Proximal bile duct tumors

Modern radiologic diagnostic approaches that identify patients with high bile duct cancer can predict resectability and provide information for biliary-enteric bypass in the case of irresectability. Twenty percent to 40% of patients are resectable by local excision with or without hepatic resection, and this represents the only opportunity for cure. Operative mortality is now acceptable and resection is associated with a median survival of approximately 35 months. Numerous palliative operative and nonoperative approaches are available, including biliary-enteric bypass, transtumoral stenting, and percutaneous endoprostheses. The role of both intraluminal and external beam radiotherapy also is discussed.     

Villous adenoma of the colon with severe fluid and electrolyte depletion: report of a case

A case of severe fluid and electrolyte depletion resulting from a massive villous adenoma of the rectosigmoid colon is presented. The syndrome is discussed, and the often insidious presentation and life-threatening aspects are emphasized.     

Choledochocele of the common bile duct

The eighth report case of choledochocele is described. This lesion is a cyst communicating with the terminal portion of the common bile duct. It is characteristically lined with duodenal mucosa and is probably a form of duplication of the duodenum. The surgical treatment is marsupialization of the cyst to the interior of the duodenum.     

Metal stents for benign and malignant bile duct strictures stents for benign and malignant bile duct strictures

Self-expanding metal stents provide a much larger diameter--up to 30 Fr--in comparison with plastic stents, which have a maximum diameter of 12 Fr. Although they have consequently been found to be far superior to plastic prostheses, they are not removable, and in benign strictures metal stents should therefore be used only in exceptional situations. Metal stents are the preferred mode of treatment for malignant strictures, provided the patient has a sufficient life expectancy although this is hard to predict in individual cases. Metal stents also seem to be superior in hilar malignancy, but the data here are limited. Future developments may include the use of covered metal stents and self-expanding stents (made of plastic or other materials) that are removable or self-dissolving.     

Papillary mucinous adenoma arising in adenomyomatous hyperplasia of the gall bladder

A case of papillary mucinous adenoma arising in adenomyomatous hyperplasia (AMH) of the gall bladder is reported. The lesion was unsuspected and discovered by routine palpation of the gall bladder during laparotomy. The adenoma developed within fundal AMH and showed cytological atypia. This case illustrates that neoplastic proliferation is indeed possible in AMH and challenges the classical opinion that AMH is devoid of neoplastic potential.     

Pyloric gland adenoma of the main pancreatic duct

A case of a pyloric gland type adenoma of the main pancreatic duct in a 69-year-old woman is reported. The tumor led to occlusion and cystic dilatation of the main duct in the pancreatic tail. The surgical resection specimen disclosed a polypoid, bilobed mass attached to the wall of the main pancreatic duct by a thin fibrous stalk. Light-microscopic examination revealed a well-demarcated nodule composed of closely packed tubular glands lined by columnar, mucin-secreting cells with abundant clear cytoplasm and basally oriented nuclei. Focal, mild cytologic atypia was seen. Pyloric metaplasia and focal papillary hyperplasia was present in the adjacent ductal epithelium. Periodic acid-Schiff reactions, with and without diastase predigestion, showed reactivity in the tubular glands, whereas alcian blue (pH 2.5) was negative. Immunohistochemical stains for chromogranin, serotonin, somatostatin, and gastrin failed to detect the respective antigens. Genetic analysis using polymerase chain reaction with mutant enrichment and allele specific oligonucleotide hybridization detected a single mutation at codon 12 of K-ras, which changed the wild-type glycine to arginine. This mutation is commonly found in invasive pancreatic ductal carcinomas. Although tumors with microscopic and immunohistochemical features consistent with pyloric gland adenoma have been described in the gallbladder, to our knowledge, this is the first reported case within the pancreatic ductal system. The finding of a K-ras, codon 12 mutation and the presence of focal dysplasia may denote neoplastic potential in association with this lesion.     

Effect of bile duct ligation on bile acid metabolism in rats

The effect of bile duct ligation on the quantitative and qualitative changes of bile acids in serum, liver, urine, and feces, and the concentration of cholesterol and phospholipids in serum and liver were examined in male rats. The concentration of bile acids in serum increased over 100-fold on day 5 but was lower than the 5-day level on days 10 and 15. The concentration in the liver also increased about 10-fold. beta-Muricholic acid predominantly increased but the secondary bile acids, deoxycholic acid and hyodeoxycholic acid, decreased. The urinary excretion of bile acids increased to about 40 mg/day per rat on the first day of bile duct ligation but this increase was reduced on day 2 to about half and remained at that level until day 24. These values exceeded that of fecal bile acids, 12 mg/day per rat, before bile duct ligation. The amount of bile acid sulfates in the urine was as low as 1% of the total. The urinary non-sulfated bile acids consisted mainly of beta-muricholic acid (60%) and cholic acid (20%), while the sulfates contained a considerable amount of unidentified acidic substances (40%) in addition to cholic acid and beta-muricholic acid. The concentration of cholesterol and phospholipids in serum markedly increased on day 5 but declined gradually thereafter. The liver cholesterol concentration did not change but the phospholipid concentration decreased. Fecal sterols did not change in both the total amount and composition. These data indicated that daily synthesis of bile acids, especially beta-muricholic acid, was accelerated in bile duct-ligated rats.     

Prognosis and treatment of bile duct carcinoma

Bile duct carcinomas present a therapeutic challenge because of different histologies, tumor locations, and resectabilities. The goal of our study was to identify prognostic factors to better delineate therapeutic options. Forty patients (30 males and 10 females) diagnosed with bile duct cancer, treated between 1985 and 1996, at Kaiser Permanente Medical Center, Los Angeles were retrospectively reviewed. Three prognostically significant variables were identified: tumor histology, tumor location, and resection. Papillary histology was the most significant determinant of long-term survival. Of six patients with papillary adenocarcinoma, four patients (67%) underwent resection, with all four achieving long-term survival. Lower-third lesions also demonstrated a survival advantage. Four out of 12 (33%) lower-third tumors were resected, with a median survival of 36 months. Irrespective of tumor histology or tumor location, tumor resection always afforded longer survival times than did palliative treatments. A prognostic classification system based on weighted values of significant variables is presented that accurately predicted long-term survival. In conclusion, bile duct tumors in general are incurable, except perhaps for a small subset of patients with papillary adenocarcinoma. Papillary histology is the most significant determinant of ultimate survival and cure. A multifunctional prognostic classification system can be helpful for this perplexing disease.     

Medical management of common bile duct stones

Common bile duct stones are a common cause of morbidity and mortality in adults. An increasing number of surgical and medical therapies are available to manage them, with different success rates reported. The various medical treatment strategies were developed during the last decade, but these medical modalities should not be contemplated as a first-line alternative of treatment. A consensus from experts is that there is no primary indication to use solvents on common bile duct stones because they have a relatively high rate of adverse effects and their success is limited compared with lithotripsy. However, there is a subgroup of patients in whom invasive or surgical treatment is risky or may fail. In these patients stone dissolution by solvent may constitute a plausible therapeutic alternative or may help reduce the size of the stones sufficiently to facilitate subsequent endoscopic extraction. Solvents may also be indicated in settings where endoscopic techniques or lithotripsy are not available and the patient has a T-tube in the common bile duct. Even in this condition, however, it is probably quicker and more effective to refer the patient to a center with expertise and technologic support to practice stone removal.