I think the correct answer is 4, although both lesions are resectable, pancreatic adenocarcinoma with synchronous hepatic metastases has no surgical indication because it does not prolong survival and has a high morbidity. Surgical bypass has more complications than placing a self-expanding metallic prosthesis that has a median patency of 6 months which is similar to the median survival of a patient with hepatic metastases of pancreatic adenocarcinoma.

I think [HIDDEN], although both lesions are resectable, pancreatic adenocarcinoma with synchronous hepatic metastases has no surgical indication because it does not prolong survival and has a high morbidity. Surgical bypass has more complications than placing a self-expanding metallic prosthesis that has a median patency of 6 months which is similar to the median survival of a patient with hepatic metastases of pancreatic adenocarcinoma.

A 76-year-old woman with no history other than hypertension consults for painless jaundice and pruritus with anorexia. Laboratory tests show a bilirubin level of 12 mg/dl (with 9.5 direct bilirubin). Abdominal ultrasound shows dilatation of the intrahepatic and extrahepatic biliary tract, together with a single 2 cm nodule located peripherally in the anterior aspect of the left lobe. CT scan confirms the findings, also demonstrating the presence of a 3.5 cm mass in the head of the pancreas. Fine needle aspiration confirms the diagnosis of adenocarcinoma. Indicate the best therapeutic option:

Adjuvant chemo/radiotherapy, conditioning radical surgery to the initial response.

Percutaneous external drainage is palliative, with eventual conversion to internal drainage in case of intolerance or complications.

Surgical biliary bypass, with or without prophylactic gastrojejunostomy depending on intraoperative findings.

Metallic biliary prosthesis by endoscopic retrograde cholangiography, with the option of palliative chemotherapy.

Cephalic duodenopancreatectomy with radiofrequency ablation or alcoholization of the liver lesion.

[Interventional radiology in the palliative treatment of pancreatic cancer].

Pancreatic carcinoma often involves the head of the pancreas and obstructive jaundice is its earliest sign. It sometimes extends to celiac plexus and duodenum causing pain and bowel obstruction respectively. Only 20% of cases are totally resectable (stage I) at the time of diagnosis. Palliative treatment is the only available therapeutic option when the tumor extends surrounding organs or has given lymphatic metastases (stage II, III, IV). The aim of this study is to evaluate effectiveness of interventional radiology procedures on unresectable cancer palliative treatment. Between Jan 90 and Sep 98, 195 patients with unresectable pancreatic carcinoma received percutaneous treatments. They were 104 males and 91 females with mean age of 74 years (range, 48-95). One hundred eighty four patients underwent biliary drainage, six patients underwent celiac plexus block, two patients were treated by bowel stenting. Two patients received both biliary and bowel stents, one patient underwent biliary drainage and celiac plexus block. Jaundice treatment was performed by placement of drainage catheters in 48 patients, polymeric endoprostheses in 58 and metallic stents in 77 (67 Wallstents). Biliary drainage was successful in all cases obtaining appreciable bilirubin serum levels reduction and jaundice regression in 175 patients (95%). In 44 patients Wallstents were placed during a single PTC session time ("one step" technique). In 21 cases (11%) peri-procedural complications occurred. Follow-up related to 85 patients shows survival rate covered between 30 and 570 days (mean, 142). Best survival values occurred in patients who underwent "one step" technique. Celiac plexus block was successful in 5/7 cases (71%) with no complications, total pain relief and withdrawal of pharmacological treatment. Bowel stenting achieved complete recanalization of intestinal loop in 2 cases but showed troubles related to management of these patients. In patients with unresectable pancreatic carcinoma palliation is the only therapeutic option and has the purpose to achieve biliary tree decompression and eliminate jaundice associated symptoms, improving quality of life and reducing hospitalization. Jaundice relief is reachable by surgical, endoscopic or percutaneous approach. Surgical palliation is characterized by disadvantageous cost-effectiveness rate. Endoscopic and percutaneous palliations are alternative, although, in selected patients, percutaneous Wallstents placement by one step technique is perhaps the most successful procedure, showing high rate of technical outcome with low complications and short time spent in hospital. Celiac plexus block under CT guidance constitutes a reliable method for management of pain. At present bowel stricture treatment is surgical.

Cholangiography

Cholangiography is the imaging of the bile duct (also known as the biliary tree) by x-rays and an injection of contrast medium. Types There are at least four types of cholangiography: Percutaneous transhepatic cholangiography (PTC): Examination of liver and bile ducts by x-rays. This is accomplished by the insertion of a thin needle into the liver carrying a contrast medium to help to see blockage in liver and bile ducts. Endoscopic retrograde cholangiopancreatography (ERCP). Although this is a form of imaging, it is both diagnostic and therapeutic, and is often classified with surgeries rather than with imaging. Primary cholangiography (or perioperative): Done in the operation room during a biliary drainage intervention. Secondary cholangiography: Done after a biliary drainage intervention.

ICD-9-CM Volume 3

() Repair of liver () Other operations on liver () Operations on gallbladder and biliary tract () Cholecystotomy and cholecystostomy () Diagnostic procedures on biliary tract () Endoscopic retrograde cholangiopancreatography (ERCP) () Cholecystectomy () Anastomosis of gallbladder or bile duct () Incision of bile duct for relief of obstruction () Other incision of bile duct () Local excision or destruction of lesion or tissue of biliary ducts and sphincter of Oddi () Repair of bile ducts () Other operations on biliary ducts and sphincter of Oddi () Other operations on biliary tract () Operations on pancreas () Pancreatotomy () Diagnostic procedures on pancreas () Local excision or destruction of pancreas and pancreatic duct () Marsupialization of pancreatic cyst () Internal drainage of pancreatic cyst () Partial pancreatectomy () Total pancreatectomy () Radical pancreaticoduodenectomy () Transplant of pancreas () Other operations on pancreas

Percutaneous transhepatic cholangiography

Technique It is predominantly now performed as a therapeutic technique. There are less invasive means of imaging the biliary tree including transabdominal ultrasound, magnetic resonance cholangiopancreatography, computed tomography and endoscopic ultrasound. If the biliary system is obstructed, percutaneous transhepatic cholangiography may be used to perform biliary drainage until a more permanent solution for the obstruction is performed (e.g. surgery). Additionally, self expanding metal stents can be placed across malignant biliary strictures to allow palliative drainage. Percutaneous placement of metal stents can be utilised when therapeutic endoscopic retrograde cholangiopancreatography has been unsuccessful, anatomy is altered precluding endoscopic access to the duodenum, or where there has been separation of the segmental biliary drainage of the liver, allowing more selective placement of metal stents.

[Efficacy of biliary by-pass operations in carcinoma of the head of the pancreas with jaundice (author's transl)].

In the present state of detection and treatment of carcinoma of the head of the pancreas, only palliative surgery is available. The debate concerning the type of bilio-digestive by-pass is far from closed. Although by-passes using the gall bladder remain rare in France, above all reserved for advanced cancer, we prefer to use the common bile duct. The choice of the by-pass depends mainly on the local conditions and on the general state of the patient. Side-to-side choledoco-duodenal anastomosis, provided the technic is perfect and there is no duodenal obstruction, remains the simplest and therefore the most commonly used by-pass. However in cases of large pancreatic carcinomas modifying the relations between the duodenum and the bile duct or stenosing the duodenum, or as a routine whenever possible, it seems to us advisable to undertake a choledoco-jejunostomy on a Y loop (the raised loop is also used for a gastrojejunostomy), and this seems to give the most rapid recovery from the jaundice, a low mortality and ensure the longest survival.

Pancreatic metastases from ocular malignant melanoma: the use of endoscopic ultrasound-guided fine-needle aspiration to establish a definitive cytologic diagnosis: a case report.

When encountering solid pancreatic lesions, nonpancreatic primary metastases are rare and differentiating a metastasis from a primary neoplastic lesion is challenging. The clinical presentation and radiologic features can be similar and the possibility of a pancreatic metastasis should be considered when the patient refers to a history of a different primary cancer. Endoscopic ultrasound offers a key anatomical advantage in accessing the pancreas and endoscopic ultrasound-guided fine-needle aspiration has become the gold standard method for diagnosing pancreatic lesions. A 58-year-old white Hispanic woman with a history of uveal malignant melanoma, presented with abdominal pain and jaundice. On admission, laboratory tests were performed (her total bilirubin was 6.37 mg/dL with a direct fraction of 5.30 mg/dL). Cross-sectional, abdominal computed tomography with contrast, showed a low-attenuating lesion localized in the pancreatic head (measuring 4 × 3 cm) and a thinner section of the distal bile duct suspicious for compression. Our patient was scheduled for an endoscopic ultrasound-guided fine-needle aspiration to establish a diagnosis. Endoscopic ultrasound showed a solid, hypoechoic, well-defined lesion with regular contours (measuring 3.17 × 2.61 cm), localized between the head and neck of the pancreas. Endoscopic ultrasound-guided fine-needle aspiration was performed with a 22G needle and cytology confirmed the diagnosis of metastatic melanoma. Our patient subsequently underwent right orbital exenteration, followed by duodenopancreatectomy without complications. At the moment our patient is receiving adjuvant chemotherapy at an outside oncology clinic. To the best of our knowledge, this is a very rare presentation of an ocular malignant melanoma with an isolated pancreatic metastasis causing symptomatic biliary obstruction. Endoscopic ultrasound-guided fine-needle aspiration has proven to be the best method to diagnose solid pancreatic lesions. In this particular case, cytology was essential in confirming the diagnosis and guiding the most adequate therapy, which was a pancreatic resection, ocular exenteration of the melanoma, followed by adjuvant chemotherapy.

InternalMed_Harrison

Tissue Diagnosis and Cytology Preoperative confirmation of malignancy is not always necessary in patients with radiologic appearances consistent with operable pancreatic cancer. However, EUS-guided fine-needle aspiration is the technique of choice when there is any doubt, and also for use in patients who require neoadjuvant treatment. It has an accuracy of approximately 90% and has a smaller risk of intraperitoneal dissemination compared with the percutaneous route. FIGURE 112-1 Coronal computed tomography showing pancre-atic cancer and dilated intrahepatic and pancreatic ducts (arrows). showing contrast in dilated pancreatic duct (arrows). Percutaneous biopsy of the pancreatic primary or liver metastases is only acceptable in patients with inoperable or metastatic disease. ERCP is a useful method for obtaining ductal brushings, but the sensitivity of ERCP for diagnosis ranges from 35 to 70%.

Endoscopic Ultrasound-Guided Biliary Drainage: Endoscopic Ultrasound-Guided Hepaticogastrostomy in Malignant Biliary Obstruction.

Patients with unresectable malignant biliary obstruction often require biliary drainage to decompress the biliary system. Endoscopic Retrograde Cholangiopancreatography (ERCP) is the primary biliary drainage method whenever possible. Percutaneous Transhepatic Biliary Drainage (PTBD) is used as a salvage method if ERCP fails. Endoscopic Ultrasound-Guided Biliary Drainage (EUS-BD) provides a feasible alternative biliary drainage method where one of the methods is EUS guided Hepaticogastrostomy (EUS-HGS). Here we describe the EUS-HGS technique in a case of unresectable malignant hilar biliary obstruction to achieve biliary drainage. Presented here is the case of a 71-year-old female with painless jaundice and weight loss for 2 weeks. Computed Tomography (CT) imaging showed a 4 x 5 cm hilar tumor with lymphadenopathy and liver metastasis. EUS fine needle biopsy (FNB) of the lesion was consistent with cholangiocarcinoma. Her bilirubin levels were 212 µmol/L (<15) during presentation. A linear echoendoscope was used to locate the left dilated intrahepatic ducts (IHD) of the liver. The segment 3 dilated IHD was identified and punctured using a 19 G needle. Contrast was used to opacify the IHDs under fluoroscopic guidance. The IHD was cannulated using a 0.025-inch guidewire. This was followed by the dilation of the fistula tract using a 6 Fr electrocautery dilator along with a 4 mm biliary balloon dilator. A partially covered metallic stent of 10 cm in length was deployed under fluoroscopic guidance. The distal part opens in the IHD and the proximal part was deployed within the working channel of the echoendoscope that subsequently released into the stomach. The patient was discharged three days after the procedure. Follow up performed in the second and fourth weeks showed that the bilirubin levels were 30 µmol/L and 14 µmol/L, respectively. This indicates that EUS-HGS is a safe method for biliary drainage in unresectable malignant biliary obstruction.

Efficacy of primary drainage by endoscopic ultrasound-guided biliary drainage for unresectable pancreatic adenocarcinoma.

Obstructive jaundice induced by pancreatic adenocarcinoma is typically treated with biliary drainage with endoscopic retrograde cholangiopancreatography (ERCP)-guided biliary drainage (ERCP-BD). Recently, endoscopic ultrasonography-guided biliary drainage (EUS-BD) was employed as an alternative method after ERCP-BD failed. We aimed to determine the efficacy and safety of EUS-BD for primary biliary drainage. Between December 2011 and February 2019, at Kawasaki General Medical Center, we retrospectively enrolled 33 patients who had undergone endoscopic biliary drainage with a metal stent, in a first attempt to relieve obstructive jaundice caused by unresectable pancreatic adenocarcinoma. We compared the technical and clinical outcomes between ERCP-BD and EUS-BD. Twenty-three patients underwent ERCP-BD and 10 underwent EUS-BD. Both groups achieved 100% technical success. The clinical success rates were similar between the groups: 91% (21/23 patients) for ERCP-BD and 100% (10/10 patients) for EUS-BD (<iP</i = 0.48). Biliary obstruction recurred in 6/23 patients (26%) treated with ERCP-BD and 1/10 patients (10%) treated with EUS-BD (<iP</i = 0.40). Other adverse events occurred in 4/23 patients (17%) in the ERCP-BD group and 1/10 patients (10%) in the EUS-BD group (<iP</i = 0.99). We suggest that EUS-BD could be employed for primary biliary drainage in patients with obstructive jaundice caused by unresectable pancreatic adenocarcinoma.

Primary adenosquamous cell carcinoma of the pancreas: the use of endoscopic ultrasound guided - fine needle aspiration to establish a definitive cytologic diagnosis.

Pancreatic cancer is the second most common malignancy of the gastrointestinal tract in the US, and adenocarcinoma has been identified as the most common type of pancreatic cancer. Different types of pancreatic cancers have been classified: adenocarcinoma, ductal adenosquamous carcinoma, solid pseudopapillary tumors, endocrine neoplasms, acinar cell carcinoma, squamous cell carcinoma, cystic tumors, primary lymphoma of the pancreas, and metastatic lesions of the pancreas. Adenosquamous carcinoma is extremely rare, behave in a very aggressive way and is responsible for the 1 to 4% of the pancreatic exocrine neoplastic lesions. We describe the case of an 82-years-old African American female, presenting to our institution with quantifiable weight loss (12 kg in 3 months), jaundice and abdominal pain. On admission, laboratory tests were obtained: total bilirubin: 11.07 mg/dl with a direct fraction of 10.32 mg/dl. Cross-sectional abdominal CT scan with contrast, showed a lesion localized in the pancreatic head (hypodense on T1, measuring 3.5 x 3.5 x 2.5 cm), with vascular invasion of the portal vein. EUS showed a solid, hypoechoic, not well-defined lesion (measuring 3.98 x 3.80 cm), localized between the head and neck of the pancreas. EUS-FNA was performed with a 22G needle using the fanning technique. The cytological specimens demonstrated components of both squamous carcinoma and adenocarcinoma. The patient underwent ERCP procedure, and biliary drainage was performed with an entirely covered metallic stent placement. After a month from the procedures, the patient died due to the severity of the disease. Endoscopic ultrasound has proven to be the best method to diagnose solid pancreatic lesions, including rare and aggressive type of tumors like primary adenosquamous cell carcinoma that we described in this very interesting case report.

Indirect biliary drainage as an alternative solution for biloma due to complicated biliary drainage.

Pancreas cancer has increased morbidity and mortality. It generally result in biliary obstruction which life threatening importance. Main biliary drainage method is endoscopic retrograde cholangiopancreatography. When endoscopic retrograde cholangiopancreatography is not successful, second preferred method is percutaneous biliary drainage. Percutaneous biliary drainage has some complications which is an invasive procedure. A complication of percutaneous biliary drainage due to patient iatrogenity which was not ever reported in the literature biliary drainage according to our literature research. In these circumstances an alternative solution is indirect biliary drainage.

[Obstruction icterus--our experience].

The most common causes of extrahepatic obstruction are choledocholithiasis, malignant and benign stenosis of biliary ducts, pancreatic head carcinoma, and chronic cephalic pancreatitis. Differentiation between hepatocellular icterus with intrahepatic obstruction and extrahepatic mechanical obstruction is of utmost importance. Differential diagnosis usually includes a combination of clinical examination, biochemical testing, ultrasonography, endoscopic retrograde cholangiopancreatography (ERCP), transhepatic cholangiography, computed tomography (CT), nuclear magnetic resonance (NMR) and endoscopic ultrasonography (EUS). Choledocholithiasis mostly develops due to concrement migration from the gallbladder. The treatment of choice is operative therapy by either conventional method with laparotomy or endoscopic concrement extraction, the latter being preferred in case of residual concrements. Malignant stenoses of extrahepatic ducts can involve any segment of the biliary ducts or the gallbladder. The main symptom is so-called painless icterus. The condition is treated surgically by radical (various types of resection) or palliative (biliodigestive anastomoses) methods. Intraoperative lesion occurring on biliary duct procedures is generally involved in the etiology of benign stenoses of extrahepatic biliary ducts. The treatment is surgical and consists of the creation of hepaticojejunal anastomosis. The study included 151 patients admitted during a 5-year period (1999-2003) to Department of Surgery, Zabok General Hospital. Icterus was caused by choledocholithiasis in 112, carcinoma of extrahepatic biliary ducts in seven, carcinoma of the gallbladder in five, and carcinoma of the head of pancreas in 18 patients. Cephalic pancreatitis, malposition of a clamp placed during laparoscopic procedure, postoperative choledochus stricture, stricture of choledochoduodenal anastomosis and multiple cystic liver disease caused icterus in nine patients. In 106 choledocholithiasis patients, the concrement was removed by choledocholithotomy; duodenotomy and papillotomy in addition to choledochotomy were required in four patients; and creation of biliodigestive anastomosis was needed in two patients due to impossible concrement removal. Biliodigestive anastomosis was created in another 20 patients with the findings of inoperable tumor of the head of pancreas, inoperable tumor of the papilla of Vater, postoperative choledochus stenosis, stenosis of choledochoduodenal anastomosis, and chronic cephalic pancreatitis. Cephalic duodenopancreatectomy was performed in two patients, whereas other methods consistent with the etiologic substrate were employed in 17 patients. The following complications were observed in 151 patients operated on: T drain fall off (n = 2), lesion of retroduodenal choledochus (n = 1), and loosening of the cholecystojejunal anastomosis suture line (n = 1). The hospital mortality rate was 3.31% (n = 5). Impairment in the biliary duodenal drainage is an etiologic factor in the development of obstructive icterus. It is of utmost importance to differentiate hepatocellular icterus with intrahepatic obstruction from extrahepatic mechanical obstruction. The treatment depends on the etiologic factor involved. Operative treatment can be fully successful in cases caused by lithiasis or benign stenosis, whereas in cases due to malignant disease a variety of radical and operative procedures associated with a variable level of success are available. Mechanical obstructive icterus of extrahepatic biliary ducts ranks high in the morbidity and mortality in the Krapina--Zagorje County. Timely diagnosis, well planned and properly performed operative procedures could considerably improve the results achieved by the operative treatment of the disease.

Preoperative biliary drainage for cancer of the head of the pancreas.

The benefits of preoperative biliary drainage, which was introduced to improve the postoperative outcome in patients with obstructive jaundice caused by a tumor of the pancreatic head, are unclear. In this multicenter, randomized trial, we compared preoperative biliary drainage with surgery alone for patients with cancer of the pancreatic head. Patients with obstructive jaundice and a bilirubin level of 40 to 250 micromol per liter (2.3 to 14.6 mg per deciliter) were randomly assigned to undergo either preoperative biliary drainage for 4 to 6 weeks, followed by surgery, or surgery alone within 1 week after diagnosis. Preoperative biliary drainage was attempted primarily with the placement of an endoprosthesis by means of endoscopic retrograde cholangiopancreatography. The primary outcome was the rate of serious complications within 120 days after randomization. We enrolled 202 patients; 96 were assigned to undergo early surgery and 106 to undergo preoperative biliary drainage; 6 patients were excluded from the analysis. The rates of serious complications were 39% (37 patients) in the early-surgery group and 74% (75 patients) in the biliary-drainage group (relative risk in the early-surgery group, 0.54; 95% confidence interval [CI], 0.41 to 0.71; P<0.001). Preoperative biliary drainage was successful in 96 patients (94%) after one or more attempts, with complications in 47 patients (46%). Surgery-related complications occurred in 35 patients (37%) in the early-surgery group and in 48 patients (47%) in the biliary-drainage group (relative risk, 0.79; 95% CI, 0.57 to 1.11; P=0.14). Mortality and the length of hospital stay did not differ significantly between the two groups. Routine preoperative biliary drainage in patients undergoing surgery for cancer of the pancreatic head increases the rate of complications. (Current Controlled Trials number, ISRCTN31939699.)

Endoscopic sphincterotomy in the management of posttraumatic biliary fistula.

Complications after nonoperative management of hepatic trauma are rare but include persistent biliary fistula in 4% of cases. Therapy usually involves surgical drainage or hepatic resection to control the fistula. The authors present a case of hepatic biliary fistula treated nonoperatively with percutaneous drainage and endoscopic sphincterotomy. A 16-year-old girl suffered a grade III parenchymal liver fracture to the right lobe in an automobile accident. She was hemodynamically stable with no coexistent injuries and was treated nonoperatively. Over 2 weeks her total bilirubin rose to 3.2 mg/dL, and alkaline phosphatase was 463 U/L. Ultrasound showed free intraperitoneal fluid, and 2 L of bilious fluid were retrieved by paracentesis. A radionuclide scan confirmed massive extravasation of isotope from the right lobe. Two drains percutaneously placed over the parenchymal fracture produced 500 to 600 mL of bile daily. Endoscopic retrograde cholangiopancreatography (ERCP) 1 week later showed a normal extrahepatic biliary system. A 1-cm sphincterotomy was performed without difficulty. Within 72 hours, percutaneous drains produced only 35 mL per day. The follow-up radionuclide scan showed no evidence of extrahepatic biliary extravasation, and 3 weeks later the drains were removed. Six months after the accident, results of the computerized tomography scan and liver function tests were normal. It was believed that endoscopic sphincterotomy reduced fistula output by decreasing the intrabiliary pressure caused by the ampulla, thus favoring internal drainage. This case demonstrates the effectiveness of endoscopic sphincterotomy as an alternative to direct surgical intervention for the management of posttraumatic biliary fistula.

[Simplified combination bypass or biliodigestive anastomosis alone in nonresectable carcinoma of the head of the pancreas?].

Between January 1, 1986 and December 31, 1992 93 patients with irresectable carcinoma of the pancreatic head underwent surgical palliation: In group I (n = 51) a single loop biliary (BB)- and gastric bypass (GB) was performed. 34 times the gastrojejunostomy was performed prophylactically. In group II (n = 42) surgical palliation was carried out only by biliary decompression in Roux-Y technique. In 30.9% gastric outlet obstruction (GOO) developed during follow-up. Both groups were comparable according to effectiveness of biliary drainage (93% (n = 42) (I); 97% (n = 38) (II)) with median post-operative bilirubin levels of 3.21 mg/dl (I) and 4.1 mg/dl (II). Cholecysto-choledocho- and hepaticojejunostomy were equally effective. Median operative time, morbidity (19.6 (I) vs. 26.2 (II)) and postoperative hospitalization were similar. Since there is a high frequency of secondary GOO after single BB we think that GB should be performed in all patients that undergo BB because secondary gastrojejunostomy at a later stage significantly increases morbidity and mortality.

Heterotopic chondroid tissue of the main bile duct mimicking Klatskin tumor: case report and review of the literature.

Heterotopic tissue in the bile duct is a very rare condition. There are a few case reports of heterotopic tissue including gastric and pancreatic cells. However, we could not find any data regarding heterotopic chondroid tissue obstructing the common bile duct in the literature. A 56-year-old woman was admitted to our hospital with complaints of progressive jaundice and pruritus. Laboratory test results were within the normal limits except bilirubin and alkaline phosphatase which were 10.8 mg/dL and 256 IU/L, respectively. Endoscopic retrograde cholangiography (ERCP) and computed tomography (CT) revealed a biliary stricture confined to the upper part of the common bile duct. The patient was operated as soon as the bilirubin level dropped below 5 mg/dL by percutaneous transhepatic cholangiography. Despite the lack of a precise confirmation, the patient was prepared for operation considering the possibility of a malignant biliary tumor since the radiographic mass findings together with hyperbilirubinemia were highly suggestive of malignancy. The patient underwent total extrahepatic bile duct resection and Roux-en-Y hepaticojejunostomy, and was discharged without any postoperative complications. Histologic examination of the bile duct and the nodule revealed the presence of a well-demarcated chondroid tissue within the subepithelial connective tissue. Herein, we presented the first case, to our knowledge, of heterotopic chondroid tissue of the common bile duct in the literature. It is a benign condition that should be considered in the differential diagnosis of stricture and mass-forming lesions of the bile duct.

[Evaluation of palliative surgical procedures in tumors of the pancreatic head].

Authors studied 87 patients with obstructive jaundice secondary to unresectable cancer of the head of the pancreas undergoing palliative biliary bypass procedure. They compared the four different types of biliodigestive anastomoses regarding to the postoperative morbidity, the mortality, the late complications and the survival. Their data suggest that Roux-en-Y choledochojejunostomy with prophylactic GEA is the optimal palliation. They studied the incidence of a second operation for duodenal obstruction. Comparing the operative mortality of each group they suggest that prophylactic gastroenterostomy adds no risk to patients, but they advise it's routine use only with choledochoenteric bypass and in lack of distant metastasis. Survival was significantly higher (p = 0.015) in the group of patients above 70 years. This data support the slower progression of the pancreatic tumor in old-age. They analyse three different factors affecting operative mortality. It was not related to the depth of jaundice and the age of the patients, but it was in a very close correlation with the preoperative blood urea nitrogen level. Authors suppose this parameter a simply and useful criteria in the selection for non-operative palliative procedures.

Endoscopic ultrasound-guided hepaticogastrostomy for advanced cholangiocarcinoma after failed stenting by endoscopic retrograde cholangiopancreatography.

Cholangiocarcinoma is common in Thailand. There are many palliative treatments available for patients with unresectable tumor, such as endoscopic retrograde cholangiopancreatography (ERCP) with stents, percutaneous transhepatic biliary drainage, or surgery. In cases in which ERCP has failed, we propose an alternative technique: the use of endoscopic ultrasound with fluoroscopy to perform hepaticogastrostomy for palliative drainage instead of percutaneous transhepatic biliary drainage. A case series study was conducted between December 2005 and December 2009 of 10 patients (4 male and 6 female, average age: 57 years) who presented with severe jaundice caused by advanced cholangiocarcinoma, who were treated with this procedure after failure to drain by ERCP. We used an electronic convex curved linear-array fluoroscopy-guided echoendoscope to drain the left dilated intrahepatic duct to the stomach by metallic wallstent. We performed the procedure with the first six patients under general anesthesia and with the other four under conscious sedation. Follow-up liver function tests were done, and clinical symptoms and survival times were recorded. Hepaticogastrostomy was unsuccessful on the first two patients (success rate = 8/10; 80%), and effective drainage was obtained in only seven patients. Average total bilirubin reduction was 14.96 mg/dL (58.75%) and 18.13 mg/dL (71.20%) after 2 weeks and 4 weeks, respectively, with good quality of life. One patient was not effectively drained because of malposition of the stent. There were two patients whose stent migrated into the stomach; one needed a second session with a second wallstent, and the other needed a double pigtail stent inside the second wallstent. Follow-up survival rates were 32-194 days (average: 123 days). Endoscopic-ultrasound-guided hepaticogastrostomy is safe and can be a good palliative option for advanced malignant biliary obstruction because it drains internally and is remote from the tumor site, promoting a long patency period of prosthesis and better quality of life.

[Carcinoma of the head of the pancreas: indication for emergency surgery].

In a recent multicentre randomized clinical trial, Van der Gaag et al. randomly assigned 220 patients to early surgery or preoperative biliary drainage ('Preoperative drainage for cancer of the head of the pancreas'). The rate of serious complications was significantly higher in the preoperative drainage group (p < 0.001), mainly because of drainage-related complications. There was no difference in surgical complications or mortality. Data on costs and impact on quality of life were not presented, but it can be predicted that the preoperative drainage strategy would be more expensive and would have greater negative impact on quality of life. If forthcoming publications by this research group confirm this suggestion, the current paradigm - obstructive jaundice, endoscopic retrograde cholangiopancreatography with stenting, delayed surgery for carcinoma of the head of the pancreas - should be changed to: obstructive jaundice due to peri-ampullary carcinoma should be considered an indication for emergency surgery.

Biloma

Biloma is collection of bile within the abdominal cavity. It happens when there is a bile leak, for example after surgery for removing the gallbladder (laparoscopic cholecystectomy), with an incidence of 0.3–2%. Other causes are biliary surgery, liver biopsy, abdominal trauma, and, rarely, spontaneous perforation. Symptoms are usually diffused or localized abdominal pain. Ascites and peritonitis are less common. Fever is often absent. Blood tests may show leukocytosis and nonspecific liver test abnormalities. Diagnosis is by abdominal ultrasound, MRCP, or HIDA scan. Treatment depends on the severity of the condition and ranges from ERCP with sphincterotomy or stent placement to surgical hepaticojejunostomy. See also Biliary injury References External links Bile Duct Leaks Biliary tract disorders

Successful Treatment of Pancreatic Fistula Following Surgery for Congenital Biliary Dilatation with Endoscopic Ultrasound-Guided Transduodenal Drainage.

Despite improvements in surgical techniques and perioperative management, postoperative pancreatic fistula (PF) is often difficult to treat and can be fatal due to various complications without effective drainage. Here, we report a case of PF following surgery for congenital biliary dilatation (CBD) successfully managed by endoscopic ultrasound (EUS)-guided transduodenal drainage. A 55-year-old woman underwent extrahepatic bile duct resection, including the gallbladder, and biliary tract reconstruction for CBD. On the 10th postoperative day (POD), computed tomography (CT) showed fluid retention observed from the upper edge of the pancreatic head to the surface of the right lobe of the liver. First, percutaneous fine-needle aspiration was performed on the fluid retention in the lateral part of the liver on the 11th POD. The amylase level in the drainage was high (30,156 U/L), and we diagnosed it as PF. Percutaneous drainage was difficult for fluid retention on the cut surface of the pancreas; thus, drainage under EUS guidance was decided. On the 13th POD, EUS was performed, a scan of the duodenal bulb revealed fluid retention with debris inside, and approximately 20-mL fluid was aspirated (amylase: 139,200 U/L). Although the inflammatory response temporarily improved, it recurred, so we decided to perform continuous drainage. On the 21st POD, EUS was performed again; a 19-G needle was used; a 0.025-in angle-type Jagwire was advanced into the fluid retention and expanded using a 7-Fr dilator; and then, a 6-Fr endoscopic nasoabscess drain (ENAD) tube was placed. On the 29th POD, CT showed that the fluid retention on the upper edge of the head of the pancreas had shrunk to a thickness of approximately 20 mm. On the 30th POD, the patient started eating. The ENAD tube was removed on the 38th POD. The patient was discharged from the hospital on the 45th POD without any symptoms. EUS-guided transduodenal drainage is an effective treatment option for postoperative PF following surgery for CBD.

Endoscopic ultrasonography-guided biliary drainage.

Endoscopic ultrasonography-guided biliary drainage (EUS-BD) has been developed as an alternative drainage method in patients with obstructive jaundice. EUS-BD is divided into EUS-guided choledochoduodenostomy (EUS-CDS), EUS-guided hepaticogastrostomy (EUS-HGS) and EUS-guided gallbladder drainage (EUS-GBD). The aim of this review is to focus on the current status and limitations of EUS-BD. A systematic review was performed to evaluate EUS-BD. MEDLINE, EMBASE and manual searches were performed to identify the pertinent English language full articles. The high success rate without fatal adverse events for EUS-CDS (93%; 28/30) and EUS-HGS (97%; 28/29) suggest the feasibility and safety of the procedures in high-volume endoscopic centers adopting various procedural techniques. Although the number of reported cases was very small, the success rate of EUS-GBD was high (100%; 14/14), without serious adverse events. Although all procedures require further assessment in a larger cohort of patients, including comparative studies between EUS-CDS or EUS-HGS versus PTBD, and EUS-GBD versus PTGBD, EUS-BD may be a promising procedure for the treatment of obstructive jaundice. However, dedicated devices for EUS-guided drainage are needed for reliable procedures.

Autoimmune pancreatitis: an adolescent case and review of literature.

We present a case of a 16-year-old adolescent boy with autoimmune pancreatitis and a review of the related literature. The patient was sent from a peripheral medical center, presenting with jaundice, pruritus, weight loss, and hyperglycemia of 20 days' duration. At admission, the patient was icteric, choluric, and acholic. His abdomen was soft and nontender, and the patient felt no pain in his abdomen. He had skin lesions because of scratching. Laboratory findings showed a blood glucose level of 135 mg%; total serum bilirubin, 29.4 mg%; direct bilirubin, 23 mg%; and alkaline phosphatase, 1100 IU/L. Abdominal ultrasound showed an enlarged head of the pancreas that was 30 x 35 mm. The parenchyma was slightly heterogeneous. Abdominal computed tomography showed an enlarged head of the pancreas with a normal body and tail, thickened duodenal wall, and dilated intra- and extrahepatic biliary tract, and the distal choledochus was not visible. Magnetic resonance imaging showed dilated intra- and extrahepatic biliary tract. The choledochus was not visible, and the cystic duct ended abruptly. The pancreas head was enlarged and homogenous, and there were no changes with contrast. Wirsung's duct was not dilated. Laparotomy was performed with a presumed diagnosis of pancreatic head tumor. The pancreas was diffusely indurated and enlarged; biopsy and intraoperative cholangiography were performed. The biliary tract was dilated with no duodenal passage of contrast, and the Wirsung's duct was not observed. Cholecystectomy was performed, and a transcystic drain was positioned. The histopathology was compatible with autoimmune pancreatitis. Prednisone treatment was started with good response. Autoimmune pancreatitis is a very rare entity among children and adolescents. It should be suspected when characteristic clinical signs and radiographic images are associated with a higher level of IgG4. Autoimmune pancreatitis is confirmed by biopsy. Treatment with prednisone often alleviates all the symptoms, as what happened in this case.

[Preoperative biliary drainage in the pancreatic head carcinoma].

Hemipancreatoduodenectomy has remained afflicted with high postoperative morbidity rates. Preoperative icterus is considered a significant risk factor. Therefore, a preoperative biliary drainage has been considered a standard preoperative procedure. This study aims to assess the preoperative drainage of the biliary tract significance with respect to the postoperative complications rates. This retrospective study includes 304 patients after completed hemipancreatoduodenectomies, who were operated in the 1st Surgical Clinic of the 1st Medical Faculty of the Charles University and the General Faculty Hospital in Prague between January 1990 and December 2002. In this trial group, 144 patients had underwent preoperative drainage of the biliary ducts and 160 patients underwent surgical procedures without the preoperative drainage. In the trial group, no significant difference in the gender rates, the history of the risk factors, the surgical procedure duration, the perioperative blood loss and the disease stage was detected. The patient trial group with the preoperative drainage of the biliary ducts completed was statistically significantly older (p = 0.05), had higher serum bilirubin levels recorded (118, respectively 81, p = 0.01), had more complications recorded postoperatively (42.4%, respectively 25%; p = 0.05), and more infectious complications (29%, respectively 13%; p = 0.05) when compared with the trial group without the preoperative drainage completed. Upon comparison of the both groups, we have not detected any statistically significant differences regarding the time interval between the diagnosis and the surgical procedure, the hospitalization duration or the mortality rates. The operated who had had the internal drainage of the biliary ducts conduted preoperatively, suffered from more complications in total as well as from more infectious complications, compared with the patients without the drainage. On the other hand, the patients who had had the preoperative drainage completed were older and had had higher preoperative bilirubin levels. With respect to the above results we strongly advise the patients with the pancreatic head carcinoma to early consult a hepatobiliary surgeon. As far as the examination algorithm is concerned, we strongly recommend using not only the spiral CT, but also non-invasive methods of examination (the MRI and the MRI cholangiography).

Diagnosis of ganglionar tuberculosis by endoscopic ultrasonography.

The endoscopic ultrasonography (EUS) is an endoscopic technique of proven clinical validity today, having a significant impact on the diagnosis and evaluation of several diseases with a low complication rate. The EUS-fine-needle aspiration (FNA) allows the evaluation of subepithelial lesions, extra-luminal lymph nodes or the gastrointestinal tract that are difficult to access by other methods with safe and high diagnostic accuracy. In the case reported, the EUS-FNA was useful for the differential diagnosis with residual biliary microlithiasis and the diagnosis of non-oncologic pathology. Male, white, 35-year-old, human immunodeficiency virus and tuberculosis treatment for about 5 months presented with jaundice. No fever, weight loss or abdominal pain. Choluria and hipocholia. History of cholecystectomy for about 1 year due to cholelithiasis. Laboratory tests showed cholestatic jaundice (direct hyperbilirrubinemia). Abdominal ultrasound showed liver without particularities, without biliary dilatation or filling defects. Initially suspected hepatitis due tuberculosis drugs so, the treatment was suspended. After a week with no drugs, no improvement in jaundice was observed. In contrast, a progressive increase indirect bilirubin. EUS performed with identification of mass along the distal common bile duct near the duodenal papilla. FNA performed with the presence of lymphocytes and tuberculosis bacile positive. After, endoscopic retrograde cholangiopancreatography was performed with sphincterotomy and placement of endoprosthesis for biliary drainage. The tuberculosis drugs were restarted with the plan to complete. The jaundice was resoluted. The patient completed 9 months of treatment and abdominal tomography has not identified a mass in that place. The EUS-FNA was proven to be a useful tool for diagnosis of non-oncologic pathologies like tuberculosis.

[Extrahepatic biliodigestive anastomoses. Analysis of 227 cases].

The authors analyze their experience with 227 biliodigestive anastomoses to compare the early and late results. Choledocholithiasis (49%) and cancer of the pancreas (25%) were the most common processes. Choledochoduodenostomy (48%), cholecystojejunostomy (22%), sphincteroplasty (18%) and hepaticojejunostomy (9%) were the techniques most often used. In 61% of cases (90% of the malignant tumors) there was an emergency indication. Twenty-one percent of the patients presented serious complications in the postoperative period (14% of the benign tumors), half of which depended on the bypass. Postoperative peritonitis (2%), external biliary fistula (4%) and acute pancreatitis (2%) were the most significant surgical complications. Hepaticojejunostomy induced the largest number of bypass-dependent complications. There were 12 deaths due to medical causes (5%), these being most numerous in subjects with neoplasms and cholecystojejunostomy, and 8 of surgical origin (4%), half of them in carriers of a hepaticojejunostomy. There was a clear decline in the morbidity of patients operated on in recent years. In the long term, 91% of the patients remained free of discomfort or had minimal symptoms. Choledochoduodenostomy or sphincteroplasty produced the best results. It is concluded that biliodigestive anastomoses yield the best early and late results with minimal secondary effects.

Palliative Measures with Ethanol Gallbladder Ablation and Endobiliary Radiofrequency Ablation Followed by Endoscopic Biliary Stent Placement in an Advanced Case of Common Bile Duct Cancer: A Case Report.

Endobiliary radiofrequency ablation (RFA) is a procedure performed widely to induce locoregional tumor control by the transfer of thermal energy to the lesion and subsequent tumor necrosis. A 72-year-old male with a prior history of acute calculous cholangitis and perforated cholecystitis was admitted to the Kyungpook National University Hospital complaining of fever and nausea. He had an indwelling percutaneous transhepatic gallbladder drainage (PTGBD) catheter from the previous episode of perforated cholecystitis. An abdominal CT scan showed marked dilation of both the intrahepatic and extrahepatic bile ducts. Common bile duct cancer was confirmed histologically after an endobiliary biopsy. A surgical resection was considered to be the initial treatment option. During open surgery, multiple metastatic nodules were present in the small bowel mesentery and anterior abdominal wall. Resection of the tumor was not feasible, so endobiliary RFA was performed prior to biliary stenting. Cholecystectomy was required for the removal of the PTGBD catheter, but the surgical procedure could not be performed due to a cystic ductal invasion of the tumor. Instead, chemical ablation of the gallbladder (GB) with pure ethanol was performed to breakdown the GB mucosa. Palliative treatment for a biliary obstruction was achieved successfully using these procedures. In addition, a PTGBD catheter was removed successfully without significant side effects. As a result, an improvement in the patient's quality of life was accomplished.

[Clinical signs, diagnosis and surgical treatment of extrahepatic biliary duct tumors].

Experience of surgical treatment of 271 patients the extrahepatic biliary ducts tumor for the 1992-1999 yrs period is presented. Indirect signs of extrahepatic biliary ducts tumor were revealed in 84% of observations. Depending on the tumor localization the trustworthiness of the endoscopic retrograde pancreatocholangiography method had constituted from 79.8 to 96.4%. Correct diagnosis was established before the operation in 94.3% of patients. Radical operation was done in 93 (34.3%) of patients, including 22 with proximal localization of tumor, 13--with central one, 10--distal, 48--terminal. Palliative operation was performed in 178 patients, in 76 of them biliodigestive anastomosis was done. Total postoperative mortality was 14.8%.

Diagnostic challenges and management of choledochal cyst in an 11-year-old child: a delayed diagnosis (a case report).

Choledochal cyst are rare congenital disease of the biliary tree. It presenting as cystic dilatations of the biliary tree can involve the extrahepatic biliary radicles, the intrahepatic biliary radicles or both. They are typically a surgical problem of infancy and childhood, but less than a quarter of the patients the diagnosis is delayed until adulthood as it presenting with vague and nonspecific signs and symptoms. In a case with biliary symptoms, abdominal ultrasound scan is the initial imaging modality of choice. Precise and accurate delineation of the biliary system mandates cholangiography with the advantage of non-invasive magnetic resonance cholangiopancreatography (MRCP) over endoscopic retrograde cholangiopancreatography. A case report of 11-year-old Tanzania girl with abdominal swelling and jaundice presented to a health facility for evaluation. She complained of abdominal swelling that her mother noticed when she was 3 years old, located above the umbilicus and since then it was not changed its size until 8 years later when it rapidly increased in size associated with non-specific dull pain. Abdominal computed tomography (CT) scan was done showed A well-defined hypo-attenuated non-enhancing retro-gastric cyst. Percutaneous transhepatic cholangiopancreatography (PTC) was performed due to inconclusive findings from CT-scan showed extrahepatic huge cystic dilatation, dilated central right hepatic ducts, left intrahepatic ducts failed to be visualize. Diagnosis of choledochal cyst type isovaleric acidaemia (IVA) was made. Explorative laparotomy was done, huge cystic mass occupying common bile duct was seen below the liver with distended gallbladder covered with visceral peritoneum. Second part of duodenum, pancreases and transverse colon was adhered to the inferior surface of the mass that further make difficult for cyst excision and reconstruction. Cyst was decongested and cholangioenterostomy with Roue-en-Y reconstruction was made. Cholecystectomy was done, hemostasis archived abdomen closed and patient sent to Intensive care units (ICU). Despite of advanced diagnostic modalities, delayed diagnosis of choledochal cyst can be a challenge due to its vague and nonspecific signs and symptoms. Excision of the cyst and reconstruction by hepatojejunostomy as the standard therapy could be difficult due to its biliary complications such as adhesion and infection and hence cyst-enterostomy drainage procedure can be done as option for relief of patient discomfort and prevent further complications.

Outcomes and limitations of endoscopic ultrasound-guided hepaticogastrostomy in malignant biliary obstruction.

Transpapillary biliary drainage in ERCP is an established method for symptomatic treatment of patients with unresectable malignant biliary obstruction. Percutaneous transhepatic biliary drainage frequently remains the treatment of choice when the transpapillary approach proves ineffective. Recently, EUS-guided extra-anatomical anastomoses of bile ducts to the gastrointestinal tract have been reported as an alternative to percutaneous biliary drainage. To assess the usefulness of extra-anatomical intrahepatic biliary duct anastomoses to the gastrointestinal tract as endotherapy for unresectable malignant biliary obstruction and to determine factors affecting the efficacy of treatment. A prospective analysis of the treatment results of all patients with unresectable biliary obstruction treated with EUS-guided hepaticogastrostomy at our institution in the years 2016-2019. Transmural intrahepatic biliary drainage (EUS-guided hepaticogastrostomy) was performed due to the ineffectiveness of ERCP in 53 patients (38 males, 15 females; mean age 74.66 [56-89] years) with unresectable biliary obstruction. Technical success of EUS-guided hepaticogastrostomy was achieved in 52/53 (98.11%) patients. Complications of endoscopic treatment were observed in 10/53 (18.87%) patients. Clinical success of EUS-guided hepaticogastrostomy was achieved in 46/53 (86.79%) patients. Bismuth type II-IV cholangiocarcinoma, hepatic metastases, ascites, suppurative cholangitis, and high blood bilirubin levels exceeding 30 mg/dL were independent factors for increased complications and inefficacy of EUS-guided hepaticogastrostomy. In the event of transpapillary biliary drainage proving ineffective, extra-anatomical anastomoses of intrahepatic bile ducts to the gastrointestinal tract provide an effective method for the treatment of patients with malignant biliary obstruction.

Percutaneous transhepatic cholangiography

Cholangiography during a biliary drainage intervention is called perioperative or primary choloangiography, and when performed later in the same drain it is called secondary cholangiography. Indications Cholestatic jaundice, to exclude extra hepatic bile duct obstruction, prior to biliary drainage procedure. If endoscopic retrograde cholangiopancreatography has failed and/or there is an obstruction in the proximal biliary tree. Contraindications Bleeding tendency Biliary tract sepsis Being unfit for surgery Hydatid cysts Ascites CLD (Chronic liver disease)

[Diagnostic and therapeutic integration in ductal carcinoma of the head of the pancreas. Preliminary note].

The diagnosis and treatment of pancreatic ductal carcinoma are managed, in our hospital, by a team of radiologist, surgeons, radiotherapists and pathologists. In periodic meetings they discuss the clinical cases before and after clinico-radiologic staging. Patients are entered one of three different treatment routes, based on their general status, on disease stage, tumor size and its arrangement around common bile duct and main pancreatic duct. Thirty-eight patients were studied: 23 of them, considered as resectable on the basis of imaging (CT, US) findings, were submitted to radical surgery and intraoperative radiotherapy (route I); of 11 unresectable cases, 8 had a bilio-digestive bypass and interstitial brachitherapy with 125I seeds (tumor size < 3 cm). Eleven patients unresectable by imaging and 1 by surgery followed treatment route II, characterized by radio-chemotherapy followed by intraluminal radiotherapy with 192Ir wires, relative to residual tumor size and to lesion arrangement around access ways. Four patients with metastases and "adequate" tumor size entered treatment route III-i.e., merely palliative luminal radiotherapy. This preliminary note stresses the importance of polyspecialistic team work in the diagnosis and treatment of pancreatic ductal carcinomas.