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Shinji Onda, Syuichi Fujioka, Yasuro Futagawa, Tomoyoshi Okamoto, Kats ...
2008 Volume 22 Issue 4 Pages
514-517
Published: October 31, 2008
Released on J-STAGE: March 27, 2009
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We report a case of hypoplastic gallbladder that was suspected by laparoscopy. A 44-year-old man came to our hospital for right epigastric pain. The gallbladder could not be identified in the gallbladder bed by ultrasound. DIC-CT failed to enhance the gallbladder, but revealed a 1cm cystic structure on the right side of the common bile duct. We attempted laparoscopic cholecystectomy with a preoperative diagnosis of chronic cholecystitis. At laparoscopy, the gallbladder bed was empty, and was replaced by fatty tissue. We were able to confirm a 1cm cystic structure on the right side of the common bile duct, without inflammation nor adhension around the gallbladder. In the absence of repeated cholecystitis, therefore he was suspected to have a hypoplastic gallbladder, and cholecystectomy was abandoned. Hypoplastic gallbladder is a rare clinical condition that should be considered when the gallbladder cannot be identified by preoperative imaging studies or during the operation.
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Shuji Suzuki, Shinichi Ban, Nobusada Koike, Nobuhiko Harada, Mamoru Su ...
2008 Volume 22 Issue 4 Pages
518-523
Published: October 31, 2008
Released on J-STAGE: March 27, 2009
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A 56-year-old man with epigastric pain was admitted to our hospital. Laboratory date showed elevated levels of liver and biliary enzymes, but US and MRCP showed no evidence of mass lesions. CT reveled slight dilatation of the left intahepatic bile duct. After 2 months, US and CT recognized severe dilatation of the left intahepatic bile duct. PTC showed stenosis of bifurcation of it and filling defect. These findings suggested cholangiocarcinoma, and we underwent left lobectomy. The resected specimen showed stenosis of it, and mucin clot in peripheral bile duct. Histopatological examination of the stenotic lesion revealed a noninvasive tumor composed of low papillary, mucin-producing neoplastic epithelium with borderline malignancy. Immunohistochemically, the neoplastic epithelium was positive for MUC5AC and MUC2, and partly positive for MUC6, but negative for MUC1. The tumor was diagnosed as a mucin producing bile duct tumor, which pathological features resembled those of intestinal type of intraductal papillary mucinous neoplasm of the pancreas.
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Jun Nakahodo, Masataka Kikuyama, Yuzo Sasada, Shigeki Koide, Toru Mats ...
2008 Volume 22 Issue 4 Pages
524-529
Published: October 31, 2008
Released on J-STAGE: March 27, 2009
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A 74-year-old male patient was admitted for evaluation of exacerbated gallbladder wall thickening and Rokitansky-Ashoff sinus dilatation with elevation of tumor markers. He had past histories of adenomyomatosis with gallstones, chronic pancreatitis with pancreatic calculi, and diabetes mellitus. Occurrence of gallbladder carcinoma was highly suspected. Computed tomography during the right hepatic arterial angiography revealed the continuous internal thin layer called a mucosal line with the enhanced thickened gallbladder wall. We considered the gallbladder wall thickening was caused by chronic cholecystitis on the basis of gallbladder adenomyomatosis with gallstones. Surgical resection was performed after exclusion of pancreatic carcinoma and the resected speciemen showed a white colored and thickened wall of the gallbladder with a smooth surface. Histopathological examination showed a marked fibrosis and scattered abscesses of the subserosal layer of the gallbladder with dilated Rokitansky-Ashoff sinuses without malignancy. The gallbladder lesion was diagnosed as chronic cholecystitis. Our case suggested the mucosal line could play an important role in differentiation of chronic cholecystitis from gallbladder carcinoma.
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Shinsuke Matsuda, Moritaka Nagai, Hideaki Suzuki
2008 Volume 22 Issue 4 Pages
530-535
Published: October 31, 2008
Released on J-STAGE: March 27, 2009
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A 39-year old man was injured in a traffic accident and admitted to another hospital with the liver injury. After 10 days he was discharged. However 20 days after the accident, he developed jaundice and was admitted to our hospital. On admission, jaundice (T-Bil; 6.6 mg/d
l) and impaired hepatic function were observed. Abdominal CT and US showed a 3 cm cystic lesion in the porta hepatis and a dilated intrahepatic bile duct and a swollen gall bladder. MRCP showed a cystic lesion and a biliary stenosis just below the confluence of the cystic duct. PTBD was performed. Tube cholangiography showed a stenosis of the common bile duct 2.5 cm in length just below the confluence of the cystic duct. A PTBD tube was successfully introduced into the lower bile duct. Bile cytology was negative. Under the diagnosis of biliary stenosis due to abdominal trauma, internal fistulization was achieved by increasing the diameter of the indwelling biliary tube to 12 Fr. After the biliary tube was exchanged for a 16 Fr biliary tube, PTCS was performed. PTCS showed inflammatory change at the middle bile duct. The biliary tube was removed 6 months after PTBD. One year after removal of the biliary tube, MRCP showed no biliary stenosis.
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Osamu Takasawa, Naotaka Fujita, Yutaka Noda, Go Kobayshi, Kei Ito, Jun ...
2008 Volume 22 Issue 4 Pages
536-543
Published: October 31, 2008
Released on J-STAGE: March 27, 2009
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We herein report three cases with unresectable malignant biliary stenosis in which transgastohepatic endosonography-guided biliary drainage (ESBD) was performed. In ESBD, a dilated intrahepatic duct was punctured via the stomach under endosonographic guidance, followed by placement of a guidewire through the puncture needle, and dilation of the puncture route and stent deployment over the guidewire.
Case 1. A 76-year-old woman with bile duct carcinoma underwent endoscopic biliary drainage (EBD). When the stent occluded, the intrahepatic bile duct was divided. Case 2. A 62-year-old man with recurrence of gallbladder cancer underwent EBD, but stent occlusion occurred frequently. Case 3. A 84-year-old woman with recurrent intrahepatic bile duct carcinoma. It was not possible to reach the papilla of Vater due to previous hepaticojejunostomy.
Transgastohepatic ESBD is a useful technique for biliary drainage in difficult EBD cases and may replace percutaneous transhepatic biliary drainage in many situations of obstructive jaundice.
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Yasuro Futagawa, Shinji Onda, Syuichi Fujioka, Tomoyoshi Okamoto, Kats ...
2008 Volume 22 Issue 4 Pages
544-550
Published: October 31, 2008
Released on J-STAGE: March 27, 2009
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A 73-year-old woman with abdominal discomfort demonstrated a stone measuring 2.0cm wall thickness at the gallbladder neck, and a low density tumor located in the liver hilum extending to right intrahepatic glisson's sheath on abdominal CT. The tumor demonstrated low intensity on T1-weighted image and high intensity on not only T2-weighted image, but also diffusion-weighted image of MRI. ERCP demonstrated smooth narrowing of the upper part of the common bile duct and right hepatic duct. Based on these findings, the diagnosis was Mirizzi's syndrome. However, obstructive jaundice developed 25 days after admission. On ERCP and CT, stenosis of the bile duct had become progressive and extended from the upper part of the common bile duct to the left and right intrahepatic duct at the secondary bifurcation. Under the diagnosis of gallbladder carcinoma, right lobectomy including extrahepatic bile duct resection was performed. Microscopically, the mass was composed of marked and dense inflammatory cell infiltration of histiocytes indicating xanthogranulomatous cholecystitis.
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Hirokazu Kimura, Yoshinari Furukawa, Yukio Kuwada, Mutsumi Hananoki, A ...
2008 Volume 22 Issue 4 Pages
551-557
Published: October 31, 2008
Released on J-STAGE: March 27, 2009
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The patient was a 57-year-old woman who consulted a nearby doctor for a chief complaint of pruritus. She was referred and admitted to our department for suspected obstructive jaundice due to a giant hepatic cyst. Blood biochemistry showed elevated levels of bilirubin and of enzymes released from the hepatobiliary system. CT and echography showed an about 12cm cystic lesion expanding the intrahepatic bile ducts in the S4 area of the liver and dilated peripheral bile ducts. The cystic wall did not show clear thickening. ERC also supported the above suspected diagnosis. However, since endoscopic nasal biliary drainage did not sufficiently alleviate jaundice, we carried out percutaneous drainage of the cyst, resulting in reduction of jaundice and the cyst size after aspiration of the contents mixed with brown-colored necrotic tissue. We performed cytologic examinations of the drained fluid several times and detected cancer cells in the 7
th examination. A left hepatic lobectomy was carried out. Histopathologic examination revealed well-differentiated adenocarcinoma cells and we diagnosed cholangiocellular carcinoma with cyst formation. We suggest that this type of case requires careful diagnostic consideration in the clinical setting.
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Masahide Hiyoshi, Kazuo Chijiiwa, Jiro Ohuchida, Naoya Imamura, Motoak ...
2008 Volume 22 Issue 4 Pages
558-562
Published: October 31, 2008
Released on J-STAGE: March 27, 2009
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We report a patient with complete common hepatic duct obstruction 10 months after intraoperative bile duct injury and successfully treated by magnetic compression anastomosis. A 69-year-old woman had undergone cholecystectomy for cholecystolithiais. During the surgery, bile duct was injured due to severe inflammation, and the injured bile duct was repaired and the T-tube was placed. Seven months later, obstructive jaundice was developed and cholangiography and cholangioscopy through the percutaneous transhepatic biliary drainage (PTBD) showed a complete obstruction at the common hepatic duct. She was refered to our hospital and the magnetic compression anastomosis was applied to the patient. An anastomosis was created between the common hepatic duct and common bile duct on 35 days after magnetic compression, and biliary stent was left for 3 months thereafter. She is now doing well 27 months after the treatment.
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Naoki Matsumura, Hiromi Tokumura, Akihiro Yasumoto, Hiroyuki Sasaki, H ...
2008 Volume 22 Issue 4 Pages
563-569
Published: October 31, 2008
Released on J-STAGE: March 27, 2009
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Case 1, a 40's woman, had abdominal pain, high fever, and jaundice. US showed that the wall of enlarged gallbladder was thick and there was high bright irregular mass as blood clot inside. Laparoscopic cholecystectomy was performed because conservative medical treatment was not effective. The gallbladder had the blood clot and a mixed stone. Pathologic findings showed that the thick wall of the gallbladder had focal ulcer from which hemorrhage occurred in gallbladder lumen. Case 2, a 40's woman, had right hypochondralgia, vomiting, high fever and jaundice. US showed enlarged gallbladder and high bright mass such like sludge inside. MRCP showed that there were blood clot as various signals in the gallbladder lumen, so that we diagnosed hemorrhagic cholecystitis and PTGBD was performed. The bile was bloody and abacterial. Laparoscopic cholecystectomy was performed on the 13 days after PTGBD. The wall of the gallbladder was thick and gangrenous and there were blood clot in it.
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Yohei Takeda, Akira Sawaki, Hideki Ishikawa, Noriyuki Hoki, Tadayuki T ...
2008 Volume 22 Issue 4 Pages
570-575
Published: October 31, 2008
Released on J-STAGE: March 27, 2009
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We report a case of cystic duct carcinoma associated with pancreaticobiliary maljunction (PBM) and diagnosed preoperatively. Case: 58-year-old female was admitted with gall bladder wall thickening detect by screening US. DIC-CT showed wall thickening at the neck of gall bladder, and ERCP showed PBM and obstruction of cystic duct. The convex type echoendoscope revealed a mass in the cystic duct. The case underwent surgery and was diagnosed pathologically as cystic duct carcinomas associated with PBM. PBM is a well known risk factor for development of biliary tract cancer. And it is sometimes difficult to make diagnosis of cystic duct carcinoma before surgery. This case suggests the need of comprehensive diagnostic imaging including EUS to diagnose the cystic duct carcinoma.
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