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We read with great interest the article by
which found an increase in cholangiocarcinoma incidence after biliary-enteric drainage for benign disease.
In their hypothesis, changes in biliary epithelium were induced by toxic carcinogenesis due to reflux of intestinal contents and bile stasis. However, this chronic irritation and carcinogenesis of the biliary mucosa after biliary-enteric anastomosis has not been reported after surgery for malignant disease. We present a case of a 65 year old woman who developed a cholangiocarcinoma eight years after duodenopancreatectomy for an ampullary carcinoma, stage I. The patient was referred to our department because of obstructive jaundice and cholangitis. Computed tomography scan showed that the patient was disease free. Percutaneous transhepatic cholangiography showed biliary-enteric anastomosis stricture and a diffuse biliary stenosis.
Percutaneous transhepatic anastomosis dilatation was performed but was ineffective. The patient was operated on and extensive fibrosis and inflammation of the biliary-enteric anastomosis and biliary duct were detected (fig 1). Resection of the stricture and hepatojejunostomy were performed. In addition to fibrotic and inflammatory tissue, histological examination showed a poorly differentiated cholangiocarcinoma with invasion of all levels of the right hepatic duct wall. Surgical margins were free of disease. The patient was discharged on the 10th postoperative day. She died 10 months after surgery.
In common with the authors, we support the hypothesis that reflux of intestinal contents, bacterial translocation, and pancreatic juice can trigger biliary mucosal changes and the carcinogenesis process.1–3 We believe that apart from those predisposing factors causing chronic cholangitis, there must be susceptibility in these patients due to genetically altered enzymes that are involved in detoxifying carcinogenic products.4 This is the first case report of malignant transformation in the biliary epithelium after biliary-enteric anastomosis for malignant disease. As there are no markers to identify patients in the early stage of development of malignant transformation, we agree with the authors1 about monitoring all patients who develop cholangitis after biliary-enteric anastomosis for benign disease and also patients with malignant disease who are in remission.
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