Lower Common Bile Duct Research Articles

Values of Contrast-Enhanced Ultrasound in Classification and Diagnosis of Common Bile Duct and Superficial Organ Lesions under Compression Algorithm.

This work aimed to investigate values of contrast-enhanced ultrasound (CEUS) under DEFLATE in the classification and diagnosis of the common bile duct and superficial lymphoid lesions. 88 patients with lower common bile duct lesions and 126 patients with superficial lymphoid lesions were selected as the subjects investigated and examined by CEUS under DEFLATE to compare characteristics and diagnostic efficiency of CEUS in different types of lesions. The time-intensity curve (TIC) was for quantitative analysis on CEUS results. The results showed that there were statistically significant differences in the comparison of time to peak (TTP), area under the curve (AUC), and gradient (Grad) of common bile duct walls in patients from the malignant group (P < 0.05), while the comparison of three indicators of patients in the benign group was not statistically remarkable (P > 0.05). In addition, there were statistically great differences in TTP, AUC, and Grad among patients in the benign and malignant groups (P < 0.05). The sensitivity, specificity, accuracy, and positive/negative predictive value of CEUS + ultrasound (US) in the diagnosis of benign and malignant lymph nodes were 92.83%, 87.14%, 89.54%, 91.23%, and 86.43%, respectively. The values of maximal intensity (Imax) in the reactive hyperplasia group (group A), lymphoma group (group B), and metastatic lymph nodes group (group C) were compared, showing statistical differences (P < 0.05). The TTP and AUC of group B were higher than those of groups A and C, respectively (P < 0.05), and the base-to-peak ascending slope (KUP) and the absolute value of the semidescending slope (KDOWN) in group C increased hugely compared to group A (P < 0.05). It indicated that CEUS examination under DEFLATE could be applied in the qualitative diagnosis of lower common bile duct lesions and superficial lymphoid lesions, which was worthy of clinical application.

Transient pancreatitis post laparoscopic cholecystectomy: A rare case report

Acute postoperative pancreatitis is an uncommon complication following laparoscopic cholecystectomy. The common complications in the early postoperative period are usually attributable to a bile duct injury or a bleeding vessel. Pancreatitis in such a setting usually resolves by conservative management unless there is an active obstruction at the lower common bile duct. Very few cases have been documented in the literature in this contention. In this case report, a case of acute pancreatitis following laparoscopic cholecystectomy is described in terms of the clinical presentation, laboratory parameters, management strategy, and a short review of the literature.

S1385 First Case of Risperidone-Associated Secondary Sclerosing Cholangitis

INTRODUCTION: Secondary sclerosing cholangitis is a rare form of sclerosing cholangitis, with cholangiography and biopsy findings that are similar to primary sclerosing cholangitis. Early recognition of secondary causes is important to delay disease progression. There has not been any report that identified antipsychotics as a potential cause of secondary sclerosing cholangitis. Herein, we present a unique case of risperidone-associated secondary sclerosing cholangitis. CASE DESCRIPTION/METHODS: A 72-year-old Caucasian female, who had been treated with risperidone for catatonic schizophrenia for six months, presented to the hospital with altered mental status and fever. Pertinent laboratory findings upon arrival were leukocytosis (white blood cell count - 11.5 × 109/L), bacteriuria, pyuria, and transaminitis (alanine aminotransferase - 597 units/L, aspartate aminotransferase - 467 units/L, gamma-glutamyl transferase - 775 units/L, and alkaline phosphatase - 535 units/L). Ultrasound of the abdomen did not show ductal dilation. Risperidone was held. The patient was treated with antibiotics for a urinary tract infection, with resolution of fever and leukocytosis. As transaminitis improved, risperidone was restarted on day 4; however, transaminitis subsequently worsened. Further work-up was negative for viral hepatitis A/B/C and CMV/EBV infection. Liver core biopsy revealed periductal inflammation with onion skinning-like pattern (Figure 1–3), consistent with secondary sclerosing cholangitis. Transaminitis improved following discontinuation of risperidone. Subsequent endoscopic retrograde cholangiopancreatography revealed three stones in the lower common bile duct, with moderate, diffuse duct dilation. DISCUSSION: Risperidone and other antipsychotics have been reported to induce cholestatic hepatitis. Previous case reports have suggested an association of risperidone with drug-induced hepatitis, as evidenced by transaminitis and inflammatory liver parenchymal changes. Our case is the first to suggest a link between risperidone and secondary sclerosing cholangitis. The fibrotic changes of biliary duct, as well as the temporal relationship between risperidone intake and elevation of hepatic enzymes, are suggestive of this diagnosis. The findings of multiple ductal stones and ductal dilation likely represent the chronic inflammatory process.Figure 1.: Hematoxylin & eosin stain demonstrates the characteristic onion-skinning changes in periductal area.Figure 2.: Trichrome stain reveals high collagen content (blue) in the onion-skinning pattern, predominantly in the periductal area, consistent with active fibroblastic proliferation.Figure 3.: Inflammatory cells infiltrate hepatic parenchyma, consistent with non-specific immune response seen in hepatitis.

S1477 A Spy Took a Bite to Get the Dx Right - A Case of Idiopathic Pancreatitis

INTRODUCTION: Autoimmune pancreatitis (AIP) is a rare form of chronic pancreatitis that is infrequently recognized and is characterized clinically by frequent presentations with obstructive jaundice. Serum IgG4 testing as a means to “rule out” IgG4 related disease may not be as helpful as initially thought and may lead to inappropriate lack of diagnosis if suspicion is low. CASE DESCRIPTION/METHODS: A 40-year-old white male with GERD, chronic portal vein thrombosis, history of alcoholism, and chronic pancreatitis (since 2015) presents with nausea, vomiting, chills, and epigastric pain radiating to the back. He has had 8 episodes in the last year and required biliary stenting for multiple biliary strictures. He denied fever, dyspnea, chest pain, hematemesis, melena, alcohol use, scorpion sting, and trauma. Labs were significant for TRG 172, Ca 8.6, Lipase 239, AST 34, ALT 37. CT of the abdomen showed acute on chronic pancreatitis with a stable biliary stent. Previous workup for pancreatitis included normal TRG and calcium levels, lack of cholelithiasis, no inciting medications or infection, and serum IgG4 level of 7.3 (normal: 2-120). After admission, lipase increased to 1321 with worsening AST/ALT and bilirubin concerning for obstruction prompting Magnetic Resonance Cholangiopancreatography (MRCP). MRCP demonstrated extensive retroperitoneal inflammation and obstruction of the biliary stent. Endoscopic retrograde cholangiopancreatography (ERCP) with SpyGlass direct visualization revealed an occluded biliary stent, multiple strictures, and exophytic tissue in the lower common bile duct which was biopsied with SpyBite. The strictures were dilated, the stent was exchanged, and the biopsies were sent for pathology. Pathology returned negative for malignancy but stained positive for IgG4 and the patient was initiated on systemic steroid therapy. DISCUSSION: With recurrent pancreatitis, classic histological findings, biliary strictures, cholangitis, and improvement with steroids in the setting of normal serum IgG4 levels; this complex patient represents a challenging case of type 1 AIP. A 2016 meta-analysis found that serum IgG4 had 87% sensitivity 83% specificity for IgG4-RD (1). Other studies suggest that many (as much as 33%) patients with biopsy-proven IgG4-RD have normal serum IgG4 (2). With these findings, we believe it is imperative that others give further consideration to tissue sampling in similar patients with difficult to define pancreatitis.Figure 1.: MRI Abd w CBD stent mass and pneumobilia.Figure 2.: Mass in CBD.Figure 3.: IgG4 stain positive tissue from CBD mass.

Surgical strategy for recurrent common bile duct stones: a 10-year experience of a single center.

Recurrence of common bile duct stones (CBDS) is common after surgical stone extraction, but the causes of recurrence are not fully understood. This study aimed to report the experience of treating recurrent CBDS. A total of 106 consecutive cases of recurrent CBDS treated from January 2006 to December 2015 were included. During surgery, the choledochoscopic pass-through test was performed to assess the structure and function of the duodenal papilla. The choledochoscopic pass-through test revealed 62 patients (58.49%) with incomplete closure of the lower end of the common bile duct, and 28 (26.42%) with stenosis at the lower common bile duct. Intra-operative bile bacterial culture was positive in 98 (92.45%) patients. The rate of complete stone clearance was 99.1%. The total recurrence rate of CBDS was 3.13%. The long-term success rate of surgical treatment (excellent and good) reached 92.7% .Duodenal papilla (Oddi sphincter) dysfunction is the main cause of recurrent CBDS. Common bile duct exploration with stone extraction, hilar ductoplasty, and Roux-en-Y hepaticojejunostomy can effectively eliminate the recurrence of CBDS and reduce the incidence of post-hepaticojejunostomy complications. Thus, it is an optimal surgical procedure for recurrent CBDS.

Radiation-free removal of common bile duct stones in pregnancy facilitated by endoscopic ultrasound and single-operator cholangioscopy.

A 26-year-old woman who was 6 months pregnant presented with a 5-day history of jaundice, right upper abdominal discomfort, and pruritus. Abdominal ultrasound showed gallstones and a dilated common bile duct (CBD) with a suspicious calculous in the lower CBD. Serum bilirubin was 2.9 mg/dL and serum alkaline phosphatase was 216 IU. A radiation-free procedure to remove choledocholithiasis was planned under propofol sedation, and informed consent was obtained.

Laparoscopic retrieval of impacted and broken dormia basket using a novel approach

We encountered a 73-year-old patient who presented with right upper abdominal pain and jaundice. On evaluation, he was found to have cholelithiasis with choledocholithiasis. Endoscopic retrograde cholangiography was attempted, but during the procedure, the wire snapped and the dormia basket got retained in the common bile duct (CBD). Laparoscopic CBD exploration was performed and the basket with calculus was found impacted in the lower CBD. The basket was disengaged by holding its tip through another dormia introduced through choledochoscope and basket with all calculi retrieved. Clearance of CBD was ascertained with choledochoscopy and CBD was closed primarily. He did well in the post-operative period and was discharged on the 5th post-operative day. At 1-year follow-up, the patient was doing well. Laparoscopic CBD exploration is a feasible and safe option for the retained dormia basket. We utilised the 'dormia with dormia technique' to retrieve the impacted basket which has not been reported before.

Diagnosis, Treatment, and Prevention of Iatrogenic Injury in the Lower Part of Common Bile Duct

Iatrogenic bile duct injury is one of the important problems in abdominal surgery and its incidence has shown an upward trend in recent years. Iatrogenic bile duct injury threatens the quality of life and life safety of patients. At present, there is a lack of diagnostic and treatment norms that have a guiding significance based on large-scale evidence-based medicine research. The injury to the lower part of the common bile duct, especially the joint of the biliary and pancreatic intestines, generally is more serious. This article introduces the current status, classification, common causes, diagnosis, treatment, and prevention regarding the iatrogenic injury in the lower common bile duct. A deeper understanding of this injury may help minimize the incidence of injury, standardize diagnosis and treatment and improve the prognosis of patients.

Application of CT and MRI in diagnosis and preoperative evaluation of periampullary carcinoma

Periampullary carcinoma includes carcinoma of head of pancreas, carcinoma of lower common bile duct, ampullary carcinoma and adenocarcinoma of duodenum. Most of the periampullary cancers shows the same clinical symptoms their imaging manifestations are overlapping or non-specific. Accurate qualitative positioning and staging of periampullary cancers are of great value in guiding of treatment plan and evaluate postoperative outcomes. CT and MRI examination have made progress in the diagnosis of periampullary carcinoma. CT scan has a good spatial and temporal resolution, while MRI has a good tissue resolution. CT and MRI examination can be used for preoperative assessment of tumor resectability and invasion range, which is of certain value. Key words: Tomography, X-ray computed; Magnetic resonance imaging; Periampullary carcinoma; Preoperative evaluation

Diagnostic value of endoscopic ultrasonography in patients with biliary-pancreatic duct dilatation

Objective To study the diagnostic value of endoscopic ultrasonography (EUS) in patients with cholangiopancreatic duct dilatation (CPDD). Methods Forty-five patients with CPDD and without any visual or detected obstructive lesions after traditional ultrasonography (US) were re-examined by EUS, CT and MRI. The diagnostic rates of EUS and the other imaging technologies were compared. Results All the 45 patients underwent successful EUS examination. Among them, there were 18 patients with periampullary tumor, 10 patients with lower common bile duct stones, 1 patient with pancreatic duct stones, 3 patients with chronic pancreatitis, 1 patient with an intrapancreatic choledochal cyst, 4 patients with inflammatory strictures of papilla of duodenum and 2 patients with terminal bile duct inflammatory stenosis. However, 1 patient with a lower common bile duct tumor, 1 patient with a small pancreatic head carcinoma and 1 patient with sphincter of Oddi dysfunction (SOD) were not diagnosed. The diagnostic rates of obstructive lesions by US, EUS, CT and MRI were 7.1%, 92.9%, 33.3%, 31.0%, respectively. The diagnostic rates of tumor were 10.0%, 90.0%, 35.0%, 25.0%, respectively. As compared with the other examination methods, EUS was best in detecting small carcinoma. Conclusion EUS plays an important role in the diagnosis of lesions causing cholangiopancreatic duct dilatation. Key words: Ultrasonography; Bile duct diseases; Pancreatic ducts; Endoscopic ultrasonography; Diagnosis

Rare variant of pancreaticobiliary maljunction associated with pancreas divisum in a child diagnosed and treated by endoscopic retrograde cholangiopancreatography: A case report

BACKGROUNDPancreaticobiliary maljunction (PBM) is an uncommon congenital anomaly of the pancreatic and biliary ductal system, defined as a union of the pancreatic and biliary ducts located outside the duodenal wall. According to the Komi classification of PBM, the common bile duct (CBD) directly fuses with the ventral pancreatic duct in all types. Pancreas divisum (PD) occurs when the ventral and dorsal ducts of the embryonic pancreas fail to fuse during the second month of fetal development. The coexistence of PBM and PD is an infrequent condition. Here, we report an unusual variant of PBM associated with PD in a pediatric patient, in whom an anomalous communication existed between the CBD and dorsal pancreatic duct.CASE SUMMARYA boy aged 4 years and 2 mo was hospitalized for abdominal pain with nausea and jaundice for 5 d. Abdominal ultrasound showed cholecystitis with cholestasis in the gallbladder, dilated middle-upper CBD, and a strong echo in the lower CBD, indicating biliary stones. The diagnosis was extrahepatic biliary obstruction caused by biliary stones, which is an indication for endoscopic retrograde cholangiopancreatography (ERCP). ERCP was performed to remove biliary stones. During the ERCP, we found a rare communication between the CBD and dorsal pancreatic duct. After clearing the CBD with a balloon, an 8.5 Fr 4-cm pigtail plastic pancreatic stent was placed in the biliary duct through the major papilla. Six months later, his biliary stent was removed after he had no symptoms and normal laboratory tests. In the following 4-year period, the child grew up normally with no more attacks of abdominal pain.CONCLUSIONWe consider that ERCP is effective and safe in pediatric patients with PBM combined with PD, and can be the initial therapy to manage such cases, especially when it is combined with aberrant communication between the CBD and dorsal pancreatic duct.

A Double-Guidewire Technique to Facilitate Deep Cannulation and Stenting in a Patient With Altered Gastrointestinal Anatomy

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with altered gastrointestinal (GI) anatomy remains a challenging procedure. We experience particular difficulty passing a catheter and devices in patients who have biliary stricture or severe deformity, despite successful biliary guiding. A 70-year-old man with Roux-en-Y reconstruction for gastric cancer suffered pancreatic head cancer with biliary stricture. Seven months after biliary stenting, he developed acute occlusive suppressive cholangitis due to stent occlusion. We extracted the stent and inserted a guidewire into the intrahepatic bile duct. However, we were unable to pass the catheter due to severe stricture of the lower common bile duct and axis-dismatch between the bile duct and the catheter. After inserting another of the same guidewire into the bile duct, we were able to easily pass the catheter into the bile duct, resulting in the successful insertion of a new plastic stent. A double-guidewire technique is useful and worth attempting for the deep insertion of devices through biliary strictures in patients with an altered GI anatomy. J Med Cases. 2019;10(1):1-3 doi: https://doi.org/10.14740/jmc3220

Obstructive jaundice due to a blood clot after ERCP: a case report and review of the literature

BackgroundEndoscopic retrograde cholangiopancreatography (ERCP) is one of the most frequently performed procedures for the treatment of biliary-pancreatic diseases. The most frequent complications of ERCP include pancreatitis, haemorrhage, perforation and cholangitis. While post-ERCP biliary bleeding leading to biliary obstruction is rare.Case presentationWe herein report a case of exceptional post-ERCP cholangitis due to a blood clot in the common bile duct (CBD). This case involves a 75-year-old woman with a history of recurring upper abdominal pain. Abdominal computerized tomography (CT) revealed dilatation of the extrahepatic bile duct with stones at the lower CBD. After ERCP, clearance of stones was obtained. The post-ERCP course was symptomatic with upper abdominal pain and a significant increase in cholestatic parameters. A second CT scan demonstrated a markedly dilated biliary tree with a longitudinal high-density image at the middle CBD. The patient was successfully treated with a repeated ERCP, and a blood clot was extracted. We also present a review of the literature published between 1985 and 2016 in PubMed. Four similar cases were reported during this period from France, Turkey, the USA and the UK, separately. Our case is the first reported in China.ConclusionsPost-ERCP biliary bleeding leading to biliary obstruction is rare. We describe a rare case of post-ERCP cholangitis due to a blood clot in the common bile duct (CBD), which is consistent with most clinical presentations of similar cases already described. An analysis of the possible pathophysiological mechanisms and a review of the current literature are provided. We attempt to attract clinicians’ attention to the differential diagnosis of post-ERCP obstruction. The complications might be severe or even fatal. The diagnosis of blood clot is based on clinical and laboratory data, particularly imaging. Repeated ERCP is often necessary and effective.

Afferent Loop Decompression Technique is Associated with a Reduction in Pancreatic Fistula Following Pancreaticoduodenectomy.

Postoperative pancreatic fistula (POPF) is a major complication and main cause of mortality after pancreaticoduodenectomy (PD). Afferent loop decompression technique (ALDT) has theoretical feasibility to reduce the rate of POPF. The aim of this study is to determine whether ALDT is a protective factor for POPF. A total of 492 consecutive patients who underwent PD between January 2012 and December 2014 were identified from a prospective database. All data were extracted and events were judged based on medical records. Propensity score matching was conducted to balance several variables. Univariate and multivariate analyses were performed, respectively, to investigate the independent risk factors for pancreatic fistula. ALDT required a nasogastric tube with multiple side holes to be placed deep into the afferent jejunal limb. The rationale for this technique was to prevent pancreatic fistula by decreasing intraluminal pressure in the afferent jejunal loop by placement of the nasogastric tube and the application of continuous low-pressure suction after surgery. The total rate of POPF for the entire cohort was 30.7%, and ISGPS grade-A/B/C POPF rates were 18.1, 10.6 and 2.0%, respectively. In-hospital mortality was 1.6%. Among the 331 patients who received ALDT, 89 developed pancreatic leakage (26.9 vs. 38.5% for non-ALDT; P = 0.009) and eight developed biliary leakage (2.4 vs. 6.2% for non-ALDT; P = 0.035). Apart from ALDT, decreased preoperative ALT, soft pancreas, long operative time and tumour presence in the lower common bile duct (as opposed to the pancreas) were identified as other independent risk factors for POPF following multivariate logistic regression analysis. ALDT may reduce the incidence of POPF after PD.

Clinical features of hemobilia in unresectable pancreatic cancer (uPC).

247 Background: Hemobilia is a life-threatening, although rare event in uPC patient(pt)s. However, there are few reports about it. The purpose of this study was to identify it’s clinical features in uPC at our institute. Methods: Data of 2066 pts who received treatment for uPC between April 2008 and August 2017 were reviewed retrospectively from the electronic medical records. Hemobilia was determined when extravasation was detected from the biliary tree artery on contrast-enhanced computed tomography (CT) or angiography. Blood clot seen in the bile duct on endoscopy was also included. Pts whose bleeding was diagnosed due to tumor invasion of the stomach or duodenum by endoscopy were excluded. CT and angiography were reviewed by an experienced radiologist. Results: Eleven pts developed hemobilia; there were no pts before 2013. All of them received gemcitabine plus nab-paclitaxel (GnP) as first-line chemotherapy. Eight pts developed hemobilia during GnP, three had it after disease progression. Every pt had at least one symptom of Quinke’s triad; upper gastrointestinal hemorrhage (n = 8, 73%), biliary colic (n = 4, 36%), and jaundice (n = 6, 55%). The median time to hemobilia after the start of GnP was 198 days (range: 43-559 days). A covered self-expanding metal stent (cSEMS) was placed in the lower common bile duct in all pts. The median time to bleeding after cSEMS placement was 87 days (range: 30-467 days). Eight pts showed pseudoaneurysm(PA). In 7 of these pts, were diagnosed by CT, the remaining by interventional radiology(IR). IR was employed initially in 6 of the 8 pts, and hemostasis was successful in all. Two pts underwent cSEMS placement and was unsuccessful in both. Of these 2 pts, one underwent IR, with successful hemostasis. Of the remaining 3 pts, 2 pts had hemostasis without treatment, and one had cSEMS placement that was successful for hemostasis. Conclusions: In our study, hemobilia was only seen after 2014. Hemobilia developed after the start of GnP in all of the pts. Pts who showed PA, successful hemostasis was obtained in all cases that underwent IR. Hemobilia should be kept in mind as a cause of upper GI bleeding in uPC pts, especially those with a biliary stent and history of GnP. IR was effective for the management of hemobilia associated with PA.

An unusual cause of obstructive jaundice in a 2-year-old child

Background and Objectives:Pancreaticobiliary ascariasis is common problem in tropical countries. The roundworm in the bile duct can cause biliary colic, obstructive jaundice, or pancreatitis. Live Ascaris worms are usually diagnosed on ultrasonography (USG) or endoscopic ultrasonographic (EUS) showing characteristic features of linear mobile echogenic structure with central anechoic lumen. However, the worm can die inside the common bile duct (CBD) and create a foreign body acting as a nidus for stone or sludge formation. Obstructive jaundice due to dead Ascaris is a rare but important cause in the developing World. As the worm shrivels up after death, accurate identification requires a high index of suspicion. The features of dead worm on EUS include hyperechoic structure without any acoustic shadow.Methods:We present a case of a 2-year-old Indian female child referred with biliary colic and jaundice for the last 3 weeks. Abdominal USG revealed multiple ill-defined, oval, hyperechoic shadows near the lower end of dilated CBD. MRCP showed multiple intraluminal curvilinear, hypointense areas in lower CBD.Results:Linear EUS from the duodenal bulb revealed dilated CBD with multiple hyperechoic structures without acoustic shadowing. It showed 2–6 mm sized curvilinear, disc-shaped, short-segment echogenic structures with central anechoic core parallel and equidistant from each other, suggestive of recently broken down parallel fragments of round worms. The central anechoic core represents the digestive tract of Ascaris. After multiple balloon sweeps on ERCP, creamy white structures and yellow-colored material were removed suggestive of recently fragmented Ascaris.Conclusions:Biliary ascariasis should be considered in any child presenting with obstructive jaundice in endemic regions.

Feasibility and safety of EUS-guided choledochoduodenostomy

Objective To analyze the feasibility and safety of EUS-guided choledochoduodenostomy(EUS-CDS) when routine ERCP failed. Methods Data of 3 consecutive patients with malignant lower bile duct obstruction, who underwent EUS-CDS with dual mushroom type covered metal stents (DMCMSs) between April 2016 and June 2016 after unsuccessful ERCP in a single center were retrospectively analysed. The treatment outcome and short-term complications were evaluated. Results EUS-CDSs were successfully performed in all 3 study patients (M/F 1/2, mean age 67.3, range 56-82) and DMCMSs were placed with a mean procedural time of 20.7 min (18-25 min). ERCP failure was due to lower common bile duct malignancy in 1 patient, and pancreatic cancer in 2 others. One patient developed duodenal bleeding after the procedure, which was successfully managed by radiological intervention. Significant reduction of serum bilirubin and liver enzyme level occurred in all 3 patients and they were all discharged. Conclusion EUS-CDS is a safe and feasible rescue method after unsuccessful ERCP at an experienced endoscopic center. Key words: Intestinal fistula; Duodenostomy; Endosonography; Stents; Feasibility studies

Laparoscopic pancreaticoduodenectomy: right-inferior-posterior "artery first" approach

To discuss the application of right-inferior-posterior "artery first" approach in laparoscopic pancreaticoduodenectomy. Clinical data of 17 patients who underwent laparoscopic pancreaticoduodenectomy through right-inferior-posterior "artery first" approach in our department from February 2014 to April 2015 were retrospectively analyzed. The operation began at the inferior flexure of duodenum. After entering the Toldt's space, the left renal vein (LRV) was revealed and the root of superior mesenteric artery (SMA) was exposed just above the LRV. SMA was dissected along its trunk till the horizontal part of duodenum. Of these 17 cases, adenocarcinoma of pancreatic head was observed in 5 cases, adenosquamous carcinoma in 2 cases, mucinous cycstic neoplasm in 1 case, adenocarcinoma of lower common bile duct in 4 cases, and duodenal papilla cancer in 5 cases. Fifteen cases were accomplished successfully with laparoscopy and 2 cases were converted to open approach. The average operating time was (320 ± 85) min and mean intraoperative blood loss was (305 ± 175) ml. The cutting margins were tumor negative in all the patients. The average number of harvested lymph node was 15.4 ± 6.5. Postoperative complication occurred in 5 cases. Two cases of bile leakage and 2 cases of pancreatic fistula were cured with conservative treatment. One case of delayed abdominal hemorrhage was resolved with reoperation. Right-inferior-posterior "artery first" approach is safe and feasible in laparoscopic pancreaticoduodenectomy.

A Resected Case of Mucinous Adenocarcinoma of the Duodenum, Mimicking Intraductal Papillary Neoplasm of the Bile Duct

Duodenum mucinous carcinoma is very rare, and the prognosis of the patient is very bad, especially when the tumor is invasive to other organs. In this case, duodenum carcinoma was invasive to common bile duct and transverse colon. Mucinous fluid, which was secreted from a duodenum tumor, was found in the dilatated bile duct. The intraductal papillary neoplasm of the bile duct was considered a differential diagnosis. We performed aggressive resection and had a good prognosis. A 74-year-old woman received a diagnosis of cholangitis and was treated with antibiotic drugs. Endoscopic retrograde cholangiopancreatography revealed a defect in the lower common bile duct with the mucoid fluid. We suspected intraductal papillary neoplasm of the bile duct, but no malignant cells were detected. One year later, gastrointestinal fiberscopy revealed a villous tumor in the postbulbar portion of the duodenum; adenocarcinoma was detected in biopsy specimens. Computed tomography revealed dilatation of the duodenum with an enhanced tumor, and dilatation of both the common and intrahepatic bile ducts. Magnetic resonance cholangiopancreatography revealed that the duodenum was connected with the common bile duct and ascending colon. We resected the segmental duodenum, extrahepatic bile duct, left lobe of liver, a partial of the transverse colon, and associated lymph nodes. Although the advanced duodenal carcinoma had poor prognosis, the patient was alive, without recurrence, 5 years after the operation.

A surgical case of haemothorax

An 83-year-old female presented with a 6-day history of painless jaundice, anorexia, dark urine, steatorrhea and weight loss of 10 kg over the past year. The only past medical history was a monoclonal gammopathy of unknown significance. She was a never-smoker and did not drink alcohol. On examination, she was apyrexial and normotensive. She was clinically jaundiced, and had 4 cm non-tender hepatomegaly. Initial blood tests revealed a bilirubin concentration of 166 μmol·L−1 (normal range 0–21 μmol·L−1), alkaline phosphatase of 371 units·L−1 (normal range 30–150 units·L−1) and an alanine transaminase of 145 units·L−1 (normal range 0–40 units·L−1). Her renal function and inflammatory markers were normal. An abdominal ultrasound showed intra-hepatic biliary dilatation, suggesting obstruction in the lower common bile duct. She went on to have a computed tomography (CT) scan of her abdomen, which showed a small amount of ascites, peritoneal nodularity, bile duct dilatation and a mass in the body and tail of the pancreas involving the aorta and left adrenal gland. Several attempts at a percutaneous trans-hepatic cholangiogram (PTC) were made, but the radiologist was unable to cannulate the biliary ducts. A stent was then inserted at endoscopic retrograde cholangiopancreatography (ERCP) and a biopsy of the mass was carried out. 24 h later the patient deteriorated with pyrexias, hypotension and new onset atrial fibrillation with a fast ventricular rate. Her white blood cell count rose to 16.5×109 cells·L−1 from 12.4×109 cells·L−1 and her C-reactive protein to 52 mg·L−1 (normal level less than 5 mg·L−1). Her haemoglobin dropped from 116 g·L−1 to 93 g·L−1. Her kidney and liver function tests also deteriorated and a chest radiograph showed a new right pleural effusion (fig. …