Biliary - Papillomatosis
Comments: This 65 year old patient was referred because of painless jaundice. He was a reasonable surgical candidate with a history of coronary artery disease. CT scan showed dilated left hepatic ducts with a somewhat atrophic left lobe; MRCP showed similar findings with some filling defects in the common hepatic duct and left hepatic duct, and mildly dilated R hepatic ducts. Endoscopic ultrasound showed multiple tissue-density polypoid structures extending from mid common bile duct into left hepatic duct, consistent with a diagnosis of biliary papillomatosis, with sparing of the right lobe.
ERCP was performed to obtain tissue diagnosis and place biliary stents while work up continued. Biopsies and brushings confirmed papillomatosis, without apparent carcinoma, and right hepatic duct stents were placed without instrumentation or contamination of the extensively involved left lobe. Two 7 french double pigtail stents (Wilson Cook) were used to avoid stent migration (likely with straight stents). Jaundice resolved
The patient was considered for extended left hepatectomy and common bile duct resection, versus liver transplantation pending confirmation of lack of involvement of the right lobe. Choledochoscopy was arranged to assess for extent of disease and to confirm sparing of the right lobe.
After removal of the stents, decompression of the right hepatic ducts is seen. Arrows point to upper and lower extent of lesion apparently below takeoff of right hepatic and below the branchpoint of right anterior and posterior sectoral ducts.
A 10 French digital video baby scope (Olympus) is inserted over a guidewire deep into the right hepatic duct and the wire is removed.
Cholangioscopic view confirms the apparent lack of involvement of the R hepatic duct to below branch of R anterior and posterior sectoral ducts.
Gradual withdrawal of the baby scope shows a bizarre, papillary lesion starting extending from the bifurcation all the way down the common duct to approximately the level of the cystic duct takeoff.
Two double pigtail biliary stents are replaced in the right hepatic duct. The patient underwent extended left hepatectomy and resection of the common bile duct, without pancreaticoduodenectomy. Margins were negative and the specimen negative for carcinoma.
| Contributed by: |
Martin L. Freeman, M.D. Professor of Medicine Hennepin County Medical Center University of Minnesota |
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Citation: Freeman, ML (Feb 16 2006). Biliary - Papillomatosis. The DAVE Project. Retrieved Sep, 6, 2010, from http://daveproject.org/viewfilms.cfm?film_id=317 Times viewed since Feb 2006: 5570 |
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