Pancreatic pseudocyst formation is a well-known complication of pancreatitis. It represents about 75% of the cystic lesions of the pancreas and might be located within or surrounding the pancreatic tissue. Sixty perce...Pancreatic pseudocyst formation is a well-known complication of pancreatitis. It represents about 75% of the cystic lesions of the pancreas and might be located within or surrounding the pancreatic tissue. Sixty percent of the occurrences resolve spontaneously and only persistent, symptomatic or complicated cysts need to be treated. Complications include infection, hemorrhage, gastric outlet obstruction, splenic infarction and rupture. The formation of fistulas to other viscera is rare and most commonly occurs within the stomach, duodenum or colon. We report a case of a patient with a pancreatic pseudocyst in communication with the common bile duct. There have been only few cases reported in the literature. We successfully managed our case by performing an endoscopicultrasound-guided drainage of the pancreatic collection and a contemporaneous stenting of the common bile duct. Performed independently, both drainages are effective, safe and well-coded and the expertise on these procedures is widespread. By our knowledge this therapeutic approach was never reported in literature but we retain this is the most correct treatment for this very rare condition.展开更多
Intraductal papillary mucinous neoplasm (IPMN) of the bile duct is still rare and not yet understood despite of its increased incidence and similar clinicopathologic characteristics compared with IPMN of the pancreas....Intraductal papillary mucinous neoplasm (IPMN) of the bile duct is still rare and not yet understood despite of its increased incidence and similar clinicopathologic characteristics compared with IPMN of the pancreas. The fistula formation into other organs can occur in IPMN, especially the pancreatic type. To our knowl-edge, only two cases of IPMN of the bile duct with a choledochoduodenal fistula were reported and we have recently experienced a case of IPMN of the bile duct penetrating into two neighboring organs of the stom-ach and duodenum presenting with abdominal pain and jaundice. Endoscopy showed thick mucin extruding from two openings of the fistulas. Endoscopic suction of thick mucin using direct peroral cholangioscopy with ultra-slim endoscope through choledochoduodenal fis-tula was very difficult and ineffective because of very thick mucin and next endoscopic suction through the stent after prior insertion of biliary metal stent into cho-ledochogastric fistula also failed. Pathologic specimen obtained from the proximal portion of the choledocho-gastric fistula near left intrahepatic bile duct through the metal stent showed a low grade adenoma. The pa-tient declined the surgical treatment due to her old age and her abdominal pain with jaundice was improved af-ter percutaneous transhepatic biliary drainage with the irrigation of N-acetylcysteine three times daily for 10 d.展开更多
Background: Rapid development and broad implementation of modern imaging methods and diagnostic techniques have greatly contributed to more precise appreciation of the anomalous conditions and pathologies of the extra...Background: Rapid development and broad implementation of modern imaging methods and diagnostic techniques have greatly contributed to more precise appreciation of the anomalous conditions and pathologies of the extrahepatic biliary system—one of the parts of the human body characterized with significant anatomical variability. Case Report: A 73-year-old female patient was admitted to The First Medical Center of Tbilisi with complaints of pain and a feeling of heaviness in the right hypochondrium, fever (38ºC), nausea, weakness, jaundice. Abdominal ultrasound revealed an enlarged gallbladder with thickened walls and a large stone incarcerated in the gallbladder neck. The diameter of the CBD was increased up to 4 cm, and large size stones present within the lumen. A CT scan has also revealed a cholecysto-duodenal fistula. Open cholecystectomy was decided as a treatment of choice. Intraoperatively was found a fistula between the fundus of the gallbladder and the duodenum, a gallbladder with thickened walls, and stones wedged into the neck, a common bile duct of significantly enlarged diameter (4 cm) with large size stones, and an accessory small diameter duct between the gallbladder and the CBD. After choledochotomy, 4 × 2 cm and 3 × 2 cm size stones were removed from CBD. During cholecystectomy, the Luschka duct was found within the gallbladder bed. Conclusion: We report on a rare case of anomaly presented in the form of an accessory bile duct between the gallbladder and the common bile duct, as well as with an accessory duct of Luschka. Additionally, significantly enlarged extrahepatic bile ducts with giant intraductal stones and cholecystoduodenal fistula were revealed. The combination of these pathologies and anomalies is extremely rare.展开更多
BACKGROUND: Significant bile leak as an uncommon complication after biliary tract surgery may constitute a serious and difficult management problem. Surgical management of biliary fistulae is associated with high morb...BACKGROUND: Significant bile leak as an uncommon complication after biliary tract surgery may constitute a serious and difficult management problem. Surgical management of biliary fistulae is associated with high morbidity and mortality. Biliary endoscopic procedures have become the treatment of choice for management of biliary Gstulae. METHODS: Ninety patients presented with bile leaks after cholecystectomy ( open cholecystectomy in 45 patients, cholecystectomy with common bile duct exploration in 20 and laparoscopic cholecystectomy in 25). The presence of bile leaks was confirmed by ERCP and the appearance of bile in percutaneous drainage of abdominal collections. Of the 90 patients with postoperative bile leaks, 18 patients had complete transaction of the common bile duct by ERCP and were subjected to bilioenteric anastomosis. In the remaining patients after cholangiography and localization of the site of bile leaks. therapeutic procedures like sphinctero-tomy, biliary stenting and nasobiliary drainage ( NBD ) were performed. If residual stones were seen in the common bile duct, sphincterotomy was followed by stone extraction using dormia basket. Nasobiliary drain or stents of 7F size were placed according to the standard techniques. The NBD was removed when bile leak stopped and closure of the fistula confirmed cholangiographically. The stents were removed after an interval of 6-8 weeks. RESULTS: Bile leaks in 72 patients occurred in the cystic duct (38 patients), the common bile duct (30 ), and the right hepatic duct (4). Of the 72 patients with post-operative bile leak, 24 had associated retained common bile duct stones and 1 had ascaris in common bile duct. All the 72 patients were subjected to therapeutic procedures including sphincterotomy with stone extraction followed by biliary stenting (24 patients), removal of ascaris and biliary stenting (1), sphincterotomy with biliary stenting (18), sphincterotomy with NBD (12), biliary stenting alone (12), and NBD alone (5). Bile leaks stopped in all patients at a median interval of 3 days (range 3-16 days) after endoscopic in- terventions. No difference was observed in efficacy and in time for the treatment of bile leak by sphincterotomy with endoprosthesis or endoprosthesis alone in patients with bile leak after surgery. CONCLUSIONS: Post-cholecystectomy bile leaks occur most commonly in the cystic duct and associated common bile duct stones are found in one-third of cases. Endoscopic therapy is safe and effective in the management of bile leaks and fistulae after surgery. Sphincterotomy with endoprosthesis or endoprosthesis alone is equally effective in the management of postoperative bile leak.展开更多
BACKGROUND Intraductal papillary neoplasm of the bile duct(IPNB) is pathologically similar to intraductal papillary mucinous neoplasm(IPMN). However, there are several significant differences between them. The rate of...BACKGROUND Intraductal papillary neoplasm of the bile duct(IPNB) is pathologically similar to intraductal papillary mucinous neoplasm(IPMN). However, there are several significant differences between them. The rate of IPMN associated with extrapancreatic malignancies has been reported to range from 10%-40%, and it may occasionally be complicated with the presence of fistulas. IPMN associated with malignant IPNB is extremely rare and only nine cases have been reported in the literature.CASE SUMMARY We report a 52-year-old man who presented with recurrent cholangitis for nine months. Computed tomography and magnetic resonance cholangiopancreatography showed the common bile duct stricture with dilated pancreatobiliary duct without other abnormal findings. The underlying pathogenesis could not be identified based on the radiologic images. Endoscopic retrograde cholangiopancreatography revealed a pancreatobiliary fistula with dilated main pancreatic duct, biliary stricture with dilated biliary tree, and mucus discharge from the enlarged orifice of the major papilla. The patient underwent SpyGlass cholangiopancreatoscopy due to a suspected mucin-producing biliary neoplasm and indeterminate main pancreatic duct dilatation. Multiple papillary growing neoplasms with vascular images, with the extent of lesions spreading in the biliopancreatic ductal lumens, were identified by SpyGlass. In addition, the presence of a pancreatobiliary fistula was also identified. The patient was diagnosed as having benign IPMN and malignant IPNB with focal invasion by postoperative pathology. Furthermore, varying histological subtypes were present in both IPMN and IPNB. Pylorus-preserving pancreaticoduodenectomy was performed on the patient with excellent results during the 52 month followup period.CONCLUSION We deemed that pancreatography and SpyGlass allowed for an efficient diagnosis of IPMN with pancreatobiliary fistula, whereas the etiology could not be identified by radiologic imaging.展开更多
BACKGROUND The influence of bile contamination on the infectious complications of patients undergoing pancreaticoduodenectomy(PD)has not been thoroughly evaluated.AIM To evaluate the effect of preoperative biliary dra...BACKGROUND The influence of bile contamination on the infectious complications of patients undergoing pancreaticoduodenectomy(PD)has not been thoroughly evaluated.AIM To evaluate the effect of preoperative biliary drainage and bile contamination on the outcomes of patients who undergo PD.METHODS The database of 4101 patients who underwent PD was reviewed.Preoperative biliary drainage was performed in 1964 patients(47.9%),and bile contamination was confirmed in 606 patients(14.8%).RESULTS The incidence of postoperative infectious complications was 37.9%in patients with preoperative biliary drainage and 42.4%in patients with biliary contamination,respectively.Patients with extrahepatic bile duct carcinoma,ampulla of Vater carcinoma,and pancreatic carcinoma had a high frequency of preoperative biliary drainage(82.9%,54.6%,and 50.8%)and bile contamination(34.3%,26.2%,and 20.2%).Bile contamination was associated with postoperative pancreatic fistula(POPF)Grade B/C,wound infection,and catheter infection.A multivariate logistic regression analysis revealed that biliary contamination(odds ratio 1.33,P=0.027)was the independent risk factor for POPF Grade B/C.The three most commonly cultured microorganisms from bile(Enterococcus,Klebsiella,and Enterobacter)were identical to those isolated from organ spaces.CONCLUSION In patients undergoing PD,bile contamination is related to postoperative infectious complication including POPF Grade B/C.The management of biliary contamination should be standardised for patients who require preoperative biliary drainage for PD,as the main microorganisms are identical in both organ spaces and bile.展开更多
BACKGROUND Mirizzi syndrome(MS) is defined as an extrinsic compression of the extrahepatic biliary system by an impacted stone in the gallbladder or the cystic duct leading to obstructive jaundice. Endoscopic retrogra...BACKGROUND Mirizzi syndrome(MS) is defined as an extrinsic compression of the extrahepatic biliary system by an impacted stone in the gallbladder or the cystic duct leading to obstructive jaundice. Endoscopic retrograde cholangiopancreatography(ERCP) could serve diagnostic and therapeutic purposes in patients with MS in addition to revealing the relationships between the cystic duct, the gallbladder, and the common bile duct(CBD). Cholecystectomy is a challenging procedure for a laparoscopic surgeon in patients with MS, and the presence of a cholecystocholedochal fistula renders preoperative diagnosis important during ERCP.AIM To evaluate cholecystocholedochal fistulas in patients with MS during ERCP before cholecystectomy.METHODS From 2004 to 2018, all patients diagnosed with MS during ERCP were enrolled in this study. Patients with associated malignancy or those who had already undergone cholecystectomy before ERCP were excluded. In total, 117 patients with MS diagnosed by ERCP were enrolled in this study. Among them, 21 patients with MS had cholecystocholedochal fistulas. MS was further confirmed during cholecystectomy to check if cholecystocholedochal fistulas were present. The clinical data, cholangiography, and endoscopic findings during ERCP were recorded and analyzed.RESULTS Gallbladder opacification on cholangiography is more frequent in patients with MS complicated by cholecystocholedochal fistulas(P < 0.001). Pus in the CBD and stricture length of the CBD longer than 2 cm were two additional independent factors associated with MS, as demonstrated by multivariate analysis(odds ratio 5.82, P = 0.002;0.12, P = 0.008, respectively).CONCLUSION Gall bladder opacification is commonly seen in patients with MS with cholecystocholedochal fistulas during pre-operative ERCP. Additional findings such as pus in the CBD and stricture length of the CBD longer than 2 cm may aid the diagnosis of MS with cholecystocholedochal fistulas.展开更多
文摘Pancreatic pseudocyst formation is a well-known complication of pancreatitis. It represents about 75% of the cystic lesions of the pancreas and might be located within or surrounding the pancreatic tissue. Sixty percent of the occurrences resolve spontaneously and only persistent, symptomatic or complicated cysts need to be treated. Complications include infection, hemorrhage, gastric outlet obstruction, splenic infarction and rupture. The formation of fistulas to other viscera is rare and most commonly occurs within the stomach, duodenum or colon. We report a case of a patient with a pancreatic pseudocyst in communication with the common bile duct. There have been only few cases reported in the literature. We successfully managed our case by performing an endoscopicultrasound-guided drainage of the pancreatic collection and a contemporaneous stenting of the common bile duct. Performed independently, both drainages are effective, safe and well-coded and the expertise on these procedures is widespread. By our knowledge this therapeutic approach was never reported in literature but we retain this is the most correct treatment for this very rare condition.
文摘Intraductal papillary mucinous neoplasm (IPMN) of the bile duct is still rare and not yet understood despite of its increased incidence and similar clinicopathologic characteristics compared with IPMN of the pancreas. The fistula formation into other organs can occur in IPMN, especially the pancreatic type. To our knowl-edge, only two cases of IPMN of the bile duct with a choledochoduodenal fistula were reported and we have recently experienced a case of IPMN of the bile duct penetrating into two neighboring organs of the stom-ach and duodenum presenting with abdominal pain and jaundice. Endoscopy showed thick mucin extruding from two openings of the fistulas. Endoscopic suction of thick mucin using direct peroral cholangioscopy with ultra-slim endoscope through choledochoduodenal fis-tula was very difficult and ineffective because of very thick mucin and next endoscopic suction through the stent after prior insertion of biliary metal stent into cho-ledochogastric fistula also failed. Pathologic specimen obtained from the proximal portion of the choledocho-gastric fistula near left intrahepatic bile duct through the metal stent showed a low grade adenoma. The pa-tient declined the surgical treatment due to her old age and her abdominal pain with jaundice was improved af-ter percutaneous transhepatic biliary drainage with the irrigation of N-acetylcysteine three times daily for 10 d.
文摘Background: Rapid development and broad implementation of modern imaging methods and diagnostic techniques have greatly contributed to more precise appreciation of the anomalous conditions and pathologies of the extrahepatic biliary system—one of the parts of the human body characterized with significant anatomical variability. Case Report: A 73-year-old female patient was admitted to The First Medical Center of Tbilisi with complaints of pain and a feeling of heaviness in the right hypochondrium, fever (38ºC), nausea, weakness, jaundice. Abdominal ultrasound revealed an enlarged gallbladder with thickened walls and a large stone incarcerated in the gallbladder neck. The diameter of the CBD was increased up to 4 cm, and large size stones present within the lumen. A CT scan has also revealed a cholecysto-duodenal fistula. Open cholecystectomy was decided as a treatment of choice. Intraoperatively was found a fistula between the fundus of the gallbladder and the duodenum, a gallbladder with thickened walls, and stones wedged into the neck, a common bile duct of significantly enlarged diameter (4 cm) with large size stones, and an accessory small diameter duct between the gallbladder and the CBD. After choledochotomy, 4 × 2 cm and 3 × 2 cm size stones were removed from CBD. During cholecystectomy, the Luschka duct was found within the gallbladder bed. Conclusion: We report on a rare case of anomaly presented in the form of an accessory bile duct between the gallbladder and the common bile duct, as well as with an accessory duct of Luschka. Additionally, significantly enlarged extrahepatic bile ducts with giant intraductal stones and cholecystoduodenal fistula were revealed. The combination of these pathologies and anomalies is extremely rare.
文摘BACKGROUND: Significant bile leak as an uncommon complication after biliary tract surgery may constitute a serious and difficult management problem. Surgical management of biliary fistulae is associated with high morbidity and mortality. Biliary endoscopic procedures have become the treatment of choice for management of biliary Gstulae. METHODS: Ninety patients presented with bile leaks after cholecystectomy ( open cholecystectomy in 45 patients, cholecystectomy with common bile duct exploration in 20 and laparoscopic cholecystectomy in 25). The presence of bile leaks was confirmed by ERCP and the appearance of bile in percutaneous drainage of abdominal collections. Of the 90 patients with postoperative bile leaks, 18 patients had complete transaction of the common bile duct by ERCP and were subjected to bilioenteric anastomosis. In the remaining patients after cholangiography and localization of the site of bile leaks. therapeutic procedures like sphinctero-tomy, biliary stenting and nasobiliary drainage ( NBD ) were performed. If residual stones were seen in the common bile duct, sphincterotomy was followed by stone extraction using dormia basket. Nasobiliary drain or stents of 7F size were placed according to the standard techniques. The NBD was removed when bile leak stopped and closure of the fistula confirmed cholangiographically. The stents were removed after an interval of 6-8 weeks. RESULTS: Bile leaks in 72 patients occurred in the cystic duct (38 patients), the common bile duct (30 ), and the right hepatic duct (4). Of the 72 patients with post-operative bile leak, 24 had associated retained common bile duct stones and 1 had ascaris in common bile duct. All the 72 patients were subjected to therapeutic procedures including sphincterotomy with stone extraction followed by biliary stenting (24 patients), removal of ascaris and biliary stenting (1), sphincterotomy with biliary stenting (18), sphincterotomy with NBD (12), biliary stenting alone (12), and NBD alone (5). Bile leaks stopped in all patients at a median interval of 3 days (range 3-16 days) after endoscopic in- terventions. No difference was observed in efficacy and in time for the treatment of bile leak by sphincterotomy with endoprosthesis or endoprosthesis alone in patients with bile leak after surgery. CONCLUSIONS: Post-cholecystectomy bile leaks occur most commonly in the cystic duct and associated common bile duct stones are found in one-third of cases. Endoscopic therapy is safe and effective in the management of bile leaks and fistulae after surgery. Sphincterotomy with endoprosthesis or endoprosthesis alone is equally effective in the management of postoperative bile leak.
文摘BACKGROUND Intraductal papillary neoplasm of the bile duct(IPNB) is pathologically similar to intraductal papillary mucinous neoplasm(IPMN). However, there are several significant differences between them. The rate of IPMN associated with extrapancreatic malignancies has been reported to range from 10%-40%, and it may occasionally be complicated with the presence of fistulas. IPMN associated with malignant IPNB is extremely rare and only nine cases have been reported in the literature.CASE SUMMARY We report a 52-year-old man who presented with recurrent cholangitis for nine months. Computed tomography and magnetic resonance cholangiopancreatography showed the common bile duct stricture with dilated pancreatobiliary duct without other abnormal findings. The underlying pathogenesis could not be identified based on the radiologic images. Endoscopic retrograde cholangiopancreatography revealed a pancreatobiliary fistula with dilated main pancreatic duct, biliary stricture with dilated biliary tree, and mucus discharge from the enlarged orifice of the major papilla. The patient underwent SpyGlass cholangiopancreatoscopy due to a suspected mucin-producing biliary neoplasm and indeterminate main pancreatic duct dilatation. Multiple papillary growing neoplasms with vascular images, with the extent of lesions spreading in the biliopancreatic ductal lumens, were identified by SpyGlass. In addition, the presence of a pancreatobiliary fistula was also identified. The patient was diagnosed as having benign IPMN and malignant IPNB with focal invasion by postoperative pathology. Furthermore, varying histological subtypes were present in both IPMN and IPNB. Pylorus-preserving pancreaticoduodenectomy was performed on the patient with excellent results during the 52 month followup period.CONCLUSION We deemed that pancreatography and SpyGlass allowed for an efficient diagnosis of IPMN with pancreatobiliary fistula, whereas the etiology could not be identified by radiologic imaging.
文摘BACKGROUND The influence of bile contamination on the infectious complications of patients undergoing pancreaticoduodenectomy(PD)has not been thoroughly evaluated.AIM To evaluate the effect of preoperative biliary drainage and bile contamination on the outcomes of patients who undergo PD.METHODS The database of 4101 patients who underwent PD was reviewed.Preoperative biliary drainage was performed in 1964 patients(47.9%),and bile contamination was confirmed in 606 patients(14.8%).RESULTS The incidence of postoperative infectious complications was 37.9%in patients with preoperative biliary drainage and 42.4%in patients with biliary contamination,respectively.Patients with extrahepatic bile duct carcinoma,ampulla of Vater carcinoma,and pancreatic carcinoma had a high frequency of preoperative biliary drainage(82.9%,54.6%,and 50.8%)and bile contamination(34.3%,26.2%,and 20.2%).Bile contamination was associated with postoperative pancreatic fistula(POPF)Grade B/C,wound infection,and catheter infection.A multivariate logistic regression analysis revealed that biliary contamination(odds ratio 1.33,P=0.027)was the independent risk factor for POPF Grade B/C.The three most commonly cultured microorganisms from bile(Enterococcus,Klebsiella,and Enterobacter)were identical to those isolated from organ spaces.CONCLUSION In patients undergoing PD,bile contamination is related to postoperative infectious complication including POPF Grade B/C.The management of biliary contamination should be standardised for patients who require preoperative biliary drainage for PD,as the main microorganisms are identical in both organ spaces and bile.
文摘BACKGROUND Mirizzi syndrome(MS) is defined as an extrinsic compression of the extrahepatic biliary system by an impacted stone in the gallbladder or the cystic duct leading to obstructive jaundice. Endoscopic retrograde cholangiopancreatography(ERCP) could serve diagnostic and therapeutic purposes in patients with MS in addition to revealing the relationships between the cystic duct, the gallbladder, and the common bile duct(CBD). Cholecystectomy is a challenging procedure for a laparoscopic surgeon in patients with MS, and the presence of a cholecystocholedochal fistula renders preoperative diagnosis important during ERCP.AIM To evaluate cholecystocholedochal fistulas in patients with MS during ERCP before cholecystectomy.METHODS From 2004 to 2018, all patients diagnosed with MS during ERCP were enrolled in this study. Patients with associated malignancy or those who had already undergone cholecystectomy before ERCP were excluded. In total, 117 patients with MS diagnosed by ERCP were enrolled in this study. Among them, 21 patients with MS had cholecystocholedochal fistulas. MS was further confirmed during cholecystectomy to check if cholecystocholedochal fistulas were present. The clinical data, cholangiography, and endoscopic findings during ERCP were recorded and analyzed.RESULTS Gallbladder opacification on cholangiography is more frequent in patients with MS complicated by cholecystocholedochal fistulas(P < 0.001). Pus in the CBD and stricture length of the CBD longer than 2 cm were two additional independent factors associated with MS, as demonstrated by multivariate analysis(odds ratio 5.82, P = 0.002;0.12, P = 0.008, respectively).CONCLUSION Gall bladder opacification is commonly seen in patients with MS with cholecystocholedochal fistulas during pre-operative ERCP. Additional findings such as pus in the CBD and stricture length of the CBD longer than 2 cm may aid the diagnosis of MS with cholecystocholedochal fistulas.
