Pancreaticobiliary Ductal System Research Articles

Risk factors for post-ERCP complications.

In the 21st century, endoscopic retrograde cholangiopancreatography (ERCP) has emerged as adiagnostic and therapeutic method for diseases of the pancreaticobiliary duct system. However, like any other diagnostic and therapeutic method, ERCP carries the risk of unwanted complications. We retrospectively followed patients who underwent ERCP examinations from January 2013 to April 2023. We focused on early post-ERCP complications and their risk factors, prevention, treatment, and mortality. Atotal of 4,814 patients were recorded, of which 175 patients had early post-ERCP complications, including acute pancreatitis, acute cholangitis, perforation, and bleeding. We focused on the statistical significance of risk factors such as BMI, repeated ERCP, bleeding disorders, and repeated pancreatitis or cholangitis. Ensuring proper preparation and appropriate indication for ERCP examination can significantly mitigate the risk of post-ERCP complications. Additionally, early diagnosis and prompt treatment of any post-ERCP complications are essential strategies for reducing mortality associated with these conditions (Tab. 3, Fig. 3, Ref. 32). Text in PDF www.elis.sk Keywords: post-ERCP complication, risk factor, BMI, prevention.

Magnetic resonance cholangiopancreatography in the evaluation of pancreatic and biliary disorders

The use of magnetic resonance cholangiopancreatography (MRCP) as a non-invasive alternative to diagnostic retrograde cholangiopancreatography (ERCP) is rising. The purpose of this visual review is to show how MRCP can be used to assess pancreatic and biliary system problems, because of the newly created technologies. MRCP has been shown to be useful in a range of pancreatic and biliary system disorders because it improves spatial resolution and allows imaging of the whole pancreaticobiliary tract during a single breath-hold. It is the newest method for pancreatic and biliary duct imaging, and it uses MR imaging to view fluid in the biliary and pancreatic ducts as high signal intensity on T2 weighted sequences. The clinical uses of MRCP in a range of pancreaticobiliary system problems are presented here, and we conclude that it is a useful diagnostic tool for imaging the pancreaticobiliary ductal system. Keywords: Bile ducts abnormalities; Bile ducts calculi; Bile ducts neoplasms; MR cholangiopancreatography; Pancreatic ducts; Pancreas; Neoplasms.

Risk factors for gallbladder cancer

Introduction and purpose: Gallbladder cancer is the most common neoplasm of the bile duct. Early GBC is usually asymptomatic, but is prone to early metastases. This means that most GBC cases are diagnosed very late, and this contributes to the poor prognosis of this disease. Less than 20% of GBC cases qualify for a potentially curable surgical resection at the moment of diagnosis. The article is an overview of available literature describing current epidemiology and etiological risk factors associated with the development of gallbladder cancer (GBC). We performed a review of the articles on the etiology and GBC carcinomatosis.Brief description of the state of knowledge: We divided risk factors of GBC into independent and dependent. The independent risk factors are: age, sex, cholelithiasis, porcelain gallbladder, gallbladder polyp, anomalous junction of the pancreaticobiliary ductal system, high BMI and obesity, and Helicobacter pylori. On the other hand, the dependent risk factors are: age of first pregnancy and number of pregnancies, xanthogranulomatous cholecystitis, lipid peroxidation products, and aflatoxins. Gallbladder cancer appears to be a multifactorial disease, but the main risk factors are: cholelithiasis and porcelain gallbladder developing from chronic cholecystitis.Conclusions: For understanding the etiopathology of GBC more studies have to be conducted, what may allow to establish reliable biomarkers and invent new preventive strategies and more effective treatment.

42 Safety of Endoscopic Retrograde Cholangiopancreatography for Choledocholithiasis in Patients With Age ≥80: A Nationwide Analysis

INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) is a necessary procedure for exploration and management of pancreaticobiliary ductal system disorders. Safety of ERCP in the elderly population with more underlying co-morbidities remains a concern. We aimed to study if ERCP, particularly for biliary calculus (BC)-related indications, is associated with higher complications including mortality in patients with age ≥80. METHODS: We performed a retrospective analysis using data from the National Inpatient Sample (NIS) from the year 2016. We included all adult patients admitted with BC who underwent ERCP, and we further identified those with concurrent pancreatitis and/or cholangitis, using ICD-10-CM codes. Patients with missing information on age, gender or inpatient mortality were excluded. We analyzed patients by two groups: age <80 and ≥80 years. Chi-square analysis and t-tests were used to compare categorical and continuous variables, respectively. Predictors of ERCP-related complications, including inpatient mortality, were assessed by multivariable logistic regression analysis. RESULTS: Total of 102,095 patients were included in the study who underwent ERCP for BC related etiology, out of which 20,530 (20.1%) were patients age ≥80 years. In the age ≥80 group, mean age was 85.4 years, and 56.5% patients were female. Unadjusted mean length of stay (6.3 vs. 5.3 days), hospitalization costs ($75,326 vs. $72,110) and inpatient mortality (2.2% vs. 0.8%) were significantly higher in patients with age ≥80. BC without pancreatitis or cholangitis was the most common indication for ERCP in both groups. Prevalence of complications related to ERCP were comparable between two groups except for cardiorespiratory complications and mortality (Table 1). On multivariate analysis, patients with age ≥80 had statistically no significant difference in complications in compared to patients with age <80 years (aOR: 0.96, 95% CI 0.92–1.01, P = 0.133). Among all patients, ERCP performed for biliary pancreatitis (BP) had 70% lower rate of complications while ERCP for cholangitis had 26% higher rate compared to ERCP for simple BC (Table 2). CONCLUSION: In the United States, about 1 in 5 ERCP for BC are performed in patients with age ≥80. Overall, BP is associated with significantly lower risk of complications. Among patients undergoing ERCP for BC-related indications, patients with age ≥80 do not carry a higher risk of ERCP-associated complications.

Simultaneous Courvoisier's and Double Duct Signs

Introduction: Presence of Courvoisier's or double duct signs in a jaundiced patient is suggestive of malignant obstruction of the pancreaticobiliary ductal system. The oncologic impact of the simultaneous occurrence of these signs on the survival of patients with periampullary cancer is unknown. Method: We report a case of obstructive jaundice secondary to an ampullary cancer demonstrating the Courvoisier's sign on clinical examination and a double duct sign on imaging. The patient underwent a pancreaticoduodenectomy which confirmed an ampullary adenocarcinoma. Result: Biductal obstruction of the CBD and MPD may result in the Courvoisier's and/or double duct signs and the diagnostic value of these signs in the evaluation of a patient with obstructive jaundice is widely accepted. Conclusion: The impact of the simultaneous occurrence of the Courvoisier's and double duct signs on survival outcome is unknown and an area for future investigation.

Diagnostic yield of secretin-enhanced magnetic resonance cholangiopancreatography in the investigation of patients with acalculous biliary pain

BackgroundSecretin-enhanced magnetic resonance cholangiopancreatography (S-MRCP) facilitates better visualization of the pancreaticobiliary ductal system but its role in patients with acalculous biliary pain (ABP) is yet to be established. The aim of this study was to assess the diagnostic yield and the role of S-MRCP in the investigation of ABP patients.MethodsThis is a retrospective analysis of patients who had S-MRCP to investigate ABP over a 5-year period from June 2008 to May 2013. The findings and diagnosis as reported in the S-MRCP were compared with the findings on MRCP. The primary endpoint was the diagnostic yield of S-MRCP in ABP patients.ResultsA total of 117 patients with ABP [28 (24%) male] had S-MRCP during the study period. The most common abnormality identified was obstruction at the level of ampulla or in the proximal pancreatic duct. S-MRCP was able to identify significant pathological findings in 8 of 34 (22%) patients in whom MRCP did not detect any abnormality. Endoscopic ultrasound (EUS) was performed in 67% of patients. S-MRCP identified abnormalities in 21 of 41 (54%) patients who had a normal EUS.ConclusionsWe conclude that the diagnostic yield of S-MRCP for recognizing anatomical variants of the pancreatic ductal system, in particular ampullary or proximal pancreatic duct stricture, is better than MRCP and EUS. These findings reflect the dynamic nature of S-MRCP and its complementary role alongside MRCP, EUS and endoscopic retrograde cholangiopancreatography in ABP patients.

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.

Endoscopic ultrasound and pancreas divisum.

Pancreas divisum is the most common congenital anatomic variation of the pancreatic ductal anatomy and in most of the individuals it is asymptomatic. However, in minority of individuals it is presumed to cause recurrent acute pancreatitis and chronic pancreatitis. Endoscopic retrograde cholangiopancreatography is the gold standard for its diagnosis, but is invasive and associated with significant adverse effects. Endoscopic ultrasound (EUS) allows the detailed evaluation of the pancreaticobiliary ductal system without injecting contrast in these ducts. Moreover, it provides detailed images of the parenchyma also. Therefore EUS, both radial and linear, has potential for being a minimally invasive diagnostic modality for pancreas divisum. A number of EUS criteria have been suggested for the diagnosis of pancreas divisum. These criteria have varying sensitivity and specificity and hence there is a need for objective and uniform criteria that have the best diagnostic accuracy. Secretin EUS has a potential for diagnosing minor papilla stenosis and thus help in planning appropriate therapy. EUS guided pancreatic duct interventions can help in draining dorsal duct in symptomatic patients with failed minor papilla cannulation. But these techniques are technically demanding and associated with potential severe complications.

A study on the human pancreaticobiliary duct system and ampulla region with their clinical considerations.

The purpose of this study is to present the variations of the pancreatic duct system and hepatopancreatic ampulla so that an awareness of these variations may help in surgical planning and prevention of ductal injury. Forty human pancreatic specimens were used to study the duct pattern of the pancreas and the formation and mode of termination of the pancreatic ducts. Also, the patency of the main pancreatic ducts, length of the hepatopancreatic ampulla, and length of the main pancreatic duct were measured. The main pancreatic duct was patent in 37 out of 40 specimens, 2 specimens showed the embryonic type of the duct system, and one had the duct obliterated at its duodenal end. The mode of termination of the main pancreatic and common pancreatic ducts was divided into four types. Seventy-five percent specimens belonged to type I, followed by type II in 22.5% and type III in 2.5% of specimens. The length of the main pancreatic duct ranged from 11 to 21.2cm, the average being 17.3cm, and the length of the hepatopancreatic ampulla varied from 1 to 10mm (1 to 2mm-5%, 3 to 8mm-55%, and more than 8mm in 15% of specimens), and it was absent in 25%. Awareness of these anomalies may help in surgical planning and prevention of undue ductal injury.

Simultaneous Courvoisier�s and Double Duct Signs

Presence of Courvoisier’s or double duct signs in a jaundiced patient is suggestive of malignant obstruction of the pancreaticobiliary ductal system however; the oncologic significance of the simultaneous occurrence of these signs is unknown. We report a case of obstructive jaundice secondary to a periampullary tumor demonstrating the Courvoisier’s sign on clinical examination and a double duct sign on imaging who underwent a Whipple operation which confirmed an ampullary adenocarcinoma.

Secretin-enhanced MR Cholangiopancreatography: Spectrum of Findings

Magnetic resonance cholangiopancreatography (MRCP) is the most effective, safe, noninvasive magnetic resonance (MR) imaging technique for the evaluation of the pancreaticobiliary ductal system. The MRCP imaging technique has substantially improved during the past 2 decades and is based mainly on the acquisition of heavily T2-weighted MR images, with variants of fast spin-echo sequences. MRCP can also be performed by utilizing the hormone secretin, which stimulates a normal pancreas to secrete a significant amount of fluid while transiently increasing the tone of the sphincter of Oddi. The transient increase in the diameter of the pancreatic duct improves the depiction of the ductal anatomy, which can be useful in patients in whom detailed evaluation of the pancreatic duct is most desired because of a suspicion of pancreatic disease. Improved depiction of the ductal anatomy can be important in (a) the differentiation of side-branch intraductal papillary mucinous neoplasms from other cystic neoplasms and (b) the diagnosis and classification of chronic pancreatitis, the disconnected pancreatic duct syndrome, and ductal anomalies such as anomalous pancreaticobiliary junction and pancreas divisum. In patients examined after pancreatectomy, stimulation with secretin can give information about the patency of the pancreaticoenteric anastomosis. Duodenal filling during the secretin-enhanced phase of the MRCP examination can be used to estimate the excretory reserve of the pancreas. Secretin is well tolerated, and complications are rarely seen. Secretin-enhanced MRCP is most useful in (a) the evaluation of acute and chronic pancreatitis, congenital variants of the pancreaticoduodenal junction, and intraductal papillary mucinous neoplasms and (b) follow-up of patients after pancreatectomy.

Curative resection of hilar cholangiocarcinoma in a 25-year-old woman: report of a case

A 25-year-old woman was referred to our hospital with persistent upper abdominal pain. Preoperative imaging studies revealed a hilar bile duct stricture with portal venous encasement, and the patient underwent curative resection involving extended left hepatectomy and segmental portal vein resection. The pathological findings demonstrated a well-differentiated tubular adenocarcinoma of the bile duct with regional lymph node metastasis (stage IIIB according to the UICC TNM classification), as well as the overexpression of p53 proteins and the K-ras gene mutation in tumor cells. The patient has shown no evidence of recurrence in the 10 months since the operation. Although there are several reports of relatively young adults with cholangiocarcinoma, the majority of such patients demonstrate either an anomalous arrangement of the pancreaticobiliary duct system or primary sclerosing cholangitis. The absence of any morphological abnormalities in this patient's biliary system implicates de novo carcinogenesis as the most likely cause of the cholangiocarcinoma.

Two cases of chronic pancreatitis associated with anomalous pancreaticobiliary ductal union andSPINK1mutation

Chronic pancreatitis is a progressive inflammatory disease resulting from repeated episodes of acute pancreatitis that impair exocrine function and eventually produce endocrine insufficiency. Some causes of chronic pancreatitis appear to be associated with alterations in the serine-protease inhibitor, Kazal type 1 (SPINK1), cationic trypsinogen (PRSS1), and cystic fibrosis-transmembrane conductance regulator (CFTR) genes, or with structural disorders in the pancreaticobiliary ductal system, such as pancreatic divisum or anomalous pancreaticobiliary ductal union (APBDU). However, it is unusual to observe both genetic alteration and structural anomaly. Here, we report 2 cases with both APBDU and a mutation in the SPINK1 genes, and we discuss the implications of these findings in clinical practice.

A case of pure carcinosarcoma of the gallbladder associated with anomalous arrangement of the pancreaticobiliary ductal system

A case of pure carcinosarcoma of the gallbladder associated with anomalous arrangement of the pancreaticobiliary ductal system

Imaging pancreatobiliary ductal system with optical coherence tomography: A review

An accurate, noninvasive and cost-effective method of in situ tissue evaluation during endoscopy would be highly advantageous for the detection of dysplasia or early cancer and for identifying different disease stages. Optical coherence tomography (OCT) is a noninvasive, high-resolution (1-10 μm) emerging optical imaging method with potential for identifying microscopic subsurface features in the pancreatic and biliary ductal system. Tissue microstructure of pancreaticobiliary ductal system has been successfully imaged by inserting an OCT probe through a standard endoscope operative channel. High-resolution OCT images and the technique's endoscopic compatibility have allowed for the microstructural diagnostic of the pancreatobiliary diseases. In this review, we discussed currently available pancreaticobiliary ductal imaging systems to assess the pancreatobiliary tissue microstructure and to evaluate varieties of pancreaticobiliary disorders and diseases. Results show that OCT can improve the quality of images of pancreatobiliary system during endoscopic retrograde cholangiopancheatography procedure, which may be important in distinguishing between the neoplastic and non-neoplastic lesions.

Etiology of recurrent acute pancreatitis, with special emphasis on pancreaticobiliary malformation

This study was aimed to investigate etiology and clinical profiles of recurrent acute pancreatitis (RAP), particularly from the morphology of the pancreaticobiliary duct system. Pancreaticobiliary morphology was examined in 230 of 381 patients with acute pancreatitis (AP) using endoscopic retrograde cholangiopancreatography. We analyzed factors associated with RAP including the pancreaticobiliary duct system. RAP was diagnosed in 74 patients (19%). Major etiologies of RAP were alcoholic (38%), idiopathic (26%) and pancreaticobiliary malformation (22%). Patients with alcoholic RAP were significantly younger (47.2±11.6 years) than those with gallstone RAP (67.3±16.8; p<0.05). RAP with pancreaticobiliary malformation (male-to-female ratio: 1:4.3; p<0.01) and gallstone RAP (1:1.7; p<0.05) occurred predominantly in females in comparison with alcoholic RAP (1:0.2). Recurrence rate was 80% for AP with pancreaticobiliary malformation, significantly higher than for the others (p<0.01). Pancreas divisum was suspected as the etiology of mild RAP in 7 patients. Four RAP patients with pancreas divisum underwent endoscopic minor papilla sphincterotomy and improved. Pancreaticobiliary maljunction with biliary dilatation (choledochal cyst) was suspected as the etiology of mild RAP in 3 patients. The 3 RAP patients with choledochal cyst underwent prophylactic flow diversion surgery with complete resection of the dilated common bile duct, and achieved improvement. High confluence of pancreaticobiliary ducts was suspected as the etiology of mild RAP in 6 patients. Pancreaticobiliary malformation is one of the major causes of RAP. As some of them benefit from endoscopic or surgical treatment, morphology of the pancreaticobiliary duct system should be examined where possible in RAP patients.

膵・胆管合流異常を伴った,いわゆる胆嚢癌肉腫の1例

膵・胆管合流異常を伴った,いわゆる胆嚢癌肉腫の1例

分流手術後の膵側遺残嚢腫内結石に対しPpPDを施行した膵・胆管合流異常,先天性胆道拡張症(戸谷I型)の1例

分流手術後の膵側遺残嚢腫内結石に対しPpPDを施行した膵・胆管合流異常,先天性胆道拡張症(戸谷I型)の1例

Sox9b Is a Key Regulator of Pancreaticobiliary Ductal System Development

The pancreaticobiliary ductal system connects the liver and pancreas to the intestine. It is composed of the hepatopancreatic ductal (HPD) system as well as the intrahepatic biliary ducts and the intrapancreatic ducts. Despite its physiological importance, the development of the pancreaticobiliary ductal system remains poorly understood. The SRY-related transcription factor SOX9 is expressed in the mammalian pancreaticobiliary ductal system, but the perinatal lethality of Sox9 heterozygous mice makes loss-of-function analyses challenging. We turned to the zebrafish to assess the role of SOX9 in pancreaticobiliary ductal system development. We first show that zebrafish sox9b recapitulates the expression pattern of mouse Sox9 in the pancreaticobiliary ductal system and use a nonsense allele of sox9b, sox9bfh313, to dissect its function in the morphogenesis of this structure. Strikingly, sox9bfh313 homozygous mutants survive to adulthood and exhibit cholestasis associated with hepatic and pancreatic duct proliferation, cyst formation, and fibrosis. Analysis of sox9bfh313 mutant embryos and larvae reveals that the HPD cells appear to mis-differentiate towards hepatic and/or pancreatic fates, resulting in a dysmorphic structure. The intrahepatic biliary cells are specified but fail to assemble into a functional network. Similarly, intrapancreatic duct formation is severely impaired in sox9bfh313 mutants, while the embryonic endocrine and acinar compartments appear unaffected. The defects in the intrahepatic and intrapancreatic ducts of sox9bfh313 mutants worsen during larval and juvenile stages, prompting the adult phenotype. We further show that Sox9b interacts with Notch signaling to regulate intrahepatic biliary network formation: sox9b expression is positively regulated by Notch signaling, while Sox9b function is required to maintain Notch signaling in the intrahepatic biliary cells. Together, these data reveal key roles for SOX9 in the morphogenesis of the pancreaticobiliary ductal system, and they cast human Sox9 as a candidate gene for pancreaticobiliary duct malformation-related pathologies.

Pancreaticobiliary duct changes of periampullary carcinomas: Quantitative analysis at MR imaging

PurposeTo quantitatively analyse the pancreaticobiliary duct changes of periampullary carcinomas with volumetric interpolated breath-hold examination (VIBE) and true fast imaging with steady-state precession (true FISP) sequence, and investigate the value of these findings in differentiation and preoperative evaluation. Materials and methodsMagnetic resonance (MR) images of 71 cases of periampullary carcinomas (34 cases of pancreatic head carcinoma, 16 cases of intrapancreatic bile duct carcinoma and 21 cases of ampullary carcinoma) confirmed histopathologically were analysed. The maximum diameter of the common bile duct (CBD) and main pancreatic duct (MPD), dilated pancreaticobiliary duct angle and the distance from the end of the proximal dilated pancreaticobiliary duct to the major papilla were measured. Analysis of variance and the Chi-squared test were performed. ResultsThese findings showed significant differences among the three subtypes: the distance from the end of proximal dilated pancreaticobiliary duct to the major papilla and pancreaticobiliary duct angle. The distance and the pancreaticobiliary duct angle were least for ampullary carcinoma among the three subtypes. The percentage of dilated CBD was 94.1%, 93.8%, and 100% for pancreatic head carcinoma, intrapancreatic bile duct carcinoma and ampullary carcinoma, respectively. And that for the dilated MPD was 58.8%, 43.8%, and 42.9%, respectively. ConclusionQuantitative analysis of the pancreaticobiliary ductal system can provide accurate and objective assessment of the pancreaticobiliary duct changes. Although benefit in differential diagnosis is limited, these findings are valuable in preoperative evaluation for both radical resection and palliative surgery.