A Case of Ileus Caused by Implantation of Cancer after Surgical Treatment of Bile Duct Carcinoma

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1 Case Report Kurume Medical Journal, 48, , 2001 A Case of Ileus Caused by Implantation of Cancer after Surgical Treatment of Bile Duct Carcinoma HISAFUMI KINOSHITA, SHINJI SATO, MITSUO HASHIMOTO, KOTARO HASHINO, TSUYOSHI TAMAE, MASAO HARA, HIROYASU IMAYAMA AND SHIGEAKI AOYAGI Department of Surgery, Kurume University School of Medicine, Kurume , Japan Summary: We encountered a patient with an ileus caused by implantation of cancer cells after surgical treatment of bile duct carcinoma. The patient was a 55-year-old male diagnosed as having cancer in the lower bile duct who underwent pancreatoduodenectomy in March The comprehensive curability was B. The patient experienced nausea and vomiting and was diagnosed as having ileus in October The symptoms were alleviated by medical treatment. Because ileus symptoms recurred in December 1998 but were not alleviated by medical treatment, the patient was hospitalized in Kurume University Hospital for surgery. A mirror reflection was observed by plain radiography of the abdomen. Ultrasonography (US) revealed dilation of the intestinal duct and hypertrophy of the intestinal wall. An ileus tube was inserted but the symptoms did not improve, and therefore, the patient underwent surgery in February Upon laparotomy, a node of milk white color about 2 cm in size was found in the region coinciding with the enhancement on CT images, and part of the intestinal duct was found to be folded and adhered to the lower surface of the liver. No recurrence was observed in the liver, peritoneum, and lymph nodes. The tumor was excised together with part of the intestinal duct and liver to remove the ileus. At present, the patient is alive without recurrence. Because recurrence of cancer by implantation of cancer cells is often localized in a limited region, early diagnosis and excision are important. Key words bile duct carcinoma, implantation, ileus INTRODUCTION In the recurrence of bile duct carcinoma, excision of the lesions is usually difficult, and the prognosis is very poor. Bile duct carcinoma often occurs as obstructive jaundice, and percutaneous transhepatic biliary drainage (PTBD) is preoperatively performed. There have been several reports in which a local recurrence was observed on the peritoneum at the site where the PTBD tube had been inserted, which could then be excised. We encountered a patient with ileus caused by implantation of cancer cells after surgical treatment of bile duct carcinoma, in whom the ileus could be removed. CASE REPORT The patient was a 55-year-old male who was diagnosed as having cancer in the lower bile duct and underwent pancreatoduodenectomy in August The patient experienced nausea and vomiting and was diagnosed as having ileus by a local physician in October The symptoms were alleviated by medical treatment. Because ileus symptoms recurred in December 1998 but were not alleviated by medical treatment, the patient was hospitalized in Kurume University Hospital for surgery. His height was 162 cm, and body weight was 62 kg. The patient had anemia in the palpebral and bulbar conjunctiva, but no jaundice and palpation of superficial lymph nodes were noted. The patient had swelling over the entire Received for publication November 1, 2000

2 184 KINOSHITA abdomen, tenderness and a decrease in intestinal murmur. A biochemical examination of blood revealed an elevation of GOT and GPT and a slight reduction of albumin and cholesterol levels. The tumor marker, CEA, was slightly elevated (Table 1). Aerosis and mirror reflection were observed in the small intestine in the median to the right upper abdomen by plain radiography of the abdomen (Fig. 1). US revealed dilation of the intestinal duct and hypertrophy of the intestinal wall. Upon injection of TABLE Laboratory data ET AL. gastrograffin via the ileus tube that had been inserted, its retention and stagnation were observed in the right upper abdomen and small intestine by plain radiography of the abdomen. The ileus was considered due to constriction of the lower small intestine (Fig. 2). An enhanced lesion of about 2 cm in size was detected by contrast CT on the lower surface of 1. on admission Fig. 2. Upon injection of gastrograffin via an ileus tube that had been inserted, its retention and stagnation were observed in the right upper abdomen and small intestine by plain radiography. The ileus was considered due to constriction of the lower small intestine. Fig. in the abdomen 1. Aerosis small and mirror intestine by plain in radiography the reflection median were Fig. 3. observed to right was upper the liver of the abdomen. Kurume detected Medical Journal An enhanced by contrast in contact Vol. 48, No. 2, 2001 lesion CT of about on the lower with the intestinal duct. 2 cm in size surface of

3 I LEUS CAUSED Fig. 4. Surgical BY IMPLANTATION schema OF CANCER and photographs during 185 CELLS surgery a) Observation during laparotomy: The small intestine at the position about 150 cm toward the mouth from the end of the ileum and part of the transverse colon and ascending jejunum were folded and adhered to the lower surface of the liver. b) The intestinal duct of about 8 cm in length including the tumor, part of the transverse colon and ascending jejunum, and the liver were excised. c) After excision of the liver, the excised site was cauterized Fig. 5. Pathohistological during surgery. observation. a) The tissues of bile duct carcinoma collected in the first surgery. b) The tumor collected in the resurgery: Adenocarcinoma with rich intestinal mainly in the lower layers of mucosa of the small intestine. Kurume Medical Journal Vol. 48, No. 2, 2001 tissues proliferated

4 186 KINOSHITA ET AL. the liver in contact with the intestinal duct (Fig. 3). Because the symptoms were not improved by treatment using the ileus tube, we performed surgery, considering the possibility that the ileus was caused by recurrence of bile duct carcinoma. Upon laparotomy, a node of milk white color about 2 cm in size was found in the region coinciding with the enhancement on CT images. The small intestine at the position about 150 cm toward the mouth from the end of the ileum and part of the transverse colon and ascending jejunum were folded and adhered to the lower surface of the liver. No metastasis was observed in the liver, peritoneum, and lymph nodes. Because the recurrence was in a single node, we considered that a good prognosis would be obtained by local excision, and excised a section of the intestinal duct of about 8 cm in length including the tumor, part of the transverse colon and ascending jejunum, and the liver to remove the ileus (Fig. 4). In the excised specimen, the tumor was 2.0 ~2.0 cm in size, milk white and elastic solid, which infiltrated the serous muscular tunics of the small intestine and transverse colon but not the mucosal surface. Pathohistologically, the adenocarcinoma with rich intestinal tissues proliferated mainly in the lower layers of the mucosa of the small intestine. Because the histological observations of the tumor were similar to those of bile duct carcinoma collected in the first surgery, the tumor was diagnosed as being caused by implantation of cancer tissues (Fig. 5). DISCUSSION Bile duct carcinomas are often in the advanced stage at the time of detection, and the prognosis is poor even if the lesions can be excised. Therefore, it is important to detect recurrence. Local recurrence of bile duct carcinomas are usually found on the posterior peritoneum in the head of the pancreas and in the anastomosed region, while distal metastases often occur in the liver and as implantation on the peritoneum. Treatment methods of recurred bile duct carcinomas include chemotherapy, radiotherapy, thermotherapy, immunotherapy and resurgery [1-6]. There have been no effective carcinostatics for cholangiocarcinomas, nor has standard chemotherapy been established. At present, such drugs as fluorouracil, adriamycin, mitomycin C and cisplatin are administered either singly or, more commonly, in combination. As radiotherapy, external irradiation or the combination of external and intracavitary irradiation is performed. Johnson et al. [7] and Mittal et al. [8] recommended the combination of external and intracavitary irradiation because local irradiation of high doses is technically difficult by external irradiation alone. Using microwaves or RF waves, local thermotherapy is also used. Ueno et al. [9] reported that patients with recurrence after excision of hilar bile duct carcinoma in the portal fissure who had undergone local thermotherapy with RF waves, radiotherapy and chemotherapy were alive for more than 3 years. Takada et al. [1] reported that constriction caused by local recurrence in the anastomosed region of the biliary duct and jejunum after excision of an upper bile duct carcinoma was improved by thermotherapy and radiotherapy. As immunochemotherapy, carcinostatics, mainly with immunoenhancing therapy using OK-432 and polysaccharide Kureha (PSK), has been used, but immunotherapy with monoclonal antibodies or cytokines has recently become common [10]. Excision of lesions caused by implantation of cancer cells is often performed in the region where a PTBD tube was inserted or on the peritoneum. Implantation of cancer cells on the peritoneum or local recurrence is rare, but excision is performed if recurrence is limited in a single or few lesions. In this study, the patient had symptoms of ileus 2 years after excision of the head of the pancreas and duodenum. It was not clear whether the ileus was caused by adhesion of the intestinal duct after surgery or implantation of cancer cells on the peritoneum. Because the symptoms were not improved by conservative treatment, surgical treatment was performed. The region of adhesion of the intestinal duct was distant from the anastomosed region of the biliary duct and jejunum, indicating that the tumor did not recur in the excised end of the biliary duct. Cancer cells were detected in the excised organs, and the excised tissues were pathohistologically similar to those excised during the first surgery. Therefore, we concluded that the recurrence in this patient was due to implantation of cancer cells during the first surgery. Because recurrence of cancer by implantation of cancer cells is often localized to a limited region, early diagnosis and excision is considered to be important. It is necessary to perform a postoperative observation of bile duct carcinoma, taking recurrence into consideration. REFERENCES 1. Takada T, Uchiyama K, and Hasegawa H. Multidisciplinary management-gallbladder and bile duct cancer-. Jpn J Clin Med 1988; 46; (in Kurume Medical Journal Vol. 48, No. 2, 2001

5 ILEUS CAUSED BY IMPLANTATION OF CANCER CELLS Odaka M, Ryu M, Usui S, Hirasawa H, Asano T et al. The role of radiotherapy in the treatment of cancer of digestive organs, liver, bile tract and pancreas. J Jpn Surg Soc 1984; 85: (in 3. Kita M, and Okawa T. External radiotherapy for inoperable carcinoma of the biliary tract. J Bil Panc 1994;15: (in 4. Kondo S, Nimura Y, Hayakawa N, Kamiya J, Kubota H et al. Surgical treatment for recurrence of biliary tract cancer. Jpn J Gastroenterol Surg 1988; 21: (in 5. Sugiura H, Suenaga M, Okawa Y, Kokubo Y, Uehara S et al. A case report of reoperation recurrent cancer of lower bile duct following pancreatoduodenectomy. Jpn J Gastroenterol Surg 1992; 25: (in 6. Uesaka K, Kamiya J, Nagino M, Yuasa N, Sano T et al. Treatment of recurrent cancer after surgery for biliary malignancies. J Jpn Surg Soc 1999; 100: (in 7. Johnson DW, Safa C, and Goffinet DR. Malignant obstractive jaundice: treatment with external beam and intracavitary radiotheraphy. Int J Radiat Oncol Biol Phys 1985;11: Mittal B, Dentsch M, and Iwatsuki S. Primary cancers of extrahepatic biliary passages. Int J Radiat Oncol Biol Phys 1985;11: Ueno K, Miyazaki I, and Nagakawa T. A case of recurrent hepatic hilar carcinoma treated effectively with multidisciplinary theraphy. J Bil Panc 1987; 8: (in 10. Koda H, and Nitsu Y. Immunotherapy for biliary tract and pancreatic cancer. J Bil Panc 1994; 15: (in Kurume Medical Journal Vol. 48, No. 2, 2001