Pancreaticobiliary Ductal Junction Research Articles

Gallbladder Carcinoma: A Review of Literature

Gallbladder cancer (GBC) is the most common cancer of the biliary tract but the sixth most common cancer of the gastrointestinal tract. This tumor has a very high death rate. It is impossible to emphasize how crucial early diagnosis is because GBC grows subtly when it is discovered later. A number of environmental and genetic factors have been linked to the beginning of GBC. Environmental variables such as cholelithiasis, chronic inflammation of the biliary tract, and parasite infections are known to have a substantial impact on the development of gallbladder cancer. Congenital causes include abnormalities in the pancreaticobiliary duct junction and biliary cysts. Over the last ten years, advancements in imaging technology coupled with a more aggressive and drastic surgical approach have enhanced patient outcomes and contributed to longer survival times for GBC patients. This review article focuses on the epidemiology of GBC, its risk factors, and clinical characteristics.

Microbiome dysbiosis in gallbladder cancer: A systemic review

Gallbladder cancer (GBC) starts in the epithelial tissue (lining of the bile duct and gallbladder). It is a type of aggressive cancer called adenocarcinoma that can spread to other tissues. Among all cases of biliary tract cancer, 50% is from GBC. It is a deadly cancer with a survival rate of 17.6% between 2007 and 2013. GBC is rarely found in the Western world, but it is commonly found in South Asia. In Southeast Asian countries, GBC plays a significant role in cancer-related morbidity and mortality. GBC incidence exhibits marked regional variability, a rare condition in the western population but having a higher frequency in India, especially the Indo-Gangetic belt and some northeast districts excluding Nagaland. This might be attributed to the differences in environmental factors and genetic predisposition modulating carcinogenesis. In GBC, only 10% of cases are identified in the early stages. The low rate of early detection is due to the lack of screening techniques and the aggressive characteristics of the tumor. Various risk factors are associated with GBC, for example, chronic cholecystitis with or without gallstones, obesity, exposure to heavy metals such as lead and arsenic, bacterial infection, congenital biliary cysts, and abnormal pancreaticobiliary duct junction. The risk factors can cause chronic gallbladder mucosa irritation, leading to dysplasia and neoplasia. GBC can form metaplasia to dysplasia in a time span of 5–15 years, then to carcinoma in situ, and finally to invasive cancer. Dysbiosis is responsible for various diseases, including cancer. Multiple triggers can cause dysbiosis, for example, environmental changes, inflammation, infection, medications, dietary changes, or genetic predisposition. Various researches show that Helicobacter pylori, human papillomavirus, Hepatitis B virus, and Hepatitis C virus microbial species can cause cancer. They are the major species responsible for 90% of infection-associated cancers. Various studies demonstrate that the strains of Salmonella and Helicobacter colonize are linked to developing GBC. While the mechanisms linking gut microbiota to GBC are not fully understood, several studies have suggested a potential association. According to a study, certain gut microbiomes, such as Fusobacterium nucleatum, found glut in GBC tissues, compared to adjacent normal tissues. By evaluating gut microbiome dysbiosis, we can see the potential link between gut microbiome dysbiosis and GBC; it may provide valuable insights into the development and progression of GBC. It could lead to the identification of new diagnostic markers and the development of novel therapeutic strategies. In GBC, the evaluation of gut microbiome dysbiosis (involving evaluating the composition, diversity, and functional capacity of the gut microbiome in patients) has emerged as a promising method for understanding the molecular mechanisms and identifying biomarkers for early prevention and detection of GBC and also investigating the possibility of any link between the gut microbiome and host immune response. In conclusion, evaluating gut microbiome dysbiosis in GBC is a promising direction for identifying potential early detection and prevention biomarkers. Additional investigation is therefore needed to determine the role of gut microbiome dysbiosis in the development and progression of GBC and to identify reliable biomarkers for clinical use.

The Many Hidden Faces of Gallbladder Carcinoma on CT and MRI Imaging-From A to Z.

Gallbladder carcinoma represents the most aggressive biliary tract cancer and the sixth most common gastrointestinal malignancy. The diagnosis is a challenging clinical task due to its clinical presentation, which is often non-specific, mimicking a heterogeneous group of diseases, as well as benign processes such as complicated cholecystitis, xanthogranulomatous cholecystitis, adenomyomatosis, porcelain gallbladder or metastasis to the gallbladder (most frequently derived from melanoma, renal cell carcinoma). Risk factors include gallstones, carcinogen exposure, porcelain gallbladder, typhoid carrier state, gallbladder polyps and abnormal pancreaticobiliary ductal junction. Typical imaging features on CT or MRI reveal three major patterns: asymmetric focal or diffuse wall-thickening of the gallbladder, a solid mass that replaces the gallbladder and invades the adjacent organs or as an intraluminal enhancement mass arising predominantly from the gallbladder fundus. The tumor can spread to the liver, the adjacent internal organs and lymph nodes. Depending on the disease stage, surgical resection is the curative treatment option in early stages and adjuvant combination chemotherapy at advanced stages. The purpose of this scientific paper is to fully illustrate and evaluate, through multimodality imaging findings (CT and MRI), different presentations and imaging scenarios of gallbladder cancer in six patients and thoroughly analyze the risk factors, patterns of spread and differential diagnosis regarding each particular case.

A case series of choledochal cyst with pancreatic divisum: A rare association.

Choledochal cysts (CC) are congenital cystic dilations of the biliary tree usually associated with abnormal pancreaticobiliary ductal junction (APBDJ), but its association with pancreatic divisum has been rarely described. We encountered four cases of CC associated with pancreatic divisum (PD). Three had Type 3 PD and one had Type 1 PD. Two cases presented with pancreatic complications, with one case requiring preoperative minor papilla sphincterotomy for recurrent pancreatitis. The association of CC with PD is infrequent, and the variable presentation alters management strategy. PD may be one of the factors responsible for complications associated with CC.

A Review of the Etiology and Epidemiology of Gallbladder Cancer: What You Need to Know.

Gallbladder cancer (GBC) is the sixth most prevalent cancer of the gastrointestinal system but the most prevalent cancer of the biliary tract. This tumor is a highly fatal condition. The importance of early diagnosis cannot be overstated because GBC develops quietly with late detection. Several genetic and environmental variables have been associated with the onset of GBC. Cholelithiasis and chronic inflammation from the biliary tract and parasite infections are prime examples of environmental factors that significantly influence the development of GBC. Abnormal pancreaticobiliary duct junction and biliary cysts are examples of congenital causes. In the past decade, new imaging technologies and a more radical and aggressive surgical approach have improved patient outcomes and aided prolonged survival for GBC patients. This review article focuses on the epidemiology of GBC, its risk factors, and clinical characteristics.

Synchronous Extrahepatic Cholangiocarcinoma and Gallbladder in Australian Patient Without an Abnormal Pancreatico-biliary Ductal Junction

Synchronous malignancies of bile duct and the gallbladder are rare. These cases are often associated with pancreatico-biliary maljunction which is characterised by a long-shared duct between the sphincter of Oddi, the branches of the common bile duct and the pancreatic duct. This predisposes the biliary epithelium to pancreatic enzyme reflux and makes the development of neoplasia more likely. We describe the case of a 64-year-old Australian female who presented with new jaundice and severe cholecystitis secondary to an impacted gallstone.

Management of Choledochal Cyst: Experience from A Tertiary Care Center of Nepal

Introduction: Choledochal cysts are infrequent congenital cystic dilation of the biliary tract. The aim of this study is to analyze the clinicopathological profile and short-term operative outcomes of patients with choledochal cysts. Methods: This is a retrospective study of 32 consecutive patients of choledochal cyst who underwent multidisciplinary management in last two and half years at Tribhuvan University Teaching Hospital, Kathmandu, Nepal. Results: A total of 32 patients, 9 males and 23 females were operated. The average age at diagnosis was 24.67±16.4 years (range from 2 to 56 years). The most common presenting symptoms were pain 31(96.88%), jaundice 10(31.25%) and mass 5(15.63%). Triad of pain, jaundice and mass was present in 4(12.5%). Transabdominal Ultrasonography (100%) was the initial diagnostic modality followed by Magnetic resonance cholangiopancreatography (MRCP) (68.75%), and contrast enhanced computed tomography (CECT) (31.25%). Endoscopic retrograde cholangiopancreatography (ERCP) was done for stent placement in 3 (9.38%) patients with severe cholangitis. Type IVA (37.5%) was the most common type of CC followed by type IC (31.23%), type IB (15.65%), type IA (12.5%) and type IVB (3.12%). Abnormal pancreaticobiliary duct junction was observed in 3 (9.38%) patients. All patients underwent open cyst excision with Roux-en-Y hepaticojejunostomy (HJ). The overall morbidity was seen in 6 patients (18.75%). There was no mortality. None of our patient had cholangiocarcinoma on pathological examination. Conclusion: Choledochal cyst was common in young females. Type IC and IVA choledochal cyst were the most common types and majority of them were symptomatic. Cyst excision with Roux-en-Y hepaticojejunostomy was the commonest surgical treatment modality and had excellent perioperative outcome.

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.

A unique choledochal cyst

Background: Herein we present a unique case of choledochal cyst (CC) which cannot be directly classified as any of the known types. Methods: Case presentation: A 57-year old female presented with ongoing right upper quadrant pain. Her history included a laparoscopic cholecystectomy after repeated episodes of gallstone pancreatitis. CT and MRI scans depicted a saccular dilatation in the middle of the extrahepatic ducts involving the cystic duct stump, consistent with a CC. An abnormal pancreaticobiliary ductal junction (APBDJ) was also noted. Results: She underwent a laparoscopic converted to open procedure due to bleeding from a pseudoaneurysm, where the extrahepatic biliary tree was excised radically, and reconstruction was performed with a Roux-en-Y hepaticojejunostomy. She was discharged 50 days later after recovering from a complicated anastomotic leak. Histological examination confirmed the presence of a CC of the cystic duct stump involving the main bile duct trunk. Conclusion: APBDJ is linked with a higher incidence of development of CCs and cholangiocarcinoma even years after excision of the extrahepatic biliary tree. So far, 40 cases of CC involving the cystic duct have been described; however, this is the first case of a CC arising from the cystic duct stump after cholecystectomy on ground of APBDJ. This unique association confirms the concept of an additional non-congenital pattern of development of CCs and highlights a new indication for long-term follow-up in patients with APBDJ.

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.

Isolated Left Hepatic Duct Drainage into the Duodenum - First MRCP Report

Abstract: Hepatic duct anomalies are well known. Bile duct anomalies are less known. Here we report a MRCP of a patient whose left hepatic duct was draining into the duodenum through a separate opening. Keywords: Left hepatic duct, Anomaly, MRCP Hepatic duct anomalies are well studied and documented. The bile duct drainage into the bowel is more or less constant [1]. Anomalies of pancreaticobiliary ductal junction (APBDJ) are also well known. APBDJ is of clinical significance in cases of cholangiocarcinoma, choledochal cyst and recurrent acute idiopathic pancreatitis [2]. Extreme abnormalities like nonjunction of pancreatic and biliary ductal anomalies are also known. There are reports of common bile duct entering into the duodenum separately [3]. While evaluating a liver donor we came across this case where the left hepatic duct was inserting separately into the duodenum while the right hepatic duct formed the junction with the pancreatic duct (Figure 1). We could not come across any such report in the literature prior to this case. The donor hepatectomy was cancelled in view of the deteriorated general condition of the recipient

Choledochal Cyst With Intestinal Metaplasia Presenting as an Unusual Case of Recurrent Cholangitis

This is the case of a 64 year old African-American female with a history of recurrent cholangitis and choledolithiasis requiring repeated Endoscopic retrograde cholangiopancreatography (ERCP) procedures. She presented to our institution with severe abdominal pain. She underwent multiple prior ERCPs at outside institution which showed fusiform dilation of biliary tree with recurrent choledocholithiasis. During ERCP at our institution she was noted to have fusiform dilation of biliary tree with very low cystic duct take off marked by very thick cystic duct insertion wall. Single operator cholangioscopy confirmed thick cystic duct insertion wall and spy bite biopsies of thick septum at cystic duct insertion showed inflammatin with intestinal metaplasia. She underwent hepaticojejunostomy with excision of the biliary tree was performed without post-surgical complications. Final pathology revealed cholechocal cyst with focal intestinal metaplasia within biliary mucosa. Choledochal cysts are rare congenital anomalies involving intra- or extrahepatic ducts1-3 with an incidence of 1 in 100,000 - 150,000 in western countries but a remarkably high incidence of 1 in 1,000 in Asia8. Etiology of choledocal cysts remains unclear; however the most popular theory proposed by Babbitt's4 which attributes the cyst formation to abnormal pancreaticobiliary duct junction (APBDJ). This allows pancreatic fluids to flow into the bile duct causing inflammation and weakness of the duct wall leading to cyst formation. cyst formation. In our present case the cyst represents the category type 1A. There is a strongIn our present case the cyst represents the category type 1A. There is a strong association of malignancy with type I and type IV cysts9, however all types are resected despite histo-pathology findings to prevent malignant transformation. Amongst the various laparotomy vs laparoscopic surgical approaches, Roux-en-Y, Hepaticojejunostomy, and complete cyst resection are currently the procedure of choice. This case highlights potential stepwise progression to cholangiocarcinoma with intestinal metaplasia as intermediate step.

The role of 64-slice CT following perfusion with iohexol via the hepatopancreatic ampulla in assessing pancreaticobiliary junctions.

The aim of this study was to delineate the structure of the pancreatic and biliary ducts in premature infants using a novel imaging method. The duodenal papillae of 30 premature infant cadavers were dissected. The pancreatic and biliary ducts were visualized using 64-detector multislice spiral computed tomography (MSCT). Contrast agent was injected into the duodenal papilla via the hepatopancreatic ampulla of Vater. MSCT scanning revealed both the pancreatic and biliary ducts as well as the common channel in 18 cases. The bile duct was visualized in the remaining 12 cases. Four patterns of the pancreaticobiliary ductal junction were noted: Y-type (73.3%), U-type (13.3%), V-type (6.7%), and II-type (6.7%). The results showed that MSCT and three-dimensional reconstruction can be used to visualize the junction pattern and common channel of the pancreatic and biliary ducts, and the structure of the surrounding tissue, in premature infants.

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.