulmonary artery, presented with hepatopathy and fibrosis. Magnetic resonance imaging (MRI) showed diffuse dilations of the biliary system, with large cystic changes suspicious for Caroli syndrome ([Fig. 1]). Endoscopic retrograde cholangiography (ERC) presented signs of secondary sclerosing cholangitis of the right liver lobe with missing contrast enhancement of the left biliary system ([Fig. 2]). Because there was no communication of the left liver lobe with the central biliary system, the patient underwent surgery to drain the left liver lobe by peripheral hepaticojejunostomy. Access to the biliary system was gained by the open biliary system of segment II and intraoperative cholangioscopy was performed using the newly developed, short digital system (SpyGlass Discover; Boston Scientific Corp., Marlborough, Massachusetts, USA) ([Video 1], [Fig. 3]). Intraoperative cholangioscopy revealed cystic dilated bile ducts, partly filled with biliary casts in accordance with the MRI imaging ([Fig. 4]). These findings further supported the diagnosis of systemic sclerosis due to severe postnatal respiratory insufficiency and circulatory problems.

Endoscopic ultrasonography-guided hepaticogastrostomy as a bridge to the definitive biliary reconstruction in a pediatric patient with left hepatic duct disruption secondary to blunt liver trauma

Abstract Case report Endoscopic ultrasonography-guided hepaticogastrostomy (EUS-HGS) is a minimally invasive technique for biliary system drainage that is used in adult patients with biliary obstruction whose papilla of Vater cannot be accessed. We report a pediatric patient who developed complete obstruction of left hepatic duct associated with liver injury and underwent EUS-HGS as a bridge to the definitive biliary reconstruction. A 7-year-old boy sustained a liver injury (Grade IV) developed bile peritonitis post-traumatic day 17 and underwent perihepatic drainage followed by endoscopic retrograde cholangiopancreatography, which revealed persistent bile leakage from B8. The left biliary system was not visible. A 7-Fr plastic stent was placed into the right biliary system, but 1 week later the patient developed diffuse dilatation of the left biliary system due to complete obstruction of left hepatic duct. EUS-HGS was performed to drain the left biliary system. A dilated bile duct (B2) was accessed using a needle through the EUS probe. A 7-Fr plastic stent was placed into B2 over the guidewire. Eight months later, he underwent elective exploratory laparotomy and hepaticojejunostomy by pediatric hepatobiliary surgeons. Conclusion Temporarily draining the biliary system by EUS-HGS is a viable option prior to definitive biliary reconstructive surgery.

S1516 Malignant Biliary Obstruction Diagnosed by Percutaneous Transhepatic Cholangioscopy With Spyglass Direct Visualization System

INTRODUCTION: Malignant biliary obstruction associated with gastric cancer is uncommon. We report a patient with obstructive jaundice due to a new biliary stricture after gastrectomy and loop gastrojejunostomy. Conventionally, enteroscopy-assisted ERCP will be needed to biopsy the stricture which can be difficult and not widely available. Here we describe an easier approach using Percutaneous Transhepatic Cholangioscopy (PTCS) with SpyglassTM Direct visualization system (SDVS). CASE DESCRIPTION/METHODS: 51-year-old male with history of gastric adenocarcinoma status post distal gastrectomy with loop gastrojejunostomy presented 3 years later with painless jaundice. Initial imaging studies including US and CT scan showed severe biliary obstruction with pronounced intrahepatic and extrahepatic ductal dilatation. MRCP revealed a proximal common bile duct stricture with resultant severe intrahepatic ductal dilation spanning approximately 1.5 cm, highly suspicious for malignancy (Image1). ERCP was not attempted due to the altered anatomy and a percutaneous internal biliary drain was placed by Interventional radiology (IR). The drain was placed through the left biliary system into the common duct and into the duodenum. Cholangiogram showed two strictures in the proximal and mid bile duct. In order to obtain the diagnosis, the decision was made to proceed with a combined endoscopic and IR guided approach. A digital cholangioscope was passed through a 12Fr sheath catheter that was placed by IR. The stricture was endoscopically visualized and appeared erythematous, friable with whitish mucosa (Image 2). Multiple biopsies were obtained using a mini biopsy forceps. Pathology revealed poorly differentiated adenocarcinoma with associated fibrosis, inflammation and necrosis. DISCUSSION: Cholangioscopy through a percutaneous transhepatic route is an attractive alternative option when traditional ERCP is technically challenging or not feasible. SDVS provides direct visualization of the biliary system increasing the diagnostic yield, as in our case where it helped to diagnose a malignant biliary stricture in a patient who was in remission from primary gastric carcinoma. PTCS with SDVS also provides therapeutic potential for choledocholithiasis, biliary strictures and local tumor ablative therapy. Though it is an invasive procedure requiring collaboration between a gastroenterologist and an interventional radiologist, as demonstrated, it is a safe and technically easy procedure with unique diagnostic and therapeutic potentials.Figure 1.: blue arrow: Proximal common bile duct stricture causing severe intrahepatic ductal dilation.Figure 2.: Biliary stricture seen using direct visualization system.

343 Bilateral Metal Stent ERCP Through an Endoscopic Ultrasound-Guided Gastrojejunal Lumen-Apposing Stent

INTRODUCTION: ERCP in patients with altered anatomy due to malignant obstruction is consistently a challenge. EUS-guided gastroenterostomy using lumen-apposing metal stents (LAMS) have been shown to be effective and safe for the relief of gastric and intestinal obstruction. We report a successful case of ERCP performed through a recently placed EUS-guided Gastroenterostomy in a patient with both malignant biliary and gastric outlet obstruction. CASE DESCRIPTION/METHODS: A 64-year-old male with a history of metastatic gallbladder cancer status-post placement of an internal-external biliary drain and percutaneous cholecystostomy was admitted to our institution with nausea, vomiting, and jaundice with concern for gastric outlet obstruction and worsening biliary obstruction on CT imaging. To relieve the gastric outlet obstruction, the decision was made to perform EUS guided gastroenterostomy with a LAMS using the “double-scope method.” An ultraslim upper endoscope traversed the stricture into the second portion of the duodenum. Water filling of the intestinal lumen was achieved with this scope while a therapeutic linear echoendoscope was simultaneously passed through the mouth into the stomach and visualized the water-distended distal duodenum and proximal jejunum. EUS-guided gastroenterostomy was performed using a 15 mm electrocautery enhanced LAMS. Balloon dilation of the stent lumen up to 15 mm was performed. The patient enjoyed a regular diet that evening. On the next day, ERCP was performed. A double channel therapeutic endoscope was advanced into the duodenum through the LAMS and bilateral metal stenting of the right and left biliary systems was performed. On follow-up, patient was able to tolerate a regular diet and jaundice improved DISCUSSION: In this case, we successfully performed bilateral metal stent placement ERCP via EUS-guided gastroenterostomy to relieve gastric outlet obstruction and biliary obstruction. The diameter of the lumen apposing metallic stent was sufficient to insert a double-channel therapeutic scope, which facilitated bilateral metal stenting. Of note, care must be taken when performing endoscopic procedures through a newly created gastrenterostomy. Watch the video: http://bit.ly/2SwvkHG

2196 A Case of Successful Endoscopic Management of Choledocholithiasis Complicated by Post-Transplant Biliary Stricture

INTRODUCTION: Post Liver transplant (LT) biliary stones, sludge and casts are a challenge to both advanced endoscopists and patients in the setting of complex anatomy, variable pathologies and multiple co-morbidities. The incidence rate of biliary stones is widely variable from 3.8%-18% and are associated with biliary strictures in roughly 90% of cases, increasing the complexity of the procedure. Here we are presenting a case of elevated liver enzymes and normal bilirubin in a LT patient with a history of post-LT biliary stricture. CASE DESCRIPTION/METHODS: 70 year old male with past medical history of fulminant hepatic failure status post orthotopic LT complicated by biliary anastomotic stricture, presented for management of new onset elevated liver enzymes ten years post LT. At the time of presentation he denied any complains of abdominal pain, nausea, vomiting, fevers, or chills. He denied any new medications or herbal supplements. Afebrile and hemodynamically stable at presentation. Labs showed WBC- 6.3, AST-202, ALT-133, GGT-1368, ALP-439 Total Bilirubin – 0.8 (Normal), INR-1.06 and Tacrolimus level -2.4. Liver biopsy showed bile ductular reaction and sparse to mild portal inflammation with minor ductulitis and endothelialitis. Abdomen ultrasound showed common bile duct with biliary ductal dilatation which may represent stones or sludge. Patient underwent ERCP revealing a large 3 × 2 cm stone in the common hepatic duct proximal to the anastomotic stenosis with marked upstream biliary dilation. The stone was partially crushed with electrohydraulic lithotripsy (EHL) via Spyglass cholangioscopy. The stone fragments were removed using an extraction balloon. Two 10 Fr x 12 cm long angled plastic stents were placed in the right and left biliary systems. A repeat ERCP was performed 8 weeks later and EHL under spyglass was performed. The ducts were subsequently cleared and stenosis resolved. DISCUSSION: Biliary stones and sludge can occur at any time after LT, with a reported incidence of 5%–10%. Our patient presented 10 years post-LT with transaminitis and normal bilirubin. Yu et al reported biliary strictures and cold ischemia time were significantly associated with bile duct stone formation after liver transplantation in a case-control study. Hence we conclude that in following patients post LT who are on immunosuppressants, the physician needs to be vigilant as patients can have a late presentation which can lead to graft loss and increased morbidity and mortality.

Combination of endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography-guided biliary drainage in malignant hilar biliary obstruction.

Adequate biliary drainage (BD), defined as more than 50% of liver volume drained, is an ideal BD method in patients with advanced and unresectable malignant hilar biliary obstruction (MHBO). Endoscopic retrograde cholangiopancreatography (ERCP) with multi-segmental BD is technically challenging. ERCP with percutaneous biliary drainage (PTBD) or PTBD alone has cumbersome maintenance of PTBD line and external bag. The utility of EUS-guided BD (EUS-BD) has risen significantly over last 5 years mostly in the clinical setting of distal bile duct obstruction. Information on EUS-BD for malignant hilar biliary obstruction (MHBO) is thus far limited to only two small studies. This review suggests a new concept of a combination of ERCP and EUS-BD (CERES) for BD in MHBO as a primary BD method whereby ERCP with a single self-expandable metal stent (SEMS) is placed into either the right or the left intrahepatic bile duct (IHD). If SEMS is placed in the right biliary system, EUS-guided hepaticogastrostomy (EUS-HGS) can subsequently be carried out. However, if the stent is placed into the left biliary system, EUS-guided hepaticoduodenostomy (EUS-HDS) is done. For MHBO with non-functioning right lobe of the liver, EUS-HGS is carried out after failed ERCP, or primary HGS can be carried out in the left lobe of liver. For MHBO with non-functioning left lobe of the liver, EUS-HDS is carried out after failed transpapillary stenting of the right lobe by ERCP. Based on our experience, CERES is promising as it can fulfil gaps of both PTBD and ERCP by allowing internal drainage that can circumvent the inconvenience associated with PTBD and offer higher technical success rate compared to ERCP with bilateral SEMS placement.

Rare case of removal of intrabiliary retained broken PTBD wire with redo-hepaticojejunostomy

This is a rare case of surgical removal of intrahepatic retained broken wire of percutaneous transheaptic biliary catheter, which caused cholagitis and severe pain in a 59-year-old female who had undergone percutaneous transhepatic biliary dilatation of stricture hepaticojejunostomy in past. This is rare case ever reported of surgical removal of a broken PTBD wire retained inside left biliary system, post percutaneous transhepatic biliary dilatation of biliary stricture. Patient also underwent redo-hepaticojejunostomy for treatment of stricture hepaticojejunostomy in same sitting. This guidewire was put by interventional radiologist for dilatation of hepaticojejunostomy stricture. Patient had developed stricture in hepaticojejunotostomy which was done in year 2007 along with choledochal cyst excision by some other Gastrosurgeon. But one reoperation as well as one interventional approach had failed to retrieve the wire retained in biliary system. After that we successfully operated this challenging case and cured her of stricture hepaticojejunostomy, cholagitis and removed the foreign body in one surgery. Postoperatively we followed her up of 2 yrs. Patient is afebrile ,free of jaundice and has normal LFT on 2 yrs of follow up.Broken guidewire during percutaneous intervention in obstructed biliary system is an emergency as it acts as foreign body, removal with reansatomosis gives a fair chance of cholangitis free survival to patient.

Abstract No. 700 Which method of biliary drainage results in the most rapid decline in bilirubin levels, primary stent or drain placement?

Compare the rate of decline in the serum total bilirubin levels post biliary drainage with placement of a primary stent or drainage catheter. Medical record review of all primary biliary stents (PBS) and biliary catheter drainage (BD) placements from January 2016 till March of 2017 at a single institution identified 81 PBS and 118 BD procedure performed in 180 patients (107 males; median age 60.66 +/- 13.33, 73 females; median age 60.69 +/- 14.43, range 8-88). Procedures performed for cholangitis and for post procedure biliary complications were excluded. 70 PBS and 83 BD met these criteria. Procedure type and decision for drainage of the right or left biliary system was under the discretion of the primary operator. Available total bilirubin (t-bili) levels were collected for patients pre-procedure (n= 153), post procedure day (POD) one (n=146), POD two (n=102), POD seven (day 9 +/- 3.2) (n=132), and POD 30 (day 31.8 +/- 8.8)(n=113). Successful drainages with a decrease in the t-bili noted at all time points; PBS (n=49) vs BD (n=52) POD 1 (23.78 +/- 16.3 vs 25.43 +/- 16.8 p=0.62), PBS vs BD POD 2 (34.87 +/- 16.96 vs 43.02 +/- 16.57 p=0.06), PBS vs BD POD 7 (56.83 +/- 20.2 vs 57.41 +/- 19.88 p=0.88), PBS vs BD POD 30 (78.53 +/- 12.48 vs 71.61 +/- 21.41 p=0.07). All drainages including procedure failures; PBS vs BD POD 1 (14.39 +/- 27.49 vs 12.69 +/- 30.68 p=0.73), PBS vs BD POD 2 (23.39 +/- 28.1 vs 21.98 +/- 59.99 p=0.90), PBS vs BD POD 7 (45.62 +/- 36.55 vs 36.81 +/- 44.94 p=0.21), PBS vs BD POD 30 (69.29 +/- 31.18 vs 47.93 +/- 62.49 p=0.02). The rate of t-bili reduction is more rapid in PBS during the first 30 days after placement. At 30 days PBS has decreased the t-bili levels in all patients by 69.29, this is statistically significant compared to the decrease in t-bili with BD (47.93) p=0.02. BD tend to fail more often in lowering the t-bili. When initially successful, BD appears to decrease the t-bili at a slightly more rapid rate then PBS. At 30 days this appears to reverse with PBS again providing the greatest percent reduction.

Radiologic evaluation of vasculobiliary anatomy in the umbilical fissure

BackgroundPreoperative evaluation of vasculobiliary anatomy in the umbilical fissure (U-point) is pivotal for perihilar cholangiocarcinoma (PCCA) applied to right-sided hepatectomy. The purpose of our study was to review the vasculobiliary anatomy in the U-point using three-dimensional (3D) reconstruction technique, to investigate the diagnostic ability of 2D scans to evaluate anatomic variations, and to discuss its surgical implications. MethodsA retrospective study of 159 patients with Bismuth type I, II, and IIIa PCCA, who received surgery at our institution from November 2012 to September 2016, was conducted. Anatomic structures were assessed using multidetector computed tomography (MDCT) by one hepatobiliary surgeon, whereas 3D images were reconstructed by an independent radiologist. Normal confluence pattern of left biliary system was defined as the left medial segmental bile duct (B4) joining the common trunk of segment II (B2) and segment III (B3) ducts, whereas aberrant confluence patterns were classified into 3 types: type I, triple confluence of B2, B3, and B4; type II, B2 draining into the common trunk of B3 and B4; type III, other patterns. Surgical anatomy of B4 was classified into the central, peripheral, and combined type according to its relation to the hepatic confluence. The lengths from the bile duct branch of Spiegel's lobe (B1l) to the orifice of B4 and the junction of B2 and B3 were measured on 3D images. The anatomy of left hepatic artery (LHA) was classified according to different origins and the spatial relationship related to the U-point. Results3D reconstruction revealed that normal confluence pattern of left biliary system was observed in 71.1% (113/159) of all patients, and variant patterns were type I in 11.9% (19/159), type II in 12.6% (20/159), and type III in 4.4% (7/159). The length from B1l to the junction of B2 and B3 was 12.1 ± 3.1 mm in type I variation, which was significantly shorter than that in normal configuration (30.0 ± 6.8 mm, P < 0.001) but significantly longer than that in type II variation (9.6 ± 3.4 mm, P = 0.019). Surgical anatomy of B4: the peripheral type was most commonly seen (74.2%, 118/159), followed by central type (15.7%, 25/159) and combined type (10.1%, 16/159). The distance between the B1l and B4 was 8.4 ± 2.4 mm in central and combined type, which was significantly shorter than that in peripheral type (14.5 ± 4.1 mm, P < 0.001). A replaced or accessory LHA from the left gastric artery was present in 6 (3.8%) and 9 (5.7%) patients, respectively. LHA running along the left caudal position of U-point was present in 143 cases (89.9%), along the right cranial position of U-point in nine cases (5.7 %), and combined position in seven cases (4.4%). Interobserver agreement of two imaging modalities was almost perfect in biliary confluence pattern (kappa = 0.90; 95% confidence interval: 0.79-1.00), substantial in surgical anatomy of B4 (kappa = 0.74; 95% confidence interval: 0.62-0.86), and perfect in LHA (kappa = 1.00). ConclusionsThoroughly understanding the imaging characters of surgical anatomy in the U-point may be benefit for preoperative evaluation of PCCA by successive review of 2D images alone, whereas 3D reconstruction technique allows detailed hepatic anatomy and individualized surgical planning for advanced cases.

Preoperative evaluation on the anatomical structures adjacent to the umbilical portion of the left portal vein using two-dimensional and three-dimensional imagings

Objective To study the anatomical variations adjacent to the umbilical portion of the left portal vein (U-point) radiologically and to determine their impact on treatment of hilar cholangiocarcinoma (HCCA). Methods From January 2014 to February 2016, 47 consecutive patients who were diagnosed to suffer from Bismuth type Ⅰ, Ⅱ or Ⅲa HCCA in our institution were retrospectively studied. All these patients underwent enhanced CT examination preoperatively and three-dimensional (3D) models were then reconstructed. Results Any variations of the left biliary system in relation to the U-point were analyzed. The findings showed that: B2 and B3 united above or lateral to the U-point in 31 patients (65.9%); B2 and B3 united medial to the U-point in 4 patients (8.5%); and B4 converged into B3 prior to B2 in 6 patients (12.8%). Rare variations were observed in 6 patients (12.8%). For the confluence patterns of B4: the central type was found in 10 patients (21.3%), the peripheral type in 35 patients (74.5%) and the combined type in 2 patients (4.2%). Analysis of the relationship between B1l and the confluence of B2 and B3 showed the distance to be (31.6±6.2) mm in the above or the lateral patterns and (13.7±4.7) mm in the medial pattern. The difference was significant (P<0.05). The distance from B1l to B4 was (7.1±2.0) mm in the central and combined types but (16.4±4.0) mm in the peripheral type. The difference was significant (P<0.05). The left hepatic artery showed variations in the origin and course pattern in 4 (8.5%) and 6 patients (12.8%), respectively. The two-dimensional (2D) and 3D imagings showed excellent consistency in the evaluation of variations of the left biliary system in relation to the U-point and the left hepatic artery. Conclusions It is very important to know the variations of the left biliary and the vascular systems adjacent to the U-point in preoperative evaluating on resectability of HCCA. An accurate assessment could be accomplished using 2D imaging alone. However, 3D reconstruction is a useful technique to use in complex case with locally advanced tumors. Key words: Umbilical portion of left portal vein; Anatomical variation; Three-dimensional imaging; Hilar cholangiocarcinoma

A rare cause of bile duct rupture

Rupture of the biliary tree is usually secondary to hepatobiliary surgery, instrumentation, or abdominal trauma. This 68-year-old lady with no previous medical history presented with pain, vomiting, abdominal distension, and breathlessness of 10 days. She had a large tender lump in the right hypochondrium. Liver function tests were normal and ultrasound showed cholelithiasis and choledocholithiasis along with subcapsular fluid collection in the right lobe of the liver. Contrast-enhancedcomputedtomographyrevealeda massive subcapsular collection in the right lobe (Fig. 1). She was treated with antibiotics, percutaneous drainage of the collection, and stenting of the common bile duct. Imaging revealed also a cutoff of the right biliary system (extrinsic compression) with a normal left biliary system (Fig. 2). She underwent cholecystectomy. Fujiwara et al. in 1998 [1] analyzed 25 cases of spontaneous bile duct rupture and found them to be related to choledocholithiasis, acute cholecystitis, hepatic infarction, liver abscess,sickle cell disease, and tuberculosis. Endoscopic retrograde cholangiopancreatography (ERCP) and stenting is indicated to locate any ongoing leak and bridge the defect or decrease resistance [2].

Sp706 Expanding Indication: EUS-Guided Hepaticoduodenostomy in Isolated Right Intrahepatic Duct Obstruction

Expanding Indication: EUS-Guided Hepaticoduodenostomy in Isolated Right Intrahepatic Duct Obstruction Se Jeong Park*, Do Hyun Park, Sang Soo Lee, Dong Wan Seo, Sung Koo Lee, Myung-Hwan Kim After failed ERCP, other alternative biliary accesses such as PTBD, repeated ERCP, or surgical bypass could be considered. PTBD has a complication rate of 10% to 30% such as bile leak, bleeding, and peritonitis. Repeat ERCP could be as an alternative if immediate biliary drainage is not required. Surgical bypass is effective, but is associated with considerable mortality and morbidity. EUSguided transgastric imaging of dilated left intrahepatic duct is a useful technique to drain the left biliary system and an effective alternative for percutaneous transhepatic biliary drainage after failed ERCP. To date, EUS-guided biliary drainage in isolated right hepatic duct obstruction has not been attempted. In our center, 4 consecutive patients were candidates for EUS-guided right hepatic duct approach within recent year with last case in October 2012. We performed three kinds of approaches to the right hepatic duct using EUS; (1) using a cholangiogram obtained by EUS-guided transduodenal puncture of the right hepatic duct as a “roadmap” to assist retrograde cannulation, (2) EUS-guided transduodenal puncture of the right hepatic duct and an antegrade balloon dilatation and stenting for bilioenteric anastomotic strictures in a patient with hepaticojejunostomy, and (3) transluminal stenting as an antegrade bypass stenting between the right hepatic duct and the duodenal wall under EUSguidance. EUS-guided hepaticoduodenostomry (EUS-HD) of right hepatic duct by expert hands may be a relatively safe and feasible alternatives after failed ERCP. Moreover, an availability in the same session without dicontinuation of sedation after failed ERCP is another great advantage. In contrast, the other alternative accesses such as PTBD, repeated ERCP, and surgery almost need another session for further procedure on a different day. Further, large multicentered study may help enhance our results.

VH22 SpyGlass® Assisted Retrieval of a Deeply Migrated Left Hepatic Duct Stent

A 37 year old female patient was referred for removal of a migrated biliary stent that was placed for benign biliary stricture induced by chronic pancreatitis. She had mild abdominal pain and deranged liver biochemistry. Previous attempts at stent removal at another hospital had failed. At fluroscopy a 7Fr plastic stent was seen deep in left biliary system.

Hyperlipidemia due to Biliary Stricture After Living-Donor Liver Transplantation

Hyperlipidemia due to Biliary Stricture After Living-Donor Liver Transplantation

Congenital tracheobiliary fistula diagnosed with contrast-enhanced CT and 3-D reformation

Congenital tracheobiliary fistula (CTBF) is a rare malformation. So far 24 cases have been reported in the English language literature. The imaging techniques used in diagnosis have been bronchography, fistulography, cholangiography, hepatobiliary nuclear imaging and MRI. We report a newborn patient who presented with right lung consolidation and biliptysis. The radiographic diagnosis of tracheobiliary fistula was made on multidetector CT scan of the chest and abdomen. Multiple 3-D volume-rendered reformations were performed. An abnormal air-filled tract was seen connecting the posteroinferior aspect of the carina and left biliary system, which was successfully treated surgically.

Changing Perspectives in the Assessment of Resectability of Hilar Cholangiocarcinoma

Changing Perspectives in the Assessment of Resectability of Hilar Cholangiocarcinoma

Unresectable Hilar Cholangiocarcinoma: Multimodality Treatment with Percutaneous and Intraluminal Plus External Radiotherapy

SummaryThe efficacy of multimodality treatment for unresectable hilar cholangiocarcinoma was evaluated in terms of outcome, survival and quality of life. Eleven patients were enrolled in the following protocol: percutaneous drainage of both right and left biliary systems; Iridium-192 intraluminal brachytherapy; replacement of the drainages with endoprotheses; external radiotherapy. Six patients completed the protocol and 5 were treated with brachytherapy alone. Mean survival was 10.5 months, similar to surgical results and higher than the control group treated with percutaneous stenting (2.75 months) or biliary drainage alone (1.75 months), with an average hospital stay of 10–15 days and no procedure-related mortality.

Complete regression of biliary strictures in primary sclerosing cholangitis with low-dose tacrolimus

This is the first case report of a patient having complete regression of biliary strictures with Tacrolimus. This patient is a 61 year old farmer who presented with jaundice and dilatation of the intrahepatic biliary tree on CT scans. He had cholelithiasis and papillary stenosis. He had typical multiple strictures within the liver compatible with sclerosing cholangitis. He had advanced cirrhosis on liver biopsy. Sphincterotomy and stenting of the left main biliary tree was done with negative brush cytology. Five months after starting Tacrolimus, the biliary stent was removed. The contralateral biliary that was not endoscopically dilated showed as much regression of stricturing as did the stented left biliary system. There was dramatic regression of strictures with therapy. Serial liver function studies showed prompt improvement and return of all functions to normal. He had no side effects from therapy and renal function remained normal. Whole blood Tacrolimus levels ranged from 2|[ndash]|4 ng.|[sol]|cc. Tacrolimus dose was 1 mg daily. The patient's average daily whole blood level was 3.09 ng.|[sol]|cc. on a 1 mg. daily dose, whereas the mean daily dose on a kilogram basis was 0.01 milligram per kilogram per day. Seventeen months after beginning therapy, the patient had repeat cholangiogram and liver biopsy. Repeat cholangiogram was normal with no strictures. The patient's liver biopsy showed no definite cirrhosis, marked improvement in histology but still there was activity of liver disease. Fibrosis was remarkably decreased. The patient's liver functions remained normal during the entire seventeen months of therapy and he had no side effects from therapy.

The Effect of Communication Between the Right and Left Liver on the Outcome of Surgical Drainage for Jaundice due to Malignant Obstruction at the Hilus of the Liver

Debate continues regarding the optimal management of irresectable malignant proximal biliary obstruction. Controversy exists concerning the ability of unilateral drainage to provide adequate biliary decompression with tumors that have occluded the communication between the right and left hepatic ductal systems. Between October 1986 and October 1989, 18 patients with malignant proximal biliary obstruction were treated by an intrahepatic biliary enteric bypass. Patients were divided into two groups based on the presence or absence of a communication between the right and left biliary systems. In Group I (n = 9), there was free communication; and in Group II (n = 9) there was no communication. There were two perioperative deaths (11%) one due to persistent cholangitis and the other to myocardial insufficiency both with one death in each group. The median survival (excluding perioperative deaths) was 5.6 months. Comparison of pre- and postoperative serum levels of bilirubin and alkaline phosphatase showed a significant decrease in each group, but no difference between the groups in the size of the reduction. Sixteen patients survived at least three months and the palliation was judged as excellent in eight, fair in five, and unchanged in three. These results demonstrate the effectiveness of biliary enteric bypass regardless of communication between the left and right biliary ductal systems.