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Summary Background Spontaneous perforation of the extrahepatic bile duct is very rare. We report a patient with a spontaneous perforation of the left hepatic bile duct who was diagnosed preoperatively. Case Report A 65-year-old woman was admitted to our hospital complaining of a right upper quadrant pain lasting for two days. She was diagnosed as having a perforated bile duct and peritonitis and underwent a laparotomy. After a cholecystectomy, T-tube drainage of the left hepatic duct was performed. The postoperative course was uneventful. The T tube was removed 25 days after the surgery. Conclusions A more noninvasive procedure, such as endoscopic treatment, should play a central role in the management of extra bile duct perforation. For this case, however, we chose to perform a laparotomy based on the patient’s general condition and the presence of peritonitis. T tube decompression is effective and a safe and reliable method. The goal of treatment is to stop the bile leakage, resolve the choledocholithiasis and cholangitis, and reconstruct the bile duct.

The patient, a 56-year-old woman, was found during routine checkup to have a disorder of hepatic function. Abdominal ultrasonography showed an ill-defined hypoechoic mass in the head and body of the pancreas; however, no blood-flow signal was observed within the tumor on Doppler ultrasonography. Abdominal computed tomography showed a low-density area in the arterial and portal venous phases. The lesion was visualized as an area of low signal intensity on both T1- and T2-weighted magnetic resonance images, whereas fluorodeoxyglucose positron emission tomography showed fluorodeoxyglucose accumulation in the tumor. Although a preoperative diagnosis was difficult to make, a rapid cytologic examination revealed evidence of a pancreatic endocrine tumor, and subtotal stomach-preserving pancreaticoduodenectomy with portal vein resection was performed. Histopathological examination showed tumor cell nests scattered in abundant fibrotic tissue; the tumor cells had proliferated in a cord-like fashion and showed immunostaining for chromogranin A. Staining for fibroblast activation protein α was seen in the fibroblastic cells contained within the fibrous stroma surrounding the tumor cell nests, whereas both the fibroblastic cells in the tumor and those in the stroma showed a high rate of staining for thrombospondin. We presume that tumor-associated fibroblasts were involved in the fibrosis of the tumor stroma.

s / Pancreatology 12 (2012) 502–597 523 Methods: 153 patients with chronic pancreatitis (CP) were included in the research in whom pancreas proximal resections were performed (pancreatoduodenal resection in 53 patients; Beger operation in modification of the clinic – in 61 patients; Bern modification – in 39 patients). Criteria of treatment efficacy were the level of distant lethality, frequency of complications and repeated interventions, marked character of exocrine and endocrine insufficiency. The pain syndrome level and professional rehabilitation of patients were estimated. Results: Late lethality related to chronic pancreatitis progressing made up 2,61%. Firstly revealed diabetes mellitus developed in 15 (9,8%) patients after all surgical interventions; reliably smaller number of such cases in patients after Beger operation was noted in comparison with pancreatoduodenal resection. Exocrine insufficiency was revealed in 27 (17,65%) patients and it doesnt depend on the operative technique. High level of professional rehabilitation was marked at all techniques which was achieved in 137 (89,54%) patients. There was a reliable improvement of parameters of the pain syndrome elimination after Beger operation in modification of the clinic in comparison with pancreatoduodenal resection. Conclusions: The performed analysis of the distant results of surgical treatment of CP patients demonstrates advantages of the pancreas proximal resection with the duodenum saving.

s / Pancreatology 12 (2012) 502–597 523 Methods: 153 patients with chronic pancreatitis (CP) were included in the research in whom pancreas proximal resections were performed (pancreatoduodenal resection in 53 patients; Beger operation in modification of the clinic – in 61 patients; Bern modification – in 39 patients). Criteria of treatment efficacy were the level of distant lethality, frequency of complications and repeated interventions, marked character of exocrine and endocrine insufficiency. The pain syndrome level and professional rehabilitation of patients were estimated. Results: Late lethality related to chronic pancreatitis progressing made up 2,61%. Firstly revealed diabetes mellitus developed in 15 (9,8%) patients after all surgical interventions; reliably smaller number of such cases in patients after Beger operation was noted in comparison with pancreatoduodenal resection. Exocrine insufficiency was revealed in 27 (17,65%) patients and it doesnt depend on the operative technique. High level of professional rehabilitation was marked at all techniques which was achieved in 137 (89,54%) patients. There was a reliable improvement of parameters of the pain syndrome elimination after Beger operation in modification of the clinic in comparison with pancreatoduodenal resection. Conclusions: The performed analysis of the distant results of surgical treatment of CP patients demonstrates advantages of the pancreas proximal resection with the duodenum saving.