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Malignant melanoma can involve any organ of the body and commonly involves the gastrointestinal tract. The first case of melanoma in the world's literature involving the cystic duct and the first in the English literature involving the common bile duct is described. This case is compared with the two cases in the world's literature with common duct involvement.
BACKGROUND AND STUDY AIMS: Most follow-up studies of patients with common bile duct stones treated with endoscopic sphincterotomy include older patients. Therefore, the aim of the present study was to do a medium-term follow-up of patients under the age of 60 years, who underwent endoscopic sphincterotomy and removal of common bile duct stones. METHODS: Eighty-six (68 women) consecutive patients less than 60 years of age (median age 47 years) were evaluated. The median observation time after endoscopic sphincterotomy was 27.1 months. Complete follow-up was accomplished in 80 patients. RESULTS: Twenty-five patients had undergone cholecystectomy prior to the endoscopic sphincterotomy. Sixty-one patients were discharged after endoscopic sphincterotomy with gallbladder left in situ. Cholecystectomy was not needed in 27 patients, of whom 23 had gallbladder stones. In 13 of 61 patients subsequent elective cholecystectomy was planned at the time of endoscopic sphincterotomy. Recurrent attacks of biliary colic required elective cholecystectomy in another thirteen patients. Acute cholecystectomy was undertaken in eight patients due to acute cholecystitis (n = 4) or biliary colic (n = 4). Seven of eight acute cholecystectomies were performed within 152 days after the endoscopic sphincterotomy. The overall median time until cholecystectomy was 51 days (25-75 percentiles, 23-103 days). CONCLUSIONS: One third of the patients had been cholecystectomized prior to the endoscopic treatment of their common bile duct stones. Nearly half of the young patients discharged after endoscopic sphincterotomy for common bile duct stones with the gallbladder left in situ at the time of endoscopic sphincterotomy managed well without any need for cholecystectomy.
We report a 69-year-old man with double cancers in the common bile duct. One cancer was located between the superior and middle parts of the bile duct, while the other cancer was in the inferior part of the bile duct. Pylorus-preserving pancreatoduodenectomy was performed. There was no communication between the two cancers in either the mucosal layer or the subepithelial layer. On pathological examination, the upper cancer was diagnosed as poorly differentiated adenocarcinoma, while the lower one was found to be moderately differentiated adenocarcinoma. We analyzed loss of heterozygosity (LOH), using microsatellite markers on five chromosomal arms, in both the upper and the lower cancers. Both cancers showed common regions of LOH at 5q, 6q, 9p, 17p, and 18q, whereas the upper cancer showed one additional region of LOH at 8p, thus suggesting progression, due to the acquisition of the additional LOH, in the upper cancer. No LOH was observed in the region between the two cancers. The presence of one additional LOH in the upper cancer suggests that the upper cancer was a metastasis of the lower one.
We studied 10 patients with pancreatitis who had persistent cholestasis secondary to compression of the common bile duct by a pancreatic pseudocyst. Elevation of the serum bilirubin or alkaline phosphatase levels, or both, (sensitive indicators of cholestasis) was present in each of our patients. The diagnosis of a pancreatic pseudocyst is best made by CAT scan and ultrasonography. These techniques will delineate the small intrapancreatic pseudocyst that otherwise may be difficult to recognize on inspection at operation. Endoscopic retrograde cholangiography and pancreatography are desirable because they delineate the anatomic alterations of the pancreatic and common bile ducts and may contribute information pertaining to the possibility of common duct obstruction by pancreatic fibrosis. In our opinion, cholestasis secondary to bile duct compression by a pseudocyst is an indication for operation. Each of our 10 patients had drainage of their pseudocysts. Cystoduodenostomy, performed in seven patients, was the method most commonly used. If there is concern regarding the patency of the common duct after drainage of the cyst, intraoperative cholangiography should be performed. This was carried out in three patients. In each patient, the preoperative elevations of serum alkaline phosphatase and serum bilirubin levels returned to normal limits after operative decompression of a pancreatic pseudocyst alone without an accompanying or subsequent bilioenteric bypass being required.
Sixty patients with chronic alcohol-induced pancreatitis with endoscopic retrograde cholangiopancreatography evidence of common bile duct stenosis were studied to determine the clinical spectrum and natural history of this complication, as well as the indications for biliary bypass. In 17% of patients, common bile duct stenosis (CBDS) was an incidental finding at ERCP, while in the remaining cases pain and jaundice were the predominant symptoms in 35% and 48%, respectively. Biliary drainage was performed in 38% of patients for persistent or recurrent jaundice, cholangitis, and while undergoing pancreatic duct or cyst drainage procedures for pain. The benign nature of CBDS in chronic alcohol-induced pancreatitis (CAIP) in patients without persistent jaundice is emphasized. In particular, no histologically proved cases of secondary biliary cirrhosis were noted. The majority of patients with CBDS due to CAIP may be safely managed without biliary bypass but require close follow-up.
Two patients with obstructive biliary symptoms were shown to have dilated bile ducts on ultrasound. Within the lumen of both distal common ducts (CBD) large low echogenicity polypoid masses without acoustic shadowing were seen. MRI in one patient showed a polypoid filling defect in the lower CBD corresponding to the ultrasound appearance. Instrumentation at the lower end of both CBDs caused disintegration of the polypoid configuration resulting in the more typical layered appearance of biliary sludge. Sludge in the gall-bladder as seen on ultrasound is rarely known to cause a pseudotumour appearance. It has not previously been reported as occurring in the CBD and awareness of the tumefactive appearance of biliary sludge in the common duct is important and should help avoid possible misinterpretation.
The effect on the common bile duct pressure of epidurally injected morphine and fentanyl, was compared with that of intravenous injections of the same drugs in 12 mongrel dogs. Intravenous injection of morphine (0.1 mg X kg-1) or fentanyl (0.01 mg X kg-1) significantly elevated the common bile duct pressure from 10.48 +/- 0.37 to 21.68 +/- 0.33 cm H2O and from 9.66 +/- 0.33 to 14.14 +/- 0.21 cm H2O respectively. These increases occurred within 4-15 minutes after injection and lasted for about 2-3 hours. When the narcotics in identical dosages were injected epidurally, the common bile duct pressures were unchanged during the four hours of investigation. Further studies are planned to determine whether this beneficial effect of epidural narcotics applies also in the human clinical situation.
The rate of recovery for hepatic clearance and extraction following release of common-duct obstruction was investigated in the rat. Male Wistar rats underwent ligation of a cannulated common bile duct. Two weeks later, the cannula was opened and implanted into the duodenum, thus re-establishing enterohepatic circulation. Hepatic extraction and indocyanine green clearance were determined in three groups of six rats each, which differed by the time elapsed from the re-establishment of communication between the common bile duct and duodenum, i.e., 1, 48 and 168 h, respectively. A fourth group, in which a sham operation was performed, served as a control. Clearance was reduced from 16.9 +/- 2.5 ml/min per kg in the control group to 2.9 +/- 0.8, 5.4 +/- 2.4, and 8.5 +/- 3.3 ml/min per kg 1, 48, and 168 h, respectively, after release of common-bile-duct obstruction. Extraction rate was reduced from 37.3 +/- 5.9% to 17.5 +/- 2.7% in the 1st hour and recovered completely at 1 week. Thus, in the rat, release of a 2-week common-bile-duct obstruction is associated with complete recovery of the extraction capacity of the liver within a week, but only incomplete recovery of clearance. This decrease in clearance seems to be due to a decrease in effective hepatic blood flow, mostly probably due to the development of porto-systemic shunts.
A unique case of primary papillary hyperplasia of the gallbladder and cystic and common bile ducts occurring in a young female without calculi, ulcerative colitis, or primary sclerosing cholangitis is reported. The papillary lesion involved the mucosa of the entire gallbladder and of the cystic and common bile ducts. Histologically, the gallbladder mucosal folds were close to one another and taller than normal. They were lined by normal-appearing columnar cells and pencil-like cells. The papillary projections of the common bile duct were lined only by columnar cells with prominent subnuclear vacuoles. No endocrine cells or cytologic atypia were noted. The differential diagnoses, including secondary hyperplasia, multiple adenomas, and papillomatosis of the gallbladder, are discussed.
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Motor activity of the sphincter of Oddi has been evaluated in 34 patients who underwent ERCP examination. Manometric recordings from the common bile duct and the sphincter of Oddi were performed with a polyethylene triple lumen catheter. At ERCP 16 patients had undamaged biliary ducts; six had undergone cholecystectomy and six had gall bladder stones; 18 patients had common bile duct stones; nine of whom had undergone cholecystectomy, and seven had gall bladder stones. Length and amplitude of the resting sphincter pressure as well as frequency, duration, amplitude, and propagating pattern of phasic contractions did not significantly differ in patients with and without common bile duct stones. Sphincter of Oddi motor activity did not appear to be influenced by the variation in the diameter of the common bile duct or by previous cholecystectomy.
A case of sarcoma botryoides of the common bile duct is described. A review of the literature reveals 24 reported cases of this entity. The clinical features of the disease and the poor prognosis associated with it are illustrated by a detailed presentation of the case. Although rare, this condition must be included in the differential diagnosis of jaundice in infancy or early childhood. Pathologic findings of diagnostic value are re-emphasized.
PURPOSE: Description of an unusual complication of laparoscopic cholecystectomy and common bile duct exploration. METHODS: Case report from experience at an Air Force tertiary care hospital in a 70-year-old woman undergoing laparoscopic cholecystectomy. Literature search for journal articles reporting similar complications using Medline, PubMed, and Ovid Internet search systems. RESULTS: A hepatic subcapsular biloma was diagnosed on postoperative day 11 from an elective laparoscopic cholecystectomy and common bile duct exploration. Review of the literature found only 2 other reports of this complication. CONCLUSIONS: Hepatic subcapsular biloma is a rare complication of laparoscopic cholecystectomy. Computed tomography is highly sensitive for diagnosing bilomas, and percutaneous drainage procedures are appropriate treatment. Imaging of the biliary tree should be performed early to determine the location and extent of bile leaks.
The laparoscopic transcystic common bile duct (CBD) approach is becoming increasingly more refined as an ideal technique to deal with gallbladder stones (GBS) and common bile duct stones (CBDS) during a single operation. Our method, transcystic CBD exploration and papilla balloon dilatation (PBD), is an easier, safer, and less invasive technique than the transcystic approaches that have previously been reported. With our method, a sheath is introduced through the cystic duct into the CBD in order to allow catheter exchange, and the CBDS is flushed out through the papilla into the duodenum after PBD. We applied our new technique, without complication, to a patient with GBS and CBDS. Our technique is one of the safest, easiest, and least invasive methods for the treatment of patients with GBS and CBDS.
In an endoscopic study of 107 patients with suspected common bile duct calculi, 26 were found at retrograde cholangiography to have juxtapapillary diverticula (JPD). Over 80% of these patients had common bile duct calculi, compared with only 52% among those without any JPD (p less than 0.01).
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A simultaneous manometric monitoring of the common bile duct (CBD) and the duodenum were performed 2 weeks after choledocholithotomy on 15 patients whose common bile ducts were explored without sphincteroplasty and 30 patients with sphincteroplasty. These manometric studies were carried out by open-tip catheters intubated into the CBD and duodenum through the T-tube at the operation. In patients without sphincteroplasty, no effects of the duodenal pressure on a CBD pressure profile were recognized, while a synchronized pressure profile of the CBD and the duodenum was obtained in patients with sphincteroplasty. By stimulation with morphine (Morphine sulfate; 0.17 mg/Kg iv bolus), waxing and waning of the pressured in the CBD without sphincteroplasty were observed with 20 cmH2O in maximum at about 13 minutes after injection. However, in the CBD with sphincteroplasty, scale-over increase of the pressure curve was seen immediately after duodenal contraction caused by morphine stimulation. A direct infusion of 5 ml of 0.1 N hydrochloride to the duodenum causes hyperperistalsis of the duodenum, which made a synchronized pressure profile in the CBD with sphincteroplasty but made no remarkable change in a pressure profile of the CBD without sphincteroplasty. These findings conclude that the sphincter of Oddi plays an important role as a "pressure barrier" between the CBD and the duodenum, and that with the destruction of this sphincter by sphincteroplasty, a pressure profile of the CBD becomes close to that of the duodenum. This simultaneous manometric study of the CBD and the duodenum might be one of most valuable methods for evaluation of completeness of the sphincteroplasty.
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