Anomalous Pancreaticobiliary Ductal Junction Research Articles

Laparoscopic choledochal cyst resection and reconstruction

Background: Choledochal cysts are benign uncommon congenital cystic dilatations of the bile duct usually associated with anomalous junction of pancreaticobiliary duct. Recurrent pancreatitis can be a possible complication in these cases resulting even in bile duct cancer if not treated. Methods: Video of a Case report Results: We present a case of a 22 years old male with recurrent pancreatitis. A Choledochal cyst (Todani type IV A) was diagnosed. A laparoscopic approach was performed with the cyst resection and https://www.ncbi.nlm.nih.gov/pubmed/29089716 reconstruction. The patient had a good recovery being discharge on the fourth postoperative day. Pathological analysis confirmed our previous diagnosis. Conclusion: Complete Laparoscopic resolution of Choledochal cysts is a feasible and acceptable approach nowadays. Although rare, physicians need to keep this diagnosis in mind, especially when recurrent pancreatitis is presented and refer the patient to a high-volume center to be correctly treated.

Case report: Left sided gall bladder associated with chylolymphatic cyst of mesentery of small intestine

Mesenteric cyst and left sided gall bladder both are rare entity. Incidence of mesenteric cyst is 1 per 1,00,000 to 2,50,000, a rare abdominal tumor, among which chylolymphatic mesenteric cyst is further rare. In left sided gall bladder, gall bladder is attached on left lateral sector of liver, left to falciform ligament and interlobar fissure. Left sided gall bladder can be a single anomaly or associated with other anomalies like duplicated gall bladder, hypoplastic bile duct, situs inversus, anomalous pancreatico-biliary ductal junction, absence of quadrate lobe, accessory liver. In our case it was associated with mesenteric cyst which is the first case to be reported to best of our knowledge.

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

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.

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.

Diagnosis and management of choledochal cyst: 20 years of single center experience.

We report the first case series from Africa and the Middle East on choledochal cyst, a disease which shows significant geographical distribution with high incidence in the Asian population. In this study, the epidemiological data of the patients are presented and analyzed. Attention was paid to diagnostic imaging and its accuracy in the diagnosis and classification of choledochal cyst. Most cases of choledochal cyst disease have type I and IV-A cysts according to the Todani classification system, which support the etiological theories of choledochal cyst, especially Babbitt's theory of the anomalous pancreaticobiliary duct junction, which are clearly stated. The difficulties and hazards of surgical management and methods used to avoid operative complications are clarified. Early and late postoperative complications are also included. This study should be followed by multicenter studies throughout Egypt to help assess the incidence of choledochal cysts in one of the largest populations in Africa and the Middle East.

An analysis of biliary anatomy according to different classification systems

Variations in biliary anatomy are common, and different classifications have been described. These classification systems have not been compared to each other in a single cohort. We report such variations in biliary anatomy on magnetic resonance cholangiopancreatography (MRCP) using six different classification systems. In 299 patients undergoing MRCP for various indications, biliary anatomy was classified as described by Couinaud (1957), Huang (1996), Karakas (2008), Choi (2003), Champetier (1994), and Ohkubo (2004). Correlation with direct cholangiography and vascular anatomy was done. Bile duct dimensions were measured. Cystic duct junction and pancreaticobiliary ductal junction (PBDJ) were classified. Normal biliary anatomy was noted in 57.8 %. The most common variants were Couinaud type D2, Choi type 3A, Huang type A1, Champetier type a, Ohkubo types D and J, and Karakas type 2a. The Ohkubo classification was the most appropriate; 3.1 % of right ducts and 6.3 % of left ducts with variant anatomy could not be classified using the Ohkubo classification. There was a good agreement between MRCP and direct cholangiography (ĸ = 0.9). Anomalous PBDJ was noted in 8.7 %. Variant biliary anatomy was not associated with gender (p = 0.194) or variant vascular anatomy (p = 0.24). Although each classification system has its merits and demerits, some anatomical variations cannot be classified using any of the previously described classifications. The Ohkubo classification system is the most applicable as it considers most clinically relevant variations pertinent to hepatobiliary surgery.

Gallbladder cancer: Can newer insights improve the outcome?

Gallbladder cancer (GBC) is the leading cause of cancer related mortality in certain geographic areas. Most of the patients with GBC have advanced disease at presentation, precluding curative resection resulting in a dismal prognosis. However, recent advances in the understanding of its epidemiology and pathogenesis coupled with development of newer diagnostic tools and therapeutic options, has resulted in enhanced optimism towards the management of the disease. The leading risk factors are gallstones, advancing age, female gender, anomalous pancreaticobiliary ductal junction, certain ethnic groups and geographic populations. Advances in radiological imaging and the advent of endoscopic ultrasound have facilitated early detection and accurate staging of the tumor. A high index of suspicion in high risk groups is necessary to pick up incidental and early GBC, as surgical resection is curative. In patients with suspected GBC, an open surgical resection that is appropriate for that stage is advocated. Adjuvant combination chemotherapy and molecular targeted therapy are emerging as effective therapeutic options in those with advanced GBC. Endoscopic palliation of biliary and gastric outlet obstruction with metallic stents has improved their quality of life. Prevention remains the hitherto less explored option to reduce GBC related mortality. Prophylactic cholecystectomy in high risk groups is a cost-effective option. A multi-disciplinary systematic global approach to initiate collaborative ventures to understand epidemiology, standardize management strategies, conduct multi-centric trials with newer therapeutic agents and initiate preventive measures, would pave way for the future conquest of the disease.

Comparative Study of the Diagnostic Ability of Magnetic Resonance Imaging and Multidetector Row Computed Tomography for Anomalous Pancreaticobiliary Ductal Junction

To compare the diagnostic performance of magnetic resonance (MR) imaging and multidetector row computed tomography (MDCT) for an anomalous pancreaticobiliary ductal junction (PBJ). This study included 26 patients who underwent MR imaging, MDCT, and endoscopic retrograde cholangiopancreatography. Seventeen of the patients were diagnosed by endoscopic retrograde cholangiopancreatography as having an anomalous PBJ. Three radiologists independently reviewed MR images alone, contrast-enhanced CT images alone, and MR images and CT images combined. Receiver operating characteristic curve analysis was used to compare diagnostic capabilities. The mean area under the receiver operating characteristic curve (Az [95% confidence interval]) was 0.75 (0.73-0.77) for MR imaging alone, 0.79 (0.70-0.89) for CT alone, and 0.84 (0.82-0.86) for the 2 modalities combined. Only between the combination and MR imaging alone was there significant difference in Az value (P < 0.05). The diagnostic performance of MR imaging and MDCT was equivalent for an anomalous PBJ. The addition of MDCT to MR imaging improved the diagnostic performance.

Strategies for diagnosis and treatment of anomalous junction of pancreaticobiliary duct complicated by acute pancreatitis and literature review

Objective To explore the strategies for diagnosis and treatment of anomalous junction of pancreaticobiliary duct (AJPBD) complicated by acute pancreatitis. Methods The clinical dataof 22 patients with abnormal pancreaticobiliary junction were analyzed retrospectively. Results The incidence of acute pancreatitis in this series was 31.8 % (7/22), thereinto, 5 cases(71.4%) in C-Ptype (the common bile duct joining the pancreatic duct) and 2(28.6%) in P-C type (the pancreatic duct joining the common bile duct). Seven patients underwent ERCP+ EST+ ENBD. Two patients with common bile duct stones were treated with stone basket and cholecystectomy was performed in two cases with gallstone. All patients were successfully treated. The follow-up for l year showed that there was no recurrence of pancreatitis. Conclusion Acute pancreatitis usually occurs in patients with AJPBD, especially in C-P type or with gallbladder stone or common bile duct stone. ERCP+EST+ENBD and prophylactic cholecystectomy are effective to prevent and treat acute pancreatitis. Key words: Pancreatitis; Anomalous junction of pancreaticobiliary duct; Endoscopic retrograde cholangiopancreatography; Cholecystectomy

Management of Type I Choledochal Cyst in Adult: Totally Laparoscopic Resection and Roux-en-Y Hepaticoenterostomy

Background/objectiveCholedochal cysts are congenital dilations of the biliary tree. The accepted mode of treatment is total excision with hepaticojejunostomy. In this retrospective study, we present our technique and results of laparoscopic choledochal cyst excisions. MethodsWe retrospectively studied 45 patients who had undergone laparoscopic choledochal cyst excision in our institutes from September 2006 to August 2009. Data including age, gender, type of cyst, symptoms, surgical technique, conversion rate, morbidity, and mortality were analyzed. ResultsThere were type Ic (cystic) choledochal cysts in 31 patients (68.9%) and type If (fusiform) in 14 patients (31.1%). An anomalous pancreaticobiliary duct junction union was found in 66.7%. Forty percent (18 out of 45) and 37.8% (17 out of 45) cases had stones within the cysts and gallbladders, respectively. The average size of the cysts was 40.3±16.9 cm2. The mean operative time was 307.7±58.0 min, the estimated operative blood loss was 252.3±162.5 ml, and the conversion rate was 8.9%. The mean hospital stay was 8.3±3.2 days. The overall morbidity rate was 17.1%, the reoperation rate was zero, and the mortality rate was also zero. ConclusionsTotally, laparoscopic management of type I choledochal cysts, although technically challenging, is safe and feasible in experienced hands.

T1569: Periampullary Choledochal Diverticula: Congenital or Acquired?

Bile duct diverticula historically have been classified as Type II choledochal cysts, an uncommon variety. Type II choledochal cysts are typically described as 1-3cm in diameter, arising from the common bile duct near the cystic duct and associated with an anomalous pancreatico-biliary duct junction. Management generally involves surgical resection because of their increased malignant potential. We have also observed, however, patients with small (<1cm) choledochal diverticula just proximal to the ampulla.

Endoscopic diagnosis and treatment of anomalous pancreaticobiliary ductal junction

Objective To evaluate application of endoscopic retrograde cholangiopancreatography （ERCP） in diagnosis and managements of anomalous pancreaticobiliary ductal junction （APBDJ）. Methods Data of APBDJ patients, including oecurence, sub-type characteristics, relationship with concurrent pancreaticobiliary diseases and endoscopic treatment, who underwent ERCP in the past 5 years, were retrospectively reviewed. Results APBDJ was diagnosed in 49 patients, which accounted for 0. 74% of all ERCP cases （6639） in the same period, among whom, there were 27 cases of P-B sub-type, 19 B-P type, and 3 complex type. Gallbladder carcinoma was accompanied in 16 patients, choledochal cyst in 19, chronic pan creatitis in 7, and pancreas divisum in 2, with morbidity rates significantly higher than those in non-APBDJ population （P 〈 0. 01 ）. The gallbladder carcinoma was most commonly seen in P-B patients （14/16）, and choledochal cyst most frequently occurred in B-P type （15/19）. The endoscopic managements applied in APBDJ patients included sphincterotomy in 10 cases, naso-biliary drainage in 16, plastic stenting in 15, metal stenting in 6, and pancreatic stent placement in 2. Conclusion ERCP is a direct and reliable method for the diagnosis of APBDJ, which is commonly complicated with gallbladder carcinoma, choledochal cyst, and chronic pancreatitis. Endoscopic therapy can be considered in accordance with complications. Key words: Cholangiopancreatography, endoscopic retrograde ; Diagnosis ; Therapy ; Anomalous pancreaticobiliary ductal junction

Identification of the transforming activity of Indian hedgehog by retroviral expression screening

To identify novel cancer-promoting genes in biliary tract cancer (BTC), we constructed a retroviral cDNA expression library from a clinical specimen of BTC with anomalous pancreaticobiliary duct junction (APBDJ), and used the library for a focus formation assay with 3T3 fibroblasts. One of the cDNAs rescued from transformed foci was found to encode Indian hedgehog homolog (IHH). The oncogenic potential of IHH was confirmed both in vitro with the focus formation assay and in vivo with a tumorigenicity assay in nude mice. The isolated IHH cDNA had no sequence alterations, suggesting that upregulation of IHH expression may contribute to malignant transformation. Quantitation of IHH mRNA among clinical specimens has revealed that the expression level of IHH in BTC with APBDJ is higher than that in BTC without APBDJ and than in non-cancerous biliary tissues. Our data thus implicate a direct role of IHH in the carcinogenesis of BTC with APBDJ.

Hepatobiliary and pancreatic: Adenomyomatosis of the gallbladder with abscess formation

Adenomyomatosis is a disease of the gallbladder characterized by epithelial proliferation, hypertrophy of the muscularis externa and outpouching of the mucosa into the thickened muscle layer resulting in the formation of Rokitansky-Aschoff sinuses. The disorder may involve the whole of the gallbladder, a segment of gallbladder (often the mid-portion) or a localized area (usually the fundus). The disorder is more common in women than in men (ratio 3:1) and increases in prevalence with advancing age. At least 50% of patients have coexisting gallstones. In resected gallbladder specimens, the frequency of adenomyomatosis is debated but appears to range between 1% and 9%. This variation may reflect the application of different pathological criteria in different studies. The cause of adenomyomatosis remains unclear but may involve increases in intraluminal pressure because of an obstructing calculus or a narrow cystic duct. There are also reports of an association with an anomalous pancreaticobiliary ductal junction. Thus far, there is no persuasive evidence of an association between adenomyomatosis and gallbladder cancer. In the patient described below, adenomyomatosis appeared to be responsible for the development of a small abscess in the gallbladder wall. This may be the first report of this complication in the medical literature. The patient was a 78-year-old woman with primary biliary cirrhosis (Scheuer stage 4) who was admitted to hospital because of abnormalities on abdominal imaging. Changes on a contrast-enhanced computed tomography (CT) scan are shown in Figure 1. The left panel shows a spherical lesion in the fundus of the gallbladder (arrowhead) while the right panel shows a more heterogeneous lesion with some enhancement by contrast (arrow). With magnetic resonance imaging, cystic structures were shown within the gallbladder lesion and these structures had high signal intensity on T2-weighted images. Serum levels of inflammatory markers and tumor markers including carbohydrate antigen 19.9 were within the reference range. The patient was treated by cholecystectomy because of the possibility of a malignant polyp. A macroscopic examination of the resected specimen showed a round tumor with apparently normal mucosa and a central dimple. Histological evaluation revealed adenomyomatosis with abscess formation but no malignancy (Figure 2). An inflammatory cell infiltrate, largely composed of neutrophils, was observed in the thickened gallbladder wall and in the Rokitansky-Aschoff sinuses (right panel).

Prognostic Factors for Gallbladder Cancer in Japan

The objective of this study was to evaluate prognostic predictors for patients with gallbladder cancer (GBC) in a Japanese nationwide data base. GBC is the most common cancer of the biliary tract in Japan. Differences in the survival rates between Japan and other countries have been noted. The authors analyzed 4424 patients with GBC in Japan between 1988 and 1997. Staging was determined in accordance with American Joint Committee on Cancer stage. Survival is related closely to the surgical stage. Five-year survival rates for stage I, II, III, IVA, and IVB (5th edition) were 83%, 70%, 45%, 23%, and 9%, respectively. These differences were significant (P < 0.0001). The survival rate for patients aged <60 years was significantly better (P < 0.05). The survival rate for patients aged >69 years was significantly worse (P < 0.01). The cholecystectomy plus combined resection of bile duct and/or liver bed resection had an effect on prolonging the survival in stage II or III disease, but extended resection did not. The patients with anomalous pancreaticobiliary ductal junction had a survival advantage over those with cholelithiasis by univariate analysis. However, multivariate analyses indicated that only age, sex, stage, operative procedures were independent prognostic factors. Stage was the strongest covariate; patients diagnosed with stage II, III, IVA, or IVB disease were 2.2, 4.2, 8.1, and 13.6 times, respectively, were more likely to die. Staging is the strongest prognostic factor for GBC, but patient outcomes were also affected by age, sex, and operative procedures. The data do not support any advantage for extended resection. Neither gallstones nor anomalous pancreaticobiliary ductal junction influenced the GBC patient outcome.

Gallbladder Carcinoma Associated with Anomalous Pancreaticobiliary Duct Junction

Anomalous pancreaticobiliary ductal junction (APBDJ) is believed to be one of the risk factors for gallbladder carcinoma. The present study aims to delineate the gallbladder carcinoma characteristics associated with APBDJ. Patients with gallbladder carcinoma associated with APBDJ between August 1992 and February 2005 were retrospectively reviewed. Two types of APBDJ classifications were considered: right-angle type (C-P) and acute-angle type (P-C). Ten of 218 patients (4.6%) with gallbladder carcinomas were associated with APBDJ. All patients were female with a mean age of 55.4 years (range 41 to 72 years). Gallstones were absent in nine patients. Seven patients (70%) had the P-C type and three patients (30%) had the C-P type. Survival differences between the P-C type and the C-P type of gallbladder carcinomas were noted (P=0.0269). Patients with incidentally detected gallbladder carcinoma had superior survival (P=0.0316). Gallbladder carcinomas associated with APBDJ were significantly related to relatively young female patients without gallbladder stones. Survival outcomes in these patients were not different from those of gallbladder carcinoma without APBDJ. In particular, the P-C type of APBDJ seemed to be more associated with relatively advanced gallbladder carcinomas, and patients with incidentally detected gallbladder carcinomas with APBDJ had superior survival.

Assessment of Anomalous Pancreaticobiliary Ductal Junction with High-Resolution Multiplanar Reformatted Images in MDCT

The objective of our study was to assess the capabilities of MDCT for the diagnosis of an anomalous pancreaticobiliary ductal junction using high-resolution multiplanar reformatted (multiplanar reconstruction) images. This study included nine patients with and 54 without an anomalous pancreaticobiliary ductal junction confirmed on direct cholangiopancreatography. Multiplanar reconstruction images with 0.5-mm continuous slices were generated from isotropic or nearly isotropic pancreatic phase images. By mainly interpreting the multiplanar reconstruction images using the Scrolling mode, two blinded reviewers independently determined whether the confluence of the pancreatic and biliary ducts joined in the pancreatic parenchyma (in other words, outside the duodenal wall). The results were correlated with the findings of direct cholangiopancreatography. The diagnostic capabilities of CT for revealing associated pancreatobiliary diseases were assessed in patients with this anomaly. Interobserver agreement in the classification of the duct confluence was high (kappa = 0.804). The duct confluence was identified in all patients except four without an anomalous pancreaticobiliary ductal junction. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of CT for diagnosing an anomalous pancreaticobiliary ductal junction were 100% (9 of 9 patients), 87% (47 of 54 patients), 89% (56 of 63 patients), 75% (9 of 12 patients), and 100% (47 of 47 patients) in the final decisions, respectively. CT showed all associated pancreatobiliary diseases except bile duct stones in two patients. MDCT enabled the diagnosis of an anomalous pancreaticobiliary ductal junction by showing whether the pancreatic and biliary ducts join within the pancreatic parenchyma on high-resolution multiplanar reconstruction images.

Management of adult choledochal cysts – a 15-year experience

Background. Choledochal cyst, a common surgical problem of childhood, can have a delayed presentation in adults. The clinical course in adults differs from that in children because of a higher incidence of associated hepatobiliary pathology. Methods. The clinical data of 57 adults with choledochal cyst managed in a general surgical unit between January 1988 and March 2003 were analysed. Results. The male:female ratio was 1:1.38 and the mean age was 34.5 years; 71.9% of the cysts belonged to Todani type I, 26.3% to type IV and 1.8% to type V. Abdominal pain and recurrent cholangitis were the commonest presentations followed by acute pancreatitis, palpable mass and bronchobiliary fistula. Anomalous pancreaticobiliary ductal junction was demonstrated in 14% of the cases. In all, 37% of the patients had undergone either wrong or suboptimal surgical procedures prior to presentation. All patients underwent complete excision of the cyst and hepaticojejunostomy. Two patients required cholangiojejunostomy and three patients required resection of the involved segments of the liver in addition. There were three anastomotic leaks and two postoperative deaths. Two anastomotic leaks resolved spontaneously while the third required surgical intervention. Forty-eight patients were available for follow-up and have remained symptom-free over a mean period of 17.6 months. Conclusions. Choledochal cyst should be considered in all patients below 40 years of age presenting with biliary colic, pancreatitis or recurrent cholangitis with associated dilatation of bile duct. Complete excision of the cyst with restoration of biliary–enteric communication by hepaticojejunostomy form the basis of ideal treatment.

Lysophosphatidylcholine suppresses apoptotic cell death by inducing cyclooxygenase-2 expression via a Raf-1 dependent mechanism in human cholangiocytes

The high incidence of biliary tract carcinoma in patients with anomalous pancreaticobiliary ductal junction (APBDJ) implicates that a compositional alteration in bile may contribute to the genesis of this cancer. Lysophosphatidylcholine (LPC) is generated in the bile of these patients. Given the role of cyclooxygenase-2 (COX-2) in biliary tract carcinogenesis, we postulated that LPC induces COX-2 in cholangiocytes. The effect of LPC on COX-2 expression in cholangiocytes was evaluated by immunoblot analysis, real-time PCR and reporter gene assay. Apoptosis was induced by TRAIL treatment, and quantified using DAPI staining. Lysophosphatidylcholine increased COX-2 protein expression in cholangiocytes in a concentration- and time-dependent manner. LPC-induced Raf-1 activation was responsible for this COX-2 induction. Accordingly, LPC increased COX-2 mRNA levels in a Raf-1 dependent manner by stabilizing COX-2 mRNA. Finally, LPC attenuated TRAIL-mediated apoptosis through a COX-2/PgE2 dependent mechanism. Collectively, these results implicate that LPC inhibits cholangiocyte apoptosis by inducing COX-2 expression via a Raf-1 dependent mechanism. This anti-apoptotic signaling may participate in biliary tract carcinogenesis in APBDJ patients, and therefore, its interruption may be a viable chemopreventative strategy.