Cholangiocarcinomas (CCAs) are malignant tumors that can develop anywhere along the biliary tree. Almost 10% of cholangiocarcinomas arise from the intra-hepatic bile ducts (iCCA); 50–60% from the bifurcation of the hepatic duct (perhilar cholangiocarcinoma, pCCA); and 20–30% from the distal bile duct (dCCA). The 7th edition of the AJCC staging system, released in 2010, divides the tumors into two major categories: perihilar (pCCA) and distal (dCCA) cholangiocarcinoma, given the differences in anatomy of the bile duct and consideration of local factors related to resectability. There are separate histological classifications for intrahepatic and extrahepatic cholangiocarcinoma. The majority of CCAs (90%) are well or moderately differentiated adenocarcinomas. Other features include invasiveness with early neural, perineural, periductal and lymphatic infiltration (more than 50% of cases at diagnosis) and longitudinal subepithelial infiltration along the wall of the bile duct up to 2 cm proximally and 1 cm distally. In this chapter the extrhepatic bile duct cancers are analyzed.
Part of the book: Bile Duct Cancer
Acute pancreatitis has a broad clinical spectrum: from mild, self-limited disease to fulminant illness resulting in multi-organ failure leading to a prolonged clinical course with up to 30% mortality in case of infected necrosis. Management of local complications such as pseudocysts and walled-off necrosis may vary from clinical observation to interventional treatment procedures. Gram negative bacteria infection may develop in up to one-third of patients with pancreatic necrosis leading to a clinical deterioration with the onset of the systemic inflammatory response syndrome and organ failure. When feasible, an interventional treatment is indicated. Percutaneous or endoscopic drainage approach are the first choices. A combination of minimally invasive techniques (step-up approach) is possible in patients with large or multiple collections. Open surgical treatment has been revised both in the timing and in the operating modalities in the last decades. Since 1990s, the surgical treatment of infected necrosis shifted to a more conservative approach. Disruption of the main pancreatic duct is present in up to 50% of patients with pancreatic fluid collections. According to the location along the Wirsung, treatment may vary from percutaneous drainage, endoscopic retrograde pancreatography with sphincterectomy or stenting to traditional surgical procedures. Patients may suffer from vascular complications in up to 23% of cases. Tissue disruption provoked by lipolytic and proteolytic enzymes, iatrogenic complications during operative procedures, splenic vein thrombosis, and pseudoaneurysms are the pathophysiological determinants of bleeding. Interventional radiology is the first line treatment and when it fails or is not possible, an urgent surgical approach should be adopted. Chylous ascites, biliary strictures and duodenal stenosis are complications that, although uncommon and transient, may have different treatment modalities from non-operative, endoscopic to open surgery.
Part of the book: Recent Advances in Pancreatitis
Pancreatitis is a major public health issue worldwide. There is geographical variation in the burden of acute and chronic pancreatitis (CP). Globally, the age-standardized prevalence rate increased from 1990 to 2017. Acute pancreatitis (AP) is now one of the most common reasons for hospitalization with a gastrointestinal condition. The essential requirements for the management of AP are accurate diagnosis, appropriate triage, high-quality supportive care, monitoring for and treatment of complications, and prevention of relapse. Clinicians should be aware of the time course and the best management of AP, identifying which patient will have a severe course allowing earlier triage to an intensive care unit and earlier initiation of effective therapy. CP is a pathologic fibroinflammatory syndrome of the pancreas in individuals with genetic, environmental, and other risk factors who develop persistent pathologic responses to parenchymal injury or stress. Diagnosing the underlying pathologic process early in the disease course and managing the syndrome to change the natural course of disease and minimize adverse disease effects are the managing paradigm. In this review, we consider recent changes in the management of acute and CP, as well as common misunderstandings and areas of ongoing controversy.
Part of the book: Multidisciplinary Management of Acute and Chronic Pancreatitis