Prognostic factors and management of carcinomas of the gallbladder and extrahepatic bile ducts

Cancers of the biliary tract are uncommon but aggressive malignancies that pose difficult problems in diagnosis and management. Long-term survival with these cancers is limited by their propensity for local invasion, so that pathologic stage becomes a major prognostic factor, and by their ability to cause biliary obstruction and sepsis and interfere with hepatic function. In selected patients, surgical resection offers the possibility of cure, but effective palliation is often the principal goal of treatment. Radiologic and endoscopic modalities thus often play a major role in patient management.     

Congenital dilatation of the bile ducts

Our experience with five cases of cystic dilatation of the extrahepatic bile ducts is reported and compared with the literature. The following conclusions have been reached: (1) The etiology of this anomaly is primarily congenital but may involve an acquired component. (2) Diagnosis should be suspected when any of the triad of abdominal pain, right upper quadrant mass, or jaundice is present. (3) The diagnosis can usually be made in infants based on the clinical picture and routine radiologic studies. (4) Retrograde cholangiopancreatography is a useful tool in making the diagnosis in older children and adults. (5) Roux-en-Y choledochocystojejunostomy is the procedure of choice for type I cysts, excision for type II, and choledochocystoduodenostomy for type III.     

Reoperations of the extrahepatic bile ducts

The results of reoperations on the extrahepatic bile ducts in 82 patient s performed, mainly, for undetected and uncorrigated changes in the extrahepatic bile ducts caused by diagnostic, tactical and technical errors made during the first operation are presented.     

Primary lithiasis of the bile ducts

An analysis is made of 24 cases of primitive lithiasis of the biliary tracts, viz; 10 of diffuse intrahepatic lithiasis, 9 of intrahepatic lithiasis localized in one of the ducts; and 5 of extrahepatic lithiasis. The most common cause were stenosis (14 cases) generally of idiopathic or congenital nature, followed by those of iatrogenic or tumoral origin. There were also cases of isolated or diffuse anomalus dilatation of the biliary ducts. A lithogenetic bile as well as infectious processes are rather considered secondary factors. The diagnosis of the real nature of the condiction was usually established in the postoperative period, this being an explanation why repeated surgery was so common (75%). There was a high postoperative mortality in the diffuse forms owing to severe manifestations of biliary sepsis perpetuated by the stones. Depending upon the individual cases the following procedures are proposed: 1) Biliodigestive anastomosis 2) Sphinteropapilloplasty 3) Dilatation and calibration of the stenosis 4) Postoperative instrumental extraction of calculi. The last-named procedure was carried out in 58% of the cases and result in an improvement in the serious prognosis. Primitive lithiasis should always be borne in mind when undertaking surgery of the biliary tracts in order to avoid additional surgery.     

Intraductal ultrasound of the bile ducts

Intraluminal ultrasound with 12.5 and 20 MHz transducer allows precise analysis of the extrahepatic bile ducts and the adjacent structures. Inflammatory and malignant thickening of the bile duct wall can be assessed without difficulty. It is not possible, however, to differentiate between benign and malignant bile duct thickening, and for this purpose biopsy is required in addition. In tumor staging intraluminal ultrasound is superior to conventional ultrasound, because tumor infiltration into the adjacent tissues can be assessed and lymph nodes along the hepaticoduodenal ligament can be detected. Owing to the ultrasound frequencies available, local staging is limited to a circumference of 1.5/2 cm. Intraluminal ultrasound provides additional information that is useful in the diagnosis and therapy of bile duct stones and in different types of palliative tumor therapy. The procedure is simple and not too time consuming, and it involves no risks to the patient.     

Topometry of normal intrahepatic bile ducts

This paper focuses on practical problems which may also prove to be of theoretical importance, by presenting a method of establishing an exact topometry of the intrahepatic bile ducts. Measurements were made on corrosive casts of the intrahepatic bile ducts from 13 human livers. On the basis of the topometric results presented it is possible to construct an adequate model by means of plastic tubes and to use it for the study of bile flow.     

Free fatty acids in gallbladder bile

Using gas chromatography and high performance liquid chromatography (HILC), we examined free fatty acid and lecithin molecular species in gallbladder biles from patients with cholesterol gallstones. Effect of free fatty acids on cholesterol nucleation in model bile was studied by a sensitive cholesterol crystal growth assay. Compared to bile of controls, biles from patients with gallstones had higher total free fatty acid level, more palmitic acid, more stearic acid, more linoleic acid and arachidonic acid. The lecithin pattern was similar in all. After free fatty acids were added to model bile, palmitic acid, oleic, acid, linoleic acid and arachidonic acid had significant effect of pro-nucleating, free fatty acids on non-protein pro-nucleating factor. These data suggest that variations in quantitation and composition of free fatty acids are importanct in the pathogenesis of cholesterol gallstone formation.     

Congenital cystic diseases of liver and extrahepatic bile ducts

The paper presents 30-year experience in treating 158 patients with congenital cystic diseases of the liver and bile ducts. Depending on the pattern of hepatobiliary lesions, the diagnostic value of techniques, such as ultrasound, computerized tomography, scintigraphy of the liver duodenoscopy with THCG was defined. Analyzing the late outcomes provided recommendations for the most optimal surgical management: cystic fenestration and tunneling in hepatic polycystosis, pericystectomy in solitary cysts of the liver, different varieties of bile draining operations in choledochal cysts and Caroli's disease.     

Formation and inhibition of lysolecithin in human gallbladder bile

Homogenized human gallbladder epithelium was incubated at 37 degrees C with 14C-lecithin in diluted gallbladder bile. During the incubation, lecithin was transformed to lysolecithin. The reaction rate was higher at pH 4.5 than at pH 7.0. No degradation of lecithin occurred if the reaction mixture did not contain the homogenate. Lysolecithin was mixed with red blood cells in (a) diluted human gallbladder bile and (b) 0.15 M saline. The surface activity in the different systems was then assessed from the amount of hemoglobin recovered in the red cell pellet after centrifugation. In human bile, 500 mug lysolecithin/ml did not affect the amount of hemoglobin recovered whereas in saline, concentrations exceeding 25-30 mug/ml affected the red blood cells such that no hemoglobin was pelleted by the centrifugation. Lysolecithin was further studied for effect upon lecithin-3H-cholesterol-dicetylphosphate liposomes containing 14C-glucose. The surface activity of lysolecithin was assessed from the distribution of 3H- and 14C-activity after centrifugation. Although 500 mug lysolecithin/ml increased the non-sedimented 14C-activity, 5000 mug lysolecithin/ml was necessary to decrease significantly the amount of sedimented 3H-activity. The results are interpreted such that phospholipase A activity from the gallbladder epithelium, if released into the gallbladder bile, may generate lysolecithin from lecithin. However, the surface activity and, thus, the inflammatory mediating activity of lysolecithin is inhibited by components in the gallbladder bile, possibly lecithin.     

Hepatocellular carcinoma presenting as a tumour of the hilar and extrahepatic bile ducts

A case of hepatocellular carcinoma extending within the large extra- and intrahepatic bile ducts is reported. No primary tumour was found in the liver parenchyma by abdominal ultrasound, spiral computed tomography or magnetic resonance, but transduodenal cholangioscopy showed tumour in the common hepatic ducts and the two main branches. Endoscopic biopsy showed highly differentiated hepatocellular carcinoma. The patient was treated with endoscopic biliary drainage and died at home 7 months after admittance.     

MRI cholangiopancreatography in the pathology of the bile ducts and pancreas

MR cholangiopancreatography (MRCP) is a recent and exciting imaging modality that allows visualization of bile and pancreatic ducts without morbidity. Although the technique of MRCP is in its early stages of development and MRCP technology is progressing MRCP will undoubtedly replace traditional techniques such as diagnostic ERCP. This article describes MRCP findings in bile or pancreatic duct diseases, analyzes the accuracy of MRCP in these diseases, and discusses the potential role of MRCP in evaluating the pathology of the biliary tract and pancreas.