Usefulness of bile cytology in the diagnostic management of patients with biliary tract obstruction

Eighteen patients with evidence of biliary tract obstruction had a total of 29 satisfactory bile samples submitted for diagnostic cytology during a two-year period. These 29 specimens were reviewed in order to determine if bile cytology is useful in the diagnostic management of patients with obstructive biliary tract disease. Twenty-one of the bile specimens were from patients with malignant biliary stricture, and eight were from patients with benign biliary obstruction. Bile cytology was positive for carcinoma in eight samples from patients with malignant stricture and was inconclusive for malignancy in two. There were no false positives. The diagnostic specificity of bile cytology was 100%, the diagnostic sensitivity was 48%, and the diagnostic accuracy was 62%. When carefully collected and promptly processed, bile proved an excellent specimen for cytologic evaluation and was a valuable adjunct to other diagnostic procedures for the detection of carcinoma causing biliary tract obstruction.     

胆囊切除术医源性胆管损伤的处理

目的:探讨开腹胆囊切除术医源性胆道损伤的诊断、手术时机和手术方式的选择。方法:对18例胆道损伤进行分析总结:分别施行了胆管修补、T管引流术10例,保守治疗2例,Roux-en-Y胆肠吻合术6例。结果:3例术后过早拔管发生吻合口狭窄,再次手术。1例因梗阻性胆管炎并发肝功能衰竭、多器官功能衰竭死亡。1例因胆肠吻合术后并发消化道出血、肝昏迷死亡。余术后良好。结论:尽早发现及正确处理对提高疗效和预防术后胆管狭窄起着决定性的作用。术中发现胆管损伤立即行端端吻合加T管引流;术后数天发现或多次胆道修补术失败者,则宜行规范的Roux-en-Y胆肠吻合术。     

A study of small bowel tumors; with special emphasis on clinical aspects

Ninety-eight patients with 100 different tumors of the small bowel were studied. There were more malignant than benign tumors. Adenocarcinoma was the commonest lesion and the ileum the most frequent anatomical site of all tumors. Except for carcinoid tumors, the lesions were observed more often in male than in female patients. The average age of patients in this series was higher than that reported in most other series. Loss of weight, and abdominal pain were the most constant symptoms. Clinical syndromes of anemia and bleeding, small bowel obstruction, biliary obstruction, perforation with peritonitis, abdominal tumor, melanosis with small bowel polyposis, and cutaneous von Recklinghausen's disease with small bowel neurofibromatosis were encountered either alone or in combination. In the group operated upon, a resection of the involved segment with end-to-end anastomosis was done when feasible. None of the patients operated upon before 1946 lived as much as five years after operation. The most common causes of death were extension of the primary tumor and metastasis, peritonitis due to perforation, associated bronchopneumonia, and hemorrhage.     

Primary Tumours of the Small Bowel and its Mesentery

Twenty-seven primary small bowel tumours encountered at the University of Alberta Hospital in a 10-year period have been reviewed. Seventeen symptomatic growths were treated by resection and 10 asymptomatic tumours were discovered incidentally. During this same period, three intramesenteric lipomas were found. Small bowel tumours were malignant in 15 of the 17 symptomatic cases and benign in seven of the nine asymptomatic cases. Carcinoid tumours, malignant lymphomas, non-lymphoid sarcomas and carcinomas were the common malignant neoplasms while adenomas, lipomas, myomas, fibromas and angiomas comprised the majority of benign growths reported. Symptoms of anorexia, anemia, abdominal pain, obstruction and hemorrhage suggest small bowel tumour if commoner pathology has been ruled out.     

CA 19-9 assay in patients with extrahepatic cholestatic jaundice

Serum concentrations of the CA 19-9 tumour marker were determined in 35 patients with histologically proven bilio-pancreatic malignancies associated with obstructive jaundice and in 35 patients with benign extrahepatic jaundice due to choledocholithiasis. At a cut-off level of 37 U/ml the sensitivity of this assay was 82.8%, but the specificity was very low (45.7%). Thus CA 19-9 can not be employed to differentiate between malignant and benign extrahepatic jaundice. Serial samples of CA 19-9 were achieved in 7 patients with benign and in 6 patients with malignant biliary obstruction, before and after the disappearance of jaundice. Serum concentrations of this tumour-antigen returned to normal concurrently with the bilirubin values only in patients with benign obstruction, remaining unchanged in all cases of malignancies. The data suggest that patients with extrahepatic jaundice should be evaluated by other examinations or by collecting serial samples for this assay.     

A STUDY OF SMALL BOWEL TUMORS—With Special Emphasis on Clinical Aspects

Ninety-eight patients with 100 different tumors of the small bowel were studied. There were more malignant than benign tumors. Adenocarcinoma was the commonest lesion and the ileum the most frequent anatomical site of all tumors. Except for carcinoid tumors, the lesions were observed more often in male than in female patients. The average age of patients in this series was higher than that reported in most other series. Loss of weight, and abdominal pain were the most constant symptoms. Clinical syndromes of anemia and bleeding, small bowel obstruction, biliary obstruction, perforation with peritonitis, abdominal tumor, melanosis with small bowel polyposis, and cutaneous von Recklinghausen''s disease with small bowel neurofibromatosis were encountered either alone or in combination.In the group operated upon, a resection of the involved segment with end-to-end anastomosis was done when feasible. None of the patients operated upon before 1946 lived as much as five years after operation. The most common causes of death were extension of the primary tumor and metastasis, peritonitis due to perforation, associated bronchopneumonia, and hemorrhage.     

Percutaneous Transhepatic Balloon Dilation of Biliary-Enteric Anastomotic Strictures after Surgical Repair of Iatrogenic Bile Duct Injuries

Purpose

To evaluate the efficacy of percutaneous balloon dilation of biliary-enteric anastomotic strictures resulting from surgical repair of laparoscopic cholecystectomy-related bile duct injuries.

Material and Methods

A total of 61 patients were referred to our institution from 1995 to 2010 for treatment of obstruction at the biliary-enteric anastomosis following surgical repair of laparoscopic cholecystectomy-related bile duct injuries. Of these 61 patients, 27 underwent surgical revision upon stricture diagnosis, and 34 patients were managed using balloon dilation. Of these 34 patients, 2 were lost to follow up, leaving 32 patients for analysis. The primary study objective was to determine the clinical success rate of balloon dilation of biliary-enteric anastomotic strictures. Secondary study objectives included determining anastomosis patency, rates of stricture recurrence following treatment, and morbidity.

Results

Balloon dilation of biliary-enteric anastomotic strictures was clinically successful in 21 of 32 patients (66%). Anastomotic stricture recurred in one of 21 patients (5%) after an average of 13.1 years of follow-up. Patients who were unsuccessfully managed with balloon dilation required significantly more invasive procedures (6.8 v. 3.4; p = 0.02) and were left with an indwelling biliary catheter for a significantly longer period of time (8.8 v. 2.0 months; p = 0.02) than patients whose strictures could be resolved by balloon dilation. No significant differences in the number of balloon dilations performed (p = 0.17) or in the maximum balloon diameter used (p = 0.99) were demonstrated for patients with successful or unsuccessful balloon dilation outcomes.

Conclusion

Percutaneous balloon dilation of anastomotic biliary strictures following surgical repair of laparoscopic cholecystectomy-related injuries may result in lasting patency of the biliary-enteric anastomosis.     

Biodegradable biliary stents coated with mesenchymal stromal cells in a porcine choledochojejunostomy model

Background aimsRoux en y anastomosis is a preferred method of biliary reconstruction in liver transplantation that involves living donors or pediatric patients. However, biliary stricture is a frequent and serious complication, accounting for up to 40% of biliary complications in these patients. Previously, we demonstrated that extraluminal delivery of adipose-derived (AD) mesenchymal stromal cells (MSCs) decreased peri-biliary fibrosis and increased neo-angiogenesis in a porcine model of duct-to-duct biliary anastomosis. In this study, we used a porcine model of Roux en y anastomosis to evaluate the beneficial impact of a novel intraluminal MSC delivery system.MethodsNine animals were divided into three groups: no stent (group 1), bare stent (group 2) and stent coated with AD-MSCs (group 3). All animals underwent cholecystectomy with roux en y choledochojejunostomy. Two animals per group were followed for 4 weeks and one animal per group was followed for 8 weeks. Cholangiograms and blood were sampled at baseline and the end of study. Biliary tissue was collected and examined by Masson trichrome staining and immunohistochemical staining for MSC markers (CD34 and CD44) and for neo-angiogenesis (CD31).ResultsTwo of three animals in group 1 developed an anastomotic site stricture. No strictures were observed in the animals of group 2 or group 3. CD34 and CD44 staining showed that AD-MSCs engrafted successfully at the anastomotic site by intraluminal delivery (group 3). Furthermore, biliary tissue from group 3 showed significantly less fibrosis and increased angiogenesis compared with the other groups.ConclusionsIntraluminal delivery of AD-MSCs resulted in successful biliary engraftment of AD-MSCs as well as reduced peri-biliary fibrosis and increased neo-angiogenesis.     

Brushing cytology in biliary tract obstruction

During a period of eight years (1980 to 1987), cytologic samples were obtained by brushing and reverse screw devices from 54 patients undergoing transhepatic cholangiography for evaluation of obstructive jaundice. Eight patients were excluded from this study, seven for inadequate follow-up and one because of unsatisfactory cytologic material. Of the remaining cases, 32 were cytologically diagnosed as adenocarcinomas; all but one patient proved to have malignant disease by histologic examination and/or through clinical follow-up. These included 21 pancreatic carcinomas, 6 bile duct carcinomas, 1 ampullary carcinoma, 1 gallbladder carcinoma and 2 metastatic carcinomas. In one case, the diagnosis of malignancy was found to be in error upon review of the cytologic smears. Of 14 patients with negative cytologic diagnoses, 7 were found to have malignant neoplasms and 7 had benign diseases. These findings indicate that, while a positive cytologic diagnosis is a reliable indicator of a malignant biliary obstruction, a negative result does not exclude malignancy.     

麻醉诱导期预保温措施对胆道闭锁患儿术中体温的影响

目的:探讨麻醉诱导期预保温措施对胆道闭锁患儿手术中体温的影响。方法:将我院2012年4月~2014年8月收治入院需要行肝门空肠吻合重建肝外胆道术的100例胆道闭锁患儿,按电脑随机法分为对照组和治疗组,每组各50例,对照组患儿麻醉诱导期采用普通盖被覆盖保温0.5 h,试验组患儿麻醉诱导期采用充气保温毯进行预保温0.5h,手术中观察并记录两组患儿的基本情况和术中体温变化。结果:两组患儿入室体温、入室室温、麻醉时室温、手术时间、出血量及输液总量比较差异均无统计学意义(P0.05)。治疗组术中发生低体温的概率为36.2%,明显低于对照组的63.8%。对照组术中患儿体温变化较大,体温下降较明显(P0.05),而治疗组体温变化相对稳定(P0.05)。结论:麻醉诱导期应用充气保温毯预保温有利于胆道闭锁患儿行肝门空肠吻合术时保持相对稳定体温,是预防胆道闭锁患儿术中发生低体温的有效方法。     

内镜下逆行胰胆管造影置放胆道支架治疗恶性梗阻性 黄疸98 例疗效分析

目的:探讨内镜下逆行胰胆管造影置放胆道支架对恶性胆道梗阻的疗效及并发症的防治。方法:选择2008年2月至2011年9月我院收治的无法手术切除或不愿手术的恶性胆道梗阻患者98例,通过放置内置支架引流观察其操作成功率、支架通畅期和退黄效果、并发症发生情况及其防治效果和患者生存期等。结果:98例患者中有88例成功通过置入胆道内置引流管,成功率为89.8%,并发症发生率为11.22%,所有成功患者术后1周黄疸明显减退,支架平均通畅期137天,患者平均生存期为163天。结论:行胆道内置支架引流创伤小,并发症少,通畅性能好,可持久有效地控制黄疸,有效缓解病情,改善全身情况,明显延长恶性胆道梗阻患者的生存期。     

Percutaneous Transhepatic Cholangiography—Report of a Technique

Percutaneous transhepatic cholangiography was carried out in 30 patients with jaundice of unknown cause. The examination was successful in 24, and the correct diagnosis was established before operation in 23.Among the specialized radiographic procedures useful in the differential diagnosis of jaundice, the percutaneous transhepatic cholangiogram is simple and reliable. It will distinguish intrahepatic from extrahepatic biliary obstruction. In benign structures, it can give a good anatomical and pathological definition of the problem which faces the surgeon. Occasionally, it may make operation unnecessary.Serious complications are hemorrhage and bile peritonitis. The incidence is low and by careful management they can be avoided.     

Clinical and cytologic features of papillary neoplasms of the breast

OBJECTIVE: To compare the cytologic features benign and malignant papillary breast lesions. STUDY DESIGN: We reviewed the clinical and cytologic features in 29 cases of intraductal papilloma and 26 cases of atypical papilloma or papillary carcinoma that had been diagnosed by histologic examination. The diameter of the mass was examined as a clinical feature. The cytologic features evaluated were as follows: bloody background, row of tall columnar cells, naked bipolar nuclei, hemosiderin-laden macrophages, myoepithelial cells, single scattered atypical cells, cellularity, nuclear atypia, nuclear grade, apocrine metaplasia, eosinophilic cytoplasmic granules, papillary clusters, small papillae, cell balls and large sheets. RESULTS: Of the features evaluated, the diameter of the mass, naked bipolar nuclei and cell balls differed significantly between benign and atypical or malignant papillary neoplasms. The average diameter of a benign papillary neoplasm was 1.8 cm, and that of an atypical or malignant papillary neoplasm was 2.2 cm (p = 0.042). Naked bipolar nuclei were found in 27 cases of benign papillary neoplasm (93.1%) versus 19 cases of atypical or malignant papillary neoplasm (73.1%) (p = 0.050). Cell balls were found in 14 (48.3%) and 21 (80.8%) cases, respectively (p = 0.012). All 6 cases in which cell balls were present and naked bipolar nuclei were absent proved to be atypical or malignant papillary neoplasms. Of 17 cases in which cell balls were absent and naked bipolar nuclei present, 13 (76.5%) were benign papillary neoplasms. CONCLUSION: Most cytologic features overlapped in benign and atypical or malignant papillary neoplasms. Although they were not pathognomonic, naked bipolar nuclei and cell balls were cytologic features that differed significantly between benign and atypical or malignant papillary neoplasms. When papillary neoplasms of the breast are suspected in a cytologic smear, the combination of clinical examination, mammography and cytologic features should be considered to make the correct diagnosis.     

Determination of the activity of nonspecific monophosphoesterases and nonspecific esterase in the liver of dogs in extrahepatic cholestasis treated surgically and with phenobarbital.

Histochemical researches on livers of 19 dogs were carried out. The dogs suffered from extrahepatic cholestasis which lasted for 28 days and was surgically induced. The dogs were divided into three groups, out of which two were given phenobarbital for 21 or 28 days. In all groups biliary obstruction was removed by surgical operation. It was shown that a combined surgical treatment with the application of phenobarbital has given better results than a surgical treatment alone.     

Posters. P19 Cervical carcinoma with metastases to the tympanic membrane: an unusual presentation

Introduction Fine needle aspiration (FNA) is a well‐established diagnostic technique which is frequently used to diagnose head and neck neoplasms. Clinical decisions concerning treatment of malignant salivary gland tumours, the extent of surgery and advisability of pre‐operative irradiation can be helped by prior knowledge of tumour type. Aim The aim of this study was to do an audit of all salivary gland FNAs carried out in Beaumont Hospital over a 14‐year period. Methods All salivary gland FNAs between 1989 and 2002 were reviewed. Where available, the corresponding follow‐up histological specimens were studied. Results During this 14‐year period, 305 patients with salivary gland lesions had FNA of the lesion performed. The total number of aspirates performed was 343. Of these, 184 had histologies available for follow‐up. Eighty‐nine aspirates were reported as inadequate; 89 as inflammatory, normal or consistent with cyst contents. One hundred and thirteen aspirates were diagnosed as a benign entity. Thirty‐three aspirates were reported as malignant (21 of which were felt to be primary to the salivary gland and 12 metastatic). Sixteen cases were called suspicious. Good correlation between FNA findings and histology was seen in the majority of cases (145 of 183). Some diagnostic problem areas were identified. These included the following: lymphomas (seven called benign on FNA), Warthin's tumour (seven not diagnosed or misdiagnosed on FNA) and mucoepidermoid carcinoma (one reported as pleomorhic adenoma and one as benign/cystic on FNA). Seven pleomorphic adenomas were not diagnosed on FNA pre‐operatively, predominantly due to inadequacy of the specimen. Three other malignancies (acinic cell carcinoma, lymphoepithelial carcinoma and carcinoma ex‐pleomorphic adenoma), while not diagnosed on FNA, were called suspicious, with re‐biopsy advised. Conclusion FNA cytology of salivary glands is an accurate method for evaluation of both benign and malignant lesions, enabling optimum surgical and adjuvant therapy decision‐making pre‐operatively. Well‐defined problem areas are identified and, therefore, clinicopathological correlation is required in these cases.     

胆道支架置入联合介入化疗对恶性胆道梗阻患者肝功能及预后的影响

目的:研究胆道支架置入联合介入化疗对恶性胆道梗阻患者肝功能及预后的影响,为临床治疗提供依据。方法:选取2013年2月到2015年2月我院收治的恶性胆道梗阻患者90例,按照随机数字表法将患者分为Ⅰ组、Ⅱ组和Ⅲ组,每组30例,Ⅰ组给予胆道支架置入联合介入化疗,Ⅱ组给予单纯胆道支架置入,Ⅲ组给予保守治疗,比较三组治疗前、后肝功能、并发症、支架通畅率及生存期。结果:治疗前三组谷草转氨酶(AST)、谷丙转氨酶(ALT)、γ-谷氨酰转移酶(r-GT)比较无统计学意义(P0.05),治疗后Ⅰ组和Ⅱ组AST、ALT和r-GT均显著改善,与治疗前和Ⅲ组比较差异具有统计学意义(P0.05),且I组显著优于Ⅱ组,比较差异具有统计学意义(P0.05),Ⅲ组治疗后AST、ALT和r-GT与治疗前比较差异无统计学意义(P0.05);Ⅰ组、Ⅱ组和Ⅲ组并发症发生率比较无统计学意义(P0.05);Ⅰ组术后3个月、6个月和12个月支架通畅率均显著高于Ⅱ组,比较差异具有统计学意义(P0.05);I组生存期显著高于Ⅱ组和Ⅲ组,Ⅱ组高于Ⅲ组,比较差异具有统计学意义(P0.05)。结论:胆道支架置入联合介入化疗治疗恶性胆道梗阻具有较好效果,能明显改善患者肝功,延长患者生存期。     

Indian file pattern of adenocarcinoma cells in effusions

OBJECTIVE: To determine the prevalence of the Indian file pattern of adenocarcinoma cells in malignant serous effusions. STUDY DESIGN: Twenty-five malignant and 10 benign effusion samples were selected. Clinical data, including the sites of the primary neoplasms, were noted. The presence or absence of Indian file arrangement of carcinoma cells and other patterns were recorded. RESULTS: Seven of the 25 positive cases showed Indian file arrangement, whereas none of the negative cases did. Their number did not show any correlation with the type and site of the primary neoplasms. In most of the 7 cases other patterns, such as 3-dimensional balls and papillations, were also present. CONCLUSION: Cells in Indian file in serous effusions are strongly suggestive of metastatic carcinoma. They are not specific to any particular site of the primary adenocarcinoma.     

恶性胆道梗阻患者所行经皮穿刺肝内胆管引流术中成功置入金属支架的术前影响因素分析

目的:探讨恶性胆道梗阻患者行PTBD(Percutaneous Transhepatic Biliary Drainage)术中金属支架置入成功率的影响因素。方法:回顾性搜集2010年10月-2017年1月上海市第一人民医院收治的因患有近端恶性胆道梗阻行PTBD术患者的相关临床资料。比较不同原发病因患者支架置入情况。根据患者支架置入是否成功将其分为支架组和非支架组,比较患者的一般临床特征。结果:胰腺癌、胃癌和胆囊癌为本研究中数量上前3位的肿瘤,将以上3组分别按照支架置入数行x~2检验,其中胰腺癌(n=18,支架=6)和胃癌(n=14,支架=11)有统计学意义。将50例患者分为支架组(n=28)和非支架组(n=22),组间比较差异有统计学意义的因素包括:白细胞计数(支架组=6.40±3.40×10~9/L,非支架组=10.74±6.41×10~9/L),中性粒细胞计数(支架组=4.90±3.06×10~9/L,非支架组=8.92±6.25×10~9/L),胆道感染(支架组=9,非支架组=15)。进一步将该50例患者分为6组:胰腺癌-胆道感染组、胃癌-胆道感染组、其他肿瘤-胆道感染组、胰腺癌+胆道感染组、胃癌+胆道感染组、其他肿瘤+胆道感染组。将以上6组分别按照支架置入数行x~2检验,胰腺癌+胆道感染组(n=11,支架=1,P=0.001)有统计学意义。结论:PTBD术对于恶性胆道梗阻是一种有效的姑息治疗手段。胆道感染是PTBD术中支架置入成功的不利因素,胰腺癌合并胆道感染会显著降低PTBD术中支架置入成功率。     

Breast Reconstruction for Malignant or Premalignant Disease

In ten patients breast reconstruction was done after surgical treatment for a premalignant or malignant breast disease. In six of these, prophylactic subcutaneous mastectomy and implant reconstruction were carried out, and in the remaining four reconstruction was done after simple or modified radical mastectomy. It is suggested that these procedures should be considered by those physicians and surgeons who undertake evaluation and treatment of breast disease in women. Breast reconstruction should be considered and offered to patients who suffer from the severe personal and emotional trauma attendant to surgical operation for breast disease.     

Preoperative aspiration cytology of breast tumors

During a ten-year period, 1,942 aspirations of 1,906 mammary tumors in 1,874 patients were performed before excisional biopsy or mastectomy. The cytology findings were categorized as positive (1,107 cases), suspicious (152 cases), atypical (183 cases), benign (166 cases) and unsatisfactory (298 cases). All cytologically positive cases with follow-up were confirmed histologically or by clinical observation. Follow-up showed that 96% of the cases in the suspicious category, 86% of the cases in the atypical category, 51% of the cases in the benign category and 72% of the cases in the unsatisfactory category had malignant neoplasms. Aspiration cytology diagnosed 1,031 of 1,539 primary malignant mammary neoplasms (67%) and 19 of 28 neoplasms (68%) metastatic to the breast; if unsatisfactory cases are excluded, these figures become 1,031 of 1,365 cases (75%) and 19 of 25 (76%), respectively. If those cases reported as suspicious are included with the positive cases and those reported as atypical are included with the negative cases, aspiration cytology would have a sensitivity of 84% for the presence of carcinoma, a specificity of 97% for the absence of carcinoma, a predictive value of 99% for a positive diagnosis and a predictive value of 56% for a negative diagnosis; the diagnostic efficiency would be 86%. Our findings reaffirmed that the cytologic diagnosis of mammary carcinomas is reliable but that negative or inconclusive cytologic findings should not be regarded as a definitive diagnosis if there is clinical suspicion of a malignant neoplasm.