1/341. An extrahepatic bile duct metastasis from a gallbladder cancer mimicking Mirizzi's syndrome. We report a case of an extrahepatic bile duct metastasis from a gallbladder cancer that mimicked Mirizzi's syndrome on cholangiography. A 67-yr-old woman was admitted to our hospital with a diagnosis of acute calculous cholecystitis. As obstructive jaundice developed after the admission, percutaneous transhepatic biliary drainage was performed to ameliorate the jaundice and to evaluate the biliary system. Tube cholangiography revealed bile duct obstruction at the hepatic hilus, and extrinsic compression of the lateral aspect of the common hepatic duct, with nonvisualization of the gallbladder. No impacted cystic duct stone was visualized on CT or ultrasonography. laparotomy revealed a gallbladder tumor as well as an extrahepatic bile duct tumor. We diagnosed that the latter was a metastasis from the gallbladder cancer, based on the histopathological features. This case is unique in that the extrahepatic bile duct metastasis obstructed both the common hepatic duct and the cystic duct, giving the appearance of Mirizzi's syndrome on cholangiography. Metastatic bile duct tumors that mimic Mirizzi's syndrome have not been previously reported. The presence of this condition should be suspected in patients with the cholangiographic features of Mirizzi's syndrome, when the CT or ultrasonographic findings fail to demonstrate an impacted cystic duct stone. ( info) |
| Carcinoids of the extrahepatic bile ducts and particularly the common bile duct are extremely rare. A 65-year-old woman presented with obstructive jaundice. Laboratory and imaging studies gave results that were consistent with an obstructing lesion in the common bile duct. In this case, a stent was inserted initially to decompress the bile ducts. Subsequently a laparotomy and pancreaticoduodenectomy were performed and a tissue diagnosis of carcinoid of the common bile duct was made. The patient was well with no evidence of recurrence 17 months postoperatively. The authors believe this is the 19th reported case of an extrahepatic bile duct carcinoid. ( info) |
3/341. Combined endoscopic and surgical management of mirizzi syndrome. mirizzi syndrome is a form of obstructive jaundice caused by a stone impacted in the gallbladder neck or the cystic duct that impinges on the common hepatic duct with or without a cholecystocholedochal fistula. This syndrome is a rare complication of cholelithiasis that accounts for 0.1% of all patients with gallstone disease. Preoperative recognition is necessary to prevent injury to the common duct during surgery. We present a patient with a preoperative diagnosis of type I mirizzi syndrome that was confirmed and drained by endoscopic retrograde cholangiography (ERC), followed by subtotal cholecystectomy. A review of the literature covering its clinical presentation, diagnosis, and surgical treatment is also presented. ( info) |
4/341. Intimal hyperplasia within biliary Wallstents: failure of recanalisation by insertion of a second endoprosthesis. We report two patients with benign biliary strictures in whom we attempted recanalisation of metallic biliary endoprostheses, occluded by intimal hyperplasia, by the insertion of further endoprostheses within the occluded stents. Initial technical success was achieved in deploying the stents and restoring patency with elimination of mural filling defects. However, we found the intimal hyperplasia to be restrained for less than 48 h. From our initial results it appears that biliary metallic stent occlusion by intimal hyperplasia is not effectively treated by insertion of a second endoprosthesis. ( info) |
5/341. mirizzi syndrome--a report of 3 cases with a review of the present classifications. We report three cases of mirizzi syndrome, two with external compression of the common hepatic duct and another with cystobiliary fistula. All patients presented with jaundice. The diagnosis was suggested by ultrasonography and confirmed by endoscopic retrograde cholangiography (ERC). All three had the stones removed surgically, one through a choledochotomy, another through an opening in the gall bladder and the third at the time of subtotal cholecystectomy. We would like to propose a simple classification of mirizzi syndrome, based on surgical procedures necessary for the correction of the pathological anatomy. If it involves the removal of calculi with some form of cholecystectomy, we consider it as Type I, whereas Type II involves the construction of a hepaticojejunostomy apart from the removal of calculi. ( info) |
6/341. Long term treatment of biliary stricture due to chronic pancreatitis with a metallic stent. The exact role of endoprostheses in the management of chronic pancreatitis-associated biliary strictures has not yet been clearly established. We report an unusual case of a patient with this condition who was treated for an unexpectedly long term with a self-expanding metallic endoprosthesis. There has only been one previous report of the use of metallic stents in this situation. It appears that metallic endoprostheses may have a role to play in the management of selected patients who have chronic pancreatitis-associated bile duct stricture. ( info) |
| In a 46-year-old man endoscopic retrograde cholangiopancreatography and computed tomography scan showed a stenosis of the common bile duct by a hypodense mass highly suggestive of a Klatskin tumor. Histologic examination of the resected tumor revealed only non-specific inflammatory, fibrotic tissue without any evidence of malignancy. Three months later, the patient presented with hydronephrosis of the left kidney. Computed tomography scan showed a retroperitoneal mass with encasement of the left ureter. A percutaneous nephrostomy was performed and immunosuppressive therapy with prednisolone and azathioprine was initiated. Under this medication, almost complete regression of the pelvic mass and reopening of the ureter were observed within 3 weeks. Eight months later, azathioprine was withdrawn and prednisolone was tapered continuously to a dose less than 10 mg/day. After a follow-up of 2 years, the patient is still well. Although the histologic findings were non-specific, further evaluation of this case suggests that Ormond's disease was responsible for the tumor that had to be resected. ( info) |
| This is a case report of a patient with chronic pancreatitis who presented with biliary, duodenal and portal vein obstruction, a mass in the head of the pancreas, and a CA 19-9 level of 372 U/ml. Thus, the concern was raised as to the possibility of pancreatic cancer in this patient. We discuss the difficulties in the diagnosis of pancreatic cancer in patients with chronic pancreatitis and the treatment options available for patients with chronic pancreatitis where the significant findings involve the head of the pancreas. Finally, a brief review is given describing the pertinent literature on the surgical treatment of chronic pancreatitis and the current indications of pancreaticoduodenectomy for chronic pancreatitis. ( info) |
9/341. Proximal bile duct stricture caused by a pancreatic pseudocyst: intra-operative placement of a metallic stent. A 61 year-old man presented with a proximal bile duct stricture caused by a pancreatic pseudocyst, which is of rare occurrence. Although it could not be determined pre-operatively whether the lesion was caused by cholangiocarcinoma or inflammatory disease, a laparotomy revealed that the proximal extrahepatic bile duct was surrounded and constricted by a pancreatic pseudocyst extending into the hepatoduodenal ligament. Since the stricture was not relieved only by removing the contents of the pseudocyst and surgical biliary diversion was considered too difficult, a self-expandable metallic stent was placed intra-operatively, at the strictured site, under ultrasonic guidance, via the transhepatic approach. The post-operative course of the patient was uneventful, and he remains well 22 months after the operation. The intra-operative placement of a metallic stent into the biliary tract can be an alternative option in the relief of biliary obstruction. ( info) |
10/341. Traumatic neuroma as a cause of obstructive jaundice. A 70-year-old man with previous cholecystectomy developed progressive obstructive jaundice, 3 months before hospitalization. Intraoperatively, a 2 x 2 x 1.5-cm mass in the distal part of the right hepatic duct was excised to release complete obstruction. It was verified as traumatic (amputation) neuroma. Despite rarity, traumatic neuroma of the bile duct should be considered in patients who have antecedent surgical procedure of the biliary tract with subsequent occurrence of extrahepatic biliary obstruction. ( info) |