Extrahepatic peribiliary glands express alpha-amylase isozymes, trypsin and pancreatic lipase: an immunohistochemical analysis

We examined expression of alpha-amylase isozymes (pancreatic and salivary), trypsin and pancreatic lipase on the epithelium of extrahepatic peribiliary glands immunohistochemically using 53 autopsied normal extrahepatic bile ducts. Three parts of the extrahepatic bile duct (common bile duct, intrapancreatic bile duct and bile duct at the ampulla of Vater) were examined in each case. Histologically, the extrahepatic bile duct harbored branched tubular glands (extrahepatic peribiliary glands). Extrahepatic peribiliary glands were few in the common bile duct and intrapancreatic bile duct and numerous in the bile duct at the ampulla of Vater. Immunohistochemically, pancreatic alpha-amylase was expressed in the epithelium of extrahepatic peribiliary glands in 42 cases (79%). Salivary alpha-amylase was expressed in the epithelium of the glands in 38 cases (72%). Trypsin was expressed in the epithelium of the glands in 32 cases (60%). Pancreatic lipase was expressed in the epithelium of the glands in 45 cases (85%). The immunoreactivity of these enzymes was granular and located in the supranuclear cytoplasm (corresponding to the Golgi apparatus) of the epithelium of the glands. We confirmed the specificity of the immunoreactivity of these enzymes with various methods. These results suggest that extrahepatic peribiliary glands produce alpha-amylase isozymes, trypsin and pancreatic lipase and secrete these enzymes into lumens of the extrahepatic bile duct. The secreted enzymes may play an important role in the physiology of the extrahepatic bile duct and bile.     

Ampullary and periampullary tumors

Ninety-eight consecutive patients with ampullary and periampullary carcinoma diagnosed between 1983-1993 were studied retrospectively. Among these patients, 66 had a carcinoma of the head of the pancreas, 10 a carcinoma of the papilla of Vater, 8 a carcinoma of the duodenum, and 14 a carcinoma of the distal common bile duct. Resectability rate ranged from 12% to 90% according to the tumor location and histologic type. Palliative procedures such as laparotomy, biopsy and bilio-digestive bypasses were performed in 27 patients. Curative resections were performed in 24 cases: 20 pancreatoduodenectomies, 2 total pancreatectomies, 1 duodenectomy, 1 common bile duct resection. The results of the surgical treatment as well as mortality and morbidity rates were compared with those of different and larger series.     

Use of endoscopic ultrasonography for evaluation of painless jaundice

Precise preoperative evaluation and staging of cases of painless jaundice is extremely important. Many of the patients are older and may have multiple medical problems that increase their operative risk. Assessment of the distal common bile duct, ampulla of Vater, and head of the pancreas is particularly difficult. Various imaging modalities are available but are not sensitive enough to detect small lesions or local invasion. Endoscopic ultrasonography is a new technique that places the transducer closer to the organ being evaluated, adding a new dimension to defining tumor invasion and extension.     

Para-aortic lymph node metastasis in carcinoma of the distal bile duct

BACKGROUND/AIMS: Lymph node dissection plays an important role in radical surgery for pancreaticoduodenal carcinomas. The aim of this study was to identify the critical areas of lymph node dissection in carcinoma of the distal bile duct. METHODOLOGY: Between January 1995 and December 1996, 20 consecutive patients with distal bile duct cancer underwent pancreaticoduodenectomy with extended lymph node dissection (including the para-aortic nodes). Histopathologic findings were examined with special reference to lymph node metastasis. RESULTS: Histological evidence of lymph node metastasis was found in 11 patients (55%). The areas with frequent metastases were the posterior pancreaticoduodenal lymph nodes (35%), and the nodes around the hepatoduodenal ligament (35%) and around the common hepatic artery (30%). Para-aortic lymph node involvement was identified in 5 patients (25%). Most of these existed in the inter-aorticocaval space. Pancreatic parenchymal invasion was present in 10 patients. Half of the patients with pancreatic invasion had para-aortic nodal involvement. Para-aortic lymph node metastasis was significantly associated with pancreatic parenchymal invasion (p<0.05). CONCLUSIONS: In carcinoma of the distal bile duct with pancreatic parenchymal invasion, extended lymph node dissection (including para-aortic nodes) should be undertaken because of the relatively high incidence of metastasis.     

Characteristics and treatment of mucin-producing tumor of the pancreas

BACKGROUND/AIMS: There has been no thorough clinicopathological analysis of a large number of cases with mucin-producing tumor of the pancreas. The aim of this study was to investigate the clinicopathological features of and therapeutic strategy for this ailment. METHODOLOGY: Two hundred and fifty-nine cases of mucin-producing tumor of the pancreas were analyzed clinicopathologically. RESULTS: Mucin-producing tumor of the pancreas was found in 177 males and 82 females (M:F=2.2:1). The mean age was 65.5 years. Jaundice, diabetes mellitus and a past history of pancreatitis were found in 15-19% of the cases. The tumor was most frequently (62%) found in the head of the pancreas. Pathologically, hyperplasia or adenoma was found in 58 cases, and adenocarcinoma in 160 cases. Five-year survival rate by the Kaplan-Meier method was 82.6% in all of the cases, and the post-operative survival curve was much better in cases with this type of carcinoma than in cases with ordinary pancreatic duct cell carcinoma (5-year survival rate: 17.3%). Organ-function preserving procedures, such as duodenum preserving subtotal resection of the head of the pancreas or spleen preserving distal pancreatectomy, might be recommended for this disease without infiltration. CONCLUSIONS: Mucin-producing tumor has unique clinicopathological characteristics, such as the dilated main pancreatic duct or branches, dilatation of the orifice of the papilla of Vater, or a good prognosis. Organ-function preserving procedures should be recommended in some cases with this ailment.     

Possible involvement of endothelial leukotrienes in acetylcholine-induced contraction in rabbit coronary artery

OBJECTIVE: To evaluate the symptoms, diagnostic procedures, and treatment by transduodenal excision, of tumours in the ampulla of Vater. DESIGN: Open study of consecutive patients. SETTING: University hospital, Denmark. SUBJECTS: Six patients with tumours in the ampulla of Vater. INTERVENTIONS: Ultrasonography, duodenoscopy, and endoscopic retrograde cholangiopancreatography (ERCP). Endoscopic biopsy if tumour was visible at the papilla. Transduodenal excision of the ampulla and anastomoses of the common duct and pancreatic duct to the duodenum. MAIN OUTCOME MEASURES: Postoperative complications and survival. RESULTS: None of the tumours could be seen on ultrasonography. All the tumours were diagnosed on duodenoscopy with ERCP. The histopathological diagnoses of the endoscopic biopsy specimens were adenoma (n = 3), suspicion of adenocarcinoma (n = 2), and adenocarcinoma (n = 1). Curative resection by transduodenal excision of the ampulla of Vater was possible in all cases. Pathological examination of the surgical specimens showed three adenomas and three adenocarcinomas. One patient had a recurrence after 2.5 years and had a further resection. Three patients died after one, three, and nine years, respectively; two had no recurrence and one was suspected of having one. The other three patients were alive 8-20 months after the operation. CONCLUSION: The procedure is recommended for small and probably benign tumours and, when technically possible, in malignant tumours in patients at high operative risk. Close postoperative follow-up with duodenoscopy and ERCP is recommended.     

Histochemistry of some acid hydrolases in striated muscles of the rat

Endoscopic sphincterotomy of the ampulla of Vater was performed in seven patients suffering from gallstones in the common bile duct and/or bile flow stasis. After this procedure, spontaneous delivery of gallstones occurred in two cases and a gallstone was extracted by our basket-tipped catheter in two cases. The electromyogram of the sphincter of Oddi after endoscopic sphincterotomy showed the similar patterns and rhythms to those before this procedure. Thus, the function (bile flow mechanism) of the sphincter was not destroyed by this procedure. Morphologic and physiologic data, therefore, lead to the conclusion that endoscopic sphincterotomy is a safe and useful procedure.     

Imaging of polypoid endoluminal growing bile duct tumors

We reviewed the radiological documents and protocols of 196 cases of bile duct tumors examined over a period of 12 years: 20 of them (10.2%) presented with a polypoid endoluminal growth. The aim of this study was to provide a better knowledge about the radiological features of this less frequent kind of tumor. In these 20 cases, the correct diagnosis of bile duct lesion was provided in 100% by E.R.C.P., P.T.C., U.S. as well as C.T., and in 42% by arteriography. The correct diagnosis of tumor was made by E.R.C.P. in 86%, by P.T.C. in 88%, by U.S. in 61%, by C.T. in 63%, and by arteriography in 25%. A correct diagnosis of tumor could be reached in all cases by combination of several examination techniques. The anatomopathological diagnosis was: bile duct adenocarcinoma (7 cases), adenocarcinoma of the ampulla of Vater (4), villous adenoma of Vater's ampulla (2), cystadenoma (1), cystadenocarcinoma (1), hepatocellular carcinoma (1), apudoma (1), and metastases (3).     

Three-dimensional magnetic resonance cholangiopancreatography for evaluation of obstructive jaundice

The purpose of this study was to assess the diagnostic value of magnetic resonance cholangiopancreatography (MRCP) in studying the anatomy, sites, and causes of obstructive jaundice. From September 1994 to May 1996 three-dimensional MRCP was performed on 31 patients with abdominal pain and obstructive jaundice with a fast spin-echo T2-weighted pulse sequence. The images were reconstructed using maximal intensity projection, AVERAGE and SURFACE algorithm processing techniques at a graphics workstation. All the reconstructed images were compared with those obtained using conventional cholangiographic techniques, such as endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography and drainage, and intraoperative cholangiography. The patients' diagnoses included choledochal cyst (13), cholangiocarcinoma (five), choledocholithiasis (four), pancreatic head carcinoma (three), rhabdomyosarcoma (one), papillary Vater carcinoma (one), recurrent gastric carcinoma (one), ascaris (one), and biliary atresia (two). Extrahepatic biliary dilatation was present in all 13 patients with choledochal cyst; the pancreatic ducts and their entrance level to the common bile duct were observed in eight of these patients. The level of obstruction in patients with cholangiocarcinoma was well documented but the biliary tract of one patient with biliary atresia was not identified by MRCP. In one patient with biliary rhabdomyosarcoma, MRCP clearly delineated the extrabiliary extension of the tumor. In a patient with ascaris in the common bile duct an increase in signal intensity inside the digestive tract of the worm denoted fluid in its gut. Lithiasis was shown in all of the four patients with choledocholithiasis. Thus, MRCP is a useful tool in the assessment of biliary tract obstruction and its causes, and is a valuable addition to ultrasonography.     

Pancreatic trauma: a rare but severe event

INTRODUCTION: High-speed motor vehicle accidents have contributed to an increasing incidence of pancreatic trauma. Early mortality is generally due to associated vascular and other intra-abdominal injury. MATERIALS AND METHODS: The authors report their experience on pancreatic trauma. Six cases were treated during the last five years. Isolated pancreatic injury was observed only in one case. Two patients received simple external drainage. Two patients required distal pancreatectomy. One patient was mistreated with ligature of distal pancreatic duct and, postoperatively, developed pseudocyst. One patient, with associated duodenal injury, died. COMMENTS: Serum amylase is often unreliable, whereas abdominal CT scans have the best sensitivity and specificity in detecting pancreatic injury. Abdominal exploration is always recommended in retroperitoneal trauma evaluation; complete pancreas mobilisation is needed to determine the integrity of the major pancreatic duct. Treatment protocols are based on severity of injury: they range from simple drainage to distal pancreatectomy (in presence of distal transection or parenchymal injury with duct injury) and to pancreaticoduodenectomy (in presence of massive injury, devascularisation, destruction of ampulla). Complications are seen in 20 to 35% of patients and the overall mortality secondary to complications ranges from 10 to 20%. Fistulas and pseudocysts are the most common complications.     

Solitary benign papilloma (papillary adenoma) of the cystic duct: a rare cause of biliary colic

Benign tumours of the extrahepatic bile ducts are rare, mostly occurring in the common bile duct and hepatic ducts. Solitary papillomas occur mainly in the gallbladder or at the ampulla of Vater. Tumours of the cystic duct are extremely rare, and we are unaware of any reports of solitary papilloma of the cystic duct. Such a case in a 72-year-old woman is presented.     

Pancreatic duct patency after pancreaticogastrostomy: long-term follow-up study

BACKGROUND/AIMS: To clarify whether the pancreatic duct remains patent during long-term follow-up of patients after pancreaticogastrostomy. In a previous study of pancreaticogastrostomy with post-operative follow up for 3 years after surgery, we found that the orifice of the pancreatic duct was difficult to detect in some patients because of swelling of the gastric mucosa. Previous studies have not examined pancreatic duct patency during long-term follow-up. METHODOLOGY: Between July 1985 and August 1989, 20 patients underwent a pylorus-preserving pancreaticoduodenectomy with reconstruction by pancreaticogastrostomy. Five of these patients were followed up post-operatively for more than 9 years to determine the patency of the pancreatic duct. All pancreatic anastomoses were performed by the telescopic method. RESULTS: All 5 patients were female, with a mean age of 65.4 years (range: 54-75). Median post-operative follow-up was 10.8 years (range: 9-12). The indications for surgery were carcinoma of the ampulla of Vater in 4 patients and chronic pancreatitis in 1 patient. Pancreatic duct patency was confirmed in 4 patients by gastroscopy and pancreatography. However, the anastomotic orifice could not be detected in the remaining patient because of complete coverage by the gastric mucosa. In this patient, pancreatic exocrine and endocrine function deteriorated with dilation of the distal pancreatic duct. The patient underwent a second operation involving dissociation of the pancreatico-gastric anastomosis and resection of about 1 cm of the fibrous, proximal portion of the pancreas. Reconstruction was performed with a Roux-en-Y pancreaticojejunostomy and a mucosa-to-mucosa anastomosis. CONCLUSIONS: Although pancreaticogastrostomy has been applied as a safe and straightforward method for reconstruction after pancreaticoduodenectomy, anastomotic stenosis is a potential late complication of this approach.     

Chemical mediation of egg dumping in the lace bug Gargaphia solani Heidemann (Heteroptera: Tingidae)

OBJECTIVE: The purpose of this study was to investigate the use of breath-hold single-shot fast spin-echo MR cholangiopancreatography in neoplastic pancreaticobiliary duct obstruction. MATERIALS AND METHODS: Breath-hold MR cholangiopancreatography was performed for preoperative examination of 32 consecutive patients with pathologically confirmed neoplastic obstruction of the biliary tract or pancreatic duct using a single-shot fast spin-echo sequence. Two observers, unaware of clinical or pathologic findings, independently reviewed the MR cholangiopancreatograms to assess level of obstruction and site of underlying tumor. Pathologic diagnoses, based on surgical or CT-guided biopsy specimens, were pancreatic tumor (n = 12), gallbladder cancer (n = 9), intrahepatic cancer (n = 9), and ampullary cancer (n = 2). RESULTS: On the basis of conventional cholangiography, CT, and surgical findings, 20 patients had isolated bile duct obstruction, 11 patients had combined pancreatic and bile duct obstruction, and one patient had isolated pancreatic duct obstruction. Isolated bile duct obstruction was classified as lobar (n = 5), hilar (n = 12), or distal (n = 3). These levels of obstruction were correctly identified in 27 (84%) and 28 (88%) of the 32 cases by the two observers. The site of the underlying tumor was identified in 27 (84%) and 29 (91%) cases by the two observers. Good interobserver agreement was reached for both level of obstruction (kappa = .70) and identification of tumor site (kappa = .75). CONCLUSION: Breath-hold single-shot fast spin-echo MR cholangiopancreatography is accurate in identifying the level of obstruction and the site of underlying tumor in neoplastic pancreaticobiliary duct obstruction, with good interobserver agreement.     

DNA loop domains in a 1.4-Mb region around the human hprt gene mapped by cleavage mediated by nuclear matrix-associated topoisomerase II

The aim of the study was the definition of the clinical features and survival of 27 resected cases of distal bile duct carcinoma. This neoplasm accounted for 14% of all periampullary malignancies treated by pancreaticoduodenectomy between 1990 and 1996. Jaundice was present in 96% of patients, but was the first symptom only in 78%. Preoperative investigations allowed to recognize distal bile duct cancer in a minority of patients (41%). Operative mortality and morbidity were 3.7 and 44%, respectively. Most patients (88%) were assigned to UICC stage IV-A. Postoperative survival was not significantly better than survival of 101 patients undergoing pancreaticoduodenectomy for pancreatic ductal carcinoma; median survival was 22 months, with a 13% 5-year survival rate. Determinants of a better prognosis were UICC stage 相似文献   

Acute otitis media in pediatrics

AIM OF THE STUDY: The aim of this retrospective study was to compare pancreatico-jejunostomy vs pancreatico-gastrostomy with regard to safety of pancreatic anastomosis after pancreatico-duodenectomy. PATIENTS AND METHODS: From January 1980 to June 1995, 171 patients underwent pancreatico-duodenectomy, 136 for pancreas, ampulla, distal bile duct or duodenum cancers, and 36 for chronic pancreatitis. Pancreatic anastomosis was realised by pancreatico-jejunostomy in 91 cases and by pancreatico-gastrostomy in 80 cases. There was no significant difference between the two groups (age, gender and primary disease). Comparison between the two groups concerned mainly postoperative mortality and morbidity. RESULTS: The overall postoperative mortality rate was significantly higher in the pancreatico-jejunostomy group (12%) than in the pancreatico-gastrostomy group (3.7%) (P = 0.05); death was directly related to necrosis of the remnant pancreas in four cases among the 14 postoperative deaths. The postoperative morbidity rate was respectively 23% after pancreatico-jejunostomy and 12.5% after pancreatico-gastrostomy; the pancreatic leakage and/or necrosis rate was higher in the pancreatico-jejunostomy group (13%) than in the pancreatico-gastrostomy group (3.75%) (P = 0.029). CONCLUSION: This study seems to demonstrate the superiority of the pancreatico-gastric anastomosis, but these results have to be confirmed or invalidated by a prospective multicentric randomised trial.     

Detection of choledocholithiasis: comparison of unenhanced helical CT and endoscopic retrograde cholangiopancreatography

PURPOSE: To compare unenhanced helical computed tomography (CT) and endoscopic retrograde cholangiopancreatography (ERCP) in the detection of common bile duct calculi. MATERIALS AND METHODS: Within 13 months, 51 patients (aged 18-94 years) with clinically suspected choledocholithiasis underwent unenhanced helical CT immediately before undergoing ERCP. CT scans were evaluated for the presence of bile duct stones, ampullary stones, the gallbladder and gallbladder stones, intrahepatic biliary dilatation, and the size of the bile duct at the porta hepatis and in the pancreatic head. ERCP images were evaluated for the presence of bile duct or ampullary stones, as well as for biliary dilatation. RESULTS: Unenhanced helical CT depicted common bile duct stones in 15 of 17 patients found to have stones at ERCP. Three patients had stones impacted at the ampulla, all of which were detected with CT. In addition, there was one false-positive finding at CT. CT had a sensitivity of 88%, a specificity of 97%, and an accuracy of 94% in the diagnosis of common bile duct stones. CONCLUSION: Unenhanced helical CT is useful for evaluating suspected choledocholithiasis.     

Gene diagnosis of pancreatic adenocarcinoma

Polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) technique was used to analyze c-Ki-ras codon 12 mutation in 27 fine needle aspiration biopsy (FNAB) specimens of the pancreas and its adjacent organs for the diagnosis of pancreatic adenocarcinoma. C-Ki-ras codon 12 mutation was present in 14 out of 15 cases of pancreatic adenocarcinoma, the positive rate was 93.33% (14/15); whereas no mutation was detected in those obtained from 12 patients with chronic pancreatitis, pancreatic cyst, gallbladder carcinoma, carcinoma of ampulla of Vater and gastric lymphoma. The results of this study verifies the PCR-RFLP technique as a practical, sensitive, rapid and reliable method for the detection of c-Ki-ras codon 12 mutation in the diagnosis of pancreatic adenocarcinoma.     

Basic principles of surgical policy in complicated chronic pancreatitis

The paper presents some experience with surgical treatment of 183 patients with complicated forms of chronic pancreatitis. The type of a surgical intervention depended on the pattern of pancreatic morphological changes. Operations of internal drainage of the pancreas in 103 patients with ductal hypertension provide the largest percentage (92.4%) of good and satisfactory results. Resectional methods of surgical treatment for chronic pancreatitis (n = 36) without signs of intraductal hypertension and with the prevalence of predominant lesions in some portions of the gland yield 80% good and satisfactory results. The incidence of postoperative complications following pancreatic resections is higher than those after drainages (16.2 versus 11.6%). The paper gives a concept of combined operations on the pancreas and bile ducts in chronic pancreatitis complicated by stricture of the distal common bile duct, revealed in 24.4% of cases.     

Biliary stricture due to mucosal hyperplasia of the common bile duct: a case report

A 71-year-old man with a tumorous lesion of the common bile duct is presented. Although histological examination of tumor biopsy specimens taken at the time of duodenoscopy or percutaneous transhepatic choledochoscopy showed mucosal hyperplasia, cancer could not be ruled out; therefore, the patient underwent pancreatoduodenectomy. However, histology showed nodular mucosal hyperplasia and an ectopic pancreas adjacent to the papilla of Vater, which was suspected to have contributed to the development of the lesion by stimulating the mucosa of the papilla and the distal common bile duct.     

Metallic stents in malignant biliary obstruction: prospective long-term clinical results

OBJECTIVE: The purpose of this prospective study was to evaluate the long-term clinical efficacy of metallic stents when used as the initial palliative treatment of patients with inoperable malignant biliary obstruction. SUBJECTS AND METHODS: From August 1991 through May 1995, 100 consecutive patients with malignant biliary obstruction were treated with percutaneous placement of metallic stents. The causes of obstruction were bile duct carcinoma (n = 50), pancreatic carcinoma (n = 17), gallbladder carcinoma (n = 6), hepatocellular carcinoma (n = 2), and metastatic lymphadenopathy in the hepatoduodenal ligament (n = 25). We used 123 stents: 64 Gianturco Z stents, 39 Hanaro spiral stents, 16 Wallstents, two tantalum Strecker stents, one Endocoil stent, and one Memotherm nitinol stent. Every 3 months we followed up all patients except those who died. The average length of follow-up was 220 days (range, 4-1125 days). Patient survival and stent patency rates were estimated by life-table analysis. RESULTS: The median length of survival for the entire patient group was 246 days: 25-week and 50-week survival rates were 62% and 25%, respectively. We found no statistically significant difference in the median length of survival between patients with hilar obstruction (256 days) and patients with common bile duct (CBD) obstruction (227 days). Patients with bile duct carcinoma had longer median survival (269 days) than did patients with other conditions (197 days). The overall median length of patency for all stents was 360 days; the 25-week and 50-week patency rates were 81% and 53%, respectively. The stent patency rate at the median length of survival was 71%. The median length of stent patency in patients with hilar obstruction (617 days) was nearly double that of patients with CBD obstruction (324 days). However, the median length of stent patency in patients with bile duct carcinoma showed no statistically significant difference from the median length in patients with other disease. Four patients (4%) died within 1 month after stent placement. Twenty-one patients (21%) developed recurrent jaundice or cholangitis. In order of frequency, the causes of recurrent jaundice were tumor overgrowth, incrustation of bile sludge, duodenal obstruction due to tumor invasion, stent impaction into the bile duct wall, stent malposition, and tumor ingrowth. CONCLUSION: Metallic stents showed a favorable patency rate with regard to patient survival. In patients with hilar obstruction, the clinical efficacy of metallic stents was superior to that in patients with CBD obstruction. We believe that placement of metallic stents is the procedure of choice for palliation of malignant biliary obstruction.