Duct Obstruction Research Articles

Approaches selection on palliative operation styles for malignant obstructive jaundice diseases

Objective To explore the selection of palliate operation styles for unresectable malignant obstructive jaundice diseases. Methods The clinical data of 112 cases of unresectable malignant obstructive jaundice diseases in the last 5 years were analyzed retrospectively. Results The rate of operation mortality was 7.1％ and the incidence rate of post-operative cholangitis was 17.3 ％.The survival time in the Roux-en-Y choledochojejunostomy group was (9.4±1.6) months, and there were no significant differences among laparotomy stent internal drainage group[(9.8±12.5)months]and the PTCD stent internal drainage group [(9.0± 3.1)months]. But survival time in the laparotomy bridge internal drainage group [(6.8±1.7)months]was significantly lower (P＜0.05). The survival times in the ERCP stent drainage group [(3.5±2.2)months]and exploratory laparotomy group [(2.8±2.7)months]were even more significantly lower (P＜0.01).Conclusion As a palliative operation for unresectable malignant obstructive jaundice diseases, Roux-en-Y choledochojejunostomy applies to the middle and distal obstruction,laparotomy stent internal drainage applies to hilar obstruction,ERCP stent drainage only applies to distal obstruction,and PTCD stent internal drainage applies to any part obstruction of the bile duct. The Roux-en-Y choledochojejunostomy, laparotomy stent internal drainage, and PTCD stent internal drainage would improve the life time and life quality of these patients. Key words: Neoplasms; Jaundice, obstructive ; Palliative care; Follow-up studies

Pancreatitis crónica: más allá del alcohol

For many years, the classification of chronic pancreatitis has been oversimplified according to whether the cause is alcoholic (60-70% of cases according to published series) or non-alcoholic (20-40% of the remaining cases). Recognition of smoking as an important risk factor and increasing identification of factors of genetic susceptibility have placed these percentages in doubt and have led to a reconceptualization of the disease as a multifactorial process. Mutations in the PRSS1, SPINK1 and CFTR genes have been confirmed as major risk factors, while mutations in the CTRC and CASR genes are considered lesser risk factors for the development of chronic pancreatitis. These genetic variants are expressed in a much higher percentage of patients with chronic pancreatitis than could be expected by chance. The trans-heterozygous combination multiplies the risk of chronic pancreatitis and demonstrates the degree of complexity of the etiopathogenic mechanisms of the disease. Ductal obstruction and autoimmunity are other important etiologic factors of chronic pancreatitis that need a specific review. The present article reviews the latest studies evaluating the role of alcohol and smoking in chronic pancreatitis and the most significant genetic factors.

Inspissated oral secretions and a review of their clinical, biological, and physiological significance

People with some chronic diseases may dehydrate and develop thick, viscous inspissated oronasal secretions that include cellular debris. This material can lead to ductal or airway obstructions that can prove to be life threatening. Asthma, allergy with superinfection, cystic fibrosis, intubated ventilation, burn injuries, and medication-induced complications are discussed in this paper. Many patients with chronic debilitating conditions may also be unable to communicate, and so may be unable to verbally convey that they have a compromised airway or an obstruction. Therefore, it is essential to maintain hydration and good oral hygiene that not only addresses the teeth and prostheses, but also the oral mucosal surfaces. People who are institutionalized and bed-ridden, in particular, need to be closely monitored to prevent adverse sequellae. A daily oral sweep with a 4 × 4 surgical sponge moistened with chlorhexidine may prevent aspiration pneumonia or a fatality due to an airway obstruction. Human oronasal secretions are involved with immunity, digestion, lubrication, and speech. Saliva is the most volumetrically important. These secretions moisturize inspired and expired air but can lose water, causing an increase in viscosity. The viscous secretions trap particles, food debris, and bacterial colonies, thereby increasing inspissations that may obstruct the airway.

Endoscopic dacryocystorhinostomy without silicone stent

Conclusion: In nasolacrimal duct (NLD) obstruction patients that undergo endoscopic dacryocystorhinostomy (DCR), creation of a patent rhinostomy with adequate epithelialization can be accomplished without a stent. However, in common canalicular obstruction patients, a silicone stent seems to have a beneficial role and to bear more favorable results. Objectives: The aim of this study was to evaluate the surgical outcome of endoscopic DCR without the use of a silicone stent. Methods: In all, 36 patients (41 eyes) who underwent endoscopic DCR were enrolled in this study. The patients were classified into a DCR with silicone stent group and a DCR without silicone stent group. Then each of the groups was subdivided into common canalicular obstruction group and NLD obstruction group. Surgical outcomes were evaluated by postoperative symptom improvement and patency of the rhinostomy under nasal endoscopic exam. Results: The epiphora was improved in 84.2% of the silicone stent group and 81.8% of the non-silicone stent group. Categorized by the level of obstruction, in common canalicular obstruction, the success rate was 84.5% (11/13) in the silicone stent group and 57.1% (4/7) in the no stent group. In NLD obstruction, the success rate was 83.0% (5/6) in the silicone stent group and 93.3% (14/15) in the no stent group.

Mammary fistula could be included in the follicular occlusion tetrad

ejd.2011.1629 Auteur(s) : Juan D. Berna-serna jdberna@gmail.com, Juan D Berna-Mestre Department of Radiology, Virgen de la Arrixaca University Hospital, 30120-El Palmar (Murcia) Spain Mammary fistula (MF), or Zuska's disease, is a recurrent condition characterised by draining periareolar abscesses in non-lactating women [1]. The aetiology of MF remains unclear. The most accepted cause is obstruction of a distal lactiferous duct by squamous metaplasia with keratinisation or epidermisation of the duct [...]

Three-Dimensional Sonography, Tomographic Sonography Imaging, and the OmniView Algorithm

The prenatal diagnosis of congenital dacryocystocele has been reported using 2D sonographic imaging, but there are very few reports of the use of 3D sonography for this diagnosis. Two cases are presented in which 3D and Doppler sonography was helpful in determining the prenatal diagnosis. The embryologic basis of this obstruction of the nasolacrimal duct is discussed along with techniques for the prenatal diagnosis, including the potential value of 3D sonography in limiting the necessity of other prenatal testing. The importance of establishing the differential diagnosis is also discussed, as there is the possibility of the dacryocystocele being secondary to a sinonasal tumor.

Repeating regional acute pancreatitis in the head of the pancreas caused by intraductal papillary mucinous neoplasms in the tail: report of a case

Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is a distinct entity characterized by papillary proliferations of mucin-producing epithelial cells with excessive mucin production and cystic dilatation of the pancreatic ducts. The clinical presentation often involves recurrent episodes of pancreatitis associated with the temporal obstruction of the main pancreatic duct caused by the hypersecretion of mucin. We herein describe a case in which the patient repeatedly experienced the occurrence of idiopathic acute pancreatitis in the head of the pancreas over a 9-year period, and who was ultimately was cured by distal pancreatectomy for IPMNs in the pancreatic tail. This case illustrates the potential pitfalls in the diagnosis of IPMNs owing to a discrepancy between the site of pancreatitis and that of the IPMN. The possible mechanisms linking acute pancreatitis with the formation of IPMNs are also reviewed.

Heterotopically Located Bartholin’s Cyst

Bartholin’s gland is about 1 cm in size located in vulvar vestibule adjacent to the hymen. It opens into the introitus with an almost 2,5 cm length duct. The Bartholin’s duct obstruction can occur as a result of non-infectious occlusion of the ostium or from infection and edema compressing the duct. In this paper we present a patient admitted to our clinic with severe vulvar pain. Her gynecological examination revealed a painful firm necrotized mass which was 4 cm in diameter on the outer side of left minor labium. The mass was excised completely and the material was send to pathology for definitive diagnosis. Histopathological examination revealed Bartholin gland cyst. To our knowledge, there isn’t any case of heterotopically located bartholin cyst when the previous literature is reviewed up to now.

Benign Recurrent Intrahepatic Cholestasis with a Single Heterozygote Mutation in the ATP8B1 Gene

Benign recurrent intrahepatic cholestasis (BRIC) is a rare autosomal recessive inherited disorder characterized by multiple recurrent episodes of severe cholestatic jaundice without obstruction of extrahepatic bile duct. We present the case of a 7-year-old boy with BRIC confirmed by mutation analysis in the ATP8B1 gene and typical clinical manifestation. Despite inheritance of BRIC, we detected a mutation on only one allele. To our knowledge, this is the first report of BRIC with a confirmed single heterozygote novel mutation in the ATP8B1 gene in Korea. (Pediatr Gastroenterol Hepatol Nutr 2012; 15: 122∼126)

Identification of Core Proteins Carrying the Sialyl Lewis a Epitope in Pancreatic Cancers Identification of Core Proteins Carrying the Sialyl Lewis a Epitope in Pancreatic Cancers

Identification of core proteins carrying the CA19-9 (carbohydrate antigen, sialyl Lewis a) epitope from various tissues will improve the diagnosis of pancreatic cancer in terms of specificity and sensitivity. In this study, we attempted to identify sialyl Lewis a-carrier proteins specifically expressed in pancreatic cancer. Pancreatic cancer is difficult to detect in the early stages of the disease, resulting in a high level of mortality. Therefore, in order to determine the correct course of treatment, it is vital to distinguish cancer from obstruction of the bile duct or other diseases. Our strategy to identify the carrier proteins was as follows: glycoproteins carrying sialyl Lewis a antigen were enriched from pancreatic cancer cell lines using anti-sialyl Lewis a antibody and then subjected to Peptide Mass Fingerprinting analysis. Based on these studies we identified nine glycoproteins carrying the sialyl Lewis a epitope. We evaluated candidate molecules by biochemical analyses of culture supernatants and human sera. In particular, we focused on one candidate molecule carrying a sialyl Lewis a epitope, Galectin-3BP/MAC2BP; M2BP, which was analyzed in detail. These results verified that our candidate molecule is a core protein carrying the sialyl Lewis a epitope. Furthermore, we demonstrated sandwich ELISA, which showed that the glycoprotein was able to detect CA19-9 antigen in culture supernatants. Our approach facilitated the identification of the core protein carrying the sialyl Lewis a epitope. We believe our approach will enable future developments in cancer glycobiomarker identification.

Bacteriological profile of cholectystitis and their implication in causing post-operative wound infections

Background: Cholecystitis is a common indication for major abdominal surgeries. It may occur with or without obstruction of common bile duct. Obstruction leads to secondary bacterial infection of bile. Bactibilia is an important predisposing factor for post-operative complications. Hence, this study was designed to determine the prevalence of bacteria in bile samples of cholecystitis patients and to correlate bactibilia and post-operative wound infection. Materials and Methods: Bile samples collected intra-operatively were subjected to gram stain, culture, and antibiotic sensitivity testing. The patients were followed-up for post-operative complications. If post-operative wound infection was found, cultures were done and correlated with bacteria isolated from bile samples. Results: Bactibilia was found in 27/50 (52%) of patients. Polymicrobial flora was found in 10% of bile samples. Escherichia coli, Klebsiella pneumoniae and Enterococcus faecalis were the predominant organisms isolated. None of the anaerobes were isolated. Extended spectrum β-lactamase and AmpC β-lactamase (AmpC) production was seen in 47% and 31.5% of Enterobacteriaceae isolates respectively. Post-operative wound infection was found in six (12%) patients who had bactibilia. Combination of piperacillin-tazobactam and amikacin was most effective in prophylactic regimen. Conclusion: The organisms responsible for bactibilia were found to cause post-operative infections in the same patient warranting the use of prophylactic antibiotics in every patient undergoing cholecystectomy. All patients undergoing open cholecystectomy should receive prophylactic antibiotics to prevent post-operative wound infections.

Resolution of Hepatic Hydatid Cyst with Biliary Communication with ERCP

Background: Hydatid cyst of the liver may be complicated by spontaneous rupture into the biliary tract with biliary obstruction. Methods: ERCP of hydatid cyst liver with biliary communication was done and bile duct cleared and cyst was assessed for resolution. Results: A 56 year lady who had jaundice, right upper abdomen pain and cholangitis was diagnosed to have hydatid cyst of liver with biliary obstruction and membranes in common bile duct. ERCP was performed and bile duct membranes were extracted and duct was cleared. Her jaundice, fever and abdominal pain resolved and the repeat CT scan abdomen also showed resolution of the liver hydatid cyst. Conclusion: Hepatic hydatid cyst with biliary communication may drain off and resolve completely after ERCP clearance of bile duct.

Endoscopic ultrasound-guided double stenting for biliary and duodenal obstruction.

Endoscopic biliary stenting for malignant biliary obstruction is currently the gold standard for biliary drainage. Biliary cancer treatment is crucial. Cases of gastric outlet obstruction that includes the duodenum because of cancer invasion and biliary obstruction are seldom observed. The required treatment for such cases is simple biliary stenting and a different treatment for duodenal obstruction. Hence, double stenting for bile duct and duodenal obstruction has drawn attention. In the present review, we state different treatment strategies for malignant duodenal obstruction and then describe double stenting in biliary obstruction that also includes non-biliary cancer malignant lesions and duodenal obstruction.

The quandary of autoimmune pancreatitis and pancreatic ductal adenocarcinoma: A case report and review of IgG4 immunostaining in a cohort of patients receiving neoadjuvant chemotherapy

ABSTRACT Introduction: Autoimmune pancreatitis (AIP) is an inflammatory disease whose clinical presentation can mimic that of pancreatic ductal adenocarcinoma (PDA). AIP can appear on imaging as a bulky, sausage­like pancreatic mass with biliary and pancreatic ductal obstruction, resembling the classic “double duct sign” appearance of PDA. A definitive preoperative diagnosis of AIP can be difficult because the two diseases (AIP and PDA) are similar in clinical presentation. Recent advances in serum marker evaluation such as IgG4 serum levels and immunostaining techniques have shown some promise in the differentiation of AIP from PDA. Case Report: We report the case of a patient with a preoperative diagnosis of locally advanced PDA who was treated with neoadjuvant gemcitabine based chemotherapy followed by surgical resection, but whose post­ resection pathology was indicative of AIP and not PDA. To explore the possibility that the pre­ resection gemcitabine­based chemotherapy had generated a complete pathological response and an inflammatory reaction of IgG4­positive plasma cells, we studied the histology features and IgG4 plasma cell immunostaining characteristics of the pathology specimens of 14 patients with a diagnosis of PDAwho were treated with neoadjuvant chemotherapy and surgical resection at our institution. Conclusion: Our results indicate that none of the patients treated with neoadjuvant chemotherapy had increased IgG4­positive plasma cell immunostaining post­ operatively, further supporting the diagnosis of AIP and not PDA in our patient.

Prevention of beta cell death in chronic pancreatitis

Chronic pancreatitis is best described as a relentless, continuous inflammatory destruction of the pancreas parenchyma, characterized by irreversible destruction of the exocrine tissues, fibrosis, and at the late stage, the destruction of endocrine cells. Current therapies for chronic pancreatitis patients focus on pain relief by medical and minimally invasive endoscopic treatment as well as surgical management with resection of diseased parenchyma and drainage of obstructed ducts. Radical treatment of chronic pancreatitis has been successful with total pancreatictomy and islet autotransplantation (TP-IAT) that may prevent maladaptive intractable pain pathways and also avoid pancreatogenic diabetes in the well-selected patient. Distinct loss of pancreatic islet cells occurs in about 30%-50% of patients during the progression of chronic pancreatitis when severe fibrosis develops at the late stage of the disease. Profound β cell apoptosis induced by stresses encountered during islet isolation and transplantation further compromises β cell survival and function after TP-IAT. The molecular mechanisms that lead to β cell dysfunction in chronic pancreatitis remain largely undelineated. In this review, we summarize factors that may contribute β cell apoptosis during the disease progress and after TP-IAT and discuss potential interventional approaches that may prevent islet cell death during these processes. Such information is critical to the development of therapeutic protocols that can preserve the viability and function of β cell in patients with chronic pancreatitis.

Correlation among pressure, diameter, and jaundice in acute obstruction of common bile duct

Objective To investigate the relationship between the pressure,diameter,and jaundice in acute obstruction of the common bile duct (CBD).Methods An automatic pressure measurement device was placed through a small tube (D =3.5 mm) into the CBD on the upper entrance of the duodenum.The pressure and diameter of the CBD were detected.The switch was then turned on and methylene blue (MB) in saline (NS 100 ml+ MB 60 mg,20 drops/min) was infused into the CBD to create CBD congestion.The pressure and diameter were detected according to the time set,and the reflux of MB to the liver was observed.Results Before the MB was injected,the pressure of the CBD was hower than 8 mm Hg ( 1 mm Hg =0.133 kPa),the diameter was 4.0 mm,and the color of the liver was normal.Seven min after the MB was introduced,the pressure was increased to 15.42 mm Hgand the diameter widened to 5.50 mm.Fifteen min after introduction the pressure was increased to 20 mm Hg and the diameter widened to 6.00 mm,the liver surface began to turn blue,indicating that the bile had begun to reflux into the liver.After 30 min,the pressure was increased to 33 mm Hg,the diameter widened to 6.7 mm,and the blue liver color enhanced.After 45 min,the pressure was increased to 21 mm Hg,the diameter widened to 7.5 mm,and the color of the liver was dark blue.After 60 min,the pressure was increased to 18 mm Hg and the diameter widened to 7.5 mm.Conclusion After the pressure rises,increase in the diameter is observed,followed by jaundice.Within a certain range,bile duct dilatation is positively correlated with the biliary pressure.The degree of jaundice and biliary duct dilatation pressure are also positively correlated.However,when the biliary pressure rises to 33 mmHg,it no longer increases,while the expansion of the width to 7.5 mm also no longer continues,indicating that duct dilatation and pressure are both self-limiting. Key words: Acute obstruction of the common bile duct; Bihary pressure ; Biliary expansion; Jaundice

A modified technique of pancreaticojejunostomy after pancreatoduodenectomy: a preliminary experience

Pancreatoduodenectomy currently represents the treatment of choice for resectable pancreatic and periampullary malignant tumours, symptomatic chronic pancreatitis, duodenal cystic dystrophy, large adenomas, diverticula and benign periampullary tumours. Pancreato-jejunostomy failure remains the main complication following pancreatoduodenectomy, even leading to death. To improve the safety of this anastomosis, a modified technique of pancreato-jejunal anastomosis with posterior double-layer suture and Wirsung duct evagination is proposed. We report our experience in eight consecutive patients (4 females, 4 males; average age 66, range 57-74) undergoing Traverso-Longmire pylorus-preserving pancreatoduodenectomy using Wirsung duct evagination and posterior double-layer suture technique. There was no mortality; the post-operative recovery was uneventful with no pancreatic anastomotic leakage. The mean post-operative stay was 15days (range 12-19). This proposed procedure could be considered an additional opportunity in the performance of a pancreato-enteric anastomosis, yielding good results and preserving from post-operative pancreatic ductal obstruction.

Congenital Miliaria Crystallina in a Term Neonate Born to a Mother with Chorioamnionitis

Miliaria crystallina (MC) is a self-limiting, superficial obstruction of the eccrine sweat ducts with subsequent extravasation of sweat, resulting in rapidly surfacing, tiny, clear, noninflammatory vesicles. The disease is seen frequently in hot, humid, tropical climates and in the neonatal period, but congenital occurrence is rare. We report a case of congenital MC in a baby born to a mother with chorioamnionitis.

Sclerosing Cholangitis after Transcatheter Arterial Chemoembolization: a Case Report

CLEROSING cholangitis represents progressing jaundice or/and paroxysmal symptom of cho- langitis, finally developing to end-stage of liver disease. When compared with primary scleros-ing cholangitis (PSC), there are no apparent differences in pathology and clinical manifestation in secondary scle-rosing cholangitis (SSC). But unlike PSC, SSC always has underlying causes, the most common being biliary ob-struction, surgical trauma and ischemic injury of bile duct during liver transplantation.

In Vivo Confocal Microscopy of Meibomian Glands in Contact Lens Wearers

To evaluate by in vivo laser scanning confocal microscopy (LSCM) the morphologic changes in the meibomian glands (MGs) and the status of periglandular inflammation in contact lens wearers (CLWs) and to investigate the correlations between clinical and confocal findings. Twenty CLWs and 20 age- and sex-matched control subjects were consecutively enrolled. Each participant completed an Ocular Surface Disease Index questionnaire and underwent a full eye examination, including tear film break-up time, fluorescein and lissamine green staining, and Schirmer test. LSCM of the MGs were performed to determine the cell density of the mucocutaneous junction epithelium, acinar unit density and diameter, glandular orifice diameters, meibum secretion reflectivity, and inhomogeneous appearance of the glandular interstice and acinar wall. All clinical parameters showed statistically significant differences between groups (P < 0.01, Mann-Whitney U test) except the Schirmer test. Confocal data (Mann-Whitney U test) showed significantly decreased basal epithelial cell density (P < 0.01), lower acinar unit diameters (P < 0.05), higher glandular orifice diameters (P < 0.05), greater secretion reflectivity (P < 0.01), and greater inhomogeneity of the periglandular interstices (P < 0.05) in CLWs compared with controls. The duration of contact lens wear was correlated with the acinar unit diameters (P < 0.05, Spearman). Morphologic changes in the MGs shown by LSCM were interpreted as signs of MG dropout, duct obstruction, and glandular inflammation. A comprehensive LSCM evaluation of the ocular surface in CLWs could better clarify the role of MG dropout and eyelid margin inflammation on the pathogenesis of CL-induced dry eye.