Analysis of the pancreato-biliary system from MRCP

We present a preprocessing and segmentation scheme designed to address the particular difficulties encountered in the analysis of magnetic resonance cholangiopancreatography (MRCP) data, as a precursor to the application of computer assisted diagnosis (CAD) techniques. MRCP generates noisy, low resolution, non-isometric data which often exhibits significant greylevel inhomogeneities. This combination of characteristics results in data volumes in which reliable segmentation and analysis are difficult to achieve. In this paper we describe a data processing approach developed to overcome these difficulties and allow for the effective application of automated CAD procedures in the analysis of the biliary tree and pancreatic duct in MRCP examinations

Distal Cholangiocarcinoma

Cholangiocarcinoma arises from the epithelial lining of the biliary tree. It accounts for approximately 3% of all gastrointestinal malignancies. This chapter looks at the new advances that have been made in the management of distal cholangiocarcinoma, based on a literature review. Diagnosis of the disease resides mainly in clinical presentation and radiological diagnosis and biopsy indicated in selected cases. Surgical resection is the main curative treatment for distal cholangiocarcinoma, and resectability of the tumor can now be assessed using multiple radiological imaging studies. Resection margins and lymph node invasion status are the two important prognostic factors after surgery. Pancreaticoduodenectomy is the standard surgical treatment of choice in distal cholangiocarcinoma; however, combined major vascular and hepatopancreaticoduodenectomy can be indicated in selected cases. Adjuvant therapy is clearly indicated after surgical resection with survival improvement, but optimal adjuvant treatment strategy has not yet been established

Caroli's disease: report of surgical options and long-term outcome of patients treated in Argentina. Multicenter study

BACKGROUND: Caroli's disease (CD) management is still controversial. AIM: The purpose of this study is to report the most frequent clinical features, treatment options, and outcome obtained after surgical management of CD. METHODS: A voluntary survey was conducted. Demographic, clinical, surgical, and pathological variables were analyzed. RESULTS: Six centers included 24 patients having received surgical treatment from 1991 to 2009. Seventeen (70.8%) patients were female, with average age of 48.7 years old (20-71), and 95.5% were symptomatic. There was left hemiliver involvement in 75% of the patients. Surgical procedures included nine left lateral sectionectomies, eight left hepatectomies, and four right hepatectomies for those with hemiliver disease, while for patients with bilateral disease, one right hepatectomy and two Roux-en-Y hepaticojejunostomies were performed. The average length of hospitalization was 7 days. For perioperative complications (25%), three patients presented minor complications (types 1-2), while major complications occurred in three patients (type 3a). No mortality was reported. After a median follow-up of 166 months, all patients are alive and free of symptoms. CD diagnosis was confirmed by histology. Congenital hepatic fibrosis was present in two patients (8.3%) and cholangiocarcinoma in one (4.2%). CONCLUSIONS: CD in Argentina is more common in females with left hemiliver involvement. Surgical resection is the best curative option in unilateral disease, providing long-term survival free of symptoms and complications. In selected cases of bilateral disease without parenchymal involvement, hepaticojejunostomy should be proposed. However, a close follow-up is mandatory because patients might progress and a transplant should be indicated.Fil: Lendoire, Javier. Gobierno de la Ciudad Autónoma de Buenos Aires. Hospital General de Agudos Doctor Cosme Argerich; ArgentinaFil: Raffin, Gabriel. Gobierno de la Ciudad Autónoma de Buenos Aires. Hospital General de Agudos Doctor Cosme Argerich; ArgentinaFil: Bracco, Ricardo. No especifíca;Fil: Russi, Rodolfo. Ministerio de Defensa. Armada Argentina. Hospital Naval Buenos Aires Cirujano Mayor Dr. Pedro Mallo; ArgentinaFil: Ardiles, Victoria. Hospital Italiano; ArgentinaFil: Gondolesi, Gabriel Eduardo. Fundación Favaloro; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Deflitto, Jorge. No especifíca;Fil: de Santibañez, Eduardo. Hospital Italiano; ArgentinaFil: Inventarza, Oscar. Gobierno de la Ciudad Autónoma de Buenos Aires. Hospital General de Agudos Doctor Cosme Argerich; Argentin

Dilated common bile duct unexplained on transabdominal ultrasonography; the role of endoscopic ultrasonography and predictors of malignancy

 Background: The aim of the this prospective study was to evaluate  the endoscopic ultrasonography (EUS) in detecting the cause of common bile duct (CBD) dilatation in patients in whom ultrasonography(US) could not indicate  the cause of dilation. Methods: Seventy patients with the search criteria of unexplained dilated CBD (diameter > 7 mm) were examined by EUS. All patients (except 4 patients with pancreatic mass) were further evaluated by ERCP. Results: The following diagnoses were made by EUS and ERCP: choledocholithiasis in 45, pancreato-biliary malignancy (PBM) in 17, papillary stenosis in 5, and no finding in 3 cases. We found that the majority of patients (95.7%) had findings on EUS to explain the etiology of their dilated CBD. The prevalence of pathology is lower (76.9%) in patients with normal liver function tests (LFTs).The yield of EUS is higher (100%) when elevated liver enzymes. Lower hemoglobin levels, larger diameter of CBD and pancreatic duct (PD) and ESR greater than 30 mm/h were independent risk factors for PBM, whereas, patients with previous cholecystectomy, normal LFTs and abdominal pain were less likely to have this diagnosis. Conclusion: the majority of patients referred for EUS for dilated CBD will have an etiology discoveredTherefore, EUS should be the first diagnostic strategy for dilated CBD of unexplained origin, even in patients with normal LFTs. In patients with dilated CBD accompanied by anemia, abnormal LFTs and ESR or dilated PD, malignancy should be considered.   

Perihilar or (Hilar) Cholangiocarcinoma: Interventional to Surgical Management

Peri-hilar cholangiocarcinoma (PHC) or hilar cholangiocarcinoma (HCCA) characterizes a critical effort to assess significantly sick patients. The existing scenery and proof to the diagnosis and treatments for hilar cholangiocarcinoma are improving day by day. Patients with HCCA encounter numerous obstacles in acquiring efficient therapies. The condition is uncommon, and the majority patients don’t have any distinct risk factors, doing selection process inadequate. The initial signs and symptoms in many cases are non-specific, and in many patients the tumors are not resectable because of involvement of the perihilar structures. MRI with MRCP offers further information about the extent of biliary involvement. Furthermore, endoscopic stenting and percutaneous drain could be useful for intricate hilar strictures. Surgical resections with negative margins are related to good likelihood of survival for patients representing with HCCA. Regardless of the accessibility of curative treatment strategies such as operative resection and liver transplantation, most sufferers with HCCA shows with repeated, metastases or locally advanced disease with a poor prognosis. Within this chapter, we have tried to elaborate the modalities of treatment from intervention to surgical approach for HCCA

Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES-AAST guidelines

Duodeno-pancreatic and extrahepatic biliary tree injuries are rare in both adult and pediatric trauma patients, and due to their anatomical location, associated injuries are very common. Mortality is primarily related to associated injuries, but morbidity remains high even in isolated injuries. Optimal management of duodeno-bilio-pancreatic injuries is dictated primarily by hemodynamic stability, clinical presentation, and grade of injury. Endoscopic and percutaneous interventions have increased the ability to non-operatively manage these injuries. Late diagnosis and treatment are both associated to increased morbidity and mortality. Sequelae of late presentations of pancreatic injury and complications of severe pancreatic trauma are also increasingly addressed endoscopically and with interventional radiology procedures. However, for moderate and severe extrahepatic biliary and severe duodeno-pancreatic injuries, immediate operative intervention is preferred as associated injuries are frequent and commonly present with hemodynamic instability or peritonitis. The aim of this paper is to present the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) duodenal, pancreatic, and extrahepatic biliary tree trauma management guidelines

Pancreatic tumors imaging: an update

Currently, ultrasound (US), computed tomography (CT) and Magnetic Resonance imaging (MRI) represent the mainstay in the evaluation of pancreatic solid and cystic tumors affecting pancreas in 80-85% and 10-15% of the cases respectively. Integration of US, CT or MR imaging is essential for an accurate assessment of pancreatic parenchyma, ducts and adjacent soft tissues in order to detect and to stage the tumor, to differentiate solid from cystic lesions and to establish an appropriate treatment. The purpose of this review is to provide an overview of pancreatic tumors and the role of imaging in their diagnosis and management. In order to a prompt and accurate diagnosis and appropriate management of pancreatic lesions, it is crucial for radiologists to know the key findings of the most frequent tumors of the pancreas and the current role of imaging modalities. A multimodality approach is often helpful. If multidetector-row CT (MDCT) is the preferred initial imaging modality in patients with clinical suspicion for pancreatic cancer, multiparametric MRI provides essential information for the detection and characterization of a wide variety of pancreatic lesions and can be used as a problem-solving tool at diagnosis and during follow-up

Tokyo Guidelines 2018 management bundles for acute cholangitis and cholecystitis

Management bundles that define items or procedures strongly recommended in clinical practice have been used in many guidelines in recent years. Application of these bundles facilitates the adaptation of guidelines and helps improve the prognosis of target diseases. In Tokyo Guidelines 2013 (TG13), we proposed management bundles for acute cholangitis and cholecystitis. Here, in Tokyo Guidelines 2018 (TG18), we redefine the management bundles for acute cholangitis and cholecystitis. Critical parts of the bundles in TG18 include the diagnostic process, severity assessment, transfer of patients if necessary, and therapeutic approach at each time point. Observance of these items and procedures should improve the prognosis of acute cholangitis and cholecystitis. Studies are now needed to evaluate the dissemination of these TG18 bundles and their effectiveness. Free full articles and mobile app of TG18 are available at: . Related clinical questions and references are also include

Efficient pre-segmentation filtering in MRCP

Magnetic Resonance Cholangiopancreatography (MRCP) is an evolving MRI technique designed for the imaging of the biliary tree, a system of narrow ducts that collect bile, produced within the liver, store it in the gall bladder, and deliver it into the small intestine as needed. Current MRCP protocols, used to diagnose problems in this ductal system, generate cluttered and noisy, low resolution, non-isometric volume data, often with significant intensity non-uniformities. This combination of undesirable characteristics presents particular challenges for the application of automated image analysis techniques. This thesis examines the development, characterisation, and testing of novel and efficient pre-segmentation filtering procedures designed to achieve increased robustness and precision in the subsequent segmentation and analysis of the biliary tree from MRCP data. A focused set of image preprocessing algorithms has been developed so as to facilitate the operation of non-complex segmentation and computer assisted diagnosis (CAD) procedures. Most notable in this regard are a number of novel techniques designed to address the key areas of this image processing task. These techniques consist of: • a new histogram preserving approach to inter-image and intervolume intensity non-uniformity correction, • a highly versatile adaptive smoothing filter, implemented as an oriented, scaled and shaped ellipsoid filter mask, • the downhill filter, an efficient new algorithm for morphological reconstruction by dilation, and • a novel approach to the reconstruction of fine branching structures in noisy volume data. Through this combination of flexible and efficient preprocessing algorithms, an effective route towards robust MRCP segmentation and analysis, and routine CAD in the assessment of the biliary tree from MRCP is presented

Flowcharts for the management of biliary tract and ampullary carcinomas

No strategies for the diagnosis and treatment of biliary tract carcinoma have been clearly described. We developed flowcharts for the diagnosis and treatment of biliary tract carcinoma on the basis of the best clinical evidence. Risk factors for bile duct carcinoma are a dilated type of pancreaticobiliary maljunction (PBM) and primary sclerosing cholangitis. A nondilated type of PBM is a risk factor for gallbladder carcinoma. Symptoms that may indicate biliary tract carcinoma are jaundice and pain in the upper right area of the abdomen. The first step of diagnosis is to carry out blood biochemistry tests and ultrasonography (US) of the abdomen. The second step of diagnosis is to find the local extension of the carcinoma by means of computed tomography (CT), magnetic resonance imaging (MRI), magnetic resonance cholangiopancreatography (MRCP), percutaneous transhepatic cholangiography (PTC), and endoscopic retrograde cholangiopancreatography (ERCP). Because resection is the only way to completely cure biliary tract carcinoma, the indications for resection are determined first. In patients with resectable disease, the indications for biliary drainage or portal vein embolization (PVE) are checked. In those with nonresectable disease, biliary stenting, chemotherapy, radiotherapy, and/or best supportive care is selected