Using machine learning models to predict the surgical risk of children with pancreaticobiliary maljunction and biliary dilatation

PURPOSE

To develop machine learning (ML) models to predict the surgical risk of children with pancreaticobiliary maljunction (PBM) and biliary dilatation.

METHODS

The subjects of this study were 157 pediatric patients who underwent surgery for PBM with biliary dilatation between January, 2015 and August, 2022. Using preoperative data, four ML models were developed, including logistic regression (LR), random forest (RF), support vector machine classifier (SVC), and extreme gradient boosting (XGBoost). The performance of each model was assessed via the area under the receiver operator characteristic curve (AUC). Model interpretations were generated by Shapley Additive Explanations. A nomogram was used to validate the best-performing model.

RESULTS

Sixty-eight patients (43.3%) were classified as the high-risk surgery group. The XGBoost model (AUC = 0.822) outperformed the LR (AUC = 0.798), RF (AUC = 0.802) and SVC (AUC = 0.804) models. In all four models, enhancement of the choledochal cystic wall and an abnormal position of the right hepatic artery were the two most important features. Moreover, the diameter of the choledochal cyst, bile duct variation, and serum amylase were selected as key predictive factors by all four models.

CONCLUSIONS

Using preoperative data, the ML models, especially XGBoost, have the potential to predict the surgical risk of children with PBM and biliary dilatation. The nomogram may provide surgeons early warning to avoid intraoperative iatrogenic injury.

Progress in research of pancreaticobiliary maljunction and biliary dilatation

Pancreaticobiliary maljunction (PBM) is a congenital anomaly that is defined as a junction of the pancreatic and bile ducts located outside the duodenal wall during the embryonic stage, resulting in bile and pancreatic juice reflux and corresponding clinical symptoms. PBM is a high risk factor for cholangiocarcinoma. PBM can occur with or without biliary dilatation (BD). Early diagnosis of PBM can prevent complications. Ultrasonography, magnetic resonance imaging, multi-slice spiral computed tomography, endoscopic ultrasonography, endoscopic retrograde cholangiopancreatography, and cholangiopancreatography are important modalities for diagnosis of this disease. The standard surgical procedure for PBM with BD is dilated cholangiectomy and choledochoenteroreconstruction. Cholecystectomy should be performed as early as possible for PBM without BD.

Todani type III: like biliary dilatation with duodenal prolapse-a case report

BACKGROUND

Biliary dilatation is a rare disease involving intrahepatic and extrahepatic biliary tract abnormalities. With the development of imaging technology, an increasing number of special cases have been diagnosed, which poses a challenge to the traditional classification method.

CASE PRESENTATION

A 50-year-old woman was admitted to the hospital due to right upper quadrant pain for more than 10 days. The patient had previous episodes of similar symptoms, which were relieved after symptomatic treatment at a local community hospital. After the symptoms developed, she underwent a computed tomography scan at the local hospital, which showed biliary dilatation; thus, she was referred to our hospital for further treatment. After admission, her magnetic resonance imaging examination also suggested biliary dilatation, but abnormal signals were found in her duodenum. First, a duodenal diverticulum was considered. Later, endoscopic ultrasonography was conducted, and the results suggested that the dilated biliary tract had herniated into the duodenum. This type of lesion is most closely classified as a Todani type III lesion. The patient finally underwent choledochectomy and Roux‑en‑Y hepaticojejunostomy, and the postoperative pathology was consistent with our preoperative diagnosis. The patient was followed up for approximately 2 years, and no obvious postoperative complications were found.

CONCLUSIONS

The manifestations of this case are relatively rare and involve one of the undiscussed categories of the Todani classification system; therefore, this case has certain clinical value. Moreover, there is no report similar to this experience in the previous literature.

Diagnosis of hilar cholangiocarcinoma using intravoxel incoherent motion diffusion-weighted magnetic resonance imaging

OBJECTIVE

To investigate the value of intravoxel incoherent motion diffusion-weighed magnetic resonance imaging (IVIM-DWI) in discriminating the pathological grades of hilar cholangiocarcinoma (HC).

PATIENTS AND METHODS

Thirty-seven HC patients were enrolled and received routine and advanced DWI scanning with multiple b-values. IVIM-DWI images were obtained using echo-planar imaging sequence.

RESULTS

The consistency of the maximum cross-sectional area ROI measuring method was higher than that of the repeated sampling ROI measuring method. ADC_slow values were closely correlated with the pathological grades of HC. The degrees of biliary dilatation and MELD scores had no influence on the negative correlation between ADC_slow values and the pathological degrees of HC patients.

CONCLUSIONS

ADC_slow values could be applied in indicating the pathological grades of HC, which was independent on the extent of biliary dilatation.

IgG4-Related Sclerosing Cholangitis Mimicking Cholangiocarcinoma

IgG4-related sclerosing cholangitis (IgG4-SC) is a relatively newly identified disease that is frequently associated with autoimmune pancreatitis. The differential diagnosis between cholangiocarcinoma, primary sclerosing cholangitis, and IgG4-SC can be challenging due to significant overlap among the clinical and imaging characteristics. We report the case of a 71-year-old woman who was diagnosed with IgG4-related disease based on increased serum IgG4 levels, imaging, and clinical presentation, which showed systemic involvement, including sclerosing cholangitis and kidneys. The patient presented with chronic jaundice. Magnetic resonance imaging revealed bile duct strictures and the dilatation of upstream bile ducts, smooth wall thickening with uniform enhancement in the delayed phase, and no vascular infiltration. Multiple low-density, wedge-shaped areas were identified in both kidneys, which were hypointense on T2-weighted images and hyperintense on diffusion-weighted images. The serum IgG4 levels of this patient were elevated to nearly 10-fold the normal upper limit. A diagnosis of IgG4-SC associated with IgG4-related kidney was made. Based on this case, pre-surgery IgG4 serum treatment in patients with non-malignant bile duct stenosis was recommended to exclude IgG4-SC.

Biliary cysts in adults. 26 years experience at a single center

Background

Biliary cysts are duct dilatation that can occur on all biliary ducts, 20–25% is diagnosed in adults. The classic triad for the clinical presentation consists on abdominal pain, jaundice and abdominal mass. The standard treatment is surgical resection and bilioenteric anastomosis. The objective of this study is to analyze the prevalence and characteristics of biliary cysts in our center.

Methods

This is an observational retrospective study, we included patients older than 16 years old with biliary cyst from march 1989 to February 2015. The demographic and clinical information was collected from the charts and electronic records available at our Hospital.

Results

Biliary cysts were reported on 52 patients, only 25 clinical charts were available. The main symptom was abdominal pain in 21 (84%). The diagnosis was performed with abdominal ultrasound in 16 (64%). The most frequent type was IA in 9 (36%). All patients were treated with surgery as a definitive management.

Discussion

Vague clinical presentation results on a delay of the diagnosis and treatment. Surgical resection is recommended for patients since they have an increased risk for malignant transformation. Postoperative complications in our patients were stenosis of bilioenteric anastomosis in 3 (12%) patients.

Conclusions

Biliary cysts require an accurate diagnosis and surgical treatment in order to decrease the risk of malignant transformation and progression of the disease. Precise surgical treatment is needed to achieve complete resection and a long term postoperative follow up is mandatory.

•

The objective is to analyze prevalence and characteristics of biliary cysts in our center.

•

Vague clinical presentation results on a delay of the diagnosis and treatment.

•

Surgery is recommended because of increased risk for malignant transformation.

•

Most common complication in our patients was stenosis of bilioenteric anastomosis.

Biliary Fasciola gigantica infestation in a nonendemic area--An intraoperative surprise

A 7year old girl infected with the zoonotic trematode, Fasciola gigantica is reported because of the extreme rarity of this condition in our region. Because of the overlap in symptomatology and radiological features, the more common amebic/pyogenic liver abscess in the initial hepatic migratory phase and later choledochal cyst/biliary ascariasis when the parasite was finally located in the extrahepatic bile ducts, were thought of delaying effective treatment. The diagnosis was confirmed only by surgical exploration. The characteristic contrast enhanced computed tomography scan features retrospectively identified were multiple clustered hypodense lesions in the liver with peripheral enhancement in the acute hepatic migratory phase, and periportal tracking in the previously affected areas of the liver with biliary dilatation and a linear hypointense lesion within the common bile duct in the chronic phase. Although a known association, she did not have eosinophilia. This child, who became symptomatic at the age of 5.5years, also appears to be one of the youngest patients reported with Fasciola gigantica.

Intrahepatic biliary dilatation caused by a small simple hepatic cyst: report of a case

Biliary obstruction caused by small simple cysts is very rare. We present a case of biliary dilatation caused by a simple cyst with a 4-cm diameter. The patient was a 75-year-old woman referred to our hospital for evaluation of a cystic tumor associated with peripheral biliary duct dilatation in the left segment of the liver. Computed tomography and magnetic resonance imaging showed that the cyst probably communicated with the intrahepatic bile duct. Malignant tumors, including intrahepatic papillary neoplasms of the bile duct, could not be ruled out; therefore, we performed surgery with the patient's consent. Histopathologic examination of the resected liver showed that the cystic lesion was a simple cyst. The finding that even small simple cysts can obstruct the biliary tract is important for the management of cystic lesions of the liver.

Endoscopic retrograde cholangiography for biliary anastomotic strictures after liver transplantation

Biliary complications after liver transplantation (LT) are an important cause of morbidity and mortality. In most cases, an anastomosis of the bile duct is performed as a duct-to-duct reconstruction, which makes endoscopic therapy with endoscopic retrograde cholangiography (ERC) feasible. Biliary anastomotic strictures (AS) are the most common cause of biliary complications. The early detection of an AS, which can sometimes be challenging given that its clinical presentation is often subtle, is of key importance to obtain high treatment success. In this review, we focus on the management of AS after LT with a special emphasis on ERC.