Many faces of pancreaticobiliary reflux

Pancreatobiliary reflux increases macrophage-secreted IL-8 and activates the PI3K/NFκB pathway to promote cholangiocarcinoma progression

BACKGROUND

Persistent pancreaticobiliary reflux (PBR) is associated with a high risk of biliary malignancy. This study aimed to evaluate the proportion of PBR in biliary tract diseases and mechanisms by which PBR promoted cholangiocarcinoma progression.

METHODS

Overall 227 consecutive patients with primary biliary tract disease participated in this study. The amylase levels in the collected bile were analyzed. The mechanisms underlying the effect of high-amylase bile on bile duct epithelial and cholangiocarcinoma cells progression were analyzed. The source of interleukin-8 (IL-8) and its effects on the biological functions of cholangiocarcinoma cells were investigated.

RESULTS

The bile amylase levels in 148 of 227 patients were higher than the upper serum amylase limit of 135 IU/L. PBR was significantly correlated with sex, pyrexia, and serum gamma-glutamyl transferase (GGT) levels in the patient cohort. High-amylase bile-induced DNA damage and genetic differences in the transcript levels of the gallbladder mucosa and facilitated the proliferation and migration of bile duct cancer cells (HUCCT1 and QBC939 cells). The concentration of many cytokines increased in high-amylase bile. IL-8 is secreted primarily by macrophages via the mitogen-activated protein kinase pathway and partially by bile duct epithelial cells. IL-8 promotes the progression of HUCCT1 and QBC939 cells by regulating the expression of epithelial-mesenchymal transition-associated proteins and activating the phosphatidylinositol 3-kinase/nuclear factor kappa-B pathway.

CONCLUSIONS

PBR is one of the primary causes of biliary disease. IL-8 secreted by macrophages or bile duct epithelial cells stimulated by high-amylase bile promotes cholangiocarcinoma progression.

Using Spin-labeled MR Imaging to Depict Slow Pancreatic Juice Flow

This study evaluated the dependence of the signal characteristics of time-spatial labeling inversion pulse (time-SLIP) on flow velocity and tag thickness to depict the pancreatic juice flow by analyzing signal profile using a tube phantom study. The tag edge property was evaluated by edge rise distance (ERD). For various slow flow velocities and tag thicknesses, the signal profile characteristics were evaluated using two indices: the tag center value (RTCV) reduction rate and the total signal value along the tube (TSVT). ERD, which was about 10% of the tag thickness, was higher for thicker tags, making slow flow detection difficult. TSVT was proportional to the thickness of the tag and was preserved irrespective of the flow velocity. RTCV became lower with higher flow velocity and decreased significantly with thinner tags. These results suggest that the visualization of pancreatic juice flow might improve stability by considering the appropriate tag thickness.

Common bile duct pressure in patients with and without cholelithiasis: A case-control study

BACKGROUND

The reflux of pancreatic enzymes into the bile duct and the gallbladder is an abnormal phenomenon that plays a role in lithogenesis and carcinogenesis. Because the pressure of the common bile duct depends on the pressures of the sphincter of Oddi, its dysfunction would be reflected in an increase in the pressure of the common bile duct in patients with cholelithiasis. The objective of this study was to measure the pressures of the common bile duct in patients with and without cholelithiasis and to relate them to the presence of pancreatobiliary reflux.

METHODS

A prospective case-control study was designed. The study universe was constituted by all patients undergoing total gastrectomy for gastric cancer stages I and II over 30 months. The primary outcome measure was to establish differences between common bile duct pressures in patients with and without cholelithiasis.

RESULTS

Common bile duct pressures in patients with gallstones showed a significant elevation (16.9 mmHg) compared to patients without gallstones (3.3 mm Hg) (p < 0.0001). These pressures correlated with the levels of amylase and lipase in gallbladder bile; higher levels were found in patients with gallstones compared to patients without gallstones (P < 0.0001).

CONCLUSIONS

Common bile duct pressure in patients with cholelithiasis was significantly higher compared to patients without cholelithiasis leading to pancreatobiliary reflux.

Common bile duct stones associated with pancreatobiliary reflux and disproportionate bile duct dilatation

Occult pancreatobiliary reflux (PBR) in patients with a normal pancreatobiliary junction has been studied by various methods, but the exact etiology, mechanisms, and implications of this reflux have not yet been clarified. The aim of this study was to investigate the degree of PBR and patterns of biliary ductal dilatation in patients with acute calculous cholangitis by endoscopic retrograde cholangiopancreatography (ERCP).We retrospectively evaluated the degree of PBR and pattern of bile duct dilatation in patients with acute calculous cholangitis due to distal CBD (common bile duct) stones (Group A) as compared with patients with malignant CBD obstruction due to distal CBD cancer (Group B). All related data were prospectively collected. Bile juice was aspirated at the proximal CBD for measurement of biliary amylase and lipase before the injection of contrast dye. The diameters of the CBD and the peripheral intrahepatic duct (IHD) were calculated after contrast dye injection. Patients with pancreatobiliary maljunction and/or gallstone pancreatitis were excluded from the study.ERCP was performed on 33 patients with calculous cholangitis (Group A) and 12 patients with malignant CBD obstruction (Group B). Mean levels of bile amylase and lipase were significantly higher (P < .05) in group A (1387 and 6737 U/l, respectively) versus those in group B (32 and 138 U/l, respectively). Thirty patients in group A (90.9%) showed disproportionate dilatation (i.e., CBD was and IHD was not dilated), whereas only 4 patients in group B (33%) showed disproportionate dilatation.The results of this study suggest that patients with calculous cholangitis exhibit PBR that is associated with disproportionate bile duct dilatation.

Pancreaticobiliary reflux as a high-risk factor for biliary malignancy: Clinical features and diagnostic advancements

Pancreaticobiliary junction is composed of complex structure with which biliary duct and pancreatic duct assemble and go out into the ampulla of Vater during duodenum wall surrounding the sphincter of Oddi. Although the sphincter of Oddi functionally prevents the reflux of pancreatic juice, pancreaticobiliary reflux (PBR) occurs when function of the sphincter of Oddi halt. The anatomically abnormal junction is termed pancreaticobiliary maljunction (PBM) and is characterized by pancreatic and bile ducts joining outside of the duodenal wall. PBM is an important anatomical finding because many studies have revealed that biliary malignancies are related due to the carcinogenetic effect of the pancreatic back flow on the biliary mucosa. On the other hand, several studies have been published on the reflux of pancreatic juice into the bile duct without morphological PBM, and the correlation of such cases with biliary diseases, especially biliary malignancies, is drawing considerable attention. Although it has long been possible to diagnose PBM by various imaging modalities, PBR without PBM has remained difficult to assess. Therefore, the pathological features of PBR without PBM have not been yet fully elucidated. Lately, a new method of diagnosing PBR without PBM has appeared, and the features of PBR without PBM should soon be better understood.

Early experience with laparoscopic excision of choledochal cyst in 41 children

OBJECTIVE

This study aims to review our center's early experience in managing children with choledochal cysts using laparoscopic excision.

METHODS

A retrospective study was carried out from the time of our first case of laparoscopic excision (2010). A total of 41 patients with choledochal cysts underwent laparoscopic choledochal cyst excision and Roux-en-Y hepaticojejunostomy. Patient demographics, operative data, and post-operative outcomes were recorded and analyzed.

RESULTS

Forty patients underwent the operation successfully, and the mean time of operation was 210 min (range 140 min to 380 min). One case was converted to an open operation due to dense adhesions. All patients recovered uneventfully and were discharged between seven and ten days post-operatively. Four patients suffered minor bile leaks after their operations, but they required only percutaneous drainage. The mean time for follow-up was six months (range 1 month to 1 year). No significant complication was noted during that time.

CONCLUSIONS

We successfully introduced laparoscopic excision of choledochal cyst in our center and have found this to be a safe and effective method. Long-term follow up is awaited.