Removal of intrahepatic bile duct stone could reduce the risk of cholangiocarcinoma: A single-center retrospective study in South Korea

BACKGROUND Intrahepatic duct(IHD)stones are among the most important risk factors for cholangiocarcinoma(CCC).Approximately 10%of patients with IHD stones develop CCC;however,there are limited studies regarding the effect of IHD stone removal on CCC development.AIM To investigate the association between IHD stone removal and CCC development.METHODS We retrospectively analyzed 397 patients with IHD stones at a tertiary referral center between January 2011 and December 2020.RESULTS CCC occurred in 36 of the 397 enrolled patients.In univariate analysis,chronic hepatitis B infection(11.1%vs 3.0%,P=0.03),carbohydrate antigen 19-9(CA19-9,176.00 vs 11.96 II/mL,P=0.010),stone located in left or both lobes(86.1%vs 70.1%,P=0.042),focal atrophy(52.8%vs 26.9%,P=0.001),duct stricture(47.2%vs 24.9%,P=0.004),and removal status of IHD stone(33.3%vs 63.2%,P<0.001)were significantly different between IHD stone patients with and without CCC.In the multivariate analysis,CA19-9>upper normal limit,carcinoembryonic antigen>upper normal limit,stones located in the left or both lobes,focal atrophy,and complete removal of IHD stones without recurrence were independent factors influencing CCC development.However,the type of removal method was not associated with CCC risk.CONCLUSION Complete removal of IHD stones without recurrence could reduce CCC risk.

Congenital left intrahepatic bile duct draining into gastric wall mimicking biliary reflux gastritis

Abnormalities and variations of the biliary ducts are not rare.Most aberrant bile ducts eventually drain into the descending part of duodenum through the papilla of vater.However,drainage of the left hepatic bile duct into the stomach is extremely rare.A 29-year old man was admitted to the hospital with the diagnosis of biliary reflux gastritis.Comprehensive imaging modalities were performed including electronic endoscopy,endoscopic ultrasonography,endoscopic retrograde cholangiopancreatography and magnetic resonance cholangio-pancreatography.Finally,congenital ectopic left intrahepatic bile duct draining into the stomach was found,which caused biliary reflux gastritis.The patient did not receive any surgery.Good recovery was achieved by medical treatment.

A case of very large intrahepatic bile duct adenoma followed for 7 years

A 70-year-old man was referred to our hospital due to abnormal liver function. A tumor of 92 mm × 61 mm was detected on ultrasound screening of the left liver lobe. Although the tumor was suspected to be intrahepatic bile duct carcinoma, he had chronic heart disease and was unable to undergo surgery. Therefore, he was followed without further testing. No increase in tumor serum markers or tumor size was observed for the subsequent 7 years. We continued to suspect intrahepatic bile duct carcinoma, and we decided to perform a tumor biopsy. Tumor biopsy findings indicated intrahepatic bile duct adenoma(BDA), which is a rare benign epithelial liver tumor typically ranging from 1 mm to20 mm. We herein report a case of very large BDA followed for 7 years.

Modified rendezvous intrahepatic bile duct cannulation technique to pass a PTBD catheter in ERCP

The rendezvous procedure combines an endoscopic technique with percutaneous transhepatic biliary drainage(PTBD).When a selective common bile duct cannulation fails,PTBD allows successful drainage and retrograde access for subsequent rendezvous techniques.Traditionally,rendezvous procedures such as the PTBDassisted over-the-wire cannulation method,or the parallel cannulation technique,may be available when a bile duct cannot be selectively cannulated.When selective intrahepatic bile duct(IHD) cannulation fails,this modified rendezvous technique may be a feasible alternative.We report the case of a modified rendezvous technique,in which the guidewire was retrogradely passed into the IHD through the C2 catheter after end-to-end contact between the tips of the sphincterotome and the C2 catheter at the ampulla's orifice,in a 39-year-old man who had been diagnosed with gallbladder carcinoma with a metastatic right IHD obstruction.Clinically this procedure may be a feasible and timesaving technique.

Clinical Studies on Ultrasound Lithotripsy in Intrahepatic Bile－duct via Abdomen

patients with left/right intrahepatic bile-duct calculi received ultrasonic lithotresis via abdomen by using the percutaneous cholecystoscopeand ultrasonic lithotresis apparatus. The results indicated that all the surgical manipulations were successful with a residual rate of 6. 7 %, compared with a residual rate of 78. 2 % in 23 cases of left/right intrahepatic bile-duct lithiasis treated simultaneously by lithotomy apparatus. The differences between them were statistically significant (μ= 4. 29, P<0. 01). Among 12 cases undergoing follow-up observation , no side effect due to ultrasonic lithotresis and no residual calculus after 2- 4 check-ups with B-mode ultrasound diagnostic set were found and all of their symptoms disappeared except for 1 case.

The abnormal expression of E-cadherin in intrahepatic bile duct epithelia cells in biliary atresia and its relationship with apoptosis

To explore the relationship between the expression of E-cadherin and the apoptosis in intrahepatic bile duct epithelial cells in biliary atresia (BA).Methods The E-cadherin expression was demonstrated by immunohistochemical staining for the liver specimens from 38 children with BA and 16 normal children.The apoptotic intrahepatic bile duct epithelial cells in these specimens were visualized by TdT-mediated dUTP-digoxigenin nick end labeling (TUNEL) assay,and the apoptotic index (AI) was calculated from the percentage of apoptotic cells in total cells.Results The intensity of E-cadherin expression in bile duct epithelial cells in BA group was lower than that in the normal control group (0.33±0.12 vs 0.62±0.20,P<0.01).On the other hand,the AI in BA group was significant higher than that in control group (51.74±19.93 vs 12.34±19.32,P<0.01).An inverse correlation was detected between the intensity of E-cadherin and the AI in the liver from children with BA.Conclusion The abnormal decrease of E-cadherin may lead to an increase of the apoptosis of intrahepatic bile epithelial cells in BA,resulting in developmental disorder of intrahepatic bile duct and ductal plate malformation in the liver.12 refs,4 figs,1 tab.

Pathological classification of intrahepatic cholangiocarcinoma based on a new concept

Intrahepatic cholangiocarcinoma (ICC) arises from the lining epithelium and peribiliary glands of the intrahepatic biliary tree and shows variable cholangiocytic dif-f-e-re-ntiation. To date-,ICC was large-ly classifie-d into adenocarcinoma and rare variants. Herein,we propose to subclassify the former,based on recent progress in the-study of-ICC including the-gross classification and hepatic progenitor/stem cells and on the pathological similarities between biliary and pancreatic neoplasms. That is,ICC is classifiable into the conventional (bile duct) type,the bile ductular type,the intraductal neoplasm type and rare variants. The conventional type is further divided into the small duct type (peripheral type) and large bile duct type (perihilar type). The former is a tubular or micropapillary adenocarcinoma while the latter involves the intrahepatic large bile duct. Bile ductular type resembles proliferated bile ductules and shows a replacing growth of the hepatic parenchyma.Hepatic progenitor cell or stem cell phenotypes such as neural cell adhesion molecule expression are frequently expressed in the bile ductular type. Intraductal type includes papillary and tubular neoplasms of the bile duct (IPNBs and ITNBs) and a superficial spreading type. IPNB and ITNB show a spectrum from a preneoplastic borderline lesion to carcinoma and may have pancreatic counterparts. At invasive sites,IPNB is associated with the conventional bile duct ICC and mucinous carcinoma. Biliary mucinous cystic neoplasm with ovarian-like stroma in its wall is different from IPNB,particularly IPNB showing cystic dilatation of the affected ducts. Rare variants of ICC include squamous/adenosquamous cell carcinoma,mucinous/signet ring cell carcinoma,clear cell type,undifferentiated type,neuroendocrine carcinoma and so on. This classification of-ICC may ope-n up a ne-w fie-ld of-re-se-arch of-ICC and contribute-to the-clini cal approach to ICC.

Apoptosis and proliferation of intrahepatic bil educt after ischemia-reperfusion injury

BACKGROUND: In orthotopic liver transplantation, ische-mic-reperfusion is one of the most important factors thatcause the incidence of biliary complicance. The aim of thisstudy was to investigate the effects of ischemia reperfusionon epithelial cells apoptosis and proliferation of intrahepaticbile duct (IBD) (>20 μm).METHODS: 30-minute warm ischemia was applied to ratlivers respectively, and experiment was performed on days2,7, 14, 28 after reperfusion. Apoptosis was determined insitu by morphology and TUNEL, and cholangiocyte proli-feration was evaluated in situ by morphometry of liver sec-tions stained for cytokeratin-19 ( CK-19) and by prolifera-ting cellular nuclear antigen staining in liver sections.RESULTS: Two days after ischemia reperfusion, apoptosisof cells was observed in large intrahepatic bile ducts (>20μm) (5.6%±1.2%) , but the number of large intrahepaticbile ducts reduced (0.32 ±0.06). Seven days after ischemiareperfusion, the apoptosis index of cholangiocytes de-creased to 1.2%±0.3%, and the number of intrahepatic bileducts began to proliferate and returned to nearly normal onday 28.CONCLUSION: Ischemia reperfusion causes a decrease inthe number of intrahepatic bile ducts (>20 μm) as a resultof a higher rate of apoptosis and absence of initial prolifera-tion.

Clinical and biological significance of precursor lesions of intrahepatic cholangiocarcinoma

Cholangiocarcinoma(CC) is primarily a malignant tumor of older adults most prevalent in Southeast Asia,where liver fluke infestation is high.However the etiology in western countries is unknown.Although the incidence of extrahepatic cholangiocarcinoma has remained constant,incidence of intrahepatic CC(ICC) which differs inmorphology,pathogenesis,risk factors,treatment and prognosis is increasing.While this increase is associated with hepatitis C virus infection,chronic nonalcoholic liver disease,obesity,and smoking,the pathogenesis of ICC and molecular alterations underlying the carcinogenesis are not completely elucidated.Benign biliary lesions such as biliary intraepithelial neoplasia,intraductal papillary neoplasm of the bile duct,von Meyenburg complex or bile duct hamartoma,and bile duct adenoma have been associated with ICC.For each of these entities,evidence suggests or supports a role as premalignant lesions.This article summarized the important biological significance of the precursor lesions of ICC and the molecular mechanisms that may be involved in intrahepatic cholangiocarcinogenesis.

Preventive effects of autologous bone marrow mononuclear cell implantation on intrahepatic ischemic-type biliary lesion in rabbits

BACKGROUND: The ischemic-type biliary lesion (ITBL) is one of the most serious biliary complications of liver transplantation. This study aimed to investigate the effects of autologous bone marrow mononuclear cell (BM-MNC) implantation on neovascularization and the prevention of intrahepatic ITBL in a rabbit model. METHODS: The rabbits were divided into control, experimental model, and cell implantation groups, with 10 in each group. The model of intrahepatic ITBL was established by clamping the hepatic artery and common bile duct. Autologous BM-MNCs were isolated from the tibial plateau by density gradient centrifugation and were implanted through the common hepatic artery. Changes in such biochemical markers as aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, gamma-glutamyltranspeptidase, total bilirubin and direct bilirubin were measured. Four weeks after operation, cholangiography, histopathological manifestations, differentiation of BM-MNCs, microvessel density and the expression of vascular endothelial growth factor were assessed. RESULTS: Compared with the experimental model group, the BM-MNC implantation group showed superiority in the time to recover normal biochemistry. The microvessel density and vascular endothelial growth factor expression of the implantation group were significantly higher than those of the control and experimental model groups. The ITBL in the experimental model group was more severe than that in the implantation group and fewer new capillary blood vessels occurred around it. CONCLUSIONS: Implanted autologous BM-MNCs can differentiate into vascular endothelial cells, promote neovascularization and improve the blood supply to the ischemic bile duct, and this provides a new way to diminish or prevent intrahepatic ITBL after liver transplantation. (Hepatobiliary Pancreat Dis Int 2010; 9:593-599)

Rat model of cholelithiasis with human gallstones implanted in cholestasis-induced virtual gallbladder

AIM:To facilitate translational research on cholelithiasis,we have developed a rat model of human gallstones by exploiting the unique biliopancreatic features of this species.METHODS:Under anesthesia,16 adult rats of equal genders underwent two times of abdominal surgery.First,their common bile duct(CBD)was ligated to cause cholestasis by total biliary obstruction(TBO).On day 0,1,3,7,14,21 and 28 after TBO,magnetic resonance imaging(MRI)was conducted to monitor the dilatation of the CBD,and blood was sampled to analyze total serum bilirubin(TSB).Secondly,on day 30,the abdomen was re-opened and gallstone(s)collected from human patients were implanted in the dilated CBD asa virtual gallbladder(VGB),which was closed by suture ligation.This rat cholelithiasis model was examined by MRI,clinical observation,microcholangiography and histology.RESULTS:All rats survived two laparotomies.After ligation,the CBD was dilated to a stable size of 4 to30 mm in diameter on day 21-28,which became a VGB.The rats initially showed signs of jaundice that diminished over time,which paralleled with the evolving TSB levels from 0.6±0.3 mg/d L before ligation,through a peak of 10.9±1.9 mg/dL on day 14,until a nearly normalized value after day 28.The dilated CBD with thickened wall allowed an incision for implantation of human gallstones of 1-10 mm in diameter.The rat cholelithiasis was proven by in vivo MRI and postmortem microcholangiography and histomorphology.CONCLUSION:A rat model cholelithiasis with human gallstones has been established,which proves feasible,safe,reliable,nontoxic and cost-effective.Given the gallstones of human origin,applications of this model may be of help in translational research such as optical detection and lysis of gallstones by systemic drug administration.

Clinical characteristics of intrahepatic biliary papilloma:A case report

BACKGROUND Intrahepatic bile duct papilloma(IPNB)is a rare benign tumour from the bile duct epithelium and has a high malignant transformation rate.Early radical resection can obviously improve the prognosis of patients,but it is difficult to be sure of the diagnosis of IPNB before operating.CASE SUMMARY This study included 28 patients with intraductal papilloma admitted to the First Hospital of Jilin University from January 2010 to November 2020 and recorded their clinical manifestations,imaging features,complications and prognosis.There were 12 males and 16 females with an average age of 61.36±8.03 years.Most patients had symptoms of biliary obstruction.Biliary dilatation and cystic mass could be seen on imaging.After surgery,IPNB was diagnosed by pathology.CONCLUSION IPNB is a rare benign tumour in the bile duct.Early diagnosis and timely R0 resection can improve the prognosis of IPNB.

Cystic Degeneration of Peripheral Intrahepatic Cholangiocarcinoma: An Atypical Presentation

Cholangiocarcinomas are primary malignant tumors of the liver that arises from the epithelium lining the small intra and extrahepatic bile ducts, and has numerous histologic types and growth patterns. At computed tomography (CT) and magnetic ressonance (MR), it has various appearences which motivated the present study;we present a case within an atypical presentation. The objective is to show the variety of differential diagnoses before an atypical aspect and the importance of the imaging methods for the diagnosis. Cholangiocarcinoma is still an uncommon neoplasm, and CT and MR are crucial for accurate diagnosis and for differentiation from other hepatic tumorous and nontumorous lesions.

Selection criteria for preoperative endoscopic retrograde cholangiopancreatography before laparoscopic cholecystectomy and endoscopic treatment of bile duct stones:Results of a retrospective,single center study between 1996-2002

AIM: The optimal treatment for bile duct stones (in terms of cost, complications and accuracy) is unclear. The aim of our study was to determine the predictive factors for preoperative endoscopic retrograde cholangiopancreatography (ERCP).METHODS: Patients undergoing preoperative ERCP (≤90 d before laparoscopic cholecystectomy) were evaluated in this retrospective study from the 1^st of January 1996 to the 31^st of December 2002. The indications for ERCP were elevated serum bilirubin, elevated liver function tests (LFT), dilated bile duct (≥8 mm) and/or stone at US examination, coexisting acute pancreatitis and/or acute pancreatitis or jaundice in patient's history. Suspected prognostic factors and the combination of factors were compared to the result of ERCRRESULTS: Two hundred and six preoperative ERCPs were performed during the observed period. The rate of successful cannulation for ERC was (97.1%). Bile duct stones were detected in 81 patients (39.3%), and successfully removed in 79 (97.5%). The number of prognostic factors correlated with the presence of bile duct stones. The positive predictive value for one prognostic factor was 1.2%, for two 43%,for three 72.5%, for four or more 91.4%.CONCLUSION: Based on our data preoperative ERCP is highly recommended in patients with three or more positive factors (high risk patients). In contrast, ERCP is not indicated in patients with zero or one factor (low risk patients).Preoperative ERCP should be offered to patients with two positive factors (moderate risk patients), however the practice should also be based on the local conditions (e.g.skill of the endoscopist, other diagnostic tools).

Modalities of testing Helicobacter pylori in patients with nonmalignant bile duct diseases

AIM:This paper describes the procedure of detection of Helicobacter pylori(H.pylori)in bile specimens in patients suffering from benign diseases of biliary ducts(lithiasis with/without nonspecific cholangitis). METHODS:The group of 72 patients entering the study consisted of 32 male and 40 female(45 % and 55 %, respectively).Bile was obtained during ERCP in 68 patients, and during cholecystectomy in 4 patients.A fast urease test (FUT)to determine the existence of H.pylori in gastric mucosa was carried out for all the patients during the endoscopic examination.The existence of genetic material of H.pylori was determined by detection of ure A gene by the method of nested PCR.The results of this reaction were shown by electrophoresis on 10 g·L^(-1)agarose gel in a band of 256 bp. RESULTS:The majority of the patients included in our study had biliary lithiasis without signs of cholangitis(48 patients, 67 %),whereas other patients were complicated by cholangitis(17 patients,24 %).Seven patients(9 %)had normal ERCP,forming thus the control group.In the group of patients with lithiasis 26 patients(24.2 %)had positive PCR of H.pylori in bile and among the patients with associated cholangitis positive PCR was detected in 9 patients(52.9 %).Among the seven patients with normal ERCP only one(14 %)had positive PCR of H.pylori.A high percentage of H.pylori infection of gastric mucosa was observed(57 patients,79 %).It was also observed that its slightly higher positivity was in the patients with distinct bile pathology:81% FLIT positive patients in the group with choledocholithiasis alone and 76 % in the group with choledocholithiasis associated with cholangitis.Seventy-one percent of the patients with regular findings had positive FUT.CONCLUSION: The prevalence of H. pylori infection both in bile and in gastric mucosa in patients with benign diseases of biliary ducts does not show a statistically significant difference in relation to the prevalence of the same with the patients with normal ERCP. The existence of H. pylori infection possibly does not play a role in pathogenesis of benign biliary diseases.

A study of bile kinetics and flow pattern of human gallbladder in vivo

Based on the principle of fluid mechanics a mathematical model of the oval gallbladder’smoving boundaries was obtained by CT,radio contrast radiography and B mode echography.Weadopted for the first time in this field,the finite element method to calculate the transient flow fieldwithin the human gallbladder in vivo and successfully made out the distribution of bile flow withinthe cyst,known as Newtonian fluid and axisymmetric flow.Thus we completed the poineering ofthe bile flow study within the gallbladder,and confirmed the way of the cholelithogenesis withinthe cyst.Theoretically the vortex flow is proved to be the mechanical factor in the formation ofgallbladder stone and several conclusions were drawn from this study:(1)near the axis of thecontacting gallbladder exists an accelerated bile out-flow column;(2)near the central cross-section ofthe flow field there exist two opposed vortex areas,the one which near the axis rotatescounterwise and flows faster;(3)a gross similarity exists between the law of attenuation of bile flowvelocity and the gallbladder contraction;(4)chololithogenesis within the cyst is related to the vortex inthe flow field.

Sinistroposition of the gallbladder and common bile duct

BACKGROUND: Despite its rare incidence, few cases of left-side gallbladder have been already published. METHODS: We reported herein the case of a 29-year-old man with a left liver tumor in whom left lateral bisegmen- tectomy was mandatory. It represents the first description of a sinistroposition of both gallbladder and common bile duct. RESULTS: Surgical exploration revealed a left-side gall- bladder , located under the left lobe of the liver. During he- patic parenchyma dissection at the left side of the round liga- ment and the Rex recessus, the common bile duct was in- jured. Complete separation of hepatic pedicle structures showed that the upper biliary convergence passed on the left side of the Rex recessus before reaching the hepatoduo- denal ligament. CONCLUSION: Only careful dissection of the hepatoduo- denal ligament up to Rex recessus level prior to liver paren- chyma resection could avoid biliary tract injury during left lobectomy.

Servqual模型评价肝内外胆管结石微创手术护理质量的研究

目的探究Servqual模型在评价肝内外胆管结石微创手术护理质量中的应用效果。方法选取2021年1月至2022年6月于九江市第一人民医院肝胆外科行肝内外胆管结石微创手术的200例住院患者作为研究对象,采用随机数字表法分为对照组与观察组,每组100例。对照组给予常规护理,观察组给予改进护理干预。两组均采用Servqual量表评估护理质量。比较两组护理质量评分,采用单因素分析和多元线性回归分析护理质量的影响因素。结果观察组移情性、保证性、反应性、可靠性、有形性及总分服务期望(E)、服务感知(P)、感知服务质量(SQ)值均高于对照组,差异有统计学意义(P<0.05);单因素分析结果显示,不同学历、家庭人均月收入、医疗支付方式、不良情绪、自理能力、病房环境、护理人员态度的患者SQ值比较差异有统计学意义(P<0.05)。多元线性回归分析结果显示,家庭人均月收入、医疗支付方式是护理质量的影响因素(P<0.05)。结论Servqual模型评价肝内外胆管结石微创手术的护理质量具有可靠性,可有效评估护理干预中存在的问题,并提出相应改进对策,提升护理质量。

Surgical treatment of the biliary ductal stricture complicating localized left hepatolithiasis

AIM To summarize the experience in the clinical treatment of the biliary ductal strictures complicating localized left hepatolithiasis in recent two decades.