Proximal Common Bile Duct Research Articles

Common bile duct perforation resulting from a gastric duplication cyst

Gastric duplication cysts are a rare cause of abdominal masses in infants. Most children present with a gastric outlet obstruction or some vague abdominal complaints. We present an unusual case of a gastric duplication cyst that created a distal common bile duct obstruction which led to a proximal common bile duct perforation.

Immunoglobulin G4 associated cholangitis: Description of an emerging clinical entity based on review of the literature

During the last decade, patients with steroid responsive sclerosing cholangitis have been described in a number of case reports and a few cases series. These patients meet diagnostic criteria for primary sclerosing cholangitis (PSC) but seem to have a better prognosis and are often, but not always, associated with autoimmune pancreatitis (AIP). Unlike biliary strictures in PSC, most PSC-like biliary strictures seen in association with AIP respond well to steroids and some have been shown to resolve after immunosuppressive treatment during prolonged follow-up. In addition, steroid-responsive dominant bile duct lesions, sometimes mimicking infiltrating hilar cholangiocarcinoma, without pancreatic abnormalities have also been reported. Here we review the literature on this emerging clinical entity and suggest that this condition of steroid responsive biliary strictures be named Immunoglobulin G4 (IgG4) Associated Cholangitis (IAC). We performed an electronic database search of MEDLINE for case reports and case series of sclerosing cholangitis with pancreatitis and/or pancreatic mass (1960–July 2006). Articles were limited to English and these case reports and cases series were reviewed and all references on the combination of sclerosing cholangitis and pancreatitis as well as IgG4 positive cholangitis without pancreatic involvement not identified by our original search were obtained. Terminology and Definition

Reversible Cholestasis and Cholangitis Induced by Biliary Drainage and Infusion in the Rat

To develop a rat model of ascending cholangitis, we constructed a controllable and accessible biliary drainage and infusion system. We first modified a reversible cholestasis model of the rat and then induced ascending cholangitis by administration of Escherichia coli into the proximal choledochostomy tube. After biliary infusion of E. coli, the liver, choledochostomy tube and bile were all positive for E. coli, but no bacteria grew in rats receiving biliary infusion of normal saline. Retrograde cholangiography of the initial choledochostomy ensured that the tube end was in the right position in the proximal common bile duct. The patency of the tube-tube choledochocholedochostomy was confirmed by a cholangiogram on day 90. Thirty days after the tube-tube choledochocholedochostomy, the livers of the experimental animals did not differ from the control livers. The tube-tube choledochocholedochostomy model not only provides reproducible, reliable, reversible cholestasis, but creates a sustainable and accessible biliary infusion system. This can be used for long-term investigations of repeated cholangitis and recurrent cholestasis.

Electrical activation of common bile duct nerves modulates sphincter of Oddi motility in the Australian possum

Background: Sphincter of Oddi (SO) motility is regulated by extrinsic and intrinsic nerves. The existence of neural circuits between the SO and the proximal extrahepatic biliary tree has been reported, but they are poorly understood. Using electrical field stimulation (EFS), we determined if a neural circuit exists between the common bile duct (CBD) and the SO in anaesthetized Australian brush‐tailed possums. Methods: The gallbladder, cystic duct or CBD were subjected to EFS with a stimulating electrode. Spontaneous SO phasic waves were measured by manometry. Results: EFS at sites on the distal CBD (12–20mm proximal to the SO), but less commonly at more proximal CBD, evoked a variety of responses consisting of an excitatory and/or inhibitory phase. Bi‐phasic responses consisting of an excitation followed by inhibition were the most common. Tri‐phasic responses were also observed as well as excitation or inhibition only. These evoked responses were blocked by topical application of local anaesthetic to the distal CBD or transection of the CBD. EFS at sites on the gallbladder body, neck or cystic duct did not consistently evoke an SO response. Pretreatment with atropine or guanethidine reduced the magnitude of the evoked response by about 50% (p<0.05), pretreatment with hexamethonium had no consistent effect and pretreatment with a nitric oxide synthase inhibitor increased the response. Discussion: A neural circuit(s) between the SO and the distal CBD modulates SO motility. Damage to this area of the CBD during bile duct exploration surgery could adversely affect SO motility.

Laparoscopic Roux-en-Y choledochojejunostomy for benign biliary disease.

Roux-en-Y choledochojejunostomy (RYCJ) is frequently used for biliary bypass surgery. However, reports on laparoscopic RYCJ are scarce. Between February 1997 and February 2002, laparoscopic RYCJ was performed in 6 patients with a recurrent common bile duct (CBD) stone or a benign biliary stricture. The first procedure involved the laparoscopic preparation of the CBD. The Roux limb prepared with an endo-GIA was brought up near the proximal CBD. An end-to-side choledochojejunostomy was then performed using an intracorporeal suture. Jejunojejunostomy was performed using an endo-GIA. The mean operating time was 358.3 minutes. A postoperative complication occurred in 1 patient who had an episode of melena, which resolved spontaneously. All patients were free of symptoms during the follow-up period (27.5 months). Laparoscopic RYCJ may be a useful option, especially in the treatment of benign biliary disease.

Endoscopic stenting for postoperative biliary strictures due to hepatic hydatid disease: effectiveness and long-term outcome.

Postoperative strictures due to hepatic hydatid disease caused by Echinococcus surgery is considered to be a rare cause of benign bile duct strictures, especially in the Western world. The aim of this retrospective study is to demonstrate possible characteristics of the strictures as well as the effectiveness of long-term endoscopic stenting. Between 1994 and 2001, we treated 10 of these cases in our clinic. All patients had surgery for hepatic Echinococcus disease one or more times. These types of benign biliary strictures, secondary to surgery of hepatic hydatid disease, were multiple and located in the proximal common bile duct. Endoscopic stent therapy was carried out in all cases containing transpapillary approach with plastic prostheses (7.5-11 French) or transhepatic approach with Yamakawa prostheses (16 French). Nine patients were available for follow-up. In 6 patients (66%), the stents were removed after a median period of 22.5 months with radiologic and clinical signs of improvement. Three patients required prolonged dilatation therapy because of stricture-recurrence. There was low overall morbidity and we recognized no therapy-associated mortality. Endoscopic stent therapy is a safe nonoperative method for the treatment of postoperative benign biliary strictures due to hepatic hydatid disease.

Surgical treatment of iatrogenic lesions of the proximal common bile duct.

Between January 1979 and September 1999 a series of 96 patients were operated on at our institution for iatrogenic biliary injuries, and among them 62 involved the proximal biliary tract. Injuries, according to the Strasberg classification, were type E2 in 18 patients, type E3 in 29 patients, and type E4 in 15 patients. The most frequent primary surgical procedures were laparoscopic cholecystectomy in 27 of the 62 patients (43.6%) and open cholecystectomy in 30 patients (48.3%). Previous repair had been attempted in 25 patients (40.3%). A total of 58 cholangiojejunostomies were performed. Repair had been performed directly, and a T-tube had been left in the main bile duct in four patients with E2 Strasberg lesions. Postoperative death occurred in four patients (6.4%). Outcome was graded as excellent, good, or poor depending on clinical symptoms, liver function tests, and the need for reintervention due to anastomotic stricture. The final outcome was evaluated in 54 patients. The mean follow-up was 5.9 +/- 0.3 years, with the longest follow-up 10.2 years. Following our first repair 49 of the 54 patients (90.7%) had excellent results, 1 (1.9%) had good results, and 4 (7.4%) had poor results. None of the patients who underwent immediate or early repair had complications. Diagnostic and therapeutic courses are given on the basis of the type of lesion and the timing of repair. We emphasize the importance of timing (i.e., carrying out surgical repair as soon as possible) and of cholangiojejunostomy reconstruction in respect to defined technical principles. Moreover, we believe that repair treatment at a hepatobiliary center with multidisciplinary competence greatly influences the final long-term outcome.

Pseudo-obstruction of the extrahepatic bile duct due to artifact from arterial pulsatile compression: a diagnostic pitfall of MR cholangiopancreatography.

To evaluate the frequency of artifact from arterial pulsatile compression as the cause of pseudo-obstruction of the extrahepatic bile duct at magnetic resonance (MR) cholangiopancreatography (MRCP) and specify the causative vessels. In 234 patients (102 men, 132 women; age range, 25-80 years), MRCP images obtained by using a single-shot turbo spin-echo sequence were reviewed to assess pseudo-obstruction of the extrahepatic bile duct caused by vascular compression. Dual-phase spiral computed tomography, contrast material-enhanced three-dimensional MR angiography, and/or digital subtraction angiography also were performed to determine the vessel that caused the pseudo-obstruction. Thirty-six pseudo-obstructions due to vascular compression were found in 33 (14%) patients. The common hepatic duct (27 [75%] sites) was the most common pseudo-obstruction site, followed by the left hepatic duct (four [11%] sites), proximal common bile duct (three [8%] sites), and right hepatic duct (two [6%] sites). The causative vessels were identified as the right hepatic artery at 24 (67%) sites; gastroduodenal artery, two (6%) sites; cystic artery, two (6%) sites; proper hepatic artery, one (3%) site; and an unspecified branch of the common hepatic artery, seven (19%) sites. At MRCP, pseudo-obstruction of the extrahepatic bile duct can be caused by pulsatile vascular compression of the hepatic and gastroduodenal arteries, and it should not be misdiagnosed as a bile duct tumor or biliary stone.

Neoadjuvant photodynamic therapy before curative resection of proximal bile duct carcinoma

Background: Hilar bile duct carcinoma has an 80% probability of local recurrence after curative resection, which might be reduced if neoadjuvant photodynamic therapy is feasible. Case and Treatment: After intravenous injection of sodium porfimer we treated an adenocarcinoma of the proximal common bile duct (T2 N0 M0, Bismuth type II) in a 72-year-old man with red laser light (applied from the lumen at a dose 250 Joules/cm 2), and the adjacent right and left hepatic and common bile duct at a dose of 125 Joules/cm 2. After 23 days the tumor was completely resected (adenocarcinoma pT2 pN0; G2). Results: In the lumenal, 4-mm-thick layer the bile duct specimen exhibited complete tumor necrosis with pigmentation of photodegraded porfimer and no viable tumor cells, while in the outer layer of the wall (at 5–8-mm depth) viable cancer cell nests without degraded porfimer were seen. The bile duct tissue showed little damage. Eighteen months after surgery, neither tumor recurrence nor stricture formation was found at the pretreated bilioenteric anastomoses. Conclusions: a) Photodynamic therapy with sodium porfimer seems to be confined to the superficial 4-mm layer of bile duct cancer. b) Neoadjuvant photodynamic therapy is feasible for hilar bile duct carcinoma.

Obstructive Jaundice, Bacterial Translocation and Interdigestive Small-Bowel Motility in Rats

Background/Aims: Translocation of gut bacteria occurs in obstructive jaundice, the underlying mechanisms are unclear. We designed this experimental study to investigate the association between interdigestive motility and the pathogenesis of bacterial translocation during biliary obstruction. Methods: Rats were fitted with jejunal myoelectrodes for the measurement of the interdigestive migrating motor complex (MMC) and with two cannulas in the proximal common bile duct (CBD) for exteriorization of biliary flow. This allowed measurement of MMCs under control conditions with an intact enterohepatic circulation and during 3 days of CBD obstruction without surgical intervention. Mesenteric lymph nodes, liver, spleen and segments of the duodenum, the jejunum and the caecum were removed for microbial culturing. Results: The MMC cycle length increased from 17.3 min before CBD obstruction to 31.9, 34.1, and 25.3 min on days 1, 2 and 3, respectively, after CBD obstruction (p < 0.05 for all days). Bacterial levels in the jejunum were significantly higher in CBD-obstructed rats than in control rats. The translocation incidence was significantly higher in rats with CBD obstruction (6/8) than in control rats (1/8). The bacterial levels in the jejunum correlated significantly with the MMC cycle length (r = 0.60, p <0.05). Conclusion: Experimental biliary obstruction is associated with disturbance of MMCs, small-bowel bacterial overgrowth and increased bacterial translocation.

Tuberculosis of the bile duct: a rare cause of obstructive jaundice.

Tuberculosis of the bile duct is extremely rare. Patients with this condition usually present with a protracted illness and obstructive jaundice, which may be confused with hepatobiliary malignancies. A retrospective review of hospital records of patients who presented with tuberculosis of the bile duct between January 1986 and December 1996 was undertaken, and data were obtained concerning clinical presentation, investigations, treatment, and follow-up. Four patients (one man and three women) with a mean age of 44.8 years had tuberculosis of the bile duct. Diagnostic imaging techniques showed bile duct dilation in all four patients. Endoscopic retrograde cholangiopancreatography (ERCP) showed a stricture in the proximal common bile duct (CBD) in one patient, a stricture in the distal CBD in one patient, a stricture in the common hepatic duct (CHD) in one patient, and multiple strictures in the CHD and left intrahepatic duct in one patient. Bile cytology and fine-needle aspiration identified correctly the diagnosis in each patient. Two patients underwent laparotomy with the initial suspicion of cholangiocarcinoma; the correct diagnosis was made based on frozen sections taken intraoperatively. One patient was treated with endoscopic stenting and three patients underwent laparotomy for bile duct obstruction. All patients received antituberculous therapy. There were no deaths; all patients remained healthy at a mean follow-up of 36.5 months. It is important to obtain a tissue diagnosis in all patients with obstructive jaundice to avoid missing this rare but curable disease. The treatment of tuberculosis of the bile duct involves relief of the bile duct obstruction and antituberculous therapy.

Utility of Single Shot Fast Spin Echo Technique in Evaluating Pancreaticobiliary Diseases : T 2 - weighted Image and Magnetic Resonance Cholangiopancreatography

Purpose : To evaluate the accuracy of T2-weighted imaging and MR cholangiopancreatog-raphy using the single shot fast spin-echo technique for evaluating pancreaticobiliary dis-ease. Materials and Methods : B e t ween March and July 1997, axial and coronal T2-weighted im-ages ( T E : 8 0 -2 00 msec) and MR cholangiopancreatograms(TE:800 -1 2 00 msec) were ob-tained in two ways [single slab (thickness:30 -50 mm) and multislice acquisition under chemical fat saturation] using SSFSE pulse sequencing in 131 cases of suspected pancreati-cobiliary disease. The accuracy of SSFSE MR imaging was assessed in 89 lesions of 74 pa-tients [male,48; female,26; age range, 3 0 -86 (mean,59)years] confirmed surgicopathological-ly(50 lesions in 39 patients) and clinically (39 lesions in 35 patients). Two radiologists re-viewed the MR images and diagnosis was determined by consensus. Results : Correct diagnosis was confirmed in 84 of 89 lesions (94 %). Seven lesions were falsely interpreted, false positive and false negative results accounting for two and five cas-e s, respective l y. Two pancreatic cancers were misdiagnosed as pancreatitis and a cancer of the proximal common bile duct(CBD) was interpreted as a distal CBD cancer. The sensitivi-ty of SSFSE MR imaging for malignancy was 93 %. One CBD stone revealed by endoscopic retrograde cholangiopancreatography (ERCP) was not detected on MR images. In contrast, a stone in the CBD seen on MR images was not apparent on subsequent ERC P. Sensitivity and specificity for calculous disease were 96 % and 99.7 %, respective l y. A benign stricture of the ampulla of Vater was falsely interpreted as normal, and correct diagnosis was possi-ble in two falsely diagnosed cases when MR images were rev i ewed retrospectively. Conclusion : The combination of T2-weighted and cholangiographic images using SSFSE is an accurate method for diagnosing pancreaticobiliary diseases.

CT of neural plexus invasion in common bile duct carcinoma.

Our purpose was to analyze the CT findings of neural plexus invasion in common bile duct carcinoma. We studied 16 patients with common bile duct carcinoma who underwent surgery. Of these, neural invasion was seen in 10 patients. CT findings were retrospectively reviewed and correlated with the surgical and pathological findings. Irregular masses adjacent to the medial aspect of the uncinate process were observed in 4 of 14 patients with distal common bile duct carcinoma. These lesions extended medially and showed contiguity with the superior mesenteric artery and/or celiac axis, corresponding to neural plexus invasion with desmoplastic change. Increased attenuation of the fat between the common bile duct and the proper hepatic artery was seen in two of two patients with proximal common bile duct carcinoma, associated with neural plexus invasion in the hepatoduodenal ligament. The location and spread of neural plexus invasion in common bile duct carcinoma are characteristic and can be diagnosed by CT.

Disrupted bile flow affects interdigestive small bowel motility in rats

Background. The role of bile flow in the regulation of small bowel motility and the migrating myoelectric complex (MMC) is unclear. We aimed to study the effects of biliary diversion or obstruction on the MMC in a newly developed rat model. Methods. In rats, myoelectrodes were implanted in the jejunum, and the proximal common bile duct (CBD) was cannulated and exteriorized at the head, enabling us to manipulate biliary flow without influencing pancreatic flow and without the need of anesthesia or additional surgery. Group A were controls without CBD cannulas. Biliary circulation was exteriorized but kept intact in group B; bile was diverted externally in group C; and the CBD was obstructed in group D. MMCs were recorded in unre-strained conditions by jejunal electromyography before and after biliary diversion or obstruction. Spontaneous recanalization of the CBD was monitored by measurement of serum bilirubin and by cholangiography. Results. Exteriorization of the CBD without interruption of bile flow did not affect MMC duration (group A, 17.3 ± 0.3 minutes [mean ± SEM]; group B, 16.5 ± 0.6 minutes). MMCs disappeared temporarily after CBD obstruction but not after biliary diversion. MMCs of increased duration were seen after 1 day in rats with biliary diversion or CBD obstruction (group C, 26.1 ± 4.4 minutes; group D, 36.3 ± 4.8 minutes [p < 0.05]). MMCs after biliary diversion or obstruction were characterized by an increased duration of phase II—like activity and decreased duration of phase I activity. Conclusions. We conclude that MMCs disappear temporarily early after CBD obstruction, but MMCs of increased duration are seen after 1 day of biliary diversion or obstruction. Thus disrupted bile flow affects interdigestive small bowel motility in rats.

Value of laparoscopic ultrasonography in staging of proximal bile duct tumors.

The additional value of laparoscopic ultrasonography was evaluated prospectively in 35 patients undergoing diagnostic laparoscopy for a suspected potentially resectable proximal bile duct tumor. Findings were compared with transabdominal ultrasonography, laparoscopy, surgery, and pathology. Laparoscopic ultrasonography was able to visualize the presence and origin of small bile duct tumors or stones and small liver metastases, which could not be seen or could be visualized only doubtfully by ultrasonography and laparoscopy. Laparoscopic ultrasonography was more useful in staging of small tumors of the gallbladder or proximal common bile duct than in staging bifurcation (Klatskin) tumors. Additional information provided by laparoscopic ultrasonography led to a change in diagnosis or tumor stage in eight patients (23%) and to avoidance of laparotomy in three patients (9%).

Endoscopic lithotripsy of bile duct stones using a new laser with automatic stone recognition

Biliary stones can be removed in 85% to 90% of patients using endoscopic sphincterotomy; in the rest alternative methods are required. Thirty-eight consecutive patients in whom conventional methods had failed underwent laser lithotripsy with a new laser system. A flashlamp-pumped pulsed laser with rhodamine 6G as dye (594 nm) has a tissue-stone recognition system that can identify bile duct stones by analyzing backscattered light and interrupt the pulse in case of tissue contact (Lithognost, Telemit, Munich, Germany). Access of the 0.25- or 0.30-mm-diameter laser fiber to the stones was achieved perorally in 18 patients. In 13 of these cases, eccentrically located stones in the middle or proximal common bile duct were targeted with a 3.4-mm miniscope introduced through a standard duodenoscope. Fluoroscopically guided peroral lithotripsy was performed in 5 patients with stones in the distal common bile duct that could be approached with a standard ERCP catheter. Percutaneous cholangioscopic laser lithotripsy was carried out in 20 patients with stones not amenable to retrograde techniques. The mean number of bile duct stones per patient was 3.6, and the average diameter of the largest stone of each patient was 25 mm (range, 8 to 52 mm). The bile ducts were cleared in all but 1 patient in a mean number of 1.3 sessions lasting 15 to 115 minutes (mean, 60). No laser-related complications were observed. The Lithognost laser was successfully used in 37 of 38 patients referred for the removal of difficult bile duct stones. The tissue-stone recognition system allows safe and effective stone disintegration even under fluoroscopic targeting or the limited direct visual control provided by miniscopes. (Gastrointest Endosc 1994;40:708-15.)

Proximal common bile duct obstruction secondary to a periampullary duodenal diverticulum: successful treatment with endoscopic stenting

Biliary obstruction resulting from the mechanical effects of a periampullary duodenal diverticulum is a rare condition. We describe a case in which this was responsible for chronic recurrent abdominal pain and an episode of cholangitis following ERCP. The ob­ struction was treated with a biliary endoprosthesis, resulting in excellent clinical and symptomatic con­

A technique for creating partial obstruction of the common bile duct in the rat

Partial obstruction of the common bile duct was produced in rats by tightly tying a 0.5 mm stainless steel rod to the proximal common bile duct. The rod was then removed from the ligature leaving a constriction around the duct. Within 2 weeks the bile duct proximal to the partial obstruction was markedly dilated. Liver histology was notable for marked proliferation of the interlobular bile ductules and minimal cholangitis, changes which are characteristic of partial obstruction.

Thermal laser-induced stenosis of the common bile duct. An alternative model for experimental research.

An experimental model of bile duct stenosis and occlusion in dogs is presented. After percutaneous cholecystostomy of the gallbladder, which had been affixed to the abdominal wall during laparotomy four weeks earlier, a standard 2 mm laser heat probe adapted to an Nd:YAG laser (1,064 nm) was advanced inside the proximal common bile duct in 12 animals, using 6 or 7 F sheaths. The proximal part of the common bile duct was exposed to laser pulses of 6 to 10 Watts for one second. Within 3 to 15 days, total occlusion or severe stenosis of the common bile duct consistently occurred and was verified by follow-up percutaneous cholecystocholangiography. No perforations occurred. Compared with other models, laser thermal damage is an easy and reliable method of producing bile duct stenoses for experimental purposes.

Endoscopic sphincterotomy of the ampulla of Vater

Endoscopic sphincterotomy at the papilla of Vater, combining and modifying technics already established for retrograde cannulation and electrosurgical polypectomy, has been successfully performed in 2 patients with removal of stones impacted in the ampulla and proximal common bile duct. The authors caution that further investigation is in order to assure the safety and efficacy of the procedure. Endoscopic sphincterotomy at the papilla of Vater, combining and modifying technics already established for retrograde cannulation and electrosurgical polypectomy, has been successfully performed in 2 patients with removal of stones impacted in the ampulla and proximal common bile duct. The authors caution that further investigation is in order to assure the safety and efficacy of the procedure.