Protein Plugs Research Articles

Cytological Characterization of Elicitin-Induced Protection in Tobacco Plants Infected by Phytophthora parasitica or Phytoplasma

ABSTRACT Elicitins, small proteins secreted by Phytophthora and Pythium spp., display the ability to induce plant resistance toward pathogens. Ultrastructural investigations of cryptogein-treated tobacco plants evidenced host defense responses such as (i) formation of a calcium pectate gel in intercellular spaces of parenchymas, (ii) impregnation of pectin by phenolic compounds in intercellular spaces of phloem bundles, and (iii) accumulation of phloem proteins (P proteins) in the lumen of leaf sieve elements. These cytological modifications lead to the enhancement of physical barriers that prevent pathogen ingress and restrict host tissue colonization when cryptogein-treated tobacco plants were challenged with the pathogen Phytophthora parasitica. Wall appositions also were observed at most sites of penetration of hyphae. Moreover, growing hyphae exhibited severe morphological damages, suggesting a modified toxic environment. The same induction of P proteins in mature sieve tubes of tobacco leaves was obtained with oligandrin treatment, another elicitin. Cryptogein or oligandrin treatment prevented symptom expression in phytoplasma-infected tobacco plants in contrast with nontreated tobacco plants. Moreover, P protein plugs and occlusion of pore sites by callose were evidenced in sieve elements of treated plants. Both these phloem modifications might prevent the in planta movement of phloem-restricted microorganisms.

Feasibility study using a new small electronic pancreatoscope: description of findings in chronic pancreatitis.

Numerous images characteristic of chronic pancreatitis have been obtained with fiberoptic peroral pancreatoscopy systems. However, the resolution of these images is inferior to that obtained with peroral electronic pancreatoscopy (PEPS). Clearer images of the pancreatic duct with chronic pancreatitis have now been documented, in some cases using PEPS alone. The significance of this finding is reported here. A total of 42 PEPS procedures were carried out in 36 patients with chronic pancreatitis, without sphincterotomy or balloon dilation of the papilla of Vater. Using endoscopic retrograde pancreatography, the patients were classified as having equivocal (n=5), mild (n=5), moderate (n=15), or marked (n=11) degrees of chronic pancreatitis. The insertion rate with PEPS was 90 % (38 of 42 procedures), and it was ultimately possible to examine five, three, 13, and 11 patients in each group, respectively. Images of turbid pancreatic juice, protein plugs of various shapes, pancreatic calculi, indistinct vascular markings, whitish mucosa, local redness, scattered redness, disappearance of the fold, deformation of the fold, irregularly dilated lumen, and stenosis were found to be characteristic of chronic pancreatitis. These images were obtained using PEPS. PEPS proved to be a feasible new technique for diagnosing chronic pancreatitis, and it was able to detect abnormal findings more clearly than other imaging methods.

Idiopathic tumefactive chronic pancreatitis: Clinical profile, histology, and natural history after resection

Background & Aims: Little is known about subjects with idiopathic tumefactive chronic pancreatitis (TCP), that is, chronic pancreatitis whose clinical presentation, usually with a mass or obstructive jaundice, suggests cancer. Methods: We independently reviewed clinical data and histology of 45 TCP (27 idiopathic, 18 alcohol induced) resected at Mayo Clinic (January 1985-March 2001). Follow-up data were obtained from medical records and mailed questionnaires. Results: Compared with alcoholic subjects, idiopathic TCP patients were older (58 ± 2 vs. 48 ± 3 yr, P < 0.001), had shorter symptom duration (median 3 vs. 24 wk, P < 0.001), were more likely to have no or mild abdominal pain (70% vs. 17%, P = 0.001), and were more often jaundiced (67% vs. 33%, P = 0.02). Three distinct histologic patterns were identified in TCP. Typical CP (n = 19) showed lobular atrophy, fat necrosis, and ductal changes (dilatation, protein plugs, and stones). Lymphoplasmacytic sclerosing pancreatitis (LPSP) (n = 14) was characterized by periductal lymphoplasmacytic infiltration, obliterative phlebitis, and cholangitis with edema. Idiopathic duct-centric CP (IDCP) (n = 12) had neutrophil-predominant lobular inflammation, without phlebitis. On correlation of clinical and histologic diagnosis, 17 of 18 (94%) patients with alcohol-induced TCP had typical CP, and 25 of 27 (93%) with idiopathic TCP had LPSP or IDCP. LPSP and IDCP were indistinguishable clinically except for higher incidence of jaundice in LPSP (93% vs. 42%, P = 0.005). In idiopathic TCP no recurrence of symptoms was observed after resection (median follow-up 49 mo). Conclusions: Idiopathic TCP is clinically and histologically distinct from alcohol-induced TCP. It is unclear whether LPSP and IDCP, 2 unique patterns of histologic injury observed in idiopathic TCP, are part of the spectrum of the same disease or represent 2 or more different entities. Resection of mass prevents recurrence of symptoms in idiopathic TCP.

Sugar-Induced Modification of Fibroblast Growth Factor 2 Reduces Its Angiogenic Activity in Vivo

Both clinical and animal studies have shown that angiogenesis is impaired in diabetes mellitus; however, the mechanisms responsible for this effect are poorly characterized. The major aims of the present study were to evaluate the effect of hyperglycemia on fibroblast growth factor 2 (FGF2)-induced angiogenesis in vivo and to determine whether FGF2 non-enzymatic glycation occurs in hyperglycemic mice. New blood vessel formation was examined in reconstituted basement membrane protein (Matrigel) plugs containing FGF2 in control normoglycemic CD1 and in hyperglycemic nonobese diabetic (NOD) mice. FGF2-induced angiogenesis in NOD mice was inhibited by 75% versus control mice (P < 0.001). When recombinant FGF2 was mixed with Matrigel and injected in mice, it was found that recombinant FGF2 glycation was significantly enhanced in plugs from NOD versus control mice (P < 0.01). In the Boyden chamber assay, the chemotactic effect of glycated FGF2 toward endothelial cells was lower than that of unmodified FGF2 (P < 0.01). Further, FGF2 glycated in vitro and co-injected with Matrigel in CD1 mice was a weaker angiogenic stimulus than unglycated FGF2 (P < 0.005). These results indicate that FGF2-induced angiogenesis is inhibited in diabetic mice, FGF2 glycation is enhanced in hyperglycemic mice, and glycation markedly reduces FGF2 chemotactic effect in vitro and its angiogenic properties in vivo. Thus, FGF2 glycation may represent a mechanism responsible for the impairment of angiogenesis in diabetes mellitus.

Electronic pancreatoscopy for the diagnosis of pancreatic diseases.

Diagnostic pancreatoscopy was performed in 56 patients using the newly developed peroral electronic pancreatoscope (PEPS). The diagnostic value of the PEPS for pancreatic diseases was evaluated. The PEPS (external diameter = 2.1 mm, bidirectional tip deflection) was developed with a minute 50,000-pixel interline charge-coupled device. Pancreatoscopy was performed by means of an endoscopic retrograde approach without sphincterotomy. The cases examined were normal (three), chronic pancreatitis (32), pancreatic cancer (eight), and intraductal papillary mucinous tumors (13). Of the 56 cases, 42 (75%) were adequately seen. In normal cases, fine capillary vessels were clearly visualized on the smooth whitish-pink mucosa. Findings in chronic pancreatitis included protein plugs, calcified stones, rough whitish mucosa, scar formation, edema, erythema, and indistinct capillary appearance. All the stenoses of chronic pancreatitis could be differentiated from those of pancreatic cancer with the PEPS. In the pancreatic cancer cases, all patients had stenoses or duct cutoffs; most cases had friable mucosa with erythema and erosive changes, and a single patient had a compressed pancreatic duct wall covered with normal epithelium. In the cases of intraductal papillary mucinous tumors, papillary tumors were visualized with extreme clarity. In the case of adenocarcinoma, the PEPS revealed oval-shaped tumors with spotty redness or villous tumors with dilation of capillary vessels. Moderate acute pancreatitis was recognized after pancreatoscopy in one of the 56 cases (1.8%). Electronic pancreatoscopy with the PEPS is feasible in most patients and technically safe, and improves diagnostic yield over conventional pancreatoscopy.

Electronic pancreatoscopy for the diagnosis of pancreatic diseases

OBJECTIVES: Diagnostic pancreatoscopy was performed in 56 patients using the newly developed peroral electronic pancreatoscope (PEPS). The diagnostic value of the PEPS for pancreatic diseases was evaluated. METHODS: The PEPS (external diameter = 2.1 mm, bidirectional tip deflection) was developed with a minute 50,000-pixel interline charge-coupled device. Pancreatoscopy was performed by means of an endoscopic retrograde approach without sphincterotomy. The cases examined were normal (three), chronic pancreatitis (32), pancreatic cancer (eight), and intraductal papillary mucinous tumors (13). RESULTS: Of the 56 cases, 42 (75%) were adequately seen. In normal cases, fine capillary vessels were clearly visualized on the smooth whitish-pink mucosa. Findings in chronic pancreatitis included protein plugs, calcified stones, rough whitish mucosa, scar formation, edema, erythema, and indistinct capillary appearance. All the stenoses of chronic pancreatitis could be differentiated from those of pancreatic cancer with the PEPS. In the pancreatic cancer cases, all patients had stenoses or duct cutoffs; most cases had friable mucosa with erythema and erosive changes, and a single patient had a compressed pancreatic duct wall covered with normal epithelium. In the cases of intraductal papillary mucinous tumors, papillary tumors were visualized with extreme clarity. In the case of adenocarcinoma, the PEPS revealed oval-shaped tumors with spotty redness or villous tumors with dilation of capillary vessels. Moderate acute pancreatitis was recognized after pancreatoscopy in one of the 56 cases (1.8%). CONCLUSIONS: Electronic pancreatoscopy with the PEPS is feasible in most patients and technically safe, and improves diagnostic yield over conventional pancreatoscopy.

A case of mediastinal pancreatic pseudocyst with pleural effusion caused obstruction of pancreatic duct by protein plug

A case of mediastinal pancreatic pseudocyst with pleural effusion caused obstruction of pancreatic duct by protein plug

Pancreatic complications in choledochal cyst and their surgical outcomes.

Follow-up results were analyzed to evaluate the surgical managements of pancreatic complications such as pancreatitis and protein plug formation in patients with choledochal cysts. Sixty-two patients with choledochal cysts treated between 1976 and 1999 were reviewed. Twenty-four were children and 38 were adults. Fifty-four patients showed primary cases. Cyst excision and hepaticoenterostomy were finally performed in 56 patients. Surgical sphincteroplasty or endoscopic sphincterotomy was performed to prevent recurrent protein plugs in six patients. The follow-up period was 8.1 +/- 6.1 years. Acute pancreatitis and protein plug formation was observed in 18 (33.3%) and 11 (20.4%) of 54 patients showing primary cases, respectively. Both acute pancreatitis and protein plug formation were observed more frequently in children from 1 to 15 years of age (70.6% and 41.2%, respectively) than in adults (18.6% and 12.5%, respectively). Acute pancreatitis and/or protein plug formation developed in four (57.1%) of seven patients who underwent cystenterostomy. Protein plug formation in the residual cyst after cyst excision was observed in two patients, one of whom had undergone sphincteroplasty. Diabetes mellitus due to chronic pancreatitis developed in one patient who was diagnosed late. No other pancreatitis or protein plug recurred postoperatively in this series. Our results suggested that cystenterostomy did not resolve pancreatic complications of choledochal cysts, and that surgical sphincteroplasty was ineffective in preventing the recurrent protein plug formation in the residual duct. In conclusion, complete cyst excision and an early diagnosis are necessary to prevent the development of chronic or recurrent pancreatitis after surgery.

Changes in the exocrine pancreas secondary to altered small intestinal function in the CF mouse.

The exocrine pancreas of the cystic fibrosis (CF) mouse (cftr(m1UNC)) is only mildly affected compared with the human disease, providing a useful model to study alterations in exocrine function. The CF mouse pancreas has approximately 50% of normal amylase levels and approximately 200% normal Muclin levels, the major sulfated glycoprotein of the pancreas. Protein biosynthetic rates and mRNA levels for amylase were not altered in CF compared with normal mice, and increases in Muclin biosynthesis and mRNA paralleled the increased protein content. Stimulated pancreatic amylase secretion in vitro and in vivo tended to be increased in CF mice but was not statistically significant compared with normal mice. We show for the first time that the CF mouse duodenum is abnormally acidic (normal intestinal pH = 6.47 +/- 0.05; CF intestinal pH = 6.15 +/- 0.07) and hypothesize that this may result in increased signaling to the exocrine pancreas. There were significant increases in CF intestinal mRNA levels for secretin (310% of normal, P < 0.001) and vasoactive intestinal peptide (148% of normal, P < 0.05). Furthermore, CF pancreatic cAMP levels were 147% of normal (P < 0.01). These data suggest that the CF pancreas may be chronically stimulated by cAMP-mediated signals, which in turn may exacerbate protein plugging in the acinar/ductal lumen, believed to be the primary cause of destruction of the pancreas in CF.

Pathogenesis of Alcohol-Induced Chronic Pancreatitis: Facts, Perceptions, and Misperceptions

The pathogenesis of chronic pancreatitis secondary to chronic alcoholism is not fully understood. A major hurdle in the understanding of the pathogenesis is the inability to study early lesions of the pancreas and the sequential changes. Facts are few; observations are many. Each new hypothesis argues against all previous hypotheses; however, clinical chronic pancreatitis is initiated by one or more of the mechanisms. Good experimental models for alcoholic pancreatitis are not available, limiting the ability to study the pathogenesis. Additional studies on genetic markers and immunologic mechanisms might explain acinar cell injury, which seems to be the earliest lesion in most, if not all, types of chronic pancreatitis. Opie's common channel and obstruction regurgitation theories seem unrelated to chronic pancreatitis. Although biochemical changes of the pancreatic secretion in alcoholic patients promote protein-plug formation, evidence is too weak to consider protein plug as the earliest change. The theory of necrosis of the acinar cell by some unknown mechanism, subsequently leading to fibrosis, is gaining support; however, it is clear that the pathogenesis of alcoholic pancreatitis is not yet fully understood.

Conformational changes of pancreatitis-associated protein (PAP) activated by trypsin lead to insoluble protein aggregates.

Pancreatitis-associated protein (PAP), a secretory acute-phase protein of the pancreatic acinar cell, is highly up-regulated early in acute pancreatitis. PAP expression returns to undetectable levels when the pancreas recovers. In the rat, three isoforms of PAP are known, all of which are upregulated during acute pancreatitis. Their functions remain obscure. Pancreatic stone protein (PSP/reg), which shows strong sequence homology to PAP, is secreted into pancreatic juice under physiologic and pathologic conditions. PSP/reg is highly susceptible to trypsin cleavage at its ARG11-ILE12 bond. Cleavage results in an N-terminal undecapeptide and a C-terminal peptide called pancreatic thread protein (PTP). PTP forms oligomeric fibrillar structures, which spontaneously sediment in vitro. PTP can be found in protein plugs or stones from patients with chronic pancreatitis. Rat PAP contains a trypsin cleavage site at the same position as PSP/reg. We hypothesize that PAP is susceptible to tryptic cleavage, and that the C-terminal cleavage product of PAP spontaneously precipitates at neutral pH. To test our hypothesis, we generated and purified recombinant PAP. Here we report the production of rat PAP I, II, and III in a yeast expression system using Pichia pastoris. We demonstrate in vitro the tryptic cleavage of rat PAP and the formation of a spontaneously precipitating peptide, which we call pancreatitis-associated thread protein (PATP). PATP displays pH-dependent solubility characteristics very similar to those of PTP.

Obstructive pancreatitis due to mucus produced by metaplastic choledochal cyst epithelium

Acute pancreatitis is a frequent complication of choledochal cysts, whereas the recurrence of pancreatitis after excision of the cyst is uncommon. Recurrent pancreatitis is thought to be related to protein plugs or stone migration into the common biliopancreatic duct or pancreatic duct. This is the case of a woman presenting with acute pancreatitis 8 years after partial cyst excision due to mucin secretion by metaplastic epithelium in the choledochal cyst remnant.

Calcium concentration and artificial precipitates in human pancreatic juice.

We studied the role of the increase in the calcium concentration in pure pancreatic juice of alcoholic noncalcified chronic pancreatitis. Pure pancreatic juice was obtained endoscopically. The pancreatic juice from patients with chronic pancreatitis was adjusted to pH 7.5; then the calcium concentration was adjusted to 0.4, 2.9, 5.4, or 10.4 mmol/L. Artificial precipitates were produced by incubation of the samples at 37 degrees C for 6 hours. Proteins in the artificial precipitates were separated by sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE), and the protein patterns were compared with the patterns of natural protein plugs from patients with chronic pancreatitis. The amount of the precipitate increased as the added calcium increased. The protein patterns of SDS-PAGE of the artificial precipitates were similar to those of protein plugs. Albumin, a-amylase, lipase, trypsinogen, and chymotrypsinogen were identified by immunoblotting both in the precipitate and in the protein plug. The increased calcium concentrations in pancreatic juice induced the formation of precipitates whose protein composition was similar to that of protein plugs. An increased calcium concentration in human pancreatic juice may play an important role in the pathogenesis of protein plugs.

Different amounts of K-ras mutant epithelial cells in pancreatic carcinoma and mass-forming pancreatitis.

Clinically, differential diagnosis of pancreatic carcinoma (PC) and so-called "mass-forming pancreatitis (MFP)" is difficult. We analyzed the amount, ductal level, and K-ras mutation of ductal hyperplasia and intraductal carcinoma in surgically resected cases of MFP (n = 18) and PC (n = 16). DNAs extracted from microdissected epithelial foci were analyzed for K-ras codon 12 mutation by nested polymerase chain reaction and restriction fragment length polymorphism. The histology of MFP showed severe destruction of exocrine tissue and pancreatic stones and/or protein plugs (72%, 13 of 18 cases) in mostly peripheral ducts. The average basal membrane lengths of nonpapillary and papillary hyperplasia in cases of carcinoma were about 4 and 15 times more than those of MFP, respectively. The frequency of K-ras mutation in hyperplastic foci increased from nonpapillary [six (27%) of 22] to papillary foci [16 (64%) of 25] in K-ras mutant PCs, but there was no difference between nonpapillary [one (6%) of 18] and papillary foci (none of 19) in K-ras wild-type PCs, and also between nonpapillary (none of 24) and papillary foci [one (7%) of 14] in MFPs.

Pathologic changes in the common bile duct of an experimental model with pancreaticobiliary maljunction without biliary dilatation.

Pancreaticobiliary maljunction (PBM), a congenital anomaly, causes regurgitation of pancreatic juice into the biliary tract, where it exerts a hazardous influence. However, changes in the common bile duct (CBD) remain obscure due to a lack of suitable experimental models. Using cats, we have developed an experimental model of PBM without bile-duct dilatation that allows the pure effects of PBM to be studied. Histologic and cellular kinetic changes in the CBD were analyzed in 6 controls and 9 experimental animals that survived for more than 6 months. CBD sections were stained with hematoxylin and eosin and a monoclonal antibody to the proliferating cell nuclear antigen (PCNA). Invaginations of the bile-duct epithelium or parietal sacculi increased, and peribiliary glands were well-developed. PCNA-positive cells significantly increased in the CBD, especially in the parietal sacculi and glands. It is concluded that PBM increases the cell cycle in CBD epithelium and subsequently developed peribiliary glands. These developed glands may be associated with the formation of protein plugs, often seen in patients with PBM.

Pancreatic Ductal Morphological Pattern and Dilatation in Postoperative Abdominal Pain in Patients with Congenital Choledochal Cyst: An Analysis of Postoperative Pancreatograms

Background: Postoperative abdominal pain associated with pancreatitis has been reported as a pancreasassociated complication after total biliary excision. The aim of the present study was to determine pancreatic ductal patterns in the head of the pancreas and evaluate pancreatic ductal dilatation in patients presenting with postoperative abdominal pain after radical biliary excision for congenital choledochal cyst. Methods: Postoperative endoscopic retrograde pancreatography (ERP) was performed in a total of 38 patients (27 female and 11 male) with a history of postoperative abdominal pain or an increase in serum and urinary amylase on laboratory analysis. Pancreatic ductal configuration and ductal dilatation were determined. Results: Pancreatic configurations included the usual type (n = 20), ansa pancreatica type (n = 11), loop type (n = 5), and divisum type (n = 2). Dilatation of the pancreatic duct was observed in 34 patients. The common channel was dilated in 29 patients. Mild postoperative pancreatitis occurred in 4 patients in the long term. Protein plugs were observed in the dilated pancreatic duct. Conclusions: Pancreatic ductal morphological pattern and ductal dilatation, possibly caused by long-standing stagnation of the pancreatic juice, may be associated with postoperative abdominal pain and pancreatitis in congenital choledochal cyst.

Diseases of the biliary tract and pancreas in the aged--results obtained by investigation of the autopsy cases

Gross and histological examination of the autopsy cases in the aged revealed that: 1. Acute interstitial pancreatitis, which was characterized by rupture of the ducts and ductules associated with profuse intraluminal exudation of polymorphonuclear leucocytes and protein plugs formation, was found in nine cases (0.62%) out of 1457 autopsies. There was scarce parenchymal or fat necrosis which might be caused by impaired secretion by atrophic parenchyma. The interstitial type may represent characteristics of acute pancreatitis in the aged. 2. Pancreatic lithiasis was found in six of 85 cases, or 7.1%. 3. Sites of isolated islets of Langerhans were found in an incidence of 26.5% (53/200), which increased with age. 4. Incidence of endocrine tumors was 10% (6/60) in individuals having histological studies of all sections and 1.6% (12/738) in individuals having histological studies of three random sections of the pancreas. The facts that multiple hormone production was found in as much as 70% and glucagon cells in as much as 85% were characteristics. 5. The atypical epithelia were observed with the highest incidence in the common pancreaticobiliary channel of the papilla of Vater, where carcinoma may arise most frequently. 6. The incidence of cystic lesions increased with age. Small cystic lesions appear to have the potential to progress to malignancy. 7. it may be possible to remove the head of the pancreas while preserving of the vascular arcades and their branches to the duodenum, the bile duct and the papilla of Vater. The artery toward the papilla of Vater is very important for the blood supply of both the papilla and second portion of the duodenum, and should be preserved in duodenum-preserving subtotal resection of the head of the pancreas. Gallbladder carcinoma was found in 94 cases, or 2.1% and gallbladder stone was found in 957 cases, or 21.4% among 4482 cases. Incidence of gallbladder carcinoma was six times higher in the cases with cholecystolithiasis than those without stone.

Regulation of PSP/reg in rat pancreas: immediate and steady-state adaptation to different diets.

Pancreatic stone protein/reg protein (PSP/reg) is a secretory pancreatic protein of hitherto unknown function. It is precursor to a spontaneously precipitating peptide called pancreatic thread protein, which is found in protein plugs within the pancreatic ductal system. Increasing PSP/reg concentrations in pancreatic juice might augment the risk of intraductal plug formation and therefore be a condition predisposing to chronic pancreatitis. Malnutrition is associated with a high incidence of chronic pancreatitis in tropical countries. In a diet study with rats, we tested the hypothesis that protein malnutrition leads to increased PSP/reg concentrations in pancreatic juice. A highly sensitive and reliable enzyme-linked immunosorbent assay (ELISA) for rat PSP/reg was newly established. Male Sprague-Dawley rats were allocated to three nearly isocaloric experimental diets, which contained 0, 45, or 82% casein, respectively, or to a control diet (22% casein). We evaluated PSP/reg expression under these four dietary conditions on the RNA and on the protein level, performing a time-course study over a period of 28 days. Our results demonstrate that PSP/reg expression is not increased because of a protein-deficient diet if investigated under steady-state conditions. After a temporary increase in PSP/reg levels due to a carbohydrate-deficient high-protein diet, we could not find signs of a diet-dependent regulation of this protein. The regulation of PSP/reg thus differs from that of most other pancreatic secretory proteins. Our findings contradict earlier reports that had drawn conclusions based solely on messenger RNA levels.

Pancreatic disorders associated with anomalous pancreaticobiliary junction

Background: The aim of this study was to establish an optimal management strategy for pancreatic disorders associated with anomalous pancreaticobiliary junction (APBJ). Methods: In 64 adult surgical cases of APBJ (common channel 15 mm or longer) (43 with and 21 without choledochal cyst), associated pancreatic disorders, pancreatographic results, and treatment outcomes were analyzed. Results: Of 64 patients, 56 had pancreatobiliary symptoms. Twenty-four patients (38%) had pancreatic disorders: acute pancreatitis (n = 20), chronic calcifying pancreatitis (n = 2), and pancreatic carcinoma (n = 2). Twenty patients (31%) had abnormal pancreatograms. The incidence of acute pancreatitis was significantly higher in patients with an abnormal pancreatogram, particularly dilatation, protein plugs or stones of the common channel or main pancreatic duct, and coexisting pancreatic ductal anomaly. All patients with choledochal cyst underwent cyst excision and hepaticojejunostomy. Eleven patients without choledochal cyst or pancreatobiliary carcinoma underwent cholecystectomy alone. Protein plugs and pancreatic stones were extracted through the bile duct stump or by sphincterotomy. No patients experienced pancreatitis during a mean postoperative follow-up of 6.7 years. Conclusions: In managing APBJ, attention should be paid to the possibility of associated pancreatic disorders and an abnormal pancreatogram. APBJ with choledochal cyst requires cyst excision. Cholecystectomy alone may be adequate for APBJ without cyst. (Surgery 1999;126:492-7.)

Pancreatic disorders associated with anomalous pancreaticobiliary junction

<h2>Abstract</h2> <b>Background:</b> The aim of this study was to establish an optimal management strategy for pancreatic disorders associated with anomalous pancreaticobiliary junction (APBJ). <b>Methods:</b> In 64 adult surgical cases of APBJ (common channel 15 mm or longer) (43 with and 21 without choledochal cyst), associated pancreatic disorders, pancreatographic results, and treatment outcomes were analyzed. <b>Results:</b> Of 64 patients, 56 had pancreatobiliary symptoms. Twenty-four patients (38%) had pancreatic disorders: acute pancreatitis (n = 20), chronic calcifying pancreatitis (n = 2), and pancreatic carcinoma (n = 2). Twenty patients (31%) had abnormal pancreatograms. The incidence of acute pancreatitis was significantly higher in patients with an abnormal pancreatogram, particularly dilatation, protein plugs or stones of the common channel or main pancreatic duct, and coexisting pancreatic ductal anomaly. All patients with choledochal cyst underwent cyst excision and hepaticojejunostomy. Eleven patients without choledochal cyst or pancreatobiliary carcinoma underwent cholecystectomy alone. Protein plugs and pancreatic stones were extracted through the bile duct stump or by sphincterotomy. No patients experienced pancreatitis during a mean postoperative follow-up of 6.7 years. <b>Conclusions:</b> In managing APBJ, attention should be paid to the possibility of associated pancreatic disorders and an abnormal pancreatogram. APBJ with choledochal cyst requires cyst excision. Cholecystectomy alone may be adequate for APBJ without cyst. (Surgery 1999;126:492-7.)