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Query: UMLS:C0027627 (metastases)
 103,950 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

We describe herein the first successful implementation of intraportal stent placement combined with right portal vein embolization as preoperative management against far advanced gallbladder carcinoma. The patient was a 66-year-old woman with obstructive jaundice, in whom computed tomography confirmed that gallbladder carcinoma had invaded the liver and that massive lymph node metastases involved the hepatoduodenal ligament. Portography also revealed severe stenosis of the main portal trunk to less than 2 mm in diameter. To prevent the contribution of intraportal thrombosis and ensure postoperative liver functional reserve, an intraportal metallic stent implantation was conducted simultaneously with right portal vein embolization via a single route using the percutaneous transhepatic approach. There were no complications following this technique, and the patient subsequently underwent hepato-ligament-pancreatoduodenectomy. The resected specimen disclosed a well-expanded stent containing no thrombus. This method could therefore be an amenable strategy for the preoperative treatment of far advanced biliary malignancies in selected patients.
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PMID:Intraportal stent placement combined with right portal vein embolization against advanced gallbladder carcinoma. 971 13

Bronchobiliary fistula is an uncommon but remarkable complication after hepatic resection. The case reported illustrates the clinical presentation and preferred initial management of these fistulae. A 61-year-old white male underwent two wedge resections for colorectal metastases to the liver with removal of a portion of the right diaphragm. Four years later, he developed obstructive jaundice secondary to tumor recurrence in the porta hepatis, which required endoscopic stent placement, radiation, and chemotherapy. Almost 2 years later, he developed frank biliptysis. Percutaneous transhepatic cholangiography (PTC) revealed occlusion of the common hepatic duct stent and a bronchobiliary fistula. With adequate reestablishment of common duct drainage, the patient rapidly improved and was discharged free of symptoms. Bronchobiliary fistulae are rare complications of hepatic resection that can present from days to years after operation. Endoscopic retrograde cholangiopancreatography and PTC are the diagnostic studies of choice and offer the possibility of therapeutic intervention. Although large series in the literature emphasize the surgical management of bronchobiliary fistulae, the reoperative procedures tend to be complicated, with a significant morbidity and mortality. Nonsurgical interventions via endoscopic retrograde cholangiopancreatography or PTC are more recently notably successful when resolution of a distal biliary obstruction is accomplished. Only after aggressive attempts at nonoperative, interventional techniques have failed should operative approaches be entertained.
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PMID:Management of bronchobiliary fistula as a late complication of hepatic resection. 973 17

A 57-year-old female patient presented with painless obstructive jaundice and mild mesogastric pain; she was in good general condition on admission. Abdominal ultrasonography revealed diffuse tumoral invasion of the liver, suggesting diffuse metastases. A liver biopsy showed a tumour with a trabecular growth pattern, composed of uniform relatively small cells, very suggestive of an endocrine carcinoma. Additional immunohistochemical stains, however, did not show any endocrine differentiation, but showed positivity for both hepatocyte-type cytokeratins (cytokeratin 8 and 18) and bile duct-type cytokeratins (cytokeratin 7 and 19). In addition, parathyroid hormone-related peptide, shown to be a good marker for cholangiocarcinoma, was immunoreactive. Electron microscopy revealed tumour cells with an intermediate phenotype: the cells clearly showed hepatocyte features on one hand and bile duct cell features on the other hand. Nine days after admission, the patient died due to liver failure and hepatic encephalopathy. Autopsy excluded another primary tumour site. Overall, this tumour was a primary liver tumour with an intermediate phenotype and with a very rapid clinical course. The intermediate (between hepatocyte and bile duct cell) phenotype suggests an immature progenitor cell origin, which is concordant with a rapid clinical course. This type of tumour has not been described previously and provides additional evidence for the existence of progenitor cells in human liver.
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PMID:Primary liver tumour of intermediate (hepatocyte-bile duct cell) phenotype: a progenitor cell tumour? 976 16

A 5-year review of 50 patients, 28 males, 22 females, with a mean age of 42 years, operated for obstructive jaundice at Ile-Ife, Nigeria was undertaken. Neoplasms of the pancreas, liver, and bile duct were the common causes. Percutaneous Transhepatic Cholangiography (PTC) with hypotonic duodenography was excellent in determining the underlying lesions. Pancreatic carcinoma accounted for 28% of cases, cholelithiasis 24%, hepatoma 22%, metastatic cancer 14%, bile duct carcinoma 10%, and traumatic pancreatic pseudocyst 2%. The patients with malignancies were older than those with biliary calculi. Biochemically, elevated alkaline phosphatase, and conjugated hyperbilirubinaemia, particularly in malignant obstructions, were diagnostic. Benigh bile ductal obstructions were surgically managed without any mortality. Malignant obstructions were surgically managed without any mortality. Malignant obstructions with their advanced presentations were less successfully managed. Biopsy alone or palliative bypass procedure could only be offered and the survival rate was dismal.
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PMID:Diagnosis, management and prognosis of obstructive jaundice in Ile-Ife, Nigeria. 992 Oct 92

Endoscopic ultrasound (EUS) is proving to be a useful tool for evaluation of clinically suspected pancreatic masses unsatisfactorily evaluated by other means of imaging. We reviewed the records of 19 patients who had CT and EUS performed for clinically suspected pancreatic masses. Each patient had subsequent surgical exploration. Nineteen patients (11 females and 8 males) presenting with symptoms (11 with obstructive jaundice, 6 with abdominal pain and weight loss) or incidental CT findings suspicious for pancreatic carcinoma underwent EUS for further pancreatic evaluation. All of these patients had exploratory laparotomies, with 13 pancreaticoduodenectomies, 3 distal pancreatectomies and splenectomies, 1 bypass procedure, 1 open pancreatic and hepatic biopsy showing metastatic disease, and 1 open exploration with negative fine-needle aspiration biopsy. EUS correctly identified pancreatic neoplasms in 17 of 19 cases, with two false positives. The tumors included 15 adenocarcinomas, 1 microcystic adenoma, and 1 lymphoma. Node status was correctly predicted in 9 of 12 specimens. Nine of 12 tumors had accurate tumor staging by EUS. Absence of vascular invasion was accurately predicted in 13 of 14 cases. Two patients had metastatic disease discovered at laparotomy. All 19 patients had preoperative abdominal CT scans, with six of these negative for pancreatic masses. EUS is more sensitive than CT in detecting pancreatic masses and is more accurate than CT in locally staging pancreatic tumors. This higher sensitivity is important because those patients with earlier stage tumors are the most likely to benefit from resection.
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PMID:Endoscopic ultrasound for diagnosis and staging of pancreatic tumors. 1039 76

Most patients with a pancreatic head carcinoma, periampullary carcinoma or a cholangiocarcinoma of the liver hilum (Klatskin tumor) present with obstructive jaundice and therefore ultrasound often is the first imaging modality. Visualization is sufficient in more than 90% of cases for adequate diagnosis and staging. Even most small papillary tumors can be diagnosed with conventional abdominal ultrasound. In pancreatic head and periampullary carcinoma vascular involvement is the most important determinant for local irresectability and can often be assessed by color Doppler US. An abnormal pulsed Doppler signal obtained from the portal venous system due to severe narrowing or occlusion is highly suspicious for major involvement and irresectability of the tumor. However, a normal pulsed Doppler signal does not exclude involvement, if the tumor has continuity with the vessel with interruption of the hyperechoic tumor vessel interface. Enlarged lymph nodes are not a major diagnostic parameter, because a reliable differentiation between reactive and malignant lymph nodes is generally not possible. Very tiny liver and peritoneal metastases are missed by abdominal US and only detectable by laparoscopy and/or laparascopic US. In cholangiocarcinoma of the liver hilum extensive biliary and vascular involvement are considered the most important factors for determining irresectability. Portal venous involvement can be assessed by color Doppler US with a high accuracy (91%). Although cholangiography (ERCP and PTC) is considered the best imaging modality in detecting proximal extension of the tumor into the biliary system US can provide useful additional information. If dilated ducts are seen without clear communication among each other within a liver lobe, extension of the tumor into the segmental bile ducts can be concluded. We consider color Doppler US, a valuable tool for preoperative imaging and staging of biliopancreatic malignancy.
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PMID:Imaging and staging of biliopancreatic malignancy: role of ultrasound. 1043 78

Two possible strategies for diagnosis and staging of patients with suspected biliopancreatic cancer and obstructive jaundice were tested in a decision analysis. One strategy was called 'surgical' strategy and consisted of only Ultrasonography and (spiral) CT scan and exploratory laparotomy in all patients without irresectable disease or distant metastases according to this work-up. The other strategy was called 'non-surgical' strategy and consisted of the above strategy, but also included ERCP and endoscopic internal drainage (stent) and diagnostic laparoscopy and laparoscopic ultrasound. In the decision analysis incidences of the outcomes after the two strategies were estimated based on the literature and our own experience, and a utility (0-1) was attributed to each separate outcome, according to the expected quality of life as judged by the team. Total utility of each strategy was calculated. It could be concluded that a non-surgical strategy would lead to a somewhat higher total utility in case the yield (i.e. prevention of unnecessary laparotomies) could be high and supposed that a beneficial effect of pre-operative internal biliary drainage was present. In case of low yield of diagnostic laparoscopy the superiority of the 'non-surgical' strategy is doubtful.
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PMID:Essentials in biliopancreatic staging: a decision analysis. 1043 10

Most patients with bilio-pancreatic malignancy are no candidate for curative resection and will need palliative treatment. Palliation in these patients is focussed on relief symptoms such as obstructive jaundice, duodenal obstruction and pain. It has been suggested that non surgical treatment (stenting) is the optimal palliation for patients with short survival and surgical bypass for those surviving more than 6 months. Unfortunately valid criteria for estimating survival are not available except for metastases. A prognostic score chart to predict survival probabilities for 3,6 and 9 months after diagnosis has been developed. The use of this prognostic score chart may help clinicians to select optimal palliative treatment for individual patients. Surgical biliary drainage can be performed by a simple cholecystoenterostomy; a choledochoduodenostomy or a choledocho/hepaticojejunostomy with Roux-Y jejunal limb reconstruction. The present data available in the literature do not give sufficient guidance to make a well deliberated selection between the different types of bypass surgery but choledochojejunostomy is generally preferred. Gastroentero-stomy is performed routinely during the biliary bypass procedure in our institution because gastric outlet obstruction has been described between 9-21% of the patients who underwent only a surgical biliary bypass but there is still controversy. Recently it was also suggested that there is an indication to perform palliative resections. No results are available to justify resections as a debulking procedure.
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PMID:Surgical palliative treatment in bilio-pancreatic malignancy. 1043 38

We report a 75-year-old woman with metachronous bile duct cancer who underwent curative resection twice and has survived for a decade. In 1989, she was admitted because her serum alkaline phosphatase level was elevated. Computed tomography (CT) showed a low-density mass, 2 cm in diameter, at the left hepatic duct and intrahepatic bile duct dilatation in the left lobe. We diagnosed the lesion as an intrahepatic bile duct cancer and performed extended left hepatic lobectomy with systematic lymph node dissection. The histological diagnosis was a well differentiated cholangiocellular carcinoma with hepatic hilar and celiac lymph node metastases (T1N2M0, Stage IVB). In 1996, she was re-admitted with obstructive jaundice. CT showed a slightly enhanced mass, 4 cm in diameter, in the pancreatic head. After reducing the jaundice by percutaneous transhepatic biliary drainage, pancreatoduodenectomy was performed. The histological diagnosis of this lesion was a moderately differentiated adenocarcinoma originating from the intrapancreatic bile duct. Ten years after the first operation, she is leading a normal daily life with no cancer recurrence. These findings suggest that repeated curative surgery can result in a long-term survival of patients with metachronous bile duct cancer.
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PMID:Metachronous bile duct cancer in a patient surviving for a decade and undergoing curative surgery twice. 1047 Jun 61

The authors report a patient with obstructive jaundice as the first clinical manifestation of a primary malignant melanoma metastatic in the ampulla of Vater. After the histologic diagnosis of the metastases was made, the primary tumor was located in the skin of the back. Obstruction jaundice secondary to ampullary obstruction due to metastatic melanoma has only been reported twice, and in neither case was jaundice the first symptom of the disease.
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PMID:Obstructive jaundice as the first clinical manifestation of a metastatic malignant melanoma in the ampulla of vater. 1047 83


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