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DOI: 10.1055/s-0029-1244103
© Georg Thieme Verlag KG Stuttgart · New York
Late onset bile duct stricture caused by iatrogenic injury during laparoscopic cholecystectomy, mimicking cholangiocellular carcinoma
G. A. BernhardtMD
Division of General Surgery
Department of Surgery
Medical University Graz
Auenbruggerplatz 29
8036 Graz
Austria
Fax: +43-316-3854666
Email: gerwin.bernhardt@klinikum-graz.at
Publication History
Publication Date:
19 April 2010 (online)
Extrahepatic cholangiocellular carcinomas are relatively rare malignant tumors. Although recent years have seen advances in diagnosis and treatment, cholangiocellular carcinomas are usually clinically silent or associated with nonspecific symptoms in the early stages; therefore, most tumors are diagnosed late, when they are inoperable [1]. The diagnosis can be especially challenging in patients with chronic cholangitis or previous hepatobiliary and pancreatic surgery.
We report an unusual case of a 49-year-old woman who presented with painless jaundice. In the past half year she had experienced loss of appetite and weight. Preoperative imaging including magnetic resonance imaging, magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiography (ERC), and computed tomography suggested cholangiocellular carcinoma (Bismuth type II/IIIb) ([Figs. 1], [2]). Brush cytology at ERC was not meaningful but a granulomatous tumor at the hilum with retained nonabsorbable sutures was found intraoperatively ([Fig. 3]). The final histological examination yielded a benign disease described as periductular fibrosis and chronic inflammation. Following a biliodigestive anastomosis, the patient’s status improved uneventfully ([Fig. 4]). A retrospective review revealed an iatrogenic bile duct injury sustained during laparoscopic cholecystectomy 9 years previously, with end-to-end repair carried out in the same session. The patient was unaware of the earlier iatrogenic lesion.
Preoperative findings can suggest malignancy even in benign disease. Correct diagnosis will depend on a careful preoperative diagnostic workup including a detailed history, with special attention to previous surgeries. Definitive diagnosis will usually require surgical exploration, as chronic biliary inflammation or obstructive cholestasis is a known risk factor for cholangiocellular carcinomas. Nonetheless, up to 15 % of suspicious tumors are benign lesions [2] [3]. Long, benign bile duct strictures are repaired with a biliodigestive anastomosis ([Fig. 4]) but they do not require extended lymphadenectomy, which is associated with increased morbidity. The long-term results of bilioenteric anastomosis for benign strictures are promising [4].
Competing interests: None
Endoscopy_UCTN_Code_CCL_1AZ_2AZ
#References
- 1 Aljiffry M, Walsh M J, Molinari M. Advances in diagnosis, treatment and palliation of cholangiocarcinoma: 1990 – 2009. World J Gastroenterol. 2009; 15 4240-4262
- 2 Gerhards M F, Vos P, van Gulik T M. et al . Incidence of benign lesions in patients resected for suspicious hilar obstruction. Br J Surg. 2001; 88 48-51
- 3 Nakayama A, Imamura H, Shimada R. et al . Proximal bile duct stricture disguised as malignant neoplasm. Surgery. 1999; 125 514-521
- 4 Lillemoe K D. Current management of bile duct injury. Br J Surg. 2008; 95 403-405
G. A. BernhardtMD
Division of General Surgery
Department of Surgery
Medical University Graz
Auenbruggerplatz 29
8036 Graz
Austria
Fax: +43-316-3854666
Email: gerwin.bernhardt@klinikum-graz.at
References
- 1 Aljiffry M, Walsh M J, Molinari M. Advances in diagnosis, treatment and palliation of cholangiocarcinoma: 1990 – 2009. World J Gastroenterol. 2009; 15 4240-4262
- 2 Gerhards M F, Vos P, van Gulik T M. et al . Incidence of benign lesions in patients resected for suspicious hilar obstruction. Br J Surg. 2001; 88 48-51
- 3 Nakayama A, Imamura H, Shimada R. et al . Proximal bile duct stricture disguised as malignant neoplasm. Surgery. 1999; 125 514-521
- 4 Lillemoe K D. Current management of bile duct injury. Br J Surg. 2008; 95 403-405
G. A. BernhardtMD
Division of General Surgery
Department of Surgery
Medical University Graz
Auenbruggerplatz 29
8036 Graz
Austria
Fax: +43-316-3854666
Email: gerwin.bernhardt@klinikum-graz.at