Traumatic neuromas of the head and neck

An interesting case of a traumatic neuroma of the greater auricular nerve provides the impetus for a discussion of head and neck neuromas. Traumatic neuromas of the head and neck are relatively rare. Division of the greater auricular nerve during parotidectomy occasionally results in a traumatic neuroma. We report a case of a 73-year-old woman who presented with a traumatic neuroma nine years after undergoing superficial parotidectomy with dissection of the facial nerve for a mixed tumor. The patient had a 1.5 cm x 1.0 cm mass located below the old surgical site over the anteromedial border of the sternocleidomastoid muscle. The patient's past history was significant for Frey's syndrome, which is the result of abnormal neurologic growth. On first impression, the tumor was thought to be a recurrence of neoplastic disease; however, because of the evaluation, traumatic neuroma was suspected. An attempt at fine-needle aspiration of the mass was too painful to be carried out. At surgery, a whitish tumor was excised which, on final pathologic examination, revealed traumatic neuroma. The surgical literature is reviewed and the subject of head and neck neuromas, including their evaluation and management, is thoroughly discussed. Knowledge of this possible diagnosis may spare the patient and the surgeon needless worry, as well as unnecessary procedures, once tumor recurrence has been ruled out.     

Traumatic biliary stricture successfully treated by percutaneous transhepatic bile duct dilatation: a case report

A 24 year-old woman complained of obstructive jaundice 24 days after blunt abdominal trauma due to a traffic accident. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a stricture, 15 mm in length, at the common bile duct associated with upper bile duct dilatation. Jaundice was reduced by percutaneous transhepatic cholangio-drainage (PTCD). A 7 Fr-sized PTCD tube was exchanged for a larger-sized catheter for percutaneous transhepatic cholangioscopy expecting gradual dilatation of the stricture. Following the confirmation of satisfactory dilatation of the stricture, the catheter was removed. There was no recurrence of jaundice 16 months later in a follow-up study.     

Yamakawa prosthesis with prolonged placement as a therapy concept exemplified by benign biliary stricture

AIM: As an alternative method to the operative revision of benign bile duct strictures, we report the use of a large-bore bile duct prosthesis (Yamakawa prosthesis) in one patient. METHODS: Bilateral percutaneous transhepatic implantation of Yamakawa prostheses (14 F right side, 12 F left side) was performed without adjunctive balloon dilatation. The prostheses were exchanged every 8 weeks under continuous antibiotic treatment and were finally removed after 8 months. RESULTS: Control cholangiography showed a normal intrahepatic biliary system on the right side and a 50% stenosis at the orifice of the left hepatic duct. Follow-up over 18 months showed no signs of recurrent disease. CONCLUSIONS: In comparison to balloon dilatation and implantation of metallic stents, prolonged bilateral splinting with large-bore Yamakawa prostheses seems to be an alternative for the treatment of benign bile duct strictures.     

Psychopathology as adaptive development along distinctive pathways

The vast majority of post-operative bile duct strictures occur following cholecystectomy, these injuries having been seen at an increased frequency since the introduction of laparoscopic cholecystectomy. Bile duct injuries usually present early in the post-operative period, obstructive jaundice or evidence of a bile leak being the most common mode of presentation. In patients presenting with a post-operative bile duct stricture months to years after surgery, cholangitis is the most common symptom. The 'gold standard' for the diagnosis of bile duct strictures is cholangiography. Percutaneous transhepatic cholangiography is generally more valuable than endoscopic retrograde cholangiography in that it defines the anatomy of the proximal biliary tree that is to be used in surgical reconstruction. The most commonly employed surgical procedure with the best overall results for the treatment of bile duct stricture is a Roux-en-Y hepaticojejunostomy. The results of the surgical repair of bile duct strictures are excellent, long-term success rates being in excess of 80% in most series. Recent data have suggested that, at intermediate follow-up of approximately 3 years, an excellent outcome can be obtained following repair of bile duct injuries after laparoscopic cholecystectomy. Percutaneous and endoscopic techniques for the dilatation of bile duct strictures can be useful adjuncts to the management of bile duct strictures if the anatomical situation and clinical scenario favour this approach. In selected patients, the results of both endoscopic and percutaneous dilatation are comparable to those of surgical reconstruction.     

Efficacy of endoscopic diagnosis and treatment for postoperative biliary leak

BACKGROUND/AIMS: The purpose of this study was to evaluate the efficacy of endoscopic approaches for the diagnosis and treatment of postoperative biliary leak. METHODOLOGY: Endoscopic retrograde cholangiopancreatography (ERCP) was performed in eight patients with postoperative biliary leak. Of 8 cases, 6 had biliary leak alone (4 cases with a cystic duct leak and 2 cases with a bile duct leak) and 2 cases with a bile duct leak were associated with a bile duct stricture. Endoscopic sphincterotomy (ES) and endoscopic biliary stenting (EBS) were employed in 5 patients and nasobiliary tube drainage (NBD) without ES was performed in 3 patients. RESULTS: In all the patients, ERCP was successfully performed and could demonstrate exact nature and site of postoperative bile duct injuries. In 2 patients with a concomitant bile duct stricture, repetitive endoprosthesis placements were required. The remaining six patients with biliary leak alone were successfully treated by temporary stenting, i.e., ES and EBS (n = 3), and NBD (n = 3). CONCLUSIONS: The patients with postoperative biliary leaks can be successfully diagnosed by ERCP and treated by temporary endoscopic methods. Among various endoscopic treatments, NBD alone appears to be preferable in treating patients with small bile leaks. However, cases with a concomitant bile duct stricture were intractable and required longer period of stenting.     

Bile duct injury following laparoscopic cholecystectomy: referral pattern and management

BACKGROUND: Laparoscopic cholecystectomy is associated with a higher incidence of bile duct injury than open cholecystectomy. This study reviews the management of bile duct injury in a tertiary hepatobiliary unit. METHODS: From 1991 to 1995, 27 patients (18 women) of median age 49 (range 25-67) years were referred to this unit with bile duct injury following elective laparoscopic cholecystectomy. Laparoscopic cholecystectomy was described as 'uneventful' in 14 and 'difficult' in 13 patients; six injuries were recognized at operation. RESULTS: Patients were transferred a median of 26 (range 0-990) days after laparoscopic cholecystectomy, although initial symptoms were recorded a median of 3 (range 0-700) days after cholecystectomy. Fifteen patients underwent additional surgery before referral. Management before referral included surgical exploration (15 patients), endoscopic cholangiography (ERC) and stent insertion (three), external drainage of bile collections (five), and conservative management (five). Management after referral included surgical reconstruction (19 patients), laparotomy with drainage (one), percutaneous drainage (two), ERC and stent insertion (two), percutaneous cholangiography with dilatation and stent placement (three), and conservative management (two). One patient died and the median inpatient stay following referral was 14 (range 7-78) days. Ten of 15 patients who had surgery before referral required a further biliary reconstruction. After median follow-up of 30 (range 3-60) months, four of nine patients with complex high injuries continue to have episodes of cholangitis and one patient has developed secondary biliary cirrhosis. CONCLUSION: Bile duct injury following laparoscopic cholecystectomy is a complex management problem and results in significant postoperative morbidity. Most patients referred after attempted repair require further reconstructive surgery, and patients with complex high injuries have a risk of long-term morbidity.     

Usefulness of cholangioscopy in patients with focal stricture of the intrahepatic duct unrelated to intrahepatic stones

BACKGROUND: Intrahepatic duct strictures are usually caused by intrahepatic duct stones and cholangitis. However, focal strictures of the intrahepatic duct unrelated to intrahepatic stones often pose diagnostic problems. This study was undertaken to prospectively evaluate the usefulness of percutaneous transhepatic cholangioscopy in patients with focal intrahepatic duct stricture and no evidence of a stone. METHODS: Seventeen patients with focal strictures of the intrahepatic duct without any evidence of a stone were included. Percutaneous transhepatic cholangioscopic examination including procurement of biopsy specimens was performed after percutaneous transhepatic biliary drainage. RESULTS: A histopathologic diagnosis was obtained in all patients (9 adenocarcinomas, 1 squamous cell carcinoma, 2 hepatocellular carcinomas, 2 adenomas, and 3 benign strictures). Of the 9 patients with bile duct adenocarcinoma, 8 underwent surgery and a curative resection was possible in 7 patients (88%). Five patients (63%) had early-stage bile duct cancer in which cancer invasion was limited to the mucosa or fibromuscular layer and there was no evidence of lymph node metastasis. CONCLUSIONS: Percutaneous transhepatic cholangioscopy in patients with focal stricture of the intrahepatic duct unrelated to choledocholithiasis is useful for diagnosis including the detection of early bile duct cancer.     

Fibrotic stricture of the extrapancreatic biliary tract: a new complication of acute pancreatitis. Two cases

Two cases of fibrotic stricture of the extrapancreatic common bile duct were observed 3 and 5.5 months after severe acute alcoholic pancreatitis. The diagnosis was made by endoscopic retrograde cholangiography in both cases. Although colonic or ureteric stenosis have been reported after acute pancreatitis, this is the first report of extrapancreatic biliary stricture occurring after acute pancreatitis. The strictures could have arisen by either an enzymatic or ischemic mechanism. Outcome was favorable after surgical hepaticojejunostomy.     

Cancer arising in choledochal cyst and management

Biliary cancer develops in 20-30% of the patients with choledochal cyst and pancreatobiliary malunion. Some bile acid fractions and refluxed pancreatic enxymes into the bile duct is probably responsible for carcinogenesis. Cancer often develops in the extrahepatic bile duct and gallbladder, and rarely in the intrahepatic duct. In cystic dilatation, cancer often occurs in the common bile duct, while in diffuse or non-dilated type it occurs in the gallbladder. Cancer usually occurs in younger patients than does biliary cancer in general population, and the average age is in the 40s. The risk of malignancy in cysts with internal drainage is higher than that in primary cysts, and early removal of the retained cyst should be performed as quickly as possible. Although the prognosis of biliary cancer is usually dismal, aggressive procedures are recently gaining better results than that by conventional methods. The prevention of cancer is the procedure of choice by early excision. Removal of the whole extrahepatic bile duct is necessary, even in case of malunion with no biliary dilatation. Cancer rarely arises in the intrahepatic duct after excisional surgery, due to long standing biliary stricture. Wide anastomosis with ductoplasty should be essential. Cancer also occurs in the remnant duct. Excision of the distal duct in the pancreas is also necessary.     

Evaluation of MRCP compared to ERCP in the diagnosis of biliary and pancreatic duct

Recently, Magnetic Resonance Cholangiopancreatography (MRCP) is developed as a noninvasive diagnostic modality in the diagnosis of biliary and pancreatic tract. Using Endoscopic Retrograde Cholangiopancreatography (ERCP) as the gold standard, we evaluated the diagnostic quality of MRCP and direct cholangiography. Fifty-six patients (9 cases of cholangiocarcinoma, 5 of gallbladder carcinoma, 1 of gallbladder carcinoma and anomalous arrangement of pancreaticobiliary ductal system, 4 of cholecystlithiasis, 3 of papillary carcinoma, 1 of adenomyomatosis of the gallbladder, 1 of primary sclerosing cholangitis, 1 of hepatolithiasis and postoperative bile duct stricture, 4 of mucin producing pancreatic tumor, 13 of pancreatic carcinoma, 1 of chronic pancreatitis and pancreas divisum, 9 of chronic pancreatitis, and 1 of chronic pancreatitis and biliary stricture) are studied prospectively with MRCP and direct cholangiography (included ERCP and percutaneous transhepatic cholangiography). The image of MRCP accorded with direct cholangiography in twenty-two of 27 patients with biliary tract disease, and in sixteen of 29 patients with pancreatic disease. The different diagnosis is observed in ten of 56 patients. In cases of not visualized gallbladder, pancreatic cyst without communicated to the pancreatic duct, and pre-stenotic dilatation of biliary and pancreatic duct, the image of MRCP was better than that of ERCP. However, the image of MRCP for the diagnosis of either benign or malignant strictures, mucin producing pancreatic tumor, and a branch of pancreatic duct in patients with pancreatic carcinoma were not suitable for evaluation than that of ERCP. In our study, ERCP is superior to MRCP due to the important information for diagnosis such as mentioned above. Therefore we advocate using ERCP as the first diagnostic tool in the diagnosis of biliary and pancreatic duct.     

MR cholangiography of congenital biliary malformations in infancy

We presented MR cholangiography (MRC) of congenital biliary malformations in infancy. MRC was obtained during induced sleeping. In two cases of congenital dilation of bile duct, MRC revealed cystic or spindle dilatation of intra- and extra hepatic bile ducts. In one biliary atresia, MRC revealed the serpentine gall bladder and cystic dilatation of the extrahepatic bile duct without connection to the dilated hilar bile duct. MR cholangiography, which can be obtained noninvasively, is useful for the diagnosis and the preoperative assessment of congenital biliary malformations in infancy.     

Effect of simultaneous exercise and noise exposure (music) on hearing

BACKGROUND: Bile duct stone is a common biliary tract disease in Taiwan. Surgery and choledochoscopy are the current methods of treatment. This is a retrospective review of 65 cases who were admitted with postoperative biliary residual stones, or cholangitis secondary to the biliary stones. Percutaneous biliary stone removals under fluoroscopy were attempted. METHODS: Either a T-tube tract or percutaneous transhepatic cholangial drainage tract or both were used for stone removal. Angiographic superselective catheterization technique was applied for superselective cholangiography to identify the location of stones and to deliver basket and electrohydraulic lithotripsy probe to the site of the stones. Balloon dilation was applied for biliary stricture. RESULTS: Most of the cases needed multiple sessions (four, on an average) to remove all stones. There were 52% of the cases who needed balloon dilation for associated biliary strictures, and 7.7% of the cases had residual stones at the end of the procedure, because of technical difficulties. Chills and fever, pancreatitis, hepatic arterial injury and perforation of the common bile duct were procedure-related complications. In follow-up studies, 15% of the cases had recurrent biliary stones and 4.6% of the patients expired from malignant biliary tumors. CONCLUSIONS: Percutaneous biliary stone removal under fluoroscopy is beneficial for direct visualization of the location and number of the stones, and the architectural changes of the bile ducts. Superselective catheterization and balloon dilation were responsible for the high success rate (92.5%) here.     

Detection of choledocholithiasis: comparison of unenhanced helical CT and endoscopic retrograde cholangiopancreatography

PURPOSE: To compare unenhanced helical computed tomography (CT) and endoscopic retrograde cholangiopancreatography (ERCP) in the detection of common bile duct calculi. MATERIALS AND METHODS: Within 13 months, 51 patients (aged 18-94 years) with clinically suspected choledocholithiasis underwent unenhanced helical CT immediately before undergoing ERCP. CT scans were evaluated for the presence of bile duct stones, ampullary stones, the gallbladder and gallbladder stones, intrahepatic biliary dilatation, and the size of the bile duct at the porta hepatis and in the pancreatic head. ERCP images were evaluated for the presence of bile duct or ampullary stones, as well as for biliary dilatation. RESULTS: Unenhanced helical CT depicted common bile duct stones in 15 of 17 patients found to have stones at ERCP. Three patients had stones impacted at the ampulla, all of which were detected with CT. In addition, there was one false-positive finding at CT. CT had a sensitivity of 88%, a specificity of 97%, and an accuracy of 94% in the diagnosis of common bile duct stones. CONCLUSION: Unenhanced helical CT is useful for evaluating suspected choledocholithiasis.     

Surgical treatment of cicatricial biliary strictures

BACKGROUND/AIMS: Cicatricial biliary strictures are usually associated with high morbidity and mortality rates, frequently related to technical difficulties of their surgical repair, mainly in hilar lesions. Interference with bile duct blood supply during surgical attempts for correction is a major factor for unsuccessful results. The aim of this study is to evaluate, after an extended follow-up period, the results obtained with a modified technique for surgical correction of cicatricial biliary strictures. METHODOLOGY: The medical records of 57 patients surgically treated for cicatricial biliary strictures between January 1984 and July 1995 were reviewed and the immediate and long term results retrospectively analyzed. Patients consisted of 46 females and 11 males. The average age was 43 years. The etiology of the biliary lesion was: cholecystectomy alone (23); cholecystectomy with duct exploration (8); T tube CBD drainage (6); Biliary-enteric anastomosis stricture (16); choledochoplasty (2) and trauma (2). In 28 cases (49.1%) the stricture was located in the upper third of the bile duct, in 28 (49.1%) in the middle third and in one case (1.7%) it was low. All patients were submitted to longitudinal Roux-en-Y hepaticojejunostomy with mucosa apposition after dissection of the anterior aspect of the biliary tract. No transanastomotic stents were used. RESULTS: Ten patients (17.5%) presented 11 postoperative complications: biliary fistula (4), duodenal fistula (1), wound infection (5), and acute pancreatitis (1). Average hospital stay was 11 days and there were no postoperative mortalities. The follow-up study was possible in 54 patients and ranged from one to ten years, with an average of 2.9 years. Four patients of 28 (14%) with hilar lesions developed stricture recurrence and cholangitis episodes, whereas no patients bearing lesions below the biliary junction had such complications. CONCLUSION: Roux-en-Y hepaticojejunostomy with mucosa apposition without transanastomotic stent performed after minimal dissection of the biliary duct, thus avoiding major interference with the bile duct blood supply, is a safe and efficient method for the surgical repair of cicatricial biliary strictures. Using this technique excellent results can be obtained in the lesions below the biliary junction and acceptable results may be achieved in patients with hilar lesions.     

Crohn''s disease and sclerosing cholangitis: CT and PTC diagnosis, with MR findings

Computed tomography (CT), percutaneous transhepatic cholangiography (PTC) and magnetic resonance imaging (MRI) findings in a case of sclerosing cholangitis associated with Crohn's disease of the colon and terminal ileum are described. CT gives additional information on dilatation of peripheral bile ducts and confirms findings of PTC, i.e. a decreased arborization of the biliary tree, a nodular appearance of the common bile duct and multifocal bile duct strictures. CT findings could be recognized on MRI which provided no additional information.     

Intra-bile duct growth of hepatocellular carcinoma: value of biliary dilatation on CT

In order to evaluate the usefulness of CT in demonstrating biliary invasion by hepatocellular carcinoma, 191 surgically proved cases were studied. Among 191 CT scans performed before surgery, six (3%) showed biliary dilatation. Pathological biliary invasion was found in eight cases (4%). Of these eight cases, four cases (50%) showed biliary dilatation on CT. In six cases with biliary dilatation on CT, pathological biliary invasion was revealed in four cases (67%). In two cases, the large (> or = 6cm) encapsulated tumors located in the hepatic hilum dilated the intrahepatic bile duct without intraductal tumor growth. We concluded that biliary dilatation on CT cannot be a sign of biliary invasion by hepatocellular carcinoma.     

Mouth-nose ring to prevent cattle from sucking

A 45-year-old man presented with diarrhea and profound weight loss over one year. His serum alkaline phosphatase was raised and ultrasonography showed dilated intrahepatic biliary ducts and upper part of common bile duct (CBD). ERCP showed papillary stenosis, dilated CBD, stricture at the confluence and saccular dilatation of the left intrahepatic biliary ducts. He was found HIV-positive. Duodenal biopsy, rectal biopsy and stool examination could not identify any opportunistic organism.     

Chronic pancreatitis: a cause of cholestasis

The bile ducts were visualised using endoscopic retrograde cholangiopancreatography (ERCP), percutaneous or intravenous cholangiography in 38 patients with non-gallstone chronic pancreatitis. Stenosis of the intrapancreatic portion of the distal common bile duct was demonstrated in 11 patients. Ten of the 11 developed transient cholestasis during exacerbations of their chronic pancreatitis. In six cholestasis eventually persisted requiring surgical relief. Secondary biliary cirrhosis was present in one patient. No evidence of pancreatic carcinoma was found in the patients explored surgically. Ten of the patients are alive more than one year after diagnosis. Chronic pancreatitis was of alcoholic aetiology in 10 of the patients with biliary stenosis. Cholestasis and biliary stricture are common but poorly recognised complications of non-gallstone chronic pancreatitis, especially when pancreatitis is severe and due to alcohol.     

Lessons learned from a complicated case of cephalic obstructive chronic pancreatitis

The authors report the complex case of a 51 year-old man admitted to his local hospital for gallbladder and common bile duct lithiasis, 1 year before admission to our hospital. There, he was treated by cholecystectomy and transduodenal biliary sphincteroplasty. He was readmitted after 3 months because of a painful episode and was discharged with the diagnosis of "relapsing acute pancreatitis in chronic pancreatitis." At our hospital, he underwent laparotomy and revision of the previous transduodenal biliary sphincteroplasty. Pancreatic sphincteroplasty and septectomy were also performed. The night after surgery, the patient suffered from acute post-operative pancreatitis complicated by severe hemorrhage due to erosion of the superior pancreaticoduodenal arteries, treated with gastroduodenal artery embolization by tungsten coils. Three months later, the patient suffered from another acute episode. An endoscopic retrograde colangio pancreatography (ERCP) showed the complete patency of the sphincteroplasties but clearly identified the persistence of a severe cephalic stricture. Therefore, the patient was readmitted to our hospital and underwent another laparotomy. A pylorus-preserving pancreaticoduodenectomy (PPPD) was performed. The post-operative course was uneventful and at 14 months follow-up the patient was in good health. The discussion focuses on the surgical treatment of chronic pancreatitis with cephalic Wirsung duct stenosis, stressing the increasing role of PPPD as a first-choice option.     

False-positive whole-body iodine-131 scan due to intrahepatic duct dilatation

Focal retention of radioactivity in the liver on whole-body 131I scan was interpreted as a metastatic lesion in a patient with well-differentiated thyroid cancer. Intrahepatic duct dilatation, usually resulting from biliary tract obstruction by bile stone, is a common disorder and may cause bile stasis. A patient with papillary thyroid cancer and a previous history of biliary tract stones had focal retention of radioactivity in the liver on whole-body 131I scan. Abdominal CT, endoscopic retrograde cholagiopancreatography, radionuclide cholangiography and sequential 131I scans demonstrated that this focal retention of radioactivity was caused by intrahepatic duct dilatation. Focal retention of radioactivity is visualized on delayed images but not on early images. The radioactivity initially increases and then decreases on following days.