Surgical procedures for perihilar cholangiocacrcinoma are right-sided hepatectomy (right hepatectomy and right trisectionectomy) and left-sided hepatectomy (left hepatectomy and left trisectionectomy). Important factors for the selection are precise evaluation of the longitudinal tumor extent and vascular invasion of perihilar cholangiocacrcinoma as well as monitoring future liver remnant function. MDCT and 3D-CT cholangiography are valuable for evaluating tumor extent and invasion, and the diagnostic accuracy is reported to be about 80%. Tumor mapping biopsy is useful for detection of tumor extent, but there remains a problem of false-positive results. Progression of radiological imaging evaluation of vascular invasion of perihilar cholangiocacrcinoma resulted in increasing numbers of combined vascular resection. Future liver remnant function should be evaluated by indocyanine green (ICG) clearance. Remnant liver volume >40% and value of remnant liver ICG K >0.05 are important for safe hepatectomy. 99mTc-GSA SPECT/CT fusion imaging and biopsy of remnant liver are supporting tools for selection of surgical method.
Transabdominal ultrasound is a non-invasive exam which can be the first choice for evaluation of gallbladder lesions. Recently, the technology of three-dimensional (3D) ultrasound has developed. In addition to the conventional findings, the 3D images were evaluated in 21 patients who underwent transabdominal 3D ultrasound for elevated gallbladder lesions (2 cancers and 19 benign polyps). The gallbladder cancer was significantly larger (21.5mm vs. 8mm, P = 0.019), and there were significant differences between the cancer and the benign polyps in the surface structure and with or without hyperechoic foci (P = 0.001, P = 0.029). All lesions can be clearly visualized by the 3D ultrasound and especially the maximum diameter, base, surface structure, and the presence of multiple lesions became easy to recognize. A transabdominal 3D ultrasound for elevated gallbladder lesions facilitates recognition of morphology and plays a supplementary role in the ultrasound diagnosis.
Biliary neuroendocrine neoplasms (NENs) are very rare. Seventeen biliary NENs were analyzed in this study. The major primary sites were gallbladder and papilla of Vater. NENs of the gallbladder were more common in women, and those of the papilla of Vater were in men. Six of the seven gallbladder NENs were neuroendocrine carcinomas (NECs). Among 10 surgical resected cases, all 7 cases except NET-G1 recurred, and the most of the recurrence was appeared in the liver. The treatment outcomes of cisplatin and irinotecan combination therapy for 11 biliary NECs were relatively good with a response rate of 72.7%, a disease control rate of 90.9%, a median progression-free survival of 7.9 months, and a median overall survival of 12.0 months. Major adverse events of grade 3 or higher included leukopenia (45.5%), neutropenia (63.6%), and anemia (27.3%). The combination therapy of cisplatin and irinotecan was feasible and showed a relatively good efficacy for biliary NECs.
Adenomyomatosis of the Gallbladder is a common benign lesion characterized by numerous branching Rokitansky-Aschoff sinuses accompanied by smooth muscle hyperplasia and an expansion of the subserosal layer. Although, adenomyomatosis is defined as the wall thickness over 3mm with 5 or more numbers of RAS within 1cm in the histopathological specimen, there is no agreed definition with imaging diagnosis. We recommend imaging diagnostic definition as "the wall thickness over 4mm with dilated RASs or intramural stones". The wall thickness should be measured by US (EUS) or enhanced CT. Microcystic area or comet-like echo as US findings, pearl necklace sign in MR images are supportive diagnostic signs for adenomyomatosis. When gallbladder cancer is suspected, the mucosal surface and the multilayer structures in the thickened wall should be evaluated by enhanced CT or EUS. Cases with abdominal symptoms, suspicious of gallbladder cancer, segmental type complicated with gallstone or hourglass deformity are indications for surgery. The cases with no symptom nor suspicious of gallbladder cancer are recommended a conservative US follow up with twice a year.
A 65-year-old man who was performed Laparoscopic Cholecystectomy against gall stones 12 years ago. When general medical checkup, US revealed cystic lesions in Morrison's pouch and abdominal wall. MRI diagnosed abscesses caused by residual gall stones.
Echo guided percutaneous drainage was failure to reduce these lesions. Abscess drainage with removal of all residual stones was mandatory, we selected single port laparoscopic surgery for intraperitoneal lesions and artificial pneumocyst for the abscess in abdominal wall. These procedures were minimal invasive and have cosmetic benefit.
A 58-year-old man undergoing treatment of hypertension and diabetes was referred our hospital with right hypocondralgia. Blood examination revealed white blood cell increase and slightly elevation of transaminase. Abdominal US and abdominal CT demonstrated small gallstones and intramural cystic lesions of the body of the gallbladder. MRI demonstrated the different content between the cystic lesions and the gallbladder. Laparoscopic cholecystectomy was performed, because the possibility of malignancy was negative. Histologically, the wall of cystic lesion was composed of fibrotic tissue with no lining epithelial cells. The Rokitansky-Aschoff sinus (RAS) lay scattered around the cystic lesions and the etiology was considered the cystic lesions due to blockade of RAS. Because intramural cystic lesion of the gallbladder is extremely rare, further experiments and accumulation of cases would be required.
We reported a case of choledochocele diagnosed by intraoperative cholangiography, which could not be found with MDCT, DIC-CT, MRCP and EUS. A 58-year-old woman visited a nearby hospital because of left lower abdominal pain and the main pancreatic duct dilatation was pointed out on CT. MRCP taken at another hospital demonstrated the possibility of pancreaticobiliary maljunction and she was referred to our hospital. On DIC-CT, both a common bile duct and a pancreatic duct were visualized, but a common channel and a communicating branch of both ducts were missing. Upper Gastrointestinal endoscopy showed the normal papilla of Vater. EUS showed the diffuse thickness of gallbladder wall and non-dilatation of the bile duct. As she denied consent to ERCP, we performed laparoscopic cholecystectomy and intraoperative cholangiography. Real-time fluoroscopic cholangiogram showed the cystic dilatation of the end of the bile duct, 10mm in diameter and subsequently revealed the pancreatic duct. Thus, we could make a diagnosis of choledochocele for the first time.
A 83-year-old female was visited previous hospital for upper abdominal pain. As a result of examination, the upper gastrointestinal perforation was suspected and she was urgently transported to our hospital. She had treated with hemodialysis for chronic renal failure. Liver disfunction were detected on blood examination. Contrast-enhanced abdominal computed tomography (CT) revealed intra-abdominal free air and fluid collection around the duodenum and the retroperitoneum. We diagnosed the patient as duodenal perforation and performed emergency surgery. Perforation and necrosis detected in the common bile duct. Since no gall stones were found, we finally diagnosed as idiopathic common bile duct perforation, and an emergency cholecystectomy and extrahepatic bile duct resection were performed. X-ray examination showed a minor leakage from the stump of bile duct on the duodenal side. Drain was removed on 42nd postoperative day and patient was transferred on 71st postoperative day. In this case, it is considered that interrupted blood flow of common bile duct led to perforation of the bile duct.
Endoscopic naso-pancreatic drainage (ENPD) is a good tool for diagnosis of pancreatic disease and for treatment of pancreatitis and postoperative pancreatic fistula (POPF) after pancreatectomy. A 66-year-old woman had loss of appetite and jaundice, and was diagnosed with perihilar cholangiocarcinoma with pancreaticobiliary maljunction. She underwent extended right hepatectomy with total caudate lobectomy, resection of the extrahepatic bile duct and portal vein. But she got POPF from bile duct margin at duodenal side. ENPD was insered and effective for treatment of POPF.
Medical information about neuroendocrine tumors (NETs) of the bile duct is incomplete due to their rarity. We herein report three cases of bile duct NETs. Case 1: CT demonstrated an isovascular mass in the lower bile duct. A transpapillary biopsy revealed neuroendocrine carcinoma (NEC). A pancreatoduodenectomy (PD) was performed, followed by adjuvant chemotherapy (CPT-11+CDDP); however, the patient died due to disease progression 32 months later. Case 2: A well-enhanced hepatic hilar tumor, not definitively diagnosed by the forceps biopsy, was resected and pathologically diagnosed as a NET (G2). Case 3: CT showed a 38mm, ill-enhanced tumor in the lower bile duct. A transpapillary forceps biopsy showed adenocarcinoma; however, the surgical specimens demonstrated NEC. Adequate tissue acquisition is necessary for the diagnosis of bile duct NEC.
A 60s-year-old man was admitted to our hospital with cholangitis and obstructive jaundice. CT revealed a mass with an unclear border that occupied almost the entire left lobe of the liver and solid components in the hilar bile duct. There was a mass in the hilar bile duct by direct cholangioscope. Total colonoscopy revealed mass in the descending colon. The patient was diagnosed with colorectal cancer and intrahepatic cholangiocarcinoma. We performed left hemicolectomy, left hepatectomy, caudate lobectomy, and extrahepatic bile duct resection. The cut surface of the resected specimen showed a tumor thrombi filling the entire bile duct and protruded into the hilar bile duct. Histopathological findings were similar to those of colorectal cancer lesions. Immunostaining was negative for CK-7 and positive for CK-20. The lesion was diagnosed as liver metastasis of the colorectal cancer.
A 61-year-old man had received 15 cycles of nivolumab, and he was treated with docetaxel for an advanced lung squamous cell carcinoma. Two months later after the final injection of nivolumab, he presented with epigastralgia. Laboratory test showed cholestasis. Abdominal computed tomography with contrast medium showed diffuse wall thickening of extrahepatic duct and ampulla of vater. Endoscopic retrograde cholangiography showed extrahepatic bile duct dilation without obstruction. Histological findings of bile duct biopsy confirmed severe infiltration of lymphocyte, dominantly composed of CD8+Tcell in subepithelial tissue. We made the diagnosis of immune checkpoint inhibitor-induced cholangitis by these findings. Because he did not respond to the initial systemic corticosteroid therapy and additional treatment of mycophenolate mofetil, we treated with azathioprine. Cholestasis improved after the administration of azathioprine, then we restarted chemotherapy.
A 47-year-old woman was admitted to our department for operation. The patient was diagnosed with chronic cholecystitis based on the findings of CT and MRI findings. Thus, the patient underwent laparoscopic cholecystectomy. Intraoperative finding revealed the aberrant hepatic duct after critical view of safety was created. The patient was discharged from our hospital without any complications. Aberrant hepatic duct is closely associated with bile duct injury. Therefore, it is important to consider aberrant hepatic duct preoperatively in patients for cholecystectomy in order to avoid bile duct injury.
Regarding endoscopic biliary drainage, we described the concept of drainage methods, details of procedures, and trouble shooting from the viewpoints of endoscopists. The gold standard for bile duct stenosis due to cholangiocarcinoma is endoscopic transpapillary bile duct drainage, not EUS-BD, not PTBD. We emphasized that bile duct drainage is just a palliative treatment and not a major treatment. So, we should consider the overall cancer treatment for patients not only biliary drainage.