Klatskin-Mimicking Lesions

Altemeier-Klatskin tumor is a perihilar cholangiocarcinoma that occurs within 2 cm of the confluence of the right and left hepatic duct at the hepatic hilum and accounts for 50–70% of all cholangiocarcinomas cases. Although imaging techniques have come very far today, this entity can still be very challenging to diagnose as there are many lesions that can mimic Klatskin tumor. In this review, we will present the most common Klatskin-mimicking lesions.

Metastatic Neoplasms of the Large Bile Ducts- A Clinicopathological Study

Introduction/Objective Biliary strictures are often considered malignant until proven otherwise. While the majority of malignant biliary strictures represent a primary neoplasm, secondary involvement by metastasis also rarely occurs. Primary cholangiocarcinoma and metastatic disease have different treatment considerations and likely different prognoses. The aim of this study is to look at the clinico-pathological characteristics of metastatic neoplasms of the bile duct. Methods/Case Report We retrospectively searched the pathology archives for biliary biopsies between 1991-2020. Patients with primary biliary, gallbladder, pancreatic, ampullary and hepatic malignancies and all cases of lymphoma were excluded from the study. A total of 20 cases were included. Results (if a Case Study enter NA) The median age of the patients was 63 years with a M:F ratio of 1.9:1. The biopsies were taken from the common bile duct (n=17), common hepatic duct (n=2) and left hepatic duct (n=1). 8 patients had synchronous and 12 had metachronous presentation. The overall median interval between the bile duct metastasis and primary was 18 months (Range: 0-100 months) for all patients and 33 months for metachronous cases. For 13 tumors, the primary site of origin was in the gastrointestinal tract (colon: 7; stomach: 4; anal canal: 1; gastro-esophageal junction: 1). Other primary sites included breast (3 cases), lung, endometrium and adrenal (1 each). One case presented with metastatic melanoma with an occult primary. Adenocarcinoma was the most common histological subtype seen in 17 cases. Other histological subtypes were squamous cell carcinoma, adrenocortical carcinoma and melanoma. Conclusion Secondary involvement of the bile duct by metastasis is rare. Most cases are metastasis from the lumenal gastrointestinal tract, with colon being the most common primary site. They are more likely to have a metachronous presentation with rare instances of bile duct metastasis as the first presentation. Awareness of secondary involvement of the biliary tree by metastasis is important as they can have prognostic and therapeutic significance.

Endoscopic Endoluminal Radiofrequency Ablation and Single-Operator Peroral Cholangioscopy System (SpyGlass) in the Diagnosis and Treatment of Intraductal Papillary Neoplasm of the Bile Duct: A Case Report and Literature Review

Background: Intraductal papillary neoplasm of the bile duct (IPNB) is a rare biliary benign tumor with atypical clinical features and is frequently misdiagnosed. Its treatment is limited and surgical resection is thought to be the only therapeutic option in patients with IPNB. With the aim of increasing the early diagnosis rate of IPNB and providing more therapeutic options for surgeons, we innovatively put forward the concept of combined utilization of SpyGlass and endoscopic endoluminal radiofrequency ablation (ERFA) in the diagnosis and treatment of IPNB.Case Presentation: An 85-year-old woman was referred to our hospital due to right upper quadrant abdominal pain. The image examinations indicated suspicious filling defects at the upper common bile duct. Further evaluation of SpyGlass cholangioscopy showed multiple reddish villous lesions at the left hepatic duct, and SpyBite biopsy under direct visualization demonstrated papillary low-grade dysplasia. In consideration of the advanced age and preference of the patient, the novel ERFA therapy was performed. The procedure was successful without periprocedural complications; the patient recovered uneventfully and was discharged 2 days after the operation. Upon follow-up, the patient was asymptomatic and in good physical condition at 8 months postoperatively.Conclusion: Preliminarily, we demonstrate that the strategy of a combination of SpyGlass and ERAF seems to be a promising, feasible, well-tolerated, and safe management for patients with IPNB. However, more data with larger patient volumes are needed to evaluate its outcomes further.

Laparoscopic Approach to Left Hepatectomy Using a Standardized Technique

Introduction: The laparoscopic approach in liver surgery has been preferred over the traditional approach in the resection of segments 2 and 3, as laparoscopic surgical technique can be standardized for easy adoption and is minimally invasive. This paper describes the laparoscopic surgical technique and recommends the patient selection criteria in the resection of segments 2, 3 and 4. Methods: This technique involves 2 key steps – early division of the left pedicle before the division of the liver parenchyma and the placement of an instrument beneath the transection plane to simulate a ‘hanging manoeuvre’ with reduced blood loss and allows the expeditious division of the liver parenchyma. Apart from the usual contraindications to liver resections, specific contraindications to this technique include patients with aberrant biliary drainage of right liver segments into the left hepatic duct, patients with tumours abutting the hilar plate and patients with tumours located near the junction of the left hepatic vein and the vena cava. Conclusion: The authors recommend these steps to serve as a standardized technique for laparoscopic hepatectomy of segments 2,3 and 4 in selected patients, allowing the learning curve for this technique to be markedly shortened

Ultrasonic Diagnosis of Intestinal Loop Obstruction After Introducing Loop Syndrome After Subtotal Gastrectomy

In this paper, a graphical diagnosis of intestinal loop obstruction input into the loop syndrome after subtotal gastrectomy based on ultrasound diagnosis is more fluid accumulating in the bridge loop. The pressure in the intestinal loop is constantly rising, causing bile and pancreatic juice excretion disorder, and dilation of intrahepatic and external bile ducts or dilation of pancreatic ducts, which is similar to the anatomical features of low biliary obstruction. For dilated bowel, the expansion of the upstream drainage pipe organ changes in physiological and pathological anatomy pathological bridge loop obstruction. The ultrasound can show good and on the ming stomach ultrasound pictures of patients with loop syndrome after major resection were analyzed. Most patients with hepatic shape changed the left hepatic duct dilatation, and the inner diameter is 4.8 cm and the length is 18.0 cm. The wall of the tube is a multi-layer structure, and fold-like echoes can be seen. The lumen does not pass through the angle between the superior mesenteric artery and the abdominal aorta. Patients with a history of pancreas Whillp or Child type surgery or a history of Roux-en-Y type biliary jejunum have clinical manifestations of bowel obstruction. The ultrasound of their bridge loop obstruction showed a long tubular anechoic dark area in the upper abdomen and dilation of the upstream drainage organ duct.

EXPERIENCE OF EVALUATION OF PATIENTS OF OBSTRUCTIVE JAUNDICE BY SONOGRAPHY AND MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY AT A TERTIARY CARE CENTRE IN EASTERN INDIA

INTRODUCTION: Jaundice means yellow due to the yellowish discolouration of skin, sclera, and mucous membrane seen in jaundice caused by bilirubin pigment. It is divided in to two forms obstructive(surgical) and non- obstructive (non-surgical). AIM AND OBJECTIVE: To evaluate patients of obstructive jaundice by sonography and magnetic resonance cholangiopancreatography and compare the reporting and ndings by both the modalities. MATERIALS AND METHODS: Cross sectional observational study done from November 2018 to October 2020 and consists of 32 patients who had clinical jaundice and consented to being subjected to both ultrasound and MRCP. OBSERVATIONS:Both USG and MRCP were able to detect extrahepatic CBD dilatation equally in 25 patients. In 5(15.6%) patients USG and MRI both demonstrated intrahepatic mass causing obstruction at the level of conuence of right and left hepatic duct or CHD. Ultrasonography was able to detect the intrinsic mass of the extrahepatic common bile duct in 2(6.2%) patients out of 32 patients in our study population. MRCP could detect the same in 6(18.7%) patients. In our study narrowing of CBD with stricture formation and upstream dilatation of biliary tree was identied in 10(31.2%) patients on MRCP. Ultrasound could diagnose the same in one patient. Both USG and MRCP were able to detect pancreatic head mass as well as pseudocyst. CONCLUSION: The accuracy of MRCP was found to be comparable to that of ERCP for diagnosis of etiology for obstructive jaundice. MRCP allows better lesion characterization and assessment. However, the patchy availability of MR machines become the main achilles heel for the surgeons as well as the radiologists. Hence the valuable role of the omnipresent ultrasonography become immense.

ANATOMIC VARIANTS OF INTRAHEPATIC BILE DUCTS AND CYSTIC DUCTS IN SAUDI ARABIA: MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY ANALYSIS IN LIVER DONORS

Background: Data regarding the pattern of the anatomical variations of biliary tree from the Middle East is considerably decient when compared with the literature available elsewhere. To dete Objective: rmine anatomic variation in branching pattern of intra hepatic bile duct and cystic duct on Magnetic resonance Cholangiopancreatography in liver donors from Saudi Arabia. Methods: This descriptive study was done at Radiology Department Prince Sultan Military Medical City Riyadh, KSA between 2019-2020 after taking IRB approval (IRB No:1404) and collecting data of liver donors (n=92) using Magnetic resonance cholangiopancreatography. Result: Regarding the right hepatic duct, in our study Type A1(69.6%) was predominant followed by Type A2(16.3%). As for the left hepatic duct, typical pattern Type A was observed in 94.6% cases. Drainage of right posterior hepatic duct into left hepatic duct, A3(7.6%) and A4(5.4%) drainage of right posterior hepatic duct into the common hepatic duct were the most common variants in our study. Accessory bile duct with segment 5 draining into CHD with segment 5and 8 draining into CHD was found in 2.2% of cases, and an aberrant bile duct in 1.1% In our study, majority (97.8% )had lateral insertion of cystic duct and in 1.4% accessory cystic duct was noted. Because of growing trend found in Conclusion: number of liver transplant surgeries being performed, magnetic resonance cholangiopancreatography (MRCP) has become optimal for noninvasive evaluation of abnormalities of the biliary tract.