Occult pancreaticobiliary reflux is a pathogenic factor of some benign biliary diseases and gallbladder cancer

Background:Pancreaticobiliary maljunction(PBM)is a well-known high-risk factor for biliary malignant tumors because of constant pancreaticobiliary reflux(PBR).However,the impact of occult pancreaticobiliary reflux(OPR),which is characterized by high bile amylase levels in individuals with anatomically normal pancreaticobiliary junction,on biliary diseases remains unclear.The aim of this study was to assess the correlation between OPR and biliary diseases.Methods:We enrolled 94 consecutive patients with normal pancreaticobiliary junction and primary biliary diseases confirmed by magnetic resonance cholangiopancreatography.We prospectively collected patients’bile samples and measured bile amylase levels.We investigated the incidence of OPR and the difference in bile amylase levels among these patients and assessed the correlation between high bile amylase levels(HBAL)and benign or malignant biliary diseases,as well as the OPR risk factors.Results:The incidence of OPR was 36.6%in patients with benign biliary diseases,26.7%in those with cholangiocarcinoma and 62.5%in those with gallbladder cancer.The median bile amylase level tended to be higher in patients with gallbladder cancer than in those with benign biliary diseases,but there was no significant difference(165.5 IU/L vs.23.0 IU/L,P=0.212).The prevalence of an HBAL with bile amylase levels of 1000-7500 IU/L was similar in patients with gallbladder cancer and benign biliary diseases.However,the incidence of HBAL with bile amylase levels greater than 7500 IU/L was significantly higher in patients with gallbladder cancer than in those with benign biliary diseases(37.5%vs.4.2%,P=0.012).Multivariate logistic regression analysis revealed that choledocholithiasis was an independent risk factor for OPR.Conclusions:OPR can occur in benign and malignant biliary diseases,and it may be a pathogenic factor for some benign biliary diseases and a high-risk factor for gallbladder cancer.There is a correlation between choledocholithiasis and OPR.

Endoscopic retrograde cholangiopancreatography in children with symptomatic pancreaticobiliary maljunction: A retrospective multicenter study

BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP)has been widely used in pediatric patients with cholangiopancreatic diseases.AIM To evaluate the efficacy,safety,and long-term follow-up results of ERCP in symptomatic pancreaticobiliary maljunction(PBM).METHODS A multicenter,retrospective study was conducted on 75 pediatric patients who were diagnosed with PBM and underwent therapeutic ERCP at three endoscopy centers between January 2008 and March 2019.They were divided into four PBM groups based on the fluoroscopy in ERCP.Their clinical characteristics,specific ERCP procedures,adverse events,and long-term follow-up results were retrospectively reviewed.RESULTS Totally,112 ERCPs were performed on the 75 children with symptomatic PBM.Clinical manifestations included abdominal pain(62/75,82.7%),vomiting(35/75,46.7%),acholic stool(4/75,5.3%),fever(3/75,4.0%),acute pancreatitis(47/75,62.7%),hyperbilirubinemia(13/75,17.3%),and elevated liver enzymes(22/75,29.3%).ERCP interventions included endoscopic sphincterotomy,endoscopic retrograde biliary or pancreatic drainage,stone extraction,etc.Procedure-related complications were observed in 12 patients and included post-ERCP pancreatitis(9/75,12.0%),gastrointestinal bleeding(1/75,1.3%),and infection(2/75,2.7%).During a mean follow-up period of 46 mo(range:2 to 134 mo),ERCP therapy alleviated the biliary obstruction and reduced the incidence of pancreatitis.The overall effective rate of ERCP therapy was 82.4%;seven patients(9.3%)were lost to follow-up,eight(11.8%)re-experienced pancreatitis,and eleven(16.2%)underwent radical surgery,known as prophylactic excision of the extrahepatic bile duct and hepaticojejunostomy.CONCLUSION ERCP is a safe and effective treatment option to relieve biliary or pancreatic obstruction in symptomatic PBM,with the characteristics of minor trauma,fewer complications,and repeatability.

Endoscopic diagnosis of pancreaticobiliary maljunction

Pancreaticobiliary maljunction (PBM) is a congenital anomaly defined as a junction of the pancreatic and bile ducts located outside the duodenal wall, usually forming a markedly long common channel. As the action of the sphincter of Oddi does not functionally affect the junction in PBM patients, continuous pancreatobiliary reflux occurs, resulting in a high incidence of biliary cancer. PBM can be divided into PBM with biliary dilatation (congenital choledochal cyst) and PBM without biliary dilatation (maximal diameter of the bile duct ≤ 10 mm). The treatment of choice for PBM is prophylactic surgery before malignant changes can take place. Endoscopic retrograde cholangiopancreatography (ERC P) is the most effective examination method for close obs ervation of the pattern of the junction site. When the communication between the pancreatic and bile ducts is maintained, despite contraction of the sphi ncter on ERCP, PBM is diagnosed. In these pat ients, levels of pancreatic enzymes in the bile are gene rally elevated, due to continuous pancreatobiliary reflux via a long common channel. Magnetic resonance cholangiopancreatography and 3D-computed tomography can diagnose PBM, based on findings of an anomalous union between the common bile duct and the pancreatic duct, in addition to a long common channel. Endoscopic ultrasonography and intraductal ultra sonography can demonstrate the junction outside the duodenal wall, and are useful for the diagnosis of asso ciated biliary cancer. Gallbladder wall thickness on ultra so nography can be a screening test for PBM.

Endoscopic ultrasonography guided-fine needle aspirationfor the diagnosis of solid pancreaticobiliary lesions:Clinicalaspects to improve the diagnosis

Endoscopic ultrasonography-guided fine-needle aspiration(EUS-FNA) has been applied to pancreaticobiliary lesions since the 1990 s and is in widespread use throughout the world today. We used this method to confirm the pathological evidence of the pancreaticobiliary lesions and to perform suitable therapies. Complications of EUS-FNA are quite rare, but some of them are severe. Operators should master conventional EUS observation and experience a minimum of 20-30 cases of supervised EUS-FNA on non-pancreatic and pancreatic lesions before attempting solo EUSFNA. Studies conducted on pancreaticobiliary EUSFNA have focused on selection of suitable instruments(e.g., needle selection) and sampling techniques(e.g., fanning method, suction level, with or without a stylet, optimum number of passes). Today, the diagnostic ability of EUS-FNA is still improving; the detection of pancreatic cancer(PC) currently has a sensitivity of 90%-95% and specificity of 95%-100%. In addition to PC, a variety of rare pancreatic tumors can be discriminated by conducting immunohistochemistry on the FNA materials. A flexible, large caliber needle has been used to obtain a large piece of tissue, which can provide sufficient histological information to be helpful in classifying benign pancreatic lesions. EUSFNA can supply high diagnostic yields even for biliary lesions or peri-pancreaticobiliary lymph nodes. This review focuses on the clinical aspects of EUS-FNA in the pancreaticobiliary field, with the aim of providing information that can enable more accurate and efficient diagnosis.

Carcinogenesis and chemoprevention of biliary tract cancer in pancreaticobiliary maljunction

Pancreaticobiliary maljunction (PBM) is a high risk factor for biliary tract cancer. In PBM, since the pancreatic duct and bile duct converge outside the duodenal wall beyond the influence of the sphincter of Oddi, pancreatic juice and bile are constantly mixed, producing a variety of harmful substances. Because of this, the biliary mucosa is repeatedly damaged and repaired, which causes an acceleration of cell proliferative activity and multiple gene mutations. Histological changes such as hyperplasia, metaplasia, and dysplasia ultimately result in a high incidence of carcinogenesis. In a nationwide survey by the Japanese Study Group on PBM, coexisting biliary tract cancer was detected in 278 of the 1627 registered cases of PBM (17.1%). Of these cases, in those with dilatation of the extrahepatic bile duct, cancer was often detected not only in the gallbladder but also in the bile ducts. More than 90% of cancer cases without dilatation of the extrahepatic bile duct develop in the gallbladder. Standard treatment for PBM is a cholecystectomy and resection of the extrahepatic bile duct. However, cholecystectomy alone is performed at nearly half of institutions in Japan. Conversely, reports of carcinogenesis in the remnant bile duct or pancreas after diversion surgery are steadily increasing. One of the causes for this is believed to be an accumulation of gene mutations which were present before surgery. Anticancer drugs are ineffective in preventing such carcinogenesis following surgery, thus the postoperative administration of chemopreventive agents may be necessary.

Western blotting in the diagnosis of duodenal-biliary and pancreaticobiliary refluxes in biliary diseases

BACKGROUND:Currently adopted diagnostic methods for duodenal-biliary and pancreaticobiliary refluxes carry many flaws,so the incidence of the two refluxes demands further larger sample size studies.This study aimed to evaluate Western blotting for the diagnosis of refluxes in biliary diseases.METHODS:An oral radionuclide 99m Tc-DTPA test(radio-nuclide,RN)was conducted for the observation of duodenal-biliary reflux prior to measuring bile radioactivity and Western blotting for detecting bile enterokinase(EK).Pancreaticobiliary reflux was assessed by biochemical and Western blotting tests for biliary amylase activity and trypsin-1,respectively.In accordance with bile sample origin,our samples were classified into ductal bile and gall bile groups;based on each individual biliary disease,we further classified the ductal bile group into five subgroups,and the gall bile group into four sub-groups.Western blotting was conducted to assess the two refluxes in biliary diseases.RESULTS:Consistencies were noted between EK and RN tests when diagnosing duodenal-biliary reflux(P<0.001).The amylase and trypsin-1 tests also showed consistency in diagnosing pancreaticobiliary reflux(P<0.001).Amylase and lipase levels within gall and ductal bile were strongly correlated(P<0.05).In the common bile duct pigment stone group,the EK and trypsin-1 positive rates were found to be insignificant(P>0.05);in the common bile duct cyst group,the EK positive rate was significantly lower than the trypsin-1 positive rate(P<0.05).CONCLUSIONS:Western blotting can accurately reflect duodenal-biliary and pancreaticobiliary refluxes.EK has greater sensitivity than RN for duodenal-biliary reflux.The majority of biliary amylase and lipase comes from the pancreas in all biliary diseases;pancreaticobiliary reflux is the predominant source in the common bile duct cyst group and duodenal-biliary reflux is responsible for the ductal pigment stone group.

Relationship between pancreaticobiliary maljunction and gallbladder carcinoma: a meta-analysis

BACKGROUND: Reports on the relationship between pancreaticobiliary maljunction (PBM) and gallbladder carcinoma (GBC) are conflicting. The frequency of PBM in GBC patients and the clinical features of GBC patients with PBM vary in different studies. DATA SOURCES: English-language articles describing the association between PBM and GBC were searched in the PubMed and Web of Science databases. Nine case-control studies fulfilled the inclusion criteria and addressed the relevant clinical questions of this analysis. Data were extracted independently by two reviewers using a predefined spreadsheet. RESULTS: The incidence of PBM was higher in GBC patients than in controls (10.60% vs 1.76%, OR: 7.41, 95% CI: 5.03 to 10.87, P<0.00001). The proportion of female patients with PBM was 1.96-fold higher than in GBC patients without PBM (80.5% vs 62.9%, OR: 1.96, 95% CI: 1.09 to 3.52, P=0.12). GBC patients with PBM were 10 years younger than those without PBM (SMD: -9.90, 95% CI: -11.70 to -8.10, P<0.00001). And a difference in the incidence of associated gallstone was found between GBC patients with and without PBM (10.8% vs 54.3% OR: 0.09, 95% CI: 0.05 to 0.17, P<0.00001). Among the GBC patients with PBM, associated congenital dilatation of the common bile duct was present with a higher incidence ranging from 52.2% to 85.7%, and 70.0%-85.7% of them belonged to the P-C type of PBM (the main pancreatic duct enters the common bile duct). No substantial heterogeneity was found and no evidence of publication bias was observed.CONCLUSIONS: PBM is a high-risk factor for developing GBC, especially the P-C type of PBM without congenital dilatation of the common bile duct. To prevent GBC, laparoscopic cholecystectomy is highly recommended for PBM patients without congenital dilatation of the common bile duct, especially relatively young female patients without gallstones.

Pancreaticobiliary reflux as a high-risk factor for biliary malignancy:Clinical features and diagnostic advancements

Pancreaticobiliary junction is composed of complex structure with which biliary duct and pancreatic duct assemble and go out into the ampulla of Vater during duodenum wall surrounding the sphincter of Oddi.Although the sphincter of Oddi functionally prevents the reflux of pancreatic juice,pancreaticobiliary reflux(PBR) occurs when function of the sphincter of Oddi halt.The anatomically abnormal junction is termed pancreaticobiliary maljunction(PBM) and is characterized by pancreatic and bile ducts joining outside of the duodenal wall.PBM is an important anatomical finding because many studies have revealed that biliary malignancies are related due to the carcinogenetic effect of the pancreatic back flow on the biliary mucosa.On the other hand,several studies have been published on the reflux of pancreatic juice into the bile duct without morphological PBM,and the correlation of such cases with biliary diseases,especially biliary malignancies,is drawing considerable attention.Although it has long been possible to diagnose PBM by various imaging modalities,PBR without PBM has remained difficult to assess.Therefore,the pathological features of PBR without PBM have not been yet fully elucidated.Lately,a new method of diagnosing PBR without PBM has appeared,and the features of PBR without PBM should soon be better understood.

Magnetic resonance cholangiopancreatography study of pancreaticobiliary maljunction and pancreaticobiliary diseases

AIM:To discuss the imaging anatomy about pancreaticobiliary ductal union,occurrence rate of pancreaticobiliary maljunction(PBM)and associated diseases in a Chinese population by using magnetic resonance cholangiopancreatography(MRCP).METHODS:Data were collected from 694 patients who underwent MRCP from January 2010 to December2012.Three hundred and ninety-three patients were male and 301 patients were female.The age range was16-92 years old and the average age was 51.8 years.The recruitment indication of all cases was patients who had clinical symptoms,such as abdominal pain,jaundice,nausea and vomiting,which thus were clinically suspected as relative pancreaticobiliary diseases.All cases were examined by MRCP using single-shot fast spin-echo sequences.In order to obtain MRCP images,the maximum intensity projection was used.RESULTS:According to the anatomy of pancreaticobiliary ductal union based on our analysis of MRCP images,all cases were classified into normal type and abnormal type according to the position of pancreaticobiliary ductal union.The abnormal type could be further divided into P-B type,B-P type and the duodenum type.By analyzing the incidence of biliary stone and inflammation,pancreatitis,biliary duct tumors and pancreatic tumors between normal and abnormal types,significant differences existed.The abnormal group was more likely to suffer from pancreaticobiliary diseases.Comparing three different types of PBM that were associated with pancreaticobiliary diseases by using Fisher’s method,the result showed that there was no significant difference in the incidence of biliary stones,cholecystitis and pancreatic tumors.The incidence of pancreatitis in B-P type and P-B type was higher than that in duodenum type;the incidence of biliary duct tumor in B-P type was higher than that in P-B type;the incidence of biliary duct tumor in duodenum type was lower than that in P-B type.The incidence of congenital choledochus dilatation in normal type and abnormal type was similar,and there was no significant difference between the two types.CONCLUSION:Types of PBM are closely related to the occurrence of pancreaticobiliary diseases.MRCP has important clinical value in the early diagnosis and preventive treatment of pancreaticobiliary diseases.

Anomalous pancreaticobiliary junction: image analysis and treatment principles

BACKGROUND: Anomalous pancreaticobiliary junction is often associated with biliary tract carcinoma and acute pan- creatitis. We assessed the value of image analysis in the diag- nosis of patients with anomalous pancreaticobiliary junction (APBJ) and the principles for the treatment of APBJ. METHODS: Sixty-four patients with APBJ were subjected to ultrasound imaging, endoscopic retrograde cholangio- pancreatography (ERCP) and magnetic resonance cholan- giopancreatography (MRCP) before surgery. The diagnos- tic accuracy of image analysis and their surgical outcomes were evaluated retrospectively. RESULTS: On ERCP and MRCP, the length of the com- mon channel was calculated to be 15 mm or longer in all patients, and the angle of the junction was more than 75° in 49 (76.6%) of the 64 patients. Of the 64 patients, 28 were defined of pancreatic duct type (P-C) (28/64, 43.75%), 32 bile duct type (C-P) (32/64, 50%), and 4 common chan- nel type (4/64, 6.25%). CONCLUSIONS: Patients with APBJ are often associated with biliary tract and pancreatic diseases, and early detec- tion and correct surgical treatment could avoid serious complications. ERCP and MRCP are accurate in the diag- nosis of APBJ.

Application of endoscopic retrograde cholangiopancreatography in the diagnosis and treatment of pancreaticobiliary disease

Objective: To validate endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis andtreatment of pancreaticobiliary disease and to improve the methodology of ERCP. Methods: From January 1977 toJune 1998, Seven thousand two hundred and thirty eight patients who were suspected to have pancreaticobiliaryduct diseases were examined with ERCP. Those who had therapeutic indications received ERCP treatment such asdrainage, dilatation and lithotomy. All cases were reviewed retrospectively, and analyzed for the clinical value andcomplications of ERCP. Results: In 7 238 patienls who underwent 7 579 ERCPs, the total success rate was94. 8%, with a 75. 7% showing rate of pancreatic duct. and 89. 1 % of the binary duct, revealing 3 492 cases ofbinary duct disease, 570 cases of pancreatic duct disease. 821 cases of diverticula and 171 cases of fistula. of which921 cases were treated endoscopically. The rate of complications arising from diagnostic ERCP was 1. 01%.without a single death, the rate of complications arising from therapeutic ERCP was 1. 3 %, two patients died(0. 22 % ). Conclusion: ERCP has important clinical value in the diagnosis and treatment of pancreaticobiliary ductdisease.

Synchronous gallbladder and pancreatic cancer associated with pancreaticobiliary maljunction

We report the case of a 46-year-old woman who presented with chronic intermittent abdominal pain without jaundice; abdominal ultrasonography showed thickening of the gallbladder wall and dilatation of the bile duct. Endoscopic retrograde cholangiopancreaticography showed pancreatobiliary maljunction with proximal common bile duct dilatation. Pancreatobiliary maljunction was diagnosed. A computed tomography scan of the abdomen showed suspected gallbladder cancer and distal common bile duct obstruction. A pancreatic head mass was incidentally found intraoperative. Radical cholecystectomy with pancreatoduodenectomy was performed. The pathological report showed gallbladder cancer that was synchronous with pancreatic head cancer. In the pancreatobiliary maljunction with pancreatobiliary reflux condition, double primary cancer of the pancreatobiliary system should be awared.

Rare variant of pancreaticobiliary maljunction associated with pancreas divisum in a child diagnosed and treated by endoscopic retrograde cholangiopancreatography: A case report

BACKGROUND Pancreaticobiliary maljunction(PBM) is an uncommon congenital anomaly of the pancreatic and biliary ductal system, defined as a union of the pancreatic and biliary ducts located outside the duodenal wall. According to the Komi classification of PBM, the common bile duct(CBD) directly fuses with the ventral pancreatic duct in all types. Pancreas divisum(PD) occurs when the ventral and dorsal ducts of the embryonic pancreas fail to fuse during the second month of fetal development. The coexistence of PBM and PD is an infrequent condition.Here, we report an unusual variant of PBM associated with PD in a pediatric patient, in whom an anomalous communication existed between the CBD and dorsal pancreatic duct.CASE SUMMARY A boy aged 4 years and 2 mo was hospitalized for abdominal pain with nausea and jaundice for 5 d. Abdominal ultrasound showed cholecystitis with cholestasis in the gallbladder, dilated middle-upper CBD, and a strong echo in the lower CBD, indicating biliary stones. The diagnosis was extrahepatic biliary obstruction caused by biliary stones, which is an indication for endoscopic retrograde cholangiopancreatography(ERCP). ERCP was performed to remove biliary stones. During the ERCP, we found a rare communication between the CBD and dorsal pancreatic duct. After clearing the CBD with a balloon, an 8.5 Fr 4-cm pigtail plastic pancreatic stent was placed in the biliary duct through the major papilla. Six months later, his biliary stent was removed after he had no symptoms and normal laboratory tests. In the following 4-year period, the child grew up normally with no more attacks of abdominal pain.CONCLUSION We consider that ERCP is effective and safe in pediatric patients with PBM combined with PD, and can be the initial therapy to manage such cases,especially when it is combined with aberrant communication between the CBD and dorsal pancreatic duct.

Application of imaging techniques in pancreaticobiliary maljunction

Imaging techniques are useful tools in the diagnosis and treatment of pancreaticobiliary maljunction(PBM).PBM is a precancerous lesion often relative to the disease of the pancreas and biliary tract,for example,cholecystolithiasis,protein plugs,and pancreatitis.For patients with PBM,early diagnosis and timely treatment are highly important,which is largely dependent on imaging techniques.The continuous development of imaging techniques,including endoscopic retrograde cholangiopancreatography,magnetic resonance cholangiopancreatography,computed tomography,ultrasound,and intraoperative cholangiography,has provided appropriate diagnostic and therapeutic tools for PBM.Imaging techniques,including non-invasive and invasive,have distinct advantages and disadvantages.The purpose of this paper is to review the application of various imaging techniques in the diagnosis and treatment of PBM.

Dysbiosis of the duodenal microbiota as a diagnostic marker for pancreaticobiliary cancer

BACKGROUND Pancreaticobiliary cancer(PB Ca)is a lethal disease,and a useful diagnostic marker is urgently needed.A correlation between the human microbiota and malignant gastrointestinal diseases was recently reported.AIM To investigate the efficacy of the duodenal microbiota for diagnosing PB Ca.METHODS We recruited 22 patients with benign pancreaticobiliary diseases(benign group)and 12 patients with PB Ca(malignant group).The duodenal microbiota of each patient was analyzed by the 16S rDNA terminal restriction fragment length polymorphism method.Patient characteristics,tumor markers,and relative abundances of the duodenal microbiota were compared between the benign and malignant groups.RESULTS Cancer antigen 19-9(CA19-9),Bifidobacterium,Clostridium cluster XVIII,and Prevotella levels differed significantly between the benign and malignant groups.Clostridium cluster XVIII had the greatest area under the receiver operating characteristic curve(AUC)among the four factors with respect to diagnosing PB Ca(cutoff value:3.038%;sensitivity:58.3%;specificity:95.2%;AUC:0.81).The combination of Clostridium cluster XVIII(cutoff value:3.038%)and CA19-9 Levels(cutoff value:18.8 U/mL)showed 91.7%sensitivity and 71.4%specificity for diagnosing PB Ca.CONCLUSION The duodenal microbiota may be useful for PB Ca screening.

The emerging role of endoscopic ultrasound for pancreaticobiliary diseases in the pediatric population

Background:Endoscopic ultrasound (EUS) is a useful diagnostic and therapeutic tool in the pediatric population.Given the high accuracy and sensitivity of EUS,it is particularly effective in evaluating pancreaticobiliary disease.Published literature in the use of pediatric EUS is limited.Therefore we aimed to review the current literature for EUS indications,safety,and effectiveness for the pediatric population.Data sources:English language articles on the use of pediatric endoscopic ultrasound in evaluating pancreaticobiliary diseases were retrieved from PubMed/MEDLINE.Results:We analyzed various retrospective studies and case series publications.Data were extrapolated for pediatric patients with pancreaticobiliary diseases.Conclusions:EUS offers superior imaging,.It is comparible to magnetic resonance imaging and/or pancreatic-protocol computed tomography.In the current literature,there are a variety of pancreaticobiliary conditions where EUS was utilized to make a diagnosis.These include recurrent pancreatitis,congenital anomalies,microlithiasis,pancreatic pseudocysts,and pancreatic mass lesions.EUS was shown to be a safe and cost-effective modality with both diagnostic and therapeutic capabilities in the pediatric population.EUS is now increasingly being recognized as a standard of care when evaluating pancreaticobiliary conditions in children.

Ligamentum teres hepatis as a graft for portal and/or superior mesenteric vein reconstruction:From bench to bedside

BACKGROUND Pancreaticoduodenectomy combined with portal vein(PV)and/or superior mesenteric vein(SMV)resection in patients with pancreaticobiliary malignancy has become a common surgical procedure.There are various grafts currently used for PV and/or SMV reconstruction,but each of these grafts have certain limitations.Therefore,it is necessary to explore novel grafts that have an extensive resource pool,are low cost with good clinical application,and are without immune response rejection or additional damage to patients.AIM To observe the anatomical and histological characteristics of the ligamentum teres hepatis(LTH)and evaluate PV/SMV reconstruction using an autologous LTH graft in pancreaticobiliary malignancy patients.METHODS In 107 patients,the post-dilated length and diameter in resected LTH specimens were measured.The general structure of the LTH specimens was observed by hematoxylin and eosin(HE)staining.Collagen fibers(CFs),elastic fibers(EFs),and smooth muscle(SM)were visualized by Verhoeff-Van Gieson staining,and the expression of CD34,factor VIII-related antigen(FVIIIAg),endothelial nitric oxide synthase(eNOS),and tissue type plasminogen activator(t-PA)were detected using immunohistochemistry in LTH and PV(control)endothelial cells.PV and/or SMV reconstruction using the autologous LTH was conducted in 26 patients with pancreaticobiliary malignancies,and the outcomes were retrospectively analyzed.RESULTS The post-dilated length of LTH was 9.67±1.43 cm,and the diameter at a pressure of 30 cm H2O was 12.82±1.32 mm at the cranial end and 7.06±1.88 mm at the caudal end.Residual cavities with smooth tunica intima covered by endothelial cells were found in HE-stained LTH specimens.The relative amounts of EFs,CFs and SM in the LTH were similar to those in the PV[EF(%):11.23±3.40 vs 11.57±2.80,P=0.62;CF(%):33.51±7.71 vs 32.11±4.82,P=0.33;SM(%):15.61±5.26 vs 16.74±4.83,P=0.32].CD34,FVIIIAg,eNOS,and t-PA were expressed in both LTH and PV endothelial cells.The PV and/or SMV reconstructions were successfully completed in all patients.The overall morbidity and mortality rates were 38.46%and 7.69%,respectively.There were no graft-related complications.The postoperative vein stenosis rates at 2 wk,1 mo,3 mo and 1 year were 7.69%,11.54%,15.38%and 19.23%,respectively.In all 5 patients affected,the degree of vascular stenosis was less than half of the reconstructed vein lumen diameter(mild stenosis),and the vessels remained patent.CONCLUSION The anatomical and histological characteristics of LTH were similar to the PV and SMV.As such,the LTH can be used as an autologous graft for PV and/or SMV reconstruction in pancreaticobiliary malignancy patients who require PV and/or SMV resection.

Choledochal cysts: Similarities and differences between Asian and Western countries

Choledochal cysts(CCs)are rare bile duct dilatations,intra-and/or extrahepatic,and have higher prevalence in the Asian population compared to Western populations.Most of the current literature on CC disease originates from Asia where these entities are most prevalent.They are thought to arise from an anomalous pancreaticobiliary junction,which are congenital anomalies between pancreatic and bile ducts.Some similarities in presentation between Eastern and Western patients exist such as female predominance,however,contemporary studies suggest that Asian patients may be more symptomatic on presentation.Even though CC disease presents with an increased malignant risk reported to be more than 10%after the second decade of life in Asian patients,this risk may be overstated in Western populations.Despite this difference in cancer risk,management guidelines for all patients with CC are based predominantly on observations reported from Asia where it is recommended that all CCs should be excised out of concern for the presence or development of biliary tract cancer.

在诊断 choledochal 包囊的磁性的回声 cholangiopancreatography 的角色: 盒子系列和评论

AIM:To determine the merits of magnetic resonance cholangiopancreatography(MRCP) as the primary diagnostic test for choledochal cysts(CC’s).METHODS:Between 2009 and 2012,patients who underwent MRCP for perioperative diagnosis were identified.Demographic information,clinical characteristics,and radiographic findings were recorded.MRCP results were compared with intraoperative findings.A PubMed search identified studies published between 1996-2012,employing MRCP as the primary preoperative imaging and comparing results with either endoscopic retrograde cholangiopancreatography(ERCP) or operative findings.Detection rates for CC’s and abnormal pancreaticobiliary junction(APBJ) were calculated.In addition detection rates for clinically related biliary pathology like choledocholithiasis and cholangiocarcinomas in patients diagnosed with CC’s were also evaluated.RESULTS:Eight patients were identified with CC’s.Six patients out of them had typeⅣCC’s,1 had type I and 1 had a new variant of choledochal cyst with confluent dilatation of the common bile duct(CBD) and cystic duct.Seven patients had an APBJ and 3 of those had a long common-channel.Gallstones were found in 2 patients,1 had a CBD stone,and 1 pancreatic-duct stone was also detected.In all cases,MRCP successfully identified the type of CC’s,as well as APBJ with ductal stones.From analyzing the literature,we found that MRCP has 96%-100% detection rate for CC’s.Additionally,we found that the range for sensitivity,specificity,and diagnostic accuracy was 53%-100%,90%-100% and 56%-100% in diagnosing APBJ.MRCP’s detection rate was 100% for choledocholithiasis and 87% for cholangiocarcinomas with concurrent CC’s.CONCLUSION:After initial ultrasound and computed tomography scan,MRCP should be the next diagnostic test in both adult and pediatric patients.ERCP should be reserved for patients where therapeutic intervention is needed.

Safety of endoscopic retrograde cholangiopancreatography in pregnancy: Fluoroscopy time and fetal exposure, does it matter?

AIM: To estimate the fetal radiation exposure using thermoluminescent dosimeters (TLD's) in pregnant patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) and assess its relevance. METHODS: Data on thirty-five therapeutic ERCPs conducted in pregnant patients from 2001 to 2009 were retrieved from a prospective database. Techniques to minimize fluoroscopy time were implemented and the fluoroscopy times captured. TLD's were placed on the mother to estimate the fetal radiation exposure and the results were compared to the maximum allowed dose of radiation to the fetus [0.005 gray (Gy)]. Obstetrics consultations were obtained and the fetus was monitored before and after the ERCP. Fluoroscopy wasperformed at 75 kVp. ERCP was performed with the patients supine by dedicated biliary endoscopists performing more than 500 cases a year. RESULTS: A total of 35 pregnant patients underwent ERCP and biliary sphincterotomy (14 in first trimester, 11 in second trimester, and 10 in third trimester). Mean maternal age was 25 years (range 16-37 years) and mean gestational age was 18.9 wk (range 4-35 wk). Mean fluoroscopy time was 0.15 min (range 0-1 min). For 23 women, the estimated fetal radiation exposure was almost negligible (< 0.0001 Gy) while for 8 women, it was within the 0.0001-0.0002 Gy range. Three women had an estimated fetal radiation exposure between 0.0002 and 0.0005 Gy and 1 woman had an estimated fetal radiation exposure greater than 0.0005 Gy. Complications included 2 post-sphincterotomy bleeds, 2 post-ERCP pancreatitis, and 1 fatal acute respiratory distress syndrome. One patient developed cholecystitis 2 d after ERCP. CONCLUSION: ERCP with modified techniques is safe during pregnancy, and estimating the fetal radiation exposure from the fluoroscopy time or measuring it via TLD's is unnecessary.