Endosonographic and histopathological staging of extrahepatic bile duct cancer: time to leave the present TNM-classification?

Prognostic Factors for Distal Bile Duct Carcinoma After Surgery

BACKGROUND

Distal bile duct carcinoma continues to be one of the most difficult cancers to manage in terms of staging and radical resection. Pancreaticoduodenectomy (PD) with regional lymph node dissection has become the standard treatment of distal bile duct carcinoma. We evaluated treatment outcomes and histological factors in patients with distal bile duct carcinoma.

METHODS

Seventy-four cases of resection of carcinoma of the distal bile ducts treated at our department during the period from January 2002 and December 2016 using PD and regional lymph node dissection as the standard surgical procedure were investigated. Survival rates of factors were analyzed using uni- and multivariate analyses.

RESULTS

The median survival time was 47.8 months. On univariate analysis, age of 70 years or older, histologically pap, pPanc2,3, pN1, pEM0, v2,3, ly2,3, ne2,3 and postoperative adjuvant chemotherapy were statistically significant factors. On multivariate analysis, histologically pap was identified as a significant independent prognostic factor. The multivariate analysis identified age of 70 years or older, pEM0, ne2,3 and postoperative adjuvant chemotherapy as showing a significant trend towards independent prognostic relevance.

CONCLUSION

The good news about resected distal bile duct carcinoma is that the percentage of those who achieved R0 resection has risen to 89.1%. Our multivariate analysis identified age of 70 years or older, pEM0, ne2,3 and postoperative adjuvant chemotherapy as prognostic factors. In order to improve the outcome of treatment, it is necessary to improve preoperative diagnostic imaging of pancreatic invasion and lymph node metastasis, establish the optimal operation range and clarify whether aortic lymph node dissection is needed to control lymph node metastasis, and establish effective regimens of chemotherapy.

Proposal of a diagnostic algorithm for intraductal ultrasonography to distinguish between benign and malignant biliary strictures

To reexamine the recognizability of intraductal ultrasonography (IDUS) findings from an imaging database and propose a novel algorithm for clinical application. IDUS images of 102 patients who had undergone IDUS examinations for indeterminate causes of common bile duct dilation were independently reviewed by two endoscopists. The strength of the inter-rater agreement between the endoscopists was analyzed using Cohen's kappa (κ). An algorithm was implemented by arranging the IDUS characteristics according to their recognizability. The proposed algorithm was evaluated by examining the inter-rater agreement and diagnostic accuracy before and after the use of the algorithm. The strength of the inter-rater agreement was good for common bile duct stones with or without acoustic shadowing; intraluminal tumors; or bile duct wall thicknesses of more than or equal to 9 mm (κ > 0.8); followed by intraluminal hypoechoic nodules without common bile duct stone characteristics (κ = 0.771); and finally eccentric wall thickening, outer layer disruption, irregular mucosa, and destructed mural layers (κ: 0.595-0.419). Our algorithm improved the strength of inter-rater agreement with a diagnostic accuracy of 81.4%. We proposed an algorithm according to the recognizability of IDUS characteristics, and it can be used by endoscopists to evaluate such characteristics and determine the cause of biliary obstruction.

Imaging techniques for assessment of inflammatory bowel disease: joint ECCO and ESGAR evidence-based consensus guidelines

The management of patients with IBD requires evaluation with objective tools, both at the time of diagnosis and throughout the course of the disease, to determine the location, extension, activity and severity of inflammatory lesions, as well as, the potential existence of complications. Whereas endoscopy is a well-established and uniformly performed diagnostic examination, the implementation of radiologic techniques for assessment of IBD is still heterogeneous; variations in technical aspects and the degrees of experience and preferences exist across countries in Europe. ECCO and ESGAR scientific societies jointly elaborated a consensus to establish standards for imaging in IBD using magnetic resonance imaging, computed tomography, ultrasonography, and including also other radiologic procedures such as conventional radiology or nuclear medicine examinations for different clinical situations that include general principles, upper GI tract, colon and rectum, perineum, liver and biliary tract, emergency situation, and the postoperative setting. The statements and general recommendations of this consensus are based on the highest level of evidence available, but significant gaps remain in certain areas such as the comparison of diagnostic accuracy between different techniques, the value for therapeutic monitoring, and the prognostic implications of particular findings.

Evaluation of normal bile duct and cholangitis by intraductal ultrasonography

BACKGROUND

The intraductal ultrasonographic findings of normal bile duct and cholangitis were examined.

METHODS

We studied 9 autopsy cases and evaluated the clinical records of 76 patients who had been subjected to papillotomy for bile duct stones removal retrospectively.

RESULT

In vitro study: Under a low pressure, the bile duct wall was thick, and the inner surface and outer contour were irregular. The wall became thinner, and the inner surface and outer contour became smooth as the pressure was increased. The thickness was 0.68 +/- 0.12 mm (mean +/- SD) all along the duct at all pressure, and 0.55 +/- 0.12 mm at a pressure above 15 cm H(2)O. The internal echo was homogenous regardless of the internal pressure used. In vivo study: We could evaluate in 70 patients (92.1%). The wall was 1.30 +/- 0.77 mm thick. There was no relationship between the severity of cholangitis and the wall thickness. The irregular inner surface, heterogeneous internal echo, and irregular outer contour correlated with the severity of cholangitis.

CONCLUSION

The normal bile duct wall was between 0.31 and 0.79 mm thick, the inner and outer surfaces were smooth, and internal echo was homogenous. An irregular inner surface, heterogeneous internal echo and an irregular outer contour were important findings of severe cholangitis.