Cases reported "Biliary Fistula"

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1/142. Mucin-producing biliary papillomatosis associated with gastrobiliary fistula.

    We report a case of mucin-producing biliary papillomatosis in a 78-year-old woman. Abdominal ultrasound (US) and computed tomography (CT) showed wall thickening and dilatation of the intrahepatic bile duct (IHBD), as well as a nodular lesion, 1.2 cm in diameter, in the left branch of the IHBD. Gastric endoscopy revealed excretion of bile-containing mucin on the anterior wall of the body of the stomach. Endoscopic ultrasonography (EUS) showed gastrobiliary fistula and discharge of mucin into the stomach. Needle biopsy of the biliary tumor revealed papillary proliferation, but no malignant cells were recognized histologically. Therefore this patient was diagnosed as having mucin-producing biliary papillomatosis forming gastrobiliary fistula. She did not present with obstructive jaundice, probably because of the fistula. She is alive, without obstructive jaundice, 16 months after the diagnosis without having had surgery. This is, to our knowledge, the first reported case of biliary papillomatosis forming gastrobiliary fistula and with the patient free of obstructive jaundice.
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2/142. Choledochoduodenal fistula at the anterior wall of the duodenal bulb: a rare complication of duodenal ulcer.

    A 38 year-old man was admitted to our hospital with the chief complaint of epigastralgia. His laboratory data revealed leukocytosis and increased serum amylase, and abdominal ultrasonography revealed diffuse swelling of the pancreas. Thus, he was diagnosed as having acute pancreatitis. Moreover, abdominal computed tomography showed pneumobilia in the gallbladder and the common bile duct. Gastroduodenal fiberscopy demonstrated peptic ulcer scars around a foramen with smooth margins at the anterior wall of the duodenal bulb. The bile juice flowed from the bottom of the foramen. Endoscopic retrograde cholangiopancreatography revealed the fistula between the common bile duct and the anterior wall of the duodenal bulb, but not the posterior wall. However, there was no pancreatico-biliary maljunction and no stones in the gallbladder or bile duct. This is a rare case of choledochoduodenal fistula at the anterior wall of the duodenal bulb caused by duodenal peptic ulcer disease.
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3/142. Interventional radiology in percutaneous management of bile duct obstruction: biliary drainage through a spontaneous common hepatic duct-duodenal fistula.

    Bile duct injuries are a serious complication of biliary surgery. We report a case of benign obstruction of the common hepatic duct associated with common hepatic duct-duodenal spontaneous fistula following complex surgical intervention. We managed percutaneously the fistula with balloon dilatation and long-term stenting, as the fistula allowed biliary flow in the duodenum. We avoided reintervention preserving biliary flow, with good clinical results after a follow-up of a 3 years. We emphasize the role of a clinically focused approach to percutaneous management of complications following biliary surgery.
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4/142. Advanced adenosquamous carcinoma of the gallbladder with bilio-biliary fistula: an uncommon case treated by hepatopancreatoduodenectomy.

    A 70 year-old female, who presented with jaundice and abdominal pain, was found to have an advanced gallbladder cancer involving the liver parenchyma, duodenum, and transverse colon. This was complicated by a bilio-biliary fistula between the gallbladder and both the right and left hepatic ducts. After obtaining an accurate pre-operative diagnosis, the patient underwent hepatopancreatoduodenectomy (HPD) with lymph node dissection around the hepatic pedicle, celiac trunk, aorta, and inferior vena cava. Histologic examination revealed adenosquamous carcinoma. This rare variant accounts for 3.5% of gallbladder cancers, and is associated with a worse prognosis than adenocarcinoma. The patient is in good condition without any signs of recurrence 42 months after the HPD. In this case report, we discuss the histological type and internal biliary fistula with regard to the literature, and the usefulness of an aggressive surgical procedure such as HPD with extended lymph node dissection which can improve survival and quality of life in selected patients.
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5/142. gallbladder carcinoma with choledochoduodenal fistula: a case report with surgical treatment.

    A 79 year-old man was admitted to our hospital because of upper abdominal pain and nausea. A mobile tumor was palpable in the right upper abdomen. Abdominal ultrasonography, computed tomography and celiac angiography revealed a gallbladder tumor. Endoscopic retrograde cholangiopancreatography revealed a fistula 1.5 cm oral to the orifice of the papilla of Vater, dilatation of the common bile duct, and a filling defect in the gallbladder. Pancreatoduodenectomy associated with reconstruction using Imanaga's method was performed under a pre-operative diagnosis of gallbladder carcinoma with choledochoduodenal fistula. The gallbladder contained a tumor and two bilirubin stones impacted in the orifice of the duodenal papilla. Histological studies confirmed that the gallbladder tumor was a mucinous adenocarcinoma and had not infiltrated the bile duct. We speculated that choledochoduodenal fistula stimulated the development of cancer due to chronic irritation from pancreatic juice reflux.
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6/142. Preservative treatment for biliobiliary fistula.

    Biliobiliary fistula is thought to be a rare type of internal biliary fistula. A 68-year-old man presented to our hospital with complaints of jaundice and general malaise. Endoscopic retrograde cholangiography was performed, but the gallbladder was not imaged. Mirizzi's sign was observed in the common hepatic duct. During the course of evaluating this inpatient, imaging revealed that a gallstone was extruded to the right hepatic duct. After incision of the papilla, stones in the bile duct were subjected to mechanical lithotripsy and were extracted. As a result of bile duct decompression, the biliobiliary fistula was closed completely 2 months later.
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7/142. Management of a patient with hepatic-thoracic-pelvic and omental hydatid cysts and post-operative bilio-cutaneous fistula: a case report.

    In humans, most hydatid cysts occur in the liver and 75% of these are single. Our patient was a 31 year-old male. His magnetic resonance imaging (MR) showed one cyst (15 x 20 cm) in the right lobe and three cysts (5 x 6 cm, 8 x 6 cm, and 5 x 5 cm) in the left lobe of the liver, two cysts (4 x 5 cm and 5 x 5 cm) on the greater omentum, and two cysts (15 x 10 and 10 x 10 cm) in the pelvis. The abdomen was entered first by a bilateral subcostal incision and then by a Phennenstiel incision. Partial cystectomy capitonnage was done on the liver cysts; the cysts on the omentum were excised, and the pelvic cysts were enucleated. The cyst in the right lobe of the liver was in communication with a thoracic cyst. An air leak developed from the thoracic cyst which had underwater drainage and bile drainage from the drain in the cavity of the right lobe cyst. Sphincterotomy was done on the seventh post-operative day by endoscopic retrograde cholangiopancreatography (ERCP). No significant effect on mean bile output from the fistula occurred. octreotide therapy was initiated, but due to abdominal pain and gas bloating the patient felt and could not tolerate, it was stopped on the fourth day; besides, it had no decreasing effect on bile output during the 4 days. Because air and bile leak continued and he had bile stained sputum, he was operated on on post-operative day 18. By right thoracotomy, the cavity and the leaking branches were closed. By right subcostal incision, cholecystectomy and T-tube drainage of the choledochus were done. On post-operative day 30, he was sent home with the T-tube and the drain in the cavity. After 3 months post-operatively, a second T-tube cholangiography was done, and a narrowing in the distal right hepatic duct and a minimal narrowing in the distal left hepatic duct were exposed. Balloon dilatation was done by way of a T-tube. Bile drainage ceased. There was no collection in the cavity in follow-up CT scanning, so the drain in the cavity, and the drainage catheter in the right hepatic duct were extracted. Evaluation of the biliary ductal system is important in bilio-cutaneous fistulas, and balloon dilatation is very effective in fistulas due to narrowing of the ducts.
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8/142. Gallstone erosion of the aorta.

    A case of fatal erosion of the abdominal aorta by gallstones is reported. The patient presented with a six-day history of melaena and died suddenly 39 hours after admission to hospital, with massive blood loss per rectum. At post-mortem examination a saccular cavity containing gallstones was found at the lower end of the common bile duct. The cavity communicated in front with the duodenum and behind with the aorta. This case appears to be the first of its kind to be reported.
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9/142. Bronchobiliary fistula after hemihepatectomy: cholangiopancreaticography, computed tomography and magnetic resonance cholangiography findings.

    A bronchobiliary fistula (BBF), which is defined by an abnormal communication between the biliary system and the bronchial tree, is an uncommon complication after hemihepatectomy, trauma, hydatid disease, choledocholithiasis and other causes of biliary obstruction. We report the case of a 56-year-old man with colon cancer, who developed a BBF 2 months after right hemihepatectomy for liver metastases. The findings at endoscopic retrograde cholangiopancreaticography (ERCP), computed tomography (CT) and magnetic resonance cholangiography (MRC) included a stricture of the common bile duct and biliary leakage from the liver resection plane with biliary infiltration of the right lower lobe of the lung. The patient was treated successfully by endoscopic insertion of a biliary plastic stent which bridged the stricture and lead to closure of the fistula.
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10/142. Biliopancreatic fistula associated with intraductal papillary-mucinous pancreatic cancer: institutional experience and review of the literature.

    Intraductal papillary-mucinous tumour is clinicopathologically characterized by papillary growth and mucin production within the pancreatic duct system. The category includes a wide range of dysplasia, ranging from adenoma to carcinoma, the latter designated as intraductal papillary-mucinous cancer. In general, the tumor renders a favorable prognosis after complete resection. However, intraductal papillary-mucinous tumor with overt invasion outside the gland has been reported to have a poor prognosis, as is the case with the usual type of duct cell cancer of the pancreas. We experienced two cases of intraductal papillary-mucinous cancer with obstructive jaundice due to impaction of thick mucus protruding from the pancreas via a "spontaneous" biliopancreatic fistula. Preoperative examinations of both patients showed a large intraductal papillary-mucinous tumor in the head of the pancreas with fistula formation between the intrapancreatic portion of the common bile duct and the main pancreatic duct. Histopathological investigation of the two resected specimens suggested that the fistula may not have developed from invasion by papillary or tubular adenocarcinoma, but from compression and destruction of the intercalating tissues by abundant mucinous secretion. The first patient died of peritoneal carcinomatosis with clinicopathologic features of pseudomyxoma peritonei 6 years after surgery. The second patient is alive and has been well for 2 years postoperatively. review of the world literature showed that half of the patients with intraductal papillary-mucinous cancer plus biliopancreatic fistula had no stromal invasion around the fistula, indicating that the fistula might have been caused by mechanical pressure. However, the other half of the cases did have stromal invasion around the fistula. Two-thirds of these cases, including our own patients, had foci of mucinous carcinoma in the stroma around the fistulization, implying that mucinous lakes in the stroma may have served as part of the "waterway" from the pancreatic duct to the bile duct, assisted by increased pressure by mucus production. Since intraductal papillary-mucinous cancer with biliopancreatic fistula has a comparatively favorable prognosis, surgical resection should be considered.
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