An Unusual Cause of Cholestasis in an Infant: Biliary Atresia Type IIB

Biliary atresia (BA) is a progressive destructive cholangiopathy of unknown etiology that presents in early infancy. It has a worldwide frequency of 1:8,000–1:15,000 and is common in Asia than in the west. Based on the level at which the lumen of the extrahepatic duct is obliterated, BA is classified into three types. Type III is the commonest (∼85%) type and has the most proximal level of obstruction in the porta hepatis, while type II in which the atresia is at the level of the common hepatic duct, is the least common (∼2.5%) and has been rarely reported. Here, we report the imaging features of an infant with type IIB biliary atresia.

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.

The Current Approach to the Diagnosis and Classification of Mirizzi Syndrome

Mirizzi syndrome occurs in up to 6% of patients with cholecystolithiasis. It is generally caused by external compression of the common hepatic duct by a gallstone impacted in the neck of the gallbladder or the cystic duct, which can lead to fistulisation. The aim of this review was to highlight the proposed classifications for Mirizzi syndrome (MS) and to provide an update on modern approaches to the diagnosis of this disease. We conducted research on various internet databases and the total number of records was 993, but after a gradual process of elimination our final review consisted of 21 articles. According to the literature, the Cesendes classification is the most commonly used, but many new suggestions have appeared. Our review shows that the ultrasonography (US) is the most frequently used method of initial diagnosis, despite still having only average sensitivity. Magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) are good methods and are similarly effective, but only the latter can be simultaneously therapeutic. Some modern methods show very high sensitivity, but are not so commonly administered. Mirizzi syndrome is still a diagnostic challenge, despite the advancement of the available tools. Preoperative diagnosis is crucial to avoid complications during treatment. New research may bring a unification of classifications and diagnostic algorithms.

Laparotomy-Assisted Direct Cholangioscopy for Bile Duct Stone Removal via an Incision of the Jejunum

A 77-year-old man presented to our hospital with epigastric pain. He had previously undergone hepatic left lateral segmentectomy, cholangiojejunostomy, and Roux-en-Y reconstruction at 42 years of age for intrahepatic stones and liver abscesses. Abdominal computed tomography and magnetic resonance cholangiopancreatography revealed bile duct stones and intrahepatic bile duct dilation of the caudate lobe. Bile duct drainage for the caudate lobe was necessary; however, the volume of his caudate lobe was very small, making percutaneous transhepatic biliary drainage (PTBD) or endoscopic ultrasound-guided biliary drainage (EUS-BD) difficult. Therefore, we attempted laparotomy-assisted endoscopic biliary drainage. Under general anesthesia, an incision was made on the jejunum approximately 15 cm from the Y-leg anastomosis. An esophagogastroduodenoscope was directly inserted into the common hepatic duct anastomosed with the jejunum. The caudate lobe branch had severe stenosis, and the area upstream of the stenosis was filled with stones, sludge, and pus. The biliary stenosis was dilated using a balloon, and the stones were completely removed using a basket and a balloon catheter. There are various methods of biliary and pancreatic surgery and gastrointestinal reconstruction, and there are cases in which PTBD, EUS-BD, and endoscopic retrograde cholangiopancreatography (ERCP) with an enteroscope are difficult. In such cases, ERCP under laparotomy could be a good treatment option.

Migration of Hem-o-lok clip into the common hepatic duct after laparoscopic bile duct exploration: A case report

Hem-o-lok clips are widely used in laparoscopic surgery. Hem-o-lok clips migration into the bile duct can lead to stone formation and granulation tissue hyperplasia. This report discusses a case wherein four clips migrated into the bile duct after laparoscopic bile duct exploration. The patient successfully underwent laparoscopy and choledocholithotomy.

Peculiarities of tactics and surgical intervention in fresh iatrogenic damage of the common liver duct

The aim of the study was to select the most optimal method for completing the operation in case of "fresh" iatrogenic damage to the common hepatic duct, which ensures a favorable course of the postoperative period and preparation for the subsequent reconstructive operation. Material and methods. The study was based on the analysis of the results of surgical treatment of 58 patients with iatrogenic damage to the extrahepatic bile ducts (EPBD) for the period from 1998 to 2018. All patients had complete "fresh" transverse transection or clamping (clipping, ligation) of the common hepatic duct during cholecystectomy. In the first group (40 patients), the operation was completed by drainage of the common hepatic duct with a "free" position of the drainage under the liver and drainage of the subhepatic region; in the second group (18 patients), the drainage of the bile duct was fixed in the bed of the gallbladder, with the formation of a Maidl-type jejunostoma to return bile. Research results and their discussion. All patients (58 people) were initially operated on in hospitals in the Tyumen region and the city of Tyumen. 32 patients (55%) underwent open cholecystectomy, 26 (45%) – laparoscopic. The operation was performed in 13 patients (22%) as planned, in 45 (78%) as an emergency. In 40 (69%) operated patients, when the gallbladder was removed, the common hepatic duct was cut, in 18 (31%) it was clipped (ligated). Out of 40 patients (first group), bile duct transection occurred with open cholecystectomy in 29 (72.5%) people, in 11 (27.5%) with laparoscopic intervention. In all, the trauma of the hepatic duct was noticed by the operating surgeon during the operation. In accordance with the adopted tactics, the surgeon through the CMH contacted the experienced surgeon on duty at the Regional Hospital (GBUZ TO "OKB № 1"), with whom he agreed on the method of completing the operation. Conclusion. The lack of experience of hospital surgeons both in solving a tactical problem, when crossing an AKI or clipping it, and in performing a reconstructive operation after an injury is detected, we consider it expedient to introduce drainage into the proximal section of the intersected duct and transport the patient to a hospital department where there are specialists with such experience. operations. Fixation of the drainage of the common hepatic duct in the bed of the gallbladder, the formation of a Maidl-type jejunostoma with a complete return of bile to the intestine can effectively prepare the patient for reconstructive surgery, improve the technical conditions for its implementation.

A CADAVERIC STUDY ON VARIATIONS OF THE COMMON HEPATIC DUCT

Variations in the anatomy of extrahepatic biliary apparatus (EHBA) has been a subject of extended research due to its clinical implications. Cholecystectomy is the commonly performed abdominal surgeries and its safety requires the adequate appreciation of anatomical abnormalities of the extrahepatic biliary tree to decrease the morbidity and mortality of the surgery. Abnormalities of the major ducts and presence of accessory ducts give rise to preoperative difculties and postoperative complications. Background & objectives: To study the normal anatomy of common hepatic duct and its variations. With the Methods: aim of the above study, a prospective descriptive study was conducted on 55 specimens with reference to the ducts. Different parameters were used as union of right and left hepatic ducts and common hepatic duct measurements and looked for variations such as accessory hepatic ducts. Results & discussion: Extrahepatic union of right and left hepatic ducts seen in 98% cases and intrahepatic union in 2%. Length of common hepatic duct varied from 1.5 to 4.7 cm with an average of 2.9cm. Accessory hepatic ducts were seen in 7 cases (13%) in which 2 joined the common hepatic duct, 1 joined LHD and 3 were to the cystic duct. All the ndings of the ducts are to enlighte Conclusions: n the anatomical knowledge of the anatomists, general and laparoscopic surgeons, oncosurgeons and to the transplant surgeons which are abundantly useful.