Anomalous Junction Research Articles

Efficacy and safety of endoscopic retrograde cholangiopancreatography for children with pancreaticobiliary diseases

Objective To assess the safety and efficacy of endoscopic retrograde cholangiopancreatography (ERCP) for children with pancreaticobiliary diseases. Methods Data of children under 14 years old who have underwent ERCP in Nanjing Drum Tower Hospital between September 2007 and August 2016 were reviewed for completion, complications and therapeutic methods. Results A total of 41 children underwent 68 ERCP, including 6(8.8%) diagnostic and 62(91.2%) therapeutic procedures. All procedures were performed under deep sedation. Cannulation failed in only 1 child with anomalous junction of pancreaticobiliary duct. The procedure success rate was 98.5%(67/68). There were 8 adverse events, including 7 mild post-ERCP pancreatitis and 1 fever. Incidence of adverse event was 11.8%(8/68). There was no such severe adverse event as bleeding, perforation, death, or other anesthesia related adverse event. Thirty-two children (78.0%) had follow-up, ranging from 2 month to 6 years. Children followed lived well with no long-term adverse event. Conclusion ERCP is an effective and safe procedure for the diagnosis and treatment of pancreaticobiliary diseases in children. Key words: Child; Endoscopic retrograde cholangiopancreatography; Diagnosis; Therapeutic endoscopy; Pancreaticobiliary diseases

膵・胆管合流異常下における胆道内逆流膵酵素の活性化機序に関する実験的,臨床的検討

膵・胆管合流異常下における胆道内逆流膵酵素の活性化機序に関する実験的,臨床的検討

A Proximal Fibularis Brevis Muscle Is Associated with Longitudinal Split Tendons: A Cadaveric Study

The anomalous distal musculotendinous junction of the fibularis brevis muscle has been hypothesized to contribute to the development of longitudinal fibularis brevis tendon tears. Specifically, the mass effect of the low-lying fibularis brevis muscle belly was thought to increase the pressure on the superior peroneal retinaculum and increase the probability of fibularis brevis tendon subluxation. A more recent examination of the fibularis brevis tendon junction found, contrary to this hypothesis, a statistically significant association between an anomalous proximal musculotendinous junction and the prevalence of longitudinal split tears. However, no rationale was offered. The present study examined the relationship between the musculotendinous junction and the prevalence of longitudinal fibularis brevis tendon tears. A total of 24 fibularis brevis tendon lengths were measured bilaterally in 12 human cadaveric specimens. The tendon lengths were assessed as the vertical distance from the most inferior aspect of the lateral malleolus to the most distal fibularis brevis musculotendinous extension. Only full-thickness tears were identified and included. The lengths of tendons with and without longitudinal tears were compared. Of the 24 tendons examined, 7 (29%) presented with full-thickness longitudinal tears from 4 cadavers (33%). The mean length for the tendons with tears was significantly longer (p < .001) than the mean length of those without tears (28.86 ± 3.02 mm versus 16.29 ± 7.30 mm). Our research concurs with the most recent findings, identifying a statistically significant association between an anomalous proximal muscle belly extension and longitudinal fibularis brevis tendon tears. Furthermore, we propose the hypothesis that a more proximal musculotendinous junction might predispose individuals to a lesser stabilizing effect of the muscle against the posterior lateral surface of the fibula, increasing the probability of anterolateral subluxation, attrition, and longitudinal tear development.

Synchronous Gall Bladder and Bile Duct Cancer: A Short Series of Seven Cases and a Brief Review of Literature

Simultaneous presence of cancer in the gall bladder and in the biliary tree could be due to local spread, metastases, de novo multifocal origin, or as part of a field change. In the past, such an association has been described in patients with anomalous pancreatico-biliary ductal junction. We studied seven consecutive patients with simultaneous gall bladder and bile duct malignancy with a view to identify the best way to treat them, and if possible to hypothesize the etiopathogenesis. Over a period of 24 months, there were seven cases, with synchronous gall bladder and extra-hepatic bile duct cancer. None of our patients had anomalous pancreatico-biliary ductal junction. Three patients were found to have inoperable disease, three other underwent curative resection, and one patient had a complete response to chemotherapy. Herein, we describe these patients and our lessons learnt from these patients with synchronous bile duct and gall bladder cancer. Of the seven patients, we were able to complete a curative resection in three patients, and the three patients were found to have inoperable disease. One patient had an excellent response to chemotherapy. Thus aggressive therapy in such patients with gall bladder cancer may be warranted in select cases. Also, the gall bladder specimens in patients undergoing surgery for cholangiocarcinoma should be analyzed in detail to identify foci of dysplasia or change in the epithelium. The pathogenesis may be due to a common field change in the biliary epithelium.

A Case of Incomplete Pancreas Divisum with Anomalous Pancreatic Duct-Biliary Duct Junction with Type IV-A Choledochal Cyst Complicated by Cystolithiasis

A 36-year-old Vietnamese woman who suffered from migraines and anxiety presented to the ED with acute abdominal pain of 3 hrs located in the mid-epigastrium and right upper quadrant, described as sharp and severe. She had one episode of non-bloody vomiting associated with chills, was afebrile and tender to palpation in the mid-epigastrium. Lab analysis noted moderate leukocytosis (14,810 cells/mcL), mild elevations in both AST (53 U/L) and ALT (43 U/L), and normal values of alkaline phosphatase, total bilirubin, lipase and lactic acid. H. pylori serum IgG was negative. RUQ sonogram revealed a hydropic gallbladder with echogenic material and a 2.7cm shadowing stone within a 4.1cm dilated common bile duct. ERCP was performed the next day. During the procedure, the minor papilla appeared prominent with pancreatic fluid draining from the orifice. The common bile duct and to a lesser extent the common hepatic duct appeared dilated. The cystic duct also appeared mildly dilated. While injecting the distal CBD, contrast was seen filling the pancreatic duct to the body >15mm from the ampullary junction. The dorsal duct was noted to be in continuity and drained to the minor papilla. A sphincterotomy and dilation to 15mm with a CRE balloon on the sphincterotome was performed. A 10F x 7cm plastic pigtail biliary stent was placed with adequate drainage. A post-procedure MRCP revealed fusiform dilatation of the CBD with a filling defect within. The proximal portion of the left hepatic duct was also dilated measuring up to 1.4cm and corresponded to type IV A choledochal cyst by Todani classification. Two days later after receiving perioperative antibiotics she underwent resection of choledochal cyst and Roux-en-Y hepaticojejunostomy without complication. Pathology noted a gallbladder size 7.5cm in length by 5.5cm in circumference with an attached bile duct cyst 9cm in circumference by approximation. One irregular green brown calculus was found and measured 2.5 x 2.2 x 1.5cm. Microscopy of the bile duct revealed ulcerated choledochal cyst and a gallbladder with no significant histologic abnormality. A JP drain and right subcostal incision staples were removed 14 days later. Eight weeks after surgery she developed MEG pain with radiation to her back and severe sepsis. LAEs and lipase were normal and a HIDA scan was negative for obstruction of the hepatobiliary tree. She was treated with a 10-day course of antibiotics and received follow-up care with transplant surgery.Figure 1Figure 2Figure 3

Prospective evaluation of yield of endoscopic ultrasonography in the etiological diagnosis of "idiopathic" acute pancreatitis

Abstract Background: Etiology of acute pancreatitis (AP) remains idiopathic in 30% of patients. Endoscopic ultrasound (EUS) has been shown to increase the diagnostic yield in patients with idiopathic AP (IAP). Aim: The aim of this study was to evaluate the role of EUS in achieving etiological diagnosis in patients with IAP. Materials and Methods: Consecutive 192 patients with IAP were evaluated prospectively with EUS over a period of 2 years. Patients who had no etiological diagnosis for AP after detailed history, clinical examination, laboratory investigations, and magnetic resonance cholangiopancreatography were included in the study. Results: The mean age of patients was 34.6 ± 12 and male:female ratio was 2.1:1. Of these, 135 patients had gallbladder intact (Group A) and 57 patients had undergone cholecystectomy (Group B). In Group A, EUS identified a possible cause in 79 (58.5%) patients; microlithiasis (n = 48), chronic pancreatitis (CP) (n = 23), common bile duct (CBD) and gallbladder stone (n = 3), pancreatic divisum (n = 3), small pancreatic tumor (n = 1), and anomalous pancreaticobiliary junction (n = 1). In Group B, EUS yielded diagnosis in 28 (49.1%) patients; CP (n = 22), ascariasis (n = 3), CBD stone (n = 2), and pancreatic divisum (n = 1). Overall EUS helped in achieving etiological diagnosis in 107 (55.1%) of patients with IAP. The presence of intact gallbladder showed a tendency for increased diagnostic yield (P = 0.06). Conclusion: EUS is a useful modality to establish the diagnosis in IAP and this technique should be incorporated in the evaluation of IAP.

Synchronous cholangiocarcinoma and gallbladder cancer: A rare presentation

Introduction: Synchronous biliary tree and gallbladder cancers are rarely encountered and reported in the literature. In this article, we report an extremely rare presentation of a patient with distal common hepatic duct (CHD), proximal common bile duct (CBD) and gallbladder cancer associated with anomalous pancreaticobiliary duct junction (APBDJ) as primary tumors. Case Report: A 40-year-old male referred to us with RUQ pain, fever, jaundice and pruritis since two weeks. PET-CT showed hypermetabolic polypoid mass in the fundus of gallbladder and a periportal node. ERCP was done but guide wire could not be passed beyond mid CBD. The findings were neoplastic mass in fundus of the gallbladder with pericholedochal lymphadenopathy. There was another neoplastic mass in the CBD. An extended cholecystectomy with extrahepatic CBD excision with a pancreaticoduodenectomy with radical lymphadenectomy was performed. Intra-operative ultrasonography was done to rule out other lesions in the pancreas and liver. Histopathological examination revealed well differentiated adenocarcinoma of gallbladder and adenocarcinoma of proximal CBD and distal CHD, stagging pT2 pN0 pMx. Conclusion: Synchronous extra hepatic and gallbladder tumors are extremely rare, their etiopathogenesis has not been properly understood and defined. Biliary cancers with PBM are thought to develop multicentrally, due to the effect of pancreatic juice reflux on the mucosa of the biliary tract.

Role of ERCP in Patients With Idiopathic Recurrent Acute Pancreatitis.

Recurrent acute pancreatitis (RAP) is defined based on the occurrence of two or more episodes of acute pancreatitis. RAP is differentiated from chronic pancreatitis based on the presence of a normal morphological appearance of the pancreas between episodes. RAP can be due to a variety of etiologies including common bile duct stones or sludge, sphincter of Oddi dysfunction (SOD), pancreas divisum (PD), anomalous pancreaticobiliary junction, genetic mutations, and alcohol related. In approximately 30% of patients, the etiology of RAP is unclear and the term "idiopathic" is used. Endoscopic retrograde cholangiopancreatography (ERCP) can be utilized in both the diagnosis and the initial management of RAP, but it has known limitations and risks. Since gallbladder sludge and SOD account for most cases with RAP, cholecystectomy and, eventually, endoscopic biliary and/or pancreatic sphincterotomy are performed as a part of management. In patients with PD-associated RAP, data from uncontrolled and primarily retrospective studies point toward a benefit from minor papillary endoscopic intervention. However, given the lack of quality data from prospective randomized controlled trials (RCTs), endoscopic management in such patients remains an individualized decision, and RCTs are needed to ascertain its true long-term benefit. Future studies to investigate the role of endoscopic therapy in preventing progression to chronic pancreatitis are needed.

Edge-state-induced Andreev oscillation in quantum anomalous Hall insulator-superconductor junctions

We study the quantum Andreev oscillation induced by interference of the edge chiral Majorana fermions in junctions made of quantum anomalous Hall (QAH) insulators and superconductors (SCs). We show two chiral Majorana fermions on a QAH edge with SC proximity generically have a momentum difference $\mathrm{\ensuremath{\Delta}}k$, which depends on the chemical potentials of both the QAH insulator and the SC. Due to the spatial interference induced by $\mathrm{\ensuremath{\Delta}}k$, the longitudinal conductance of QAH-SC junctions oscillates with respect to the edge lengths and the chemical potentials, which can be probed via charge transport. Furthermore, we show the dynamical SC phase fluctuation will give rise to a geometrical correction to the longitudinal conductance of the junctions.

Clinicopathologic Differences in Patients with Gallbladder Cancer According to the Presence of Anomalous Biliopancreatic Junction.

Anomalous biliopancreatic junction (ABPJ) is a risk factor for gallbladder cancer (GBC). This study investigated the significance of ABPJ in patients with GBC. Of the 453 patients with GBC underwent surgery at Seoul National University Hospital between 2000 and 2014, the 401 patients who can be assessed for the presence of ABPJ with radiologic image were analyzed. The 401 patients with GBC included 183 (45.6 %) males and 218 (54.4 %) females. ABPJ was identified in 69 (17.2 %) patients, 22 (31.9 %) males and 47 (68.1 %) females. Choledochal cyst (CC) was identified in 18 (4.5 %) patients, all of whom had ABPJ. Curative surgery was accomplished in 68.1 %. A comparison of patients with and without ABPJ showed that mean age (59.9 vs. 65.1 years, p < 0.001) and association with gallbladder stone (8.7 vs. 24.7 %, p = 0.002) were significantly lower in the ABPJ group, while the proportion of female (68.1 vs. 51.5 %, p = 0.012), bile duct resection rate (47.8 vs. 18.4 %, p < 0.001), and curative resection rate (81.1 vs. 65.7 %, p = 0.003) were significantly higher in the ABPJ group. Overall 5-year survival rates were similar in the ABPJ and non-ABPJ groups (74.4 vs. 69.0 %, p = 0.533). In patients with ABPJ, the presence of CC did not have a significant effect on survival (p = 0.099). ABPJ was found in 17.2 % of patients with GBC. ABPJ is associated with younger age, female gender, absence of gallbladder stones, higher BDR rate, and higher curative resection rate. However, neither ABPJ nor CC was prognostic of survival in curatively treated patients with GBC.

Sphincter of Oddi Dysfunction and the Formation of Adult Choledochal Cyst Following Cholecystectomy: A Retrospective Cohort Study.

To determine the causes underlying the formation of adult choledochal cyst.Anomalous pancreaticobiliary junction is the most widely accepted theory regarding the etiology of choledochal cyst. However, choledochal cysts have been found in patients in the absence of this anomaly. Because the number of adult patients with choledochal cyst is increasing, it is important to address this controversy.Bile amylase levels in the cysts of 27 patients (8 males and 19 females) who had undergone cholecystectomy were retrospectively evaluated.The average age of the 27 patients was 45.8 ± 10.1 years and the majority (85.2%) were diagnosed with Todani type I cysts. None of the patients had dilatation of the common bile duct prior to surgery. There were 6 (22.2%) patients with anomalous pancreaticobiliary junction. However, amylase levels did not significantly differ between patients with and without this anomaly (P = 0.251). According to bile amylase levels, pancreatobiliary reflux was present in 21 (77.8%) patients. The mean amylase level significantly differed in patients with pancreatobiliary reflux (23,462 ± 11,510 IU/L) and those without (235 ± 103 IU/L) (P < 0.001). In patients with pancreatobiliary reflux, only 4 patients had anomalous pancreaticobiliary junction. That is, the majority of patients (17/21, 81%) having pancreatobiliary reflux did not have an anomalous junction of the pancreatic and biliary ducts.Since the only explanation for pancreatobiliary reflux in patients with a normal pancreaticobiliary junction is sphincter of Oddi dysfunction, we proposed that the formation of adult choledochal cyst is mainly due to sphincter of Oddi dysfunction.

Congenital double bile duct presenting as recurrent cholangitis in a child

Double common bile duct (DCBD) is a rare congenital anomaly. Most of these bile duct anomalies are associated with bile duct stones, anomalous pancreaticobiliary junction (APBJ), pancreatitis and bile duct or gastric cancers. Early detection and treatment is important to avoid long term complications. Surgical resection of the anomalous bile duct and reconstruction of the biliary enteric anastomosis is the treatment of choice. We report a rare case of DCBD anomaly in a girl, who presented with recurrent cholangitis. She had type Va DCBD anomaly. She underwent successful resection of the bile duct and reconstruction of the biliary enteric anastomosis. Preoperative imaging and diagnosis of the congenital biliary anomaly is very important to avoid intraoperative bile duct injury. Review of the literature shows very few cases of type Va DCBD, presenting with either bile duct stones or APBJ.

Anomalous Junction of the Pancreaticobiliary Ductal System With a Long Common Channel in a Patient With Chromosome 14 Translocation Causing Recurrent Acute and Chronic Pancreatitis

The pancreatic duct (PD) and common bile duct (CBD) normally join with a short (4-5mm) common channel into the duodenum. Rarely, anomalous junctions can occur outside the duodenum where they are no longer influenced by the sphincter of Boyden. One such anomaly is the ‘long common channel' in which the PD inserts into the CBD outside the duodenum and a common channel over 15mm enters the duodenum. These cases are associated with higher incidence of chronic pancreatitis as both bile and pancreatic juices are allowed to reflux into the opposing channel. We present the case of a two year and 3 month old toddler with a past medical history of chromosome 14 translocation (Turner Syndrome variant), agenesis of the corpus callosum, possible optic nerve atrophy, s/p Nissen procedure x2 and gastric tube dependence who presented to the hospital with abdominal pain. Of note, she had recurrent bouts of biliary pancreatitis as well as pancreatitis of unclear etiology. Her symptoms began at 20 months of age when she was jaundiced and underwent MRCP demonstrating gallbladder sludge, and biliary stenosis. She subsequently underwent laparoscopic cholecystectomy but continued to develop recurrent bouts of pancreatitis. Endoscopic cholangiopancreatography (ERCP) demonstrated diffuse irregularity with dilatation (6mm) and beading of the main ventral pancreatic duct in the head of the pancreas and tortuosity with clubbing of the side branches. Also noted was a long 20mm common channel with the pancreatic duct entering the common bile duct (CBD) 2cm above the ampulla. At ERCP, filling of the pancreatic duct was noted upon injecting contrast in the distal CBD. This anatomic variation with an anomalous high entry of the pancreatic duct into the CBD with clear bile reflux into the pancreatic duct was the likely etiology of the patient's recurrent acute on chronic pancreatitis. A 5 french/5cm pigtail stent was endoscopically placed into the pancreatic duct, preventing reflux of bile into the pancreatic duct. This was subsequently changed 2 weeks later. Post-stenting, no recurrent bouts of pancreatitis were noted and the patient did not require hospital readmission. She subsequently underwent laparoscopic choledochoduodenostomy without incident. She remains thriving at this time without further episodes of pancreatitis since surgery. This is the first reported case of an anomalous long common channel in a toddler with a chromosome 14 translocation. Further, it is the first case to successfully treat a long common channel endoscopically with a pancreatic stent, and surgically with choledochoduodenostomy. The development of severe chronic pancreatitis in this case in an unfortunate sequela of the persistent bile reflux through this anomaly.

Type III choledochal cyst and anomalous pancreatobiliary junction

Type III choledochal cyst and anomalous pancreatobiliary junction

Choledochocele: Choledochal Cyst Ora Distinct Entity?

Choledochocele represents a cystic dilatation of the distal common bile duct and it’s included in Todani’s classification as type III choledochal cysts. We report a case of a 66-years-old man who presented a suspected gallbladder lithiasis with colic abdominal pain, vomit, fever, jaundice and abnormal liver function tests. However the endoscopic retrograde cholangio-pancreatography revealed the absence of stones in the common bile duct and the presence of a 15mm-wide choledochocele that was successfully treated with an endoscopic sphincterotomy. Additionally a comprehensive review of the literature of the last 15 years was performed, collecting 105 cases of choledochocele. The available data were classified in 10 variables and subsequently analysed. Summarizing all data, we noticed that choledochocele presents different characteristics if compared with other types of choledochal cysts: The population affected is older, there isn’t a strong female prevalence, the most frequent manifestation is pancreatitis instead of jaundice and cholangitis, the association with anomalous pancreato-biliary duct junction is rare and the risk of malignancy is lower. The standard for the diagnosis is endoscopic retrograde cholangio-pancreatography instead of magnetic resonance cholangio-pancreatography and the most accepted treatment is endoscopic sphincterotomy in order to allow the correct outflow of the biliary juice. In conclusion, even if choledochocele is commonly considered a type of cystic dilatation of the common biliary duct and it is usually included in the choledochal cysts classification, it has to be considered as a distinct entity with its own features.

Adult choledochal cysts: current update on classification, pathogenesis, and cross-sectional imaging findings

Approximately 20% of choledochal cysts (CC) present in adult patients and they are commonly associated with a high risk of complications, including malignancy. Additionally, children who underwent internal drainage procedures for CCs can develop complications during adulthood despite treatment. Concepts regarding classification and pathogenesis of the CCs have been evolving. While new subtypes are being added to the widely accepted Todani classification system, simplified classification schemes have also been proposed to guide appropriate management. The exact etiology of CCs is currently unknown. The two leading theories involve either the presence of an anomalous pancreatico-biliary junction with associated reflux of pancreatic juice into the biliary system or, more recently, some form of antenatal biliary obstruction with resulting proximal bile duct dilation. Imaging studies play an important role in the initial diagnosis, surgical planning, and long-term surveillance of CCs.

Gallbladder carcinoma: Prognostic factors and therapeutic options

The outcome of gallbladder carcinoma is poor, and the overall 5-year survival rate is less than 5%. In early-stage disease, a 5-year survival rate up to 75% can be achieved if stage-adjusted therapy is performed. There is wide geographic variability in the frequency of gallbladder carcinoma, which can only be explained by an interaction between genetic factors and their alteration. Gallstones and chronic cholecystitis are important risk factors in the formation of gallbladder malignancies. Factors such as chronic bacterial infection, primary sclerosing cholangitis, an anomalous junction of the pancreaticobiliary duct, and several types of gallbladder polyps are associated with a higher risk of gallbladder cancer. There is also an interesting correlation between risk factors and the histological type of cancer. However, despite theoretical risk factors, only a third of gallbladder carcinomas are recognized preoperatively. In most patients, the tumor is diagnosed by the pathologist after a routine cholecystectomy for a benign disease and is termed ''incidental or occult gallbladder carcinoma'' (IGBC). A cholecystectomy is performed frequently due to the minimal invasiveness of the laparoscopic technique. Therefore, the postoperative diagnosis of potentially curable early-stage disease is more frequent. A second radical re-resection to complete a radical cholecystectomy is required for several IGBCs. However, the literature and guidelines used in different countries differ regarding the radicality or T-stage criteria for performing a radical cholecystectomy. The NCCN guidelines and data from the German registry (GR), which records the largest number of incidental gallbladder carcinomas in Europe, indicate that carcinomas infiltrating the muscularis propria or beyond require radical surgery. According to GR data and current literature, a wedge resection with a combined dissection of the lymph nodes of the hepatoduodenal ligament is adequate for T1b and T2 carcinomas. The reason for a radical cholecystectomy after simple CE in a formally R0 situation is either occult invasion or hepatic spread with unknown lymphogenic dissemination. Unfortunately, there are diverse interpretations and practices regarding stage-adjusted therapy for gallbladder carcinoma. The current data suggest that more radical therapy is warranted.

Invasive Squamous Cell Carcinoma of Gallbladder Presenting as Colonic Obstruction

Introduction: Gallbladder cancers are rare, with the most common histologic variant to be adenocarcinoma. Pure squamous cell carcinomas (SCC) are extremely uncommon accounting for 2% of all gallbladder cancers. Multiple risk factors have been identified including gallstones, porcelain gallbladder, polyps, biliary cysts, chronic infections, anomalous pancreatobiliary duct junction, and carcinogenic exposure. We report a case of squamous cell carcinoma of the gallbladder presenting with 3 months of abdominal pain associated with constipation and nausea, vomiting, and distention. Her initial ultrasound revealed cholelithiaisis but otherwise normal biliary tree and gallbladder, and after consultation with a surgeon she was scheduled for an outpatient cholecystectomy. However, during the interval period she had worsening of her symptoms and she also endorsed a 10-pound weight loss. Computed tomography (CT) of her abdomen showed a heterogeneously enhancing mass surrounding the colon with noted obstruction at the hepatic flexure and proximal colon, as well as cecal dilation. She then underwent a colonoscopy that found a mass causing a partial colon obstruction at the hepatic flexure. Subsequently, a colonic stent was placed using a guide wire, to relieve the obstruction and numerous biopsies were taken. Biopsies revealed invasive SCC that infiltrated submucosal soft tissues which was positive for cytokeratin 7, 5, 6, and p63, suggestive of gallbladder primary. She then underwent laparoscopy and biopsies of the intra-abdominal mass, which again showed locally invasive SCC arising from the gallbladder. Given her locally advanced status, she was not felt to be a surgical candidate, and was started on systemic therapy with gemcitabine and cisplatin. Despite chemotherapy, however, patient returned within 2 months with numerous necrotic metastases throughout her liver, demonstrating the difficulty in treating these type of cancers.Figure 1: Axial CT images.Figure 2: Bulging mass on the right lateral wall and colon stent placement.Figure 3: Laproscopic images of right upper quadrant mass and transverse colon. Mass is fixed and invading the liver.

Anomalous junctions characterized by Raman spectroscopy in SixGe1−x nanowires with axially degraded components

The characterization of junctions in nanowires by high-resolution transmission electron microscopy with spherical aberration correction is tricky and tedious. Many disadvantages also exist, including rigorous sample preparation and structural damage inflicted by high-energy electrons. In this work, we present a simple, low-cost, and non-destructive Raman spectroscopy method of characterizing anomalous junctions in nanowires with axially degraded components. The Raman spectra of SixGe1−x nanowires with axially degraded components are studied in detail using a confocal micro-Raman spectrometer. Three Raman peaks (νSi–Si = 490 cm−1, νSi–Ge = 400 cm−1, and νGe–Ge = 284 cm−1) up-shift with increased Si content. This up-shift originates in the bond compression induced by a confined effect on the radial direction of nanowire. The anomalous junctions in SixGe1−x nanowires with axially degraded components are then observed by Raman spectroscopy and verified by transmission electron microscopy energy-dispersive X-ray spectroscopy. The anomalous junctions of SixGe1−x nanowires with axially degraded components are due to the vortex flow of inlet SiH4 and GeH4 gas in their synthesis. The anomalous junctions can be used as raw materials for fabricating devices with special functions.

Anomalous Pancreaticobiliary Junction

Anomalous Pancreaticobiliary Junction