Biliopancreatic Tract Research Articles

Duodenal Fluid Analysis as a Rewarding Approach to Detect Low-Abundance Mutations in Biliopancreatic Cancers.

Diagnosis of biliopancreatic cancers by the available serum tumor markers, imaging, and histopathological tissue specimen examination remains a challenge. Circulating cell-free DNA derived from matched pairs of secretin-stimulated duodenal fluid (DF) and plasma from 10 patients with biliopancreatic diseases and 8 control subjects was analyzed using AmpliSeq™ HD technology for Ion Torrent Next-Generation Sequencing to evaluate the potential of liquid biopsy with DF in biliopancreatic cancers. The median cfDNA concentration was greater in DF-derived than in plasma-derived samples. A total of 13 variants were detected: 11 vs. 1 were exclusive for DF relative to the plasma source, and 1 was shared between the two body fluids. According to the four-tier systems, 10 clinical tier-I-II (76.9%), 1 tier-III (7.7%), and 2 tier-IV (15.4%) variants were identified. Notably, the 11 tier-I-III variants were exclusively found in DF-derived cfDNA from five patients with biliopancreatic cancers, and were detected in seven genes (KRAS, TP53, BRAF, CDKN2A, RNF43, GNAS, and PIK3CA); 82% of the tier-I-III variants had a low abundance, with a VAF < 6%. The mutational profiling of DF seems to be a reliable and promising tool for identifying cancer-associated alterations in malignant cancers of the biliopancreatic tract.

Petersen hernia, a rare type of hernia in our department

61 years old female with previous surgical history of Roux-en-Y gastric bypass (3 years ago) and earlier hysterectomy admitted to our surgical department with clinical and radiological signs of small intestinal obstruction. Urgent intervention had been performed with following findings: Petersen herniation of alimentary tract including the – biliopancreatic tract and the small bowel extending to the midpart of the terminal ileum. Viability of herniated intestinal tract had been confirmed, and reposition of herniated parts through the Petersen hernia had been done. Closure with non-absorbable running suture of the gap between the transverse colon and the mesenteriun of the alimentary limb had been performed. Patient was fit for discharge on the fifth postoperative day.

Single-balloon Enteroscopy Assisted Endoscopic Retrograde Cholangiopancreatography with the Rendezvous Technique

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered upper gastrointestinal anatomy such as a Roux-en-Y anastomosis is challenging. The use of balloon-assisted enteroscopy allows evaluation of the surgically excluded segment, access to the biliopancreatic tract and performance of endoscopic therapy. A 79-year-old female patient, with history of cholecistectomy (2005) and total gastrectomy with Roux-en-Y anastomosis for gastric cancer (pT2N0M0, 2007), suffered from recurrent episodes of cholangitis (2012). Abdominal ultrasonography revealed pronounced bile duct dilation (20mm) caused by a large gallstone (17mm) in the distal third of the common bile duct. After a failed standard ERCP, a percutaneous transhepatic biliary drainage (PTBD) was initially performed to relieve the obstruction. However, stone extraction was not accomplished. Therefore, she was referred to us for SBE-assisted ERCP, which was performed using a rendezvous technique, since there was a previously placed PTDB. The SBE (SIF-Q180 Olympus Medical Systems, Tokyo, Japan) was advanced to the afferent limb up to the papilla, where externalization of the percutaneously inserted guidewire was observed. A

Raoultella planticola-associated cholangitis and sepsis: a case report and literature review

### Learning Point for Clinicians Raoultella planticola is a rare and possibly underestimated cause of severe human infection and its presence should be suspected in older patients with a history of cancer, immune-suppression and recent exposure to traumatic injuries or invasive medical procedures. The frequent involvement of the bilio-pancreatic tract suggests the importance of the gut flora as a bacterial reservoir in clinically relevant infections. Raoultella planticola 1 is a Gram-negative anaerobic bacterium and a rare cause of human infection. Twelve cases of clinically relevant human infections (two fatal) have been described so far in the English literature. A 70-year-old male with a history of chronic obstructive pulmonary disease and bronchiectasis was diagnosed with pancreatic adenocarcinoma. Due to significant mass-effect on the biliary …

Imaging of the murine biliopancreatic tract at 7 tesla: Technique and results in a model of primary sclerosing cholangitis

To assess the feasibility of a 7 Tesla (T) MR cholangiopancreatography (MRCP) protocol to image the morphology and detect and intraindividually monitor pathological changes of the biliopancreatic tract in a mouse model of primary sclerosing cholangitis (PSC). Six female Mdr2(Abcb)(-/-) mice, a well-established model of PSC, were imaged five times during weeks 10-19. Three wild-type controls were imaged at age 15 weeks. MRCP acquisition with three-dimensional fast recovery fast spin echo sequences (3D-FRFSE) was performed using three sequences with different resolutions, repetition times (TR), and with/without respiration-gating in a 7 T preclinical MRI system. Image quality and visualization of five biliopancreatic structures were evaluated by three independent readers. Image quality was rated diagnostically sufficient in 86% of the datasets acquired without gating and in 100% for the respiration-gated sequences. Intrahepatic ducts were well visualized (≥ 97%) in Mdr2(-/-) mice. Stenoses and dilatations of the biliary ducts were intraindividually monitored. Progression and regression of bile duct pathologies were sufficiently assessed during the observation time. High-quality respiration-gated MRCP of the Mdr2(-/-) PSC model at 7 T allows for in vivo imaging of murine biliopancreatic tract and monitoring of bile duct pathologies, permitting longitudinal intraindividual studies in murine models of inflammatory bile duct diseases.

Transgastric Endoscopic Retrograde Cholangiopancreatography for the Management of Biliary Tract Disease after Roux-en-Y Gastric Bypass Treatment for Obesity

Roux-en-Y gastric bypass (RYGB) is an effective treatment for morbid obesity. However, it may lead to diseases of the bilio-pancreatic tract. We evaluated transgastric endoscopic retrograde cholangiopancreatography (ERCP) for managing common biliary tract diseases in patients that underwent RYGB treatment for obesity. This prospective study was conducted between 2003 and 2010 at three medical institutions. We included 23 patients with a mean body mass index of 28.2 kg/m(2) after RYGB treatment. ERCP was performed in all patients to manage biliary tract diseases within 9 to 27 months (mean 16.3 months) of RYGB surgery. The gastrotomy was conducted through the anterior wall of the greater curve of the excluded stomach. A duodenoscope was introduced in the direction of the ostomy to perform the ERCP with sphincterotomy. All patients underwent an ERCP and papillotomy without incident. Ten patients underwent simultaneous cholecystectomy. A total of 17 gallstones were removed. The average gastrotomy duration was 92.69 min; the average hospital stay was 2 days. One patient had mild acute pancreatitis that resolved clinically. There was no mortality. Laparoscopy-assisted transgastric ERCP was feasible and safe for patients after RYGB. The necessary equipment is available in most bariatric surgery centers.

Diffusion-weighted imaging of biliopancreatic disorders: Correlation with conventional magnetic resonance imaging

Diffusion-weighted magnetic resonance imaging (DWI) is a well established method for the evaluation of intracranial diseases, such as acute stroke. DWI for extracranial application is more difficult due to physiological motion artifacts and the heterogeneous composition of the organs. However, thanks to the newer technical development of DWI, DWI has become increasingly used over the past few years in extracranial organs including the abdomen and pelvis. Most previous studies of DWI have been limited to the evaluation of diffuse parenchymal abnormalities and focal lesions in abdominal organs, whereas there are few studies about DWI for the evaluation of the biliopancreatic tract. Although further studies are needed to determine its performance in evaluating bile duct, gallbladder and pancreas diseases, DWI has potential in the assessment of the functional information on the biliopancreatic tract concerning the status of tissue cellularity, because increased cellularity is associated with impeded diffusion, as indicated by a reduction in the apparent diffusion coefficient. The detection of malignant lesions and their differentiation from benign tumor-like lesions in the biliopancreatic tract could be improved using DWI in conjunction with findings obtained with conventional magnetic resonance cholagiopancreatography. Additionally, DWI can be useful for the assessment of the biliopancreatic tract in patients with renal impairment because contrast-enhanced computed tomography or magnetic resonance scans should be avoided in these patients.

M1412: Endoscopic Inanimate Biological Simulators for Training in Endoscopic Mucosal Dissection

Simulators have been widely used as a training method; they reproduce real, difficult and rare situations. In endoscopy, they allow training, skill development, standardization of techniques and the performance of a greater number of risk-free procedures. The EASIE (Erlangen Active Simulator for Interventional Endoscopy) biological simulator has been widely accepted. In this model the upper gastrointestinal (GI) and biliopancreatic tract of slaughter house pigs is placed inside a human-like mannequin. Studies have shown that it is plausible to reproduce GI tract lesions in animal inanimate models for training purposes. Early gastric cancer is limited to the mucosa or submucosa regardless of lymph node status. Endoscopic resection is the standard treatment for early gastric cancer in Japan and its acceptance is increasing worldwide. Endoscopic submucosal dissection (ESD) allows en bloc resection of larger lesions, requires longer procedure time and has more complications than endoscopic mucosal resection (EMR).

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. In PBM patients, this anomaly allows regurgitation between the pancreatobiliary and biliopancreatic tract. Since hydrostatic pressure within the pancreatic duct is usually higher than that in the common bile duct, pancreatic juice frequently refluxes into the bile duct. As a result, pancreatic enzyme levels are generally very high in the bile and there is a related high incidence of biliary cancer. PBM can be divided into PBM with biliary dilatation (congenital choledochal cyst [CCC]) and PBM without biliary dilatation (maximal diameter of the bile duct <or= 10 mm). In 42 CCC patients, bile duct and gallbladder cancer was seen in 7 and in 8, respectively. In 49 PBM patients without biliary dilatation, only gallbladder cancer was detected in 33 patients. Because of the increased cell proliferation with random K-ras mutations, the gallbladder mucosa of PBM patients should be considered premalignant. CCC treatment is prophylactic flow-diversion surgery, but only prophylactic cholecystectomy is usually performed for PBM without biliary dilatation. Pancreatobiliary reflux and premalignant changes in the gallbladder can occur in patients with a relatively long common channel (high confluence of pancreaticobiliary ducts).

Laparoscopic Sleeve Gastrectomy with Duodenojejunal Bypass: Technique and Preliminary Results

Obesity and metabolic disorders related to it have become a serious problem in Asia. Furthermore, gastric cancer in Asia is one of the frequent diseases on which to perform treatments. We introduced the technique of laparoscopic sleeve gastrectomy with duodenojejunal bypass (LSG/DJB) for patients with a risk of gastric cancer and compared the results of our initial series with those of other procedures. Twenty-one patients underwent a LSG/DJB from April 2007 to November 2008. The mean preoperative weight and body mass index (BMI) were 108.0 kg and 41.0 kg/m(2), respectively. High risks of gastric cancer were determined as having a Helicobacter pylori positive with atrophic change of mucosa or a family history of gastric cancer. Operations were performed with five ports. Initially, SG and dissection of posterior wall of duodenum were carried out. Subsequently, DJB was added with 50-100 cm of biliopancreatic tract and 150-200 cm of alimentally tract. DJB consisted of a jejunojejunostomy created by a linear stapler and hand sewing closure and duodenojujunostomy by hand sewing with two layers. A LSG/DJB was performed successfully in all patients. The mean operation time was 217 +/- 38 min. The weight loss and percent excess BMI loss for LSG/DJB were similar to those for laparoscopic Roux-en-Y gastric bypasses. There was no mortality; however, one patient had leakage from a staple line of esophagogastric junction and reqiured drainage and stenting. No dumping, stenosis, marginal ulcer, or nutritional problems were observed during postoperative follow-up. All of the main comorbidities improved after this procedure. LSG/DJB is a feasible, safe, and effective procedure for the treatment of morbidly obese patients with the risk of gastric cancer.

P29: Metabolic over-adaptation to calorie restriction after Roux-en-Y gastric bypass does not predict the 1-year weight loss

as Helicobacter pylori positive with atrophy mucosal change or family history of gastric cancer. Methods: We have performed 10 cases of LSGB for the cases with risk of gastric cancer. High risk of gastric cancer was determined as Helicobacter pylori positive with atrophy mucosal change or family history of gastric cancer. We performed LSGB with 5 trocar (15mm, 12mm x3, 5mm). Lap Sleeve Gastrectomy and dissection of posterior wall of duodenum were done. Then Duodenal Jejunal Roux en Y Bypass was done with 50-100cm of biliopancreatic tract and 150-200cm of alimentally tract. Jejunojejunostomy was performed by linear stapler and hand suturing closure and duodenojujunostomy was by hand suturing with 2 layers. Results: We performed 10 cases of LSGB. Gender was 1 males and 9 females. Average preoperative weight and BMI was 106.6 -10.7kg and 41.7 -5.2. Eight patients had diabetes or IGT. Mean excess weight loss was 46 -10, 64 -4, 76% at 3, 6, 9 month postoperatively and it was almost same with result of gastric bypass. We had no mortality but one patient had leakage from EGJ staple line and needed drainage and stenting. Postoperative 75g OGTT revealed LSGB improved both insulin resistance and insulin secretions more than Lap sleeve gastrectomy only procedure. No dumping, no stenosis and no marginal ulcer were observed. Conclusion: LSGB is effective, safe and feasible procedures for treatment of morbid obesity and diabetes for patient with risk of gastric cancer.

Bilio-pancreatic bypass for obesity: II. Initial experience in man.

After a successful trial of bilio-pancreatic bypass in dogs, a clinical study has been completed in 18 patients followed for more than 1 year. The operation has been modified to achieve the best weight reduction, and forming the bilio-pancreatic tract of equal length to the alimentary tract with a short common ileal tract, the average weight loss as a percentage of the preoperative body weight was 24.1 +/- 5.4 per cent (mean +/- s.d.) at 6 months and 33.7 +/- 4.1 per cent at 12 months. The only immediate complication was a wound dehiscence, and there were no late complications. Liver function studies showed the absence of hepatic deterioration and liver biopsies showed improvement of liver morphology 1 year after the operation. It is suggested that this procedure may be an alternative to jejuno-ileal bypass in the management of obesity.

Biliary tract infection in patients with acute biliary pancreatitis.

The presence of infective microorganisms in the bilio-pancreatic tract is believed to be important in both the onset and outcome of acute biliary pancreatitis. In this study, the characteristics of bile colonization or infection in human pancreatitis were investigated in order to optimize prophylactic antibiotic therapy. In 174 patients, 22 clinical and biological factors were recorded prospectively on admission and compared with the bacteriological findings at the time of surgery. There was a significant difference between patients with negative or positive bile cultures in six parameters: Age (57.7 +/- 1.7 vs. 68.5 +/- 1.5 years, p < 0.001), serum concentrations of glucose (132 +/- 4 vs. 149 +/- 6 mg/dL, p < 0.02) and alanine aminotransferase (ALT) (304 +/- 28 vs. 226 +/- 25 IU/L, p < 0.05) and hematocrit (43.4 +/- 0.4% vs. 41.7 +/- 0.5%, p < 0.05), Glasgow pancreatitis score (1.58 +/- 0.11 vs. 1.97 +/- 0.10, p < 0.01) and APACHE II score (6.20 +/- 0.38 vs. 7.82 +/- 0.35, p < 0.005). The prediction of the presence of bacteria in bile by each of these individual parameters, however, was of variable accuracy. From 82 patients with positive bile cultures, a total of 150 microorganisms were isolated, including 66 gram-positive aerobes, 66 gram-negative facultative anaerobes, 15 obligate anaerobes, and three fungi. The most common organisms were Escherichia coli (20.6%), followed by enterococci (18%) and streptococci (15.3%). Patients with acute biliary pancreatitis who manifest abnormalities of one or more of the above-mentioned risk factors are more likely to have positive bile cultures. Whether such patients might benefit from early antibiotic therapy directed against both gram-negative bacilli and gram-positive cocci needs to be determined.

Fungal prophylaxis in biliopancreatic surgery in immunocompromised patients

Abstract Background Fungal infection is a devastating complication with an increased incidence in the past decade. Immune-depressed patients undergoing high-risk procedures have an increased incidence of surgical infection, particularly due to fungal colonization. Methods Twenty patients undergoing pancreas transplantation, 20 kidney transplant patients undergoing biliary tract surgery, 20 patients with human immunodeficiency virus (HIV) undergoing biliary tract surgery and 20 patients undergoing pancreatic resection for neoplasms were enrolled in a prospective study concerning perioperative surgical infection. All patients underwent surgical procedures by the same surgeon. All had preoperative blood counts, assay of CD lymphocyte populations, complete nutritional evaluation and similar antibiotic prophylaxis. Perioperative care was done to a similar standard and only patients undergoing pancreas transplantation received fungal prophylaxis (nystatin wash and swallow). In patients with clinical signs of infection, cultures were sent with special consideration to fungal infection. Results Two of the patients undergoing pancreas transplantation (one of whom died from disseminated candidiasis), three of the kidney transplant patients (two on the wound, one in the catheter), three patients with HIV (two on bile culture, one in the bloodstream) and one of the patients undergoing pancreatic resection (pancreatic fistula and bloodstream) had fungal infection. All patients had concomitant bacterial infections at the time of fungal infection (60 per cent Staphylococcus epidermidis). Patients with fungal infection had increased levels of immunosuppression with decreased CD4 recounts (pancreas transplants and patients with HIV), increased perioperative levels of blood glucose requiring insulin treatment, prolonged antibiotic therapy with broad-spectrum antibiotics (piperacillin–tazobactam), previous positive cultures from the bile of the biliary tract or the duodenum of the transplanted pancreas, and concomitant bacterial infections (especially opportunistic). Conclusion Surgical patients with positive cultures from surgical specimens, prolonged broad-spectrum antibiotic therapy and severely decreased lymphocyte immune function had an increased incidence of fungal infection with significant morbidity and mortality rates. Fungal prophylaxis is strongly recommended in these high-risk patients undergoing biliopancreatic tract surgery.

Miniscopes

Various miniscopes are available for cholangioscopy and pancreatoscopy, differing in the size of the external diameter and the instrumentation channel, the angulation system and the optical performance. For the per-oral route, the devices are inserted through a carrier duodenoscope. Ultra-thin instruments can be introduced into the biliopancreatic tract without the need for endoscopic sphincterotomy. Larger and steerable miniscopes are required for target biopsies and the approach to proximal lesions. Percutaneous cholangioscopy is more invasive and should be restricted to cases with a difficult anatomy or intrahepatic biliary disease. These techniques can be useful for the diagnosis of lesions that cannot be differentiated by indirect imaging methods. However, further studies are needed to evaluate their impact on clinical outcome. Controlled trials indicate that cholangioscopic lithotripsy is an effective and rapid alternative to other therapeutic methods for difficult bile duct stones. Mini-endoscopy is restricted to specific centres because of the high costs of the instruments, limited indications and the need for special endoscopic expertise.