Video Endoscopic Sequence 1 of 3.

Adenocarcinoma of the Gallbladder.

 Adenocarcinoma of the gallblader that infiltrates the
 duodenal walls.
 A 53 year-old female with adenocarcinoma of the
 gallblader.
 


                         Medline.

Video Endoscopic Sequence 2 of 3.

A biliar stent 12 Fr. was placeed in the Vater papilla.

Video Endoscopic Sequence 3 of 3.

 Due to recurrent episodic bleeding, successfully used of
 argon plasma coagulation (APC) is performed as a
 palliative treatment.

Video Endoscopic Sequence 1 of 4.

 Adenocarcinoma of Papilla of Vater. Duodenoscopic view.

Video Endoscopic Sequence 2 of 4.

Papilla of Vater Periampullary Region.

 Carcinoma of the ampulla of Vater is a malignant tumor
 arising within 2 cm of the distal end of the common bile
 duct, where it passes through the wall of the duodenum and
 ampullary papilla. The common bile duct merges with the
 pancreatic duct of Wirsung at this point and exits through
 the ampulla into the duodenum.

Video Endoscopic Sequence 3 of 4.

 The most distal portion of the common bile duct is dilated
 (ie, forms the ampulla of Vater) and is surrounded by the
 sphincter of Oddi, which spirals upward around the terminal
 portion of the duct. Because of biliary outflow obstruction,
 carcinoma of the ampulla of Vater tends to present early,
 as opposed to other pancreatic neoplasms that often are
 advanced at the time of diagnosis.

Video Endoscopic Sequence 4 of 4.

 Ampullary cancer most often is seen in the fifth through the
 seventh decades of life.

Carcinoma of the papilla of Vater.

 This image and the video is observed through a
 forward-viewing endoscope. 

Villous adenoma Adenoma of Vater Papilla and Juxtapapillary diverticula.

 This is the case of a seventy-three year old male with a
 biopsy proven ampullary villous adenoma, presented with
 jaundice, showed markedly elevated alkaline fosfatase
 and the abdominal ultrasound displays a dilated biliary tree.
 Adenomas of the papilla of Vater are relatively rare
 tumours. They are of particular interest, not only because
 of their particular topography, but also because the
 adenoma-carcinoma sequence - accepted in the colorectum
 has also been postulated to apply to the papilla of Vater.
 In fact, ampullary adenoma is often considered to be a
 precancerous lesion.

Video Endoscopic Sequence 1 of 5.

 Adenocarcinoma of Papilla of Vater

Forward-viewing gastroscope.

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Video Endoscopic Sequence 2 of 5.

Adenocarcinoma of Papilla of Vater. Duodenoscopic view.

Video Endoscopic Sequence 3 of 5.

 Carcinoma of the ampulla of Vater is a malignant tumor
 arising within 2 cm of the distal end of the common bile
 duct, where it passes through the wall of the duodenum and
 ampullary papilla. The common bile duct merges with the
 pancreatic duct of Wirsung at this point and exits through
 the ampulla into the duodenum. The most distal portion of
 the common bile duct is dilated (ie, forms the ampulla of
 Vater) and is surrounded by the sphincter of Oddi, which
 spirals upward around the terminal portion of the duct.
 Because of biliary outflow obstruction, carcinoma of the
 ampulla of Vater tends to manifest early, as opposed to
 other pancreatic neoplasms that often are advanced at the
 time of diagnosis.

Video Endoscopic Sequence 4 of 5.

Chromoendoscopy with indigo carmin stain.

 Curative surgical resection is the only option for long-term
 survival. Surgical or radiologic biliary decompression, relief
 of gastric outlet obstruction, and adequate pain control may
 improve the quality of life but do not affect overall survival
 rate.

Video Endoscopic Sequence 5 of 5.

 Lymph nodes metastases are present in as many as half of
 patients. Pericanalicular lymph nodes usually are the first
 to be involved. Nodes along the superior mesenteric,
 gastroduodenal, common hepatic, and splenic arteries, as
 well as the celiac trunk, are the second station of lymph
 nodes. Perineural, vascular, and lymphatic invasion are
 associated with a poor prognosis. Liver is the most common
 site (66%) of distant metastasis, followed by lymph nodes
 (22%). In advanced cases, lung metastasis also may occur.

Video Endoscopic Sequence 1 of 20.

Cholangiocarcinoma that infiltrated a Periampullary Duodenal Diverticula and the head of the pancreas.

 This 77 year-old male, presented with silent jaundice, he
 has been under medical check up with an upper endoscopy,
 Computed Tomography and different Imaging Studies in
 another institution but the diagnosis was overlooked.

Video Endoscopic Sequence 2 of 20.

 Cholangiocarcinomas (CCCs) are malignancies of the
 biliary duct system that may originate in the liver and
 extrahepatic bile ducts, which terminate at the ampulla of
 Vater. CCCs are encountered in 3 geographic regions:
 intrahepatic, extrahepatic (ie, perihilar), and distal
 extrahepatic. Perihilar tumors are the most common, and
 intrahepatic tumors are the least common. Perihilar tumors,
 also called Klatskin tumors (after Klatskin's description of
 them in 1965), occur at the bifurcation of right and left
 hepatic ducts.

Video Endoscopic Sequence 3 of 20.

Video Endoscopic Sequence 4 of 20.

Video Endoscopic Sequence 5 of 20.

This picture shows the duodenum with the diverticula.

Video Endoscopic Sequence 6 of 20.

Clinical Features
 

• Most common presenting clinical features of perihilar or extrahepatic tumours are those of biliary obstruction: jaundice, pale stool, dark urine, and pruritus.
• Right upper quadrant pain, fever, and rigors suggest
  cholangitis (this is unusual without drainage attempts).
• Cholangiocarcinoma usually presents after the disease is advanced. This is particularly true with more proximal intrahepatic and perihilar tumours obstructing one duct, which often present with systemic manifestations of malignancy, such as malaise, fatigue, and weight loss.
• Some cases are detected incidentally as a result of deranged liver function tests, or ultrasound scans performed for other indications.

Video Endoscopic Sequence 7 of 20.

Video Endoscopic Sequence 8 of 20.

 Distal choledoco duct tumor pushing and distorting
 adjacent duodenal diverticulum.

 Cholangiocarcinoma and bile duct cancer are often used
 interchangeably. Primary biliary tract malignancies. More
 than 95% of these malignancies are cholangiocarcinomas
 (epithelial adenocarcinomas ) frequently found in the
 extrahepatic biliary tree.

Video Endoscopic Sequence 9 of 20.

 Close up of cholangiolar tumor and duodenal diverticulum

 The tumor is usually small and may arise anywhere along
 the biliary tree, from the small intrahepatic bile ducts to the
 common bile duct. Microscopically, cholangiocarcinoma
 may resemble adenocarcinoma. These bile ductale tumors
 may be well differentiated, while others are poorly
 differentiated.

Video Endoscopic Sequence 10 of 20.

 Tumor with pancreatic tissue at the bottom

 Cholangiocarcinomas are usually slow-growing tumors that
 spread locally via the lymphatic system. Treatment and
 long-term prognosis are dependent upon the location of the
 mass. Lesions located in the distal or middle portion of the
 extrahepatic bile duct (20% and 35%, respectively) have a
 better prognosis than tumors in the proximal third, which
 include about 45% of bile duct cancers (including
 Klatskin’s tumors — hilar variants).

Video Endoscopic Sequence 11 of 20.

 An inverted picture of tumor showing the duodenal,
 diverticular and pancreatic relations

 Large solitary tumors are characteristic of peripheral
 cholangiocarcinoma; however, a multinodular type may
 occur. These tumors have a fibrous stroma, are firm and
 grayish white in color, and are not well vascularized. Hilar
 cholangiocarcinoma are usually firm, intramural, annular
 tumors that encircle the bile duct, or may be bulky hard
 masses that are on the duct or hilar region and extend into
 the liver. They may also appear as a spongy friable mass
 in the lumen of the bile duct. There may be metastatic
 nodules throughout the liver with dilation of bile ducts
 peripheral to the mass.
 

Video Endoscopic Sequence 12 of 20.

 Diverticular opening and tumor invading the ampullar
 region. There was not possible identification of the
 ampullar openig.

WHO classification of carcinomas of the liver

• Hepatocellular carcinoma
• Combined hepatocellular cholangiocarcinoma
• Cholangiocarcinoma, intrahepatic
• Bile duct cystadenocarcinoma
• Undifferentiated carcinoma

Video Endoscopic Sequence 13 of 20.

 Complete tumoral obstruction of the distal choledoco the
 duodenal diverticulum is located to the right.

 The incidence of biliary cancers corresponds to mortality
 rates as the prognosis from these tumours is very poor.

Video Endoscopic Sequence 14 of 20.

WHO classification of carcinomas of the extrahepatic bile ducts.

• Carcinoma in situ
• Adenocarcinoma
• Papillary adenocarcinoma
• Adenocarcinoma, intestinal-type
• Mucinous adenocarcinoma
• Clear cell adenocarcinoma
• Signet ring cell carcinoma
• Adenosquamous carcinoma
• Squamous cell carcinoma
• Small cell carcinoma (oat cell carcinoma)
• Undifferentiated carcinoma.

Video Endoscopic Sequence 15 of 20.

Neoplastic tubulopapillar tissue infiltrating and replacing the Vater ampulla.

 Histological Grade

• Most cholangiocarcinomas (95%) are adenocarcinomas.
• Adenocarcinomas are classified 1 to 4 according to the percentage of tumour that is composed of glandular tissue.
• Some types of adenocarcinoma are however not graded: carcinoma in situ, clear cell adenocarcinoma, and papillary adenocarcinoma.
• Signet ring cell carcinoma is given a grade of 3 and small cell.
• Carcinoma a grade of 4. Squamous cell carcinomas are graded according to the least differentiated areas. Most studies have demonstrated a relation between histological grade and postoperative outcome although stage is more important.

Video Endoscopic Sequence 16 of 20.

 Large and small malignant cholangiolar ducts

 Anatomical classification “Cholangiocarcinoma” originally
 referred only to primary

• tumours of the intrahepatic bile ducts and was not used for extrahepatic bile duct tumours but the term is now regarded as inclusive of intrahepatic, perihilar, and distal extrahepatic tumours of the bile ducts. 20–25% are intrahepatic. 50–60% of all cases of cholangiocarcinoma are perihilar tumours (those involving the bifurcation of the ducts are “Klatskin” tumours).
• Most Klatskin tumours may have been coded as intrahepatic
• tumours for purposes of death certification.
• 20–25% are distal extrahepatic tumours.
• About 5% of tumours may be multifocal.
• The extent of duct involvement by perihilar tumoursmay be
• classified as suggested by Bismuth:
• type I: tumours below the confluence of the left and right hepatic ducts;
• type II: tumours reaching the confluence but not involving the left or right hepatic ducts;

Video Endoscopic Sequence 17 of 20.

Microscopic pattern of the tumor with columnar epithelium and hyperchromatic nuclei.

Video Endoscopic Sequence 18 of 20.

Terminal biliar duct with neoplastic small glands proliferation and mucosa of the choledoco with neoplasia.

Video Endoscopic Sequence 19 of 20.

Low power detail of tumor invasion to the pancreas head at left superior corner and to the periampullar duodeno at right inferior corner.

Video Endoscopic Sequence 20 of 20.