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Value of multidetector row CT in the assessment of longitudinal extension of cholangiocarcinoma: correlation between MDCT and microscopic findings. World J Surg 2009; 33:1459-67. [PMID: 19381719 DOI: 10.1007/s00268-009-0025-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND A few authors have reported the value of multidetector row CT (MDCT) for evaluating the longitudinal extent of cholangiocarcinoma. They have not focused on CT attenuation of a tumor and actual tumor extent along the bile ducts. We designed the present study to analyze attenuation. METHODS Between January 2003 and July 2005, 113 consecutive patients with cholangiocarcinoma underwent a surgical resection following MDCT. Of these MDCT studies, 73 (perihilar cholangiocarcinoma, n = 62; middle and distal cholangiocarcinoma, n = 11) were suitable for analysis, and the patients were enrolled in the study. Patients were divided according to tumor hypoattenuation and hyperattenuation on MDCT. Histologic differentiation, desmoplastic reaction, and vascular density were microscopically compared with the tumor attenuation to differentiate the characteristics of the attenuation. The extent of cancer along the bile duct diagnosed by MDCT was compared with the actual extent determined by the microscopic findings. RESULTS Hyperattenuated tumor was observed in 40 patients. There was no difference in histologic differentiation, desmoplastic reaction, or vascular density between the hyperattenuated and hypoattenuated cholangiocarcinomas. Neither the proximal nor the distal borders between the normal and thickened bile duct wall could be determined in the 33 patients with hypoattenuated tumor; in contrast, an accurate assessment of extent of tumor was obtained in 76% of the proximal borders and 82% of the distal borders in the 40 patients with hyperattenuated tumor. CONCLUSIONS Although the cause of the difference between the hyperattenuated and hypoattenuated cholangiocarcinoma still is unclear, MDCT can be an alternative to direct cholangiography in selected patients with hyperattenuated cholangiocarcinoma.
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JARNAGIN W, D'ANGELICA M, BLUMGART L. Intrahepatic and Extrahepatic Biliary Cancer. SURGERY OF THE LIVER, BILIARY TRACT AND PANCREAS 2007:782-826. [DOI: 10.1016/b978-1-4160-3256-4.50063-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2025]
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Wakai T, Shirai Y, Hatakeyama K. Peroral cholangioscopy for non-invasive papillary cholangiocarcinoma with extensive superficial ductal spread. World J Gastroenterol 2005; 11:6554-6. [PMID: 16425434 PMCID: PMC4355804 DOI: 10.3748/wjg.v11.i41.6554] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Papillary carcinoma arising from the extrahepatic bile duct often shows superficial ductal spread. We report herein the case of a patient with extensive superficial spread of non-invasive papillary cholangiocarcinoma, which was depicted with peroral cholangioscopy. A 65-year-old woman presented with the sudden-onset of severe epigastric pain. Ultrasonography revealed acute acalculous cholecystitis. Endoscopic retrograde cholangiography found small protruding lesions around the confluence of the cystic duct, suggestive of a cholangiocarcinoma. As the contour of the middle and upper bile ducts it was slightly irregular on the cholangiogram, the presence of superficial ductal spread was suspected. Peroral cholangioscopy revealed small papillary lesions around the confluence of the cystic duct and fine granular mucosal lesions in the middle and upper bile ducts and the right hepatic duct, suggesting a superficially spreading tumor. A right hepatectomy with bile duct resection was performed and no residual tumor was found. Histological examination revealed a non-invasive papillary carcinoma arising from the cystic duct with extensive superficial spread. Our experience of this case and a review of the literature suggest that a fine granular or fine papillary appearance of the ductal mucosae on cholangioscopy indicates superficial spread of papillary cholangiocarcinoma, for which peroral cholangioscopy is an efficient diagnostic option.
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Affiliation(s)
- Toshifumi Wakai
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-dori, Niigata, Niigata 951-8510, Japan
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Okamoto A, Tsuruta K, Matsumoto G, Takahashi T, Kamisawa T, Egawa N, Funata N. Papillary carcinoma of the extrahepatic bile duct: characteristic features and implications in surgical treatment. J Am Coll Surg 2003; 196:394-401. [PMID: 12648691 DOI: 10.1016/s1072-7515(02)01664-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Papillary carcinoma of the extrahepatic bile duct presents clinically and histologically distinct features relevant to surgical decision-making. STUDY DESIGN Serial sections of 15 specimens of resected papillary carcinoma of the bile duct were histologically examined to determine mode of spread, possibility of multicentric tumor origins, and coincidence with other neoplastic lesions. The presence of anomalous pancreaticobiliary ductal union was also investigated. These characteristics were considered with regard to surgical treatment. RESULTS Three patients displaying pancreaticobiliary maljunction and one of three patients with a long common channel (> or = 8 mm) exhibited multicentric tumors. Eight patients (53%) demonstrated superficial spread along a mean length of 37.8 mm (range, 5 to 67 mm) of bile duct mucosa. Multicentric tumors developed synchronously in 4 patients, while metachronous tumors were identified in three patients displaying tumor histology similar to the primary lesions. Two of these three underwent successful repeated resection. Concomitant neoplastic lesions in the biliary tract were identified as mucosal dysplasia in four patients and cholangiocellular carcinoma of the liver in two. All tumors but one were removed via hepatic lobectomy or pancreatoduodenectomy, or both, resulting in a 5-year survival rate of 60%. CONCLUSIONS Aggressive resection offers clear survival benefits for patients presenting with tumors displaying extensive superficial spread or multicentric origins. Closer attention should be paid to long common channels in relation to carcinogenesis of the bile duct, in addition to pancreaticobiliary maljunction. The risk of secondary tumor development remains, particularly in patients with pancreaticobiliary maljunction even after excision of the tumor-bearing extrahepatic bile duct.
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Affiliation(s)
- Atsutake Okamoto
- Department of Surgery, Tokyo Metropolitan Komagome Hospital, Japan
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p53 labeling index in cholangioscopic biopsies is useful for determining spread of bile duct carcinomas. Gastrointest Endosc 2002. [DOI: 10.1016/s0016-5107(02)70118-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
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Kim MH, Yasuda K. Percutaneous transhepatic cholangioscopic examination: a necessity for the biliary endoscopist. Gastrointest Endosc 2001; 53:695-7. [PMID: 11323611 DOI: 10.1067/mge.2001.114414] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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Abstract
BACKGROUND Cholangioscopy has been used in the treatment of bile duct stones and the diagnosis of various bile duct tumors. However, the cholangioscopic characteristics of the various types of bile duct tumors have not been clearly described. We analyzed the results of cholangioscopic examinations and classified the findings according to tumor histology. METHODS Cholangioscopic findings from 111 patients with benign or malignant bile duct tumors were reviewed. The mucosal changes, the presence of neovascularization, and the patterns of luminal narrowing were analyzed and compared with the histologic diagnosis. RESULTS Bile duct adenocarcinoma can be classified into 3 different types according to the cholangioscopic findings: nodular, papillary, and infiltrative. Bile duct adenoma, hepatocellular carcinoma and other types of bile duct cancer such as mucin-hypersecreting cholangiocarcinoma, biliary cystadenocarcinoma, and squamous cell carcinoma also presented unique cholangioscopic characteristics. CONCLUSIONS Bile duct tumors exhibit characteristic cholangioscopic findings and cholangioscopy seems to be useful for differential diagnosis.
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Affiliation(s)
- D W Seo
- Department of Internal Medicine, Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Percutaneous Transhepatic Cholangioscopy in the Treatment of Complicated Intrahepatic Biliary Strictures and Hepatolithiasis With Internal Metallic Stent. Surg Laparosc Endosc Percutan Tech 2000. [DOI: 10.1097/00129689-200010000-00004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
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Tamada K, Ohashi A, Tomiyama T, Miyata T, Wada S, Satoh Y, Ido K, Sugano K. Double-catheter method to prevent dislodgement during percutaneous transhepatic cholangioscopy. Gastrointest Endosc 2000; 52:246-50. [PMID: 10922103 DOI: 10.1067/mge.2000.107220] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND We evaluated the utility of the double-catheter method to establish the track for percutaneous transhepatic cholangioscopy (PTCS). METHODS Dilatation of the percutaneous transhepatic track to 16F for PTCS was attempted in 105 patients. The results were prospectively analyzed. Using the single-catheter method (n = 22), a 16F PTCS catheter was replaced without the inner catheter. Using the double-catheter method (n = 83), a 7F catheter with a balloon tip was inserted through a 16F PTCS catheter. The balloon was located distal to the major duodenal papilla. The double-catheter method was further subclassified as follows: Method 2A (n = 62), the tip of the outer catheter (16F) was not advanced through biliary stenoses; Method 2B (n = 21), the catheter was advanced through biliary stenoses. RESULTS In the patients treated by the double-catheter method, dislodgement of the catheter did not occur, whereas the single-catheter became dislodged in 18% (p < 0.0005). The morbidity of method 2A (0%) was less than that of method 2B (14%) (p < 0.005). CONCLUSION The double-catheter method prevents dislodgement of the PTCS catheter. The outer catheter should not be advanced to the biliary stenosis.
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Affiliation(s)
- K Tamada
- Department of Gastroenterology, Jichi Medical School, Yakushiji, Tochigi, Japan
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Tamada K, Kurihara K, Tomiyama T, Ohashi A, Wada S, Satoh Y, Miyata T, Ido K, Sugano K. How many biopsies should be performed during percutaneous transhepatic cholangioscopy to diagnose biliary tract cancer? Gastrointest Endosc 1999; 50:653-8. [PMID: 10536321 DOI: 10.1016/s0016-5107(99)80014-5] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND The sensitivity of biopsy in the diagnosis of cholangiocarcinoma using percutaneous transhepatic cholangioscopy is not well defined. METHODS Patients with a biliary tract malignancy (n = 52) underwent directed biopsy during percutaneous transhepatic cholangioscopy using a 1.8 mm diameter forceps. Histologic findings were correlated with endoscopic appearance. RESULTS A diagnosis of carcinoma was made in all four patients with a tumor of the major duodenal papilla and in all 15 patients with a polypoid bile duct tumor with two biopsies from the mass. In 19 patients with stenotic bile duct cancer, a positive diagnosis was made in 95% of cases when three biopsies were taken from the margin of the stenotic area. When cholangioscopy showed a tortuous, dilated vessel (n = 10), the diagnosis of cancer was made with two biopsies taken from the margin of the stenosis. In 14 patients with metastatic bile duct cancer, the diagnosis was made in only 43% of cases when three biopsies were taken from the margin of the stenosis. When combined with results from the three biopsies taken from within the area of stenosis, the sensitivity for diagnosing pancreatic cancer improved from 20% to 60%. CONCLUSIONS Directed cholangioscopic biopsies are highly sensitive for the diagnosis of cholangiocarcinoma but less sensitive for cancer metastatic to the bile duct. The numbers and locations of the biopsies required to make a diagnosis of carcinoma depend on the origin and cholangioscopic appearance of the tumor.
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Affiliation(s)
- K Tamada
- Department of Gastroenterology and Pathology, Jichi Medical School, Yakushiji, Tochigi, Japan
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Tamada K, Yasuda Y, Nagai H, Tomiyama T, Tano S, Kanai N, Ohashi A, Aizawa T, Ido K, Kimura K. Limitation of cholangiography in assessing longitudinal spread of extrahepatic bile duct carcinoma to the hepatic side. J Gastroenterol Hepatol 1999; 14:691-8. [PMID: 10440214 DOI: 10.1046/j.1440-1746.1999.01894.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND Preoperative assessment of longitudinal spread of bile duct carcinoma (BDC) to the hepatic side remains a difficult problem for diagnostic imaging. METHODS We studied the accuracy of cholangiography in assessing BDC. In 54 patients with extrahepatic bile duct cancer, cholangiographic findings were compared retrospectively with the histological findings of the resected specimens. RESULTS Histological examination of specimens indicated longitudinal spread of the tumour to the hepatic side in 22 of 54 patients. The accuracy of cholangiography in assessing the extent of the longitudinal spread was only 34/54 (63%). When the cholangiographic images showed a main tumour with a collapsed edge, there was a significantly higher frequency of longitudinal spread compared with tumours with sharp edges (P< 0.05). In contrast, the accuracy of mapping biopsy under percutaneous transhepatic cholangioscopy (n=24) was 83%. CONCLUSIONS Cholangiography cannot accurately assess the extent of the longitudinal spread of bile duct cancer. When cholangiographic images show a tumour with a collapsed edge, preoperative or intraoperative histological examination is essential to determine a suitable surgical line.
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Affiliation(s)
- K Tamada
- Department of Gastroenterology, Jichi Medical School, Tochigi, Japan.
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Seo DW, Kim MH, Lee SK, Myung SJ, Kang GH, Ha HK, Suh DJ, Min YI. Usefulness of cholangioscopy in patients with focal stricture of the intrahepatic duct unrelated to intrahepatic stones. Gastrointest Endosc 1999; 49:204-9. [PMID: 9925699 DOI: 10.1016/s0016-5107(99)70487-6] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Intrahepatic duct strictures are usually caused by intrahepatic duct stones and cholangitis. However, focal strictures of the intrahepatic duct unrelated to intrahepatic stones often pose diagnostic problems. This study was undertaken to prospectively evaluate the usefulness of percutaneous transhepatic cholangioscopy in patients with focal intrahepatic duct stricture and no evidence of a stone. METHODS Seventeen patients with focal strictures of the intrahepatic duct without any evidence of a stone were included. Percutaneous transhepatic cholangioscopic examination including procurement of biopsy specimens was performed after percutaneous transhepatic biliary drainage. RESULTS A histopathologic diagnosis was obtained in all patients (9 adenocarcinomas, 1 squamous cell carcinoma, 2 hepatocellular carcinomas, 2 adenomas, and 3 benign strictures). Of the 9 patients with bile duct adenocarcinoma, 8 underwent surgery and a curative resection was possible in 7 patients (88%). Five patients (63%) had early-stage bile duct cancer in which cancer invasion was limited to the mucosa or fibromuscular layer and there was no evidence of lymph node metastasis. CONCLUSIONS Percutaneous transhepatic cholangioscopy in patients with focal stricture of the intrahepatic duct unrelated to choledocholithiasis is useful for diagnosis including the detection of early bile duct cancer.
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Affiliation(s)
- D W Seo
- Departments of Internal Medicine, Pathology, and Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Sakamoto E, Nimura Y, Hayakawa N, Kamiya J, Kondo S, Nagino M, Kanai M, Miyachi M, Uesaka K. The pattern of infiltration at the proximal border of hilar bile duct carcinoma: a histologic analysis of 62 resected cases. Ann Surg 1998; 227:405-11. [PMID: 9527064 PMCID: PMC1191279 DOI: 10.1097/00000658-199803000-00013] [Citation(s) in RCA: 211] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To clarify the importance of different patterns of infiltration at the proximal border of hilar bile duct carcinomas. SUMMARY BACKGROUND DATA There are few detailed pathologic studies on the proximal resection margins in patients with hilar bile duct carcinoma. METHODS Serial sections of 62 specimens of resected hilar bile duct carcinoma were examined histologically to determine the involved layers and routes of invasion at the proximal border. The degree of cancer extension was determined, and the relation between the length of the tumor-free resection margin and postoperative anastomotic recurrences was analyzed. RESULTS Mucosal extension was predominant in papillary and nodular tumors, but submucosal extension was predominant in diffusely infiltrating and nodular-infiltrating tumors. Submucosal extension usually consisted of direct or lymphatic invasion. The mean length of submucosal extension was 6.0 mm. Superficial spread of cancer, defined as mucosal extension of more than 20 mm from the main lesion, was seen in 8 specimens. No patient had an anastomotic recurrence when the tumor-free resection margin was greater than 5 mm. CONCLUSIONS The pattern of infiltration at the proximal border of resected hilar bile duct carcinomas is closely related to the gross tumor type. The length of submucosal extension is usually less than 10 mm. Superficial spread of cancer is seen in more than 10% of cases. A tumor-free proximal resection margin of 5 mm appears to be adequate in hilar bile duct carcinoma.
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Affiliation(s)
- E Sakamoto
- First Department of Surgery, Nagoya University School of Medicine, Japan
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Sano T, Nimura Y, Hayakawa N, Kamiya J, Nagino M, Kanai M, Miyachi M, Uesaka K. Clinical utility of percutaneous transhepatic cholangioscopy in defining tumor extent: a case of mucin-producing bile duct carcinoma originating in the left caudate lobe. Gastrointest Endosc 1997; 46:455-8. [PMID: 9402123 DOI: 10.1016/s0016-5107(97)70042-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- T Sano
- First Department of Surgery, Nagoya University School of Medicine, Japan
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Hausegger KA, Mischinger HJ, Karaic R, Klein GE, Kugler C, Kern R, Uggowitzer M, Szolar D. Percutaneous cholangioscopy in obstructed biliary metal stents. Cardiovasc Intervent Radiol 1997; 20:191-6. [PMID: 9134842 DOI: 10.1007/s002709900135] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE To reevaluate the reasons for the occlusion of self-expanding biliary metal stents, on the basis of cholangioscopic findings. METHODS Percutaneous transhepatic cholangioscopy (PTCS) was performed in 15 patients with obstructed biliary Wallstents. The reason for stent insertion was a malignant obstruction in 14 patients; 1 had a benign biliary stricture. Conventional noncovered stents had been inserted in 12 patients; in 3 cases a polyurethanecovered prototype Wallstent had been used. Stent occlusions occurred after 1-55 months. PTCS was performed with a 2.3-mm endoscope through an 11 Fr sheath. Biopsies were taken via the working channel of the endoscope. RESULTS In all patients with noncovered stents the inner surface of the stent was highly irregular with seaweed-like protrusions (biopsy-proven granulation tissue). Stent incorporation varied from absent (n = 1) to subtotal (n = 8), but was always incomplete, no matter how long the stent had been in place. Tumor ingrowth was histologically proven in 2 patients. One patient had a large occluding concrement at the proximal end of the stent. In patients with covered stents, the inner surface appeared more regular; however, viable granulation tissue was found inside two stents and tumor ingrowth in one of them. CONCLUSION PTCS showed that incorporation of the stent is virtually always incomplete. The factors contributing most to stent occlusion are the buildup of granulation tissue, bile sludge, and tumor overgrowth. Stone formation and tumor ingrowth can also be important, although less common causes of occlusion. A polyurethane stent covering could not prevent tumor ingrowth in one patient and the buildup of viable granulation tissue inside the stent in two further patients; mean stent patency in the three patients with such a stent was 3 months.
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Affiliation(s)
- K A Hausegger
- Department of Radiology, Karl-Franzens Universität Graz, Austria
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Akiyama H, Nimura Y, Kondo S, Kamiya J, Nagino M, Miyachi M, Kanai M. Multiple intramural cysts of the bile duct. Gastrointest Endosc 1997; 45:310-2. [PMID: 9087842 DOI: 10.1016/s0016-5107(97)70278-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- H Akiyama
- First Department of Surgery, Nagoya University, School of Medicine, Japan
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