Pancreatobiliary Ductal System Research Articles

Oral effervescent agent improving magnetic resonance cholangiopancreatography.

BackgroundThe purpose of our study was to validate the oral effervescent agent improving magnetic resonance cholangiopancreatography (MRCP) in patients with suspicious pancreatobiliary disease.MethodsOne hundred and eleven consecutive patients with alleged or suspected pancreatobiliary tree problems who had undergone two-dimensional (2D) MRCP imaging both before and after oral effervescent enhancement (conventional-MRCP and enhanced-MRCP) were included. Two radiologists independently scored overall image quality, visualization of ten ductal segments, and gastroduodenal fluid signal intensity score. In consensus, they assessed the presence of gastroduodenal fluids and pancreatobiliary tree overlapping. The data were analyzed using Wilcoxon’s signed-rank test, McNemar test, and paired t-test.ResultsThe grades of overall image quality and individual biliary duct visualization for ten targeted ductal segments, and gastroduodenal fluid signal intensity scores increased significantly on enhanced-MRCP by both readers (P≤0.02), but there was no significant increase for pancreatic duct (PD) at head and tail. On enhanced-MRCP, gastroduodenal fluids except for gastric fundus were less detected rather than those on conventional-MRCP. Anatomic structures of gastroduodenal fluids overlapping extrahepatic bile duct were mainly gastric antrum, duodenal bulb, and 2nd portion on conventional-MRCP. However, these fluids were less overlapped on enhanced-MRCP (P<0.001). Gastric body and antrum were main anatomic structures of gastroduodenal fluids overlapping PD on conventional-MRCP, and fluid in these locations significantly less overlapped PD on enhanced-MRCP (P≤0.02).ConclusionsOral administration of effervescent agent provided effective elimination of gastroduodenal fluid overlapping pancreatobiliary ductal system at MRCP and can improve the quality of the examination in the patients with known or suspected pancreatobiliary disease.

Pedunculated early gallbladder carcinoma associated with anomalous arrangement of the pancreatobiliary ductal system

Pedunculated early gallbladder carcinoma associated with anomalous arrangement of the pancreatobiliary ductal system

Efficacy of oral contrast agents for upper gastrointestinal signal suppression in MRCP: A systematic review of the literature.

BackgroundOrally administered substances which suppress signals from gastrointestinal fluid can be used to enhance image quality in magnetic resonance cholangiopancreatography (MRCP). In daily practice, the available substances range from commercial products to regular viands such as fruit juices.PurposeTo provide an overview on the significance of and the substances used as gastrointestinal fluid signal suppressors in MRCP.Material and MethodsA systematic review of the existing literature was performed to evaluate the efficacy and efficiency of oral T2-signal suppressors in MRCP.ResultsTwenty-five publications on 16 different oral contrast media were identified. The most commonly used substances were ferumoxsil, ferric ammonium citrate, and pineapple juice. Twenty-three out of 25 publications supported the use of oral signal suppressors in MRCP. Advantages of oral signal suppressors include improved visualization of the pancreatobiliary ductal system, increased help with differential diagnoses, and higher detection rates of relevant diagnoses due to a reduction of overlaying signals.ConclusionThe application of oral substances for gastrointestinal signal suppression in MRCP is recommendable. A variety of substances are used in daily routine with good but varying effectivity and patient tolerance.

Digital, Catheter-Based Single-Operator Cholangiopancreatoscopes: Can Pancreatoscopy and Cholangioscopy Become Routine Procedures?

Working length 214cm Accessory channel diameter 1.2mm (3.6 French) outine visualization of the pancreatobiliary ductal Rsystem is probably the last endoscopic frontier in the alimentary tract. Although miniature endoscopes for insertion into the biliary or pancreatic ducts have been around for many years, cholangioscopy and pancreatoscopy are yet to become routine procedures. Performance of these procedures has remained mostly confined to large academic medical centers because of a variety of factors including lack of access to appropriate equipment, lack of expertise, and lack of user-friendliness of currently available endoscopes. The birth of catheter-based cholangiopancreatoscopes in the last decade by introduction of the Spyglass Direct Visualization System (DVS) (Boston Scientific, Natick, MA) led to more widespread use of cholangiopancreatoscopy. However, due to less that optimal image quality, the initial enthusiasm for routine use of this device soon faded. A new version of this catheter-based system with improved digital image has now been released. This article and the accompanying video present the use of this new technology in the pancreatobiliary ductal system and illustrate how it may lead to more widespread use of cholangiopancreatoscopy.

Diagnostic and therapeutic cholangiopancreatoscopy: performance of a new digital cholangioscope

High-definition cholangioscopes provide excellent images of the pancreatobiliary ductal system and may play a significant role in diagnosis and treatment of various pancreatobiliary disorders. To assess the performance of a new digital cholangioscope for diagnosis and treatment of pancreatobiliary disorders in clinical practice. Prospective study. Academic hospital, tertiary-care referral center. Consecutive patients with suspected pancreatobiliary disorders. Diagnostic or therapeutic high-definition digital cholangiopancreatoscopy. Satisfactory visualization of the ductal mucosa and lumen and treatment of pancreatobiliary disorders when indicated. A total of 28 cholangioscopy and 4 pancreatoscopy procedures were completed before breakdown ofthe cholangioscope. Excellent views of the ductal lumen and mucosa were obtained in all patients. In the 18 patients with indeterminate biliary strictures, high-definition cholangioscopy identified all cholangiocarcinomas but labeled as malignant only 1 of 4 strictures caused by pancreatic cancer (sensitivity 73%). All benign strictures were correctly labeled (specificity 100%). Cholangioscopy proved helpful in evaluation of various biliary disorders and lithotripsy of pancreatic stones under direct vision. Single center, small number of patients. High-definition cholangioscopy is a useful adjunct to ERCP in the diagnosis and treatment of pancreatobiliary disorders. Although fragility of the cholangioscope remains a problem, the changes made in the construction of this prototype digital cholangioscope have significantly increased its durability.

Gallbladder carcinoma associated with anomalous union of pancreatobiliary ductal system

A 64-year-old woman was admitted with mild right upper quadrant abdominal pain. Her physical examination revealed a moderately nourished female with normal vital sign and no evidence of jaundice or anemia. Preoperative diagnosis was choledochal cyst with anomalous union of pancreaticobiliary duct (AUPBD), long Y-shaped type and gallbladder (GB) cancer. An extended cholecystectomy, excision of the common bile duct and biliary diversion via Roux-en Y hepaticojejunostomy was performed. The gallbladder cancer showed invasion to perimuscular connective tissue and no extension beyond serosa. Twelve months after curative resection, the patient had no evidence of tumor recurrence.

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.

Functional MRI of the Pancreaticobiliary System

Non-invasive Magnetic Resonance CholangioPancreatography (MRCP) allows a direct visualization of the pancreatobiliary ductal system without administration of contrast materials or ionizing radiation by utilizing contrastrelated properties of fluids excreted by liver and pancreas into the biliary and pancreatic ducts. MRCP enables visualization of the ductal system at a resting state, thereby more accurately displaying the caliber of the native ducts. Consequently, non-invasive MRCP has essentially replaced invasive procedures such as percutaneous transhepatic cholangiography and sole diagnostic endoscopic retrograde cholangiopancreatography. Current state-of-the-art MRCP techniques provide high-resolution visualization of the native pancreatobiliary ductal system, however, many early symptoms of pancreatobiliary diseases are being compensated for and masked by pancreatobiliary parenchymal and ductal structures, emphasizing that the pancreatobiliary tree is part of a functional system. To enhance sensitivity in pancreatic imaging, pathophysiologic characteristics can be further exploited: The introduction of perfusion/diffusion-weighted imaging in combination with secretin-induced increase in parenchymal perfusion and ductal secretion will simplify the detection of generalized perfusional defects in the pancreatic parenchyma, will allow a quantification of the remaining pancreatic excretory reserve, and will help to confirm a suspected loss of ductal distensibility. Cholecystokinin-induced stimulation of functional characteristics of the biliary system in combination with MRCP imaging will allow the quantification of gallbladder ejection fraction and biliary diameter, and will lead to an increase of diagnostic sensitivity to detect microlithiasis as well as biliary leakages without application of ionizing radiation. Contrast-enhanced imaging of the biliary tree is usually part of a comprehensive evaluation of the liver utilizing hepatocyte- targeted contrast agents which undergo an active transport into the intracellular space of the hepatocytes, where they are further metabolized and eliminated through the biliary system and subsequently allow parenchymal as well as biliary assessment employing T1 - weighted pulse sequences. Keywords: percutaneous transhepatic cholangiography, secretin, fast spin echo, parenchymal perfusion, apparent diffusion coefficient, amine precursor uptake and decarboxylation

Mini-probe ultrasound of the upper gastrointestinal tract--1995 state of the art and perspectives. Workshop on Mini-Probe Ultrasound in Gastroenterology, Münster, 28 October 1995

Endoscopic ultrasound (EUS) allows for intraluminal sonographic imaging of the oesophagus, stomach, pancreatobiliary duct system, the papilla of Vater, as well as the colon and rectum. EUS has proved valuable for diagnosis and staging of tumours of the upper intestinal tract. EUS can also provide valuable additional information concerning lesions that cannot be immediately classified. As doing this involves, first, removal of the conventional endoscope and, second, insertion of the echo endoscope, EUS is not suitable for routine examinations. Therefore EUS has remained an independent endoscopic diagnostic modality. Moreover, due to their diameter conventional echoendoscopes cannot be inserted into the pancreatobiliary duct system. Fine calibre high frequency ultrasound probes promise a resolution of less than 2 mm in diameter. The following report is a summary of a one-day workshop which took place in Muenster, Germany on Oct. 28, 1995. Its goal was to define the current state of the art of miniaturised endoscopic ultrasound probes in the field of gastroenterology. During this workshop, possible clinical applications for diagnosis, therapy, as well as follow-up were described and discussed. The potential of miniaturised endoscopic ultrasound probes was explored in terms of possible future technical developments.

Dynamic Secretin-enhanced MR Cholangiopancreatography

Secretin causes temporary dilatation of pancreatic ducts, principally by increasing pancreatic exocrine secretions, and thus allows better visualization of the ducts at magnetic resonance (MR) cholangiopancreatography. Secretin-enhanced MR cholangiopancreatography is useful for detection and diagnosis of a variety of congenital, inflammatory, and neoplastic conditions of the pancreas. Although MR cholangiopancreatography without secretin is a reliable method for evaluating the pancreatobiliary ductal system, the authors believe that secretin-enhanced MR cholangiopancreatography gives additional valuable functional and anatomic information about the pancreatic duct and pancreatic excretory capacity.

Main pancreatic duct, common bile duct and sphincter of Oddi structure visualized by optical coherence tomography: An ex vivo study compared with histology

Background Optical coherence tomography has been proposed to obtain high-resolution imaging of tissue structure of GI tract. Up till now, the optical coherence tomography appearance of the common bile duct, main pancreatic duct and sphincter of Oddi wall structure has not yet been defined. Aims To compare, in a prospective study, optical coherence tomography images of pancreato-biliary ductal system with histology and identify the optical coherence tomography pattern of the normal wall structure of the ducts. Methods Multiple sections of non-neoplastic segments of five consecutive ex vivo human pancreatic specimens were investigated by optical coherence tomography scanning within 1 h of resection. Sixty optical coherence tomography images were compared with the corresponding histological findings. Results Optical coherence tomography appearance of normal common bile duct, main pancreatic duct and sphincter of Oddi is characterized by a differentiated three-layer architecture with a regular surface and a homogeneous back-scattered signal, corresponding to the single layer of epithelial cells, the connective-muscular layer and the muscular or acinar structure, respectively. Optical coherence tomography and histology findings were concordant in all cases. Conclusions Optical coherence tomography was able to provide in real-time images of wall structure of the normal common bile duct, main pancreatic duct and sphincter of Oddi that are similar to those obtained by histology. These results suggest that optical coherence tomography could enable high-resolution images to be obtained from the pancreato-biliary system during an ERCP procedure.

Acute pancreatitis associated with peroral double-balloon enteroscopy: A case report

A 58-year-old Japanese man had tarry stool and severe anemia. Neither upper nor lower gastrointestinal (GI) endoscopy showed any localized lesions. Thus, the source of his GI bleeding was suspected to be in the small intestine, and he underwent peroral double-balloon enteroscopy (DBE) using EN-450T5 (Fujinon-Toshiba ES System Co., Tokyo, Japan). There were no lesions considered to be the source of GI bleeding. After the procedure, the patient began to experience abdominal pain. Laboratory tests revealed hyperamylasemia and abdominal computed tomography revealed an inflammation of the pancreas and the peripancreas. He was thus diagnosed to have acute pancreatitis. Conservative treatments resulted in both clinical and laboratory amelioration. He had no history of alcohol ingestion, gallstone disease or pancreatitis. Magnetic resonance cholangiopancreatography demonstrated no structural alterations and no stones in the pancreatobiliary ductal system. As his abdominal pain started after the procedure, his acute pancreatitis was thus thought to have been related to the peroral DBE. This is the first reported case of acute pancreatitis probably associated with peroral DBE.

Cancer of the gallbladder associated with anomalous junction of the pancreatobiliary duct system without bile duct dilatation.

The aim of this study was to delineate clinical features and prognosis of cancer of the gallbladder associated with anomalous junction of the pancreatobiliary duct system without bile duct dilatation, and to determine methods for managing the disease. A retrospective study of seven patients is presented. A further 27 cases from the Japanese literature were reviewed retrospectively with regard to method of treatment and prognosis. In 11 of 18 patients in whom staging was known the tumour was stage V, representing advanced disease. In seven of 34 cases curative operation was performed; only two patients survived for > 3 years. This poor outcome was due largely to delayed diagnosis of cancer of the gallbladder. Prophylactic cholecystectomy is recommended in patients with this anomalous junction without bile duct dilatation or a malignant lesion in the gallbladder, because of the high incidence of cancer of the biliary tract.

Clinical study of choledochocele: is it a risk factor for biliary malignancies?

We aimed to clarify the clinical characteristics of choledochocele and to evaluate the possibility of choledochocele as a risk factor for biliary malignancies. The clinical feature, the configuration of the pancreatobiliary ductal system, coexistent pancreatobiliary lesions, and amylase level in bile in 21 patients with choledochocele were reviewed. The correlation between the configuration, comorbid diseases, and amylase level in the bile was investigated. There was a female predominance, and 57% of the patients showed abdominal pain. Quite a few patients showed elevation of the levels of hepatobiliary enzymes. The configuration of the pancreatobiliary ductal system and choledochocele was classified into two categories: type I, where the choledochocele and pancreatic duct were visualized independently or simultaneously (90.5%); and type II, where the pancreatic duct was visualized after filling of the choledochocele (9.5%). Among coexistent bilio-pancreatic diseases, biliary stone diseases were the most frequent. Biliary malignancy was seen in 3 patients (14.3%). The amylase level in the bile was high in 50% (4/8) of the patients examined. The rate of abnormal elevation of amylase level in the bile in the two types of pancreatobiliary ductal system and choledochocele was 3/7 and 1/1, respectively. The prevalence of organic abnormal arrangement of the pancreatobiliary ductal system in which the choledochocele serves as a common channel is low. However, there are patients with suspected functional abnormal arrangement of the pancreatobiliary ductal system, who may possibly be a high-risk group for biliary malignancy.

Adenosquamous carcinoma of the extrahepatic biliary tract: clinicopathological analysis of Japanese cases of this uncommon disease

We analyzed the clinicopathologic variables and postoperative outcomes in patients with extrahepatic adenosquamous carcinoma to identify important factors for predicting postresection prognosis. Thirty-six patients in Japan who underwent surgical resection for adenosquamous carcinoma of the extrahepatic biliary tract, with curative intent by the end of 2003, were studied. A retrospective review, with univariate and multivariate analyses, was performed on the clinical records of patients who underwent surgical exploration for adenosquamous carcinoma of the common bile duct. The clinical and pathologic factors that influenced patient survival were analyzed. The operative mortality rate in the patient cohort was 3%. The overall 1-, 3-, and 5-year survival rates were 57%, 26%, and 16%, respectively, and the median survival was 13 months. Univariate and multivariate analyses revealed that independent negative prognostic factors in resected specimens were: (1) the presence of pancreatic invasion, (2) the presence of n2 and n3 lymph node metastasis, and (3) curability C status. The presence of an abnormal arrangement of the pancreatobiliary ductal system and pathological serosal invasion of the tumor tended to be associated with poor survival. Curative surgical resection for adenosquamous carcinoma remains the only effective treatment, because it offers the chance of long-term survival. New adjuvant strategies are required for improvements in patient outcomes.

Biliary papillomatosis arising in a congenital choledochal cyst: report of a case.

We report a rare case of biliary papillomatosis arising in a congenital choledochal cyst, with an anomalous junction of the pancreatobiliary ductal system (AJPBDS). A 50-year-old woman was admitted to our department with epigastralgia, and imaging studies showed two masses in the cystic common bile duct and an AJPBDS. We made a preoperative diagnosis of biliary tract cancer, considering the size of the masses and the presence of the AJPBDS, and performed a pylorus-preserving pancreatoduodenectomy. The resected specimen contained two papillary tumors, which were subsequently diagnosed as benign papillomas. Histopathological and oncological examinations indicated that the lesions were involved in the development and progression of carcinogenesis because a point mutation of the K- ras gene and overexpression of p53 protein were detected. These findings suggest that biliary papillomatosis is a precancerous lesion induced by an AJPBDS.

Intraductal ultrasound in the biliary tract.

Although endoscopic ultrasonography (EUS) represents a major advance in endoscopic imaging, endosonography using dedicated echoendoscopes has some serious drawbacks, including the diameter of the echoendoscope (12 to 13 mm), the lack of intraluminal examination of the pancreatobiliary duct system due to the size of the instrument, unsatisfactory image quality and resolution for small lesions, and the need for a second examination separate from the previous routine endoscopy. Recently developed ultrasonographic miniprobes (diameter, about 2 mm; frequency, 12 to 20 MHz) can be passed through the working channel of standard endoscopes to provide high-frequency ultrasound images. These miniprobes may overcome some of the noted drawbacks and add to the safety and convenience of patients. Moreover, in various diseases of the gastrointestinal tract and the pancreatobiliary ductal system, the diagnostic accuracy of miniprobe ultrasonography has been proven to be superior to that of EUS. Miniprobe ultrasonography is a promising tool that adds new capabilities to the armamentarium of gastroenterologic diagnostic assessment.

Bile Peritonitis Due To Choledochal Cyst Perforation In Infants

저자들은 1983년 1월부터 1998년 1월까지 총담관낭 환아 28례 중 4례(14.2 %)에서 자연적으로 발생한 총담관낭 천공에의한 담즙성 복막염을 경험하였고 이 중 3례에서 일차적인 낭종 절제와 간관공장 문합술을 시행하였으며 이 모든 예에서 합병증 없이 회복되었기에 문헌 고찰과 함께 보고하는 바이다. 총담관낭 천공에의한 답즙성 복막염치료는 일차적 낭종 절제와 간관 공장 문합술이 안전하고 효과적인 방법이라고 생각된다. 【Choledochal cyst is rare in the western countries, but common in oriental countries. Complicatioins include ascending cholangitis, recurrent pancreatities, progressive biliary cirrhosis, portal hypertension, stone formation and later malignant transformation. Bile peritonitis secondary to rupture is one of the rarest complications, with an incidence of 1.8 % to 18 %. The anomalous arrangement of the pancreatobiliary ductal system with a long common channel may cause inflammation leading to perforation of the cyst. The authors found 4 cases (14.2 %) of bile peritonitis among 28 cases of choledochal cyst treated from Jan. 1983 to Jan. 1998. The patients ages ranged from 6 months to 3 years and three were female. The perforation sites were located on the common bile duct at its junction with the cystic duct in 2 cases, the distal cyst wall in 1 case and the left hepatic duct at its junction with cyst in 1 case. The types of choledochal cysts by Todani's classification were Type IVa in 3 cases and type I in 1 case. By the new Komi's classification utilizing operative cholangiogram there were 2 cases of Type Ia, 1 case of type IIb and 1 case of type III. One stage cyst excision and hepaticojejunostomy(Roux-en Y type) was done in 3 cases, and two staged operation in 1 case. All patients had an uneventful course postoperatively. The average day of discharge was 9.8th postoperatively. In conclusion, primary excision of the choledochal cyst and biliary reconstruction is a safe and effective treatment of ruptured choledochal cyst in infants.】

Histopathologic Studies of the Pancreatobiliary Ductal System on the Pathogenesis of Biliary Atresia

Histopathologic Studies of the Pancreatobiliary Ductal System on the Pathogenesis of Biliary Atresia

Aberrant hepatic duct connected with the main pancreatic duct by anomalous pancreato-biliary ductal union: Case report

An aberrant hepatic duct directly connected to the main pancreatic duct with anomalous arrangement of the pancreato-biliary ductal system is reported here, the first report of such a case, to our knowledge. A 53-year-old woman was admitted to our hospital because of cholecystolithiasis with abdominal pain in the right upper quadrant. Endoscopic retrograde cholangiopancreatography (ERCP) showed that an aberrant hepatic duct, which independently drained the right posterior segment of the liver, connected to the main pancreatic duct at a high insertion site distal to the sphincter area of the major papilla. The common bile duct (containing stones), on the other hand, united with the main pancreatic duct in a normal fashion. Cholecystectomy and bile duct lithotomy were performed. The aberrant hepatic duct was separated from the main pancreatic duct just above the junction, and was anastomosed side-by-side to the common hepatic duct. The embryologic development of this lesion is not clear, but is discussed in this report.