Pancreaticobiliary reflux in patients with a normal pancreaticobiliary junction: Pathologic implications

Identification of changes in bile composition in pancreaticobiliary reflux based on liquid chromatography/mass spectrometry metabolomics

INTRODUCTION

Pancreaticobiliary reflux (PBR) can induce gallstone formation; however, its pathogenic mechanism remains unclear. In this study, we explored the mechanism of PBR by the non-targeted metabolomic analysis of bile in patients with PBR.

OBJECTIVE

The aim of this study was to investigate the pathogenic mechanism in PBR by the non-targeted metabolomic analysis of bile collected during surgery.

METHODS

Sixty patients who underwent gallstone surgery at our center from December 2020 to May 2021 were enrolled in the study. According to the level of bile amylase, 30 patients with increased bile amylase ( > 110 U/L) were classified into the PBR group, and the remaining 30 patients were classified into the control group (≤ 110 U/L). The metabolomic analysis of bile was performed.

RESULTS

The orthogonal projections to latent structure-discriminant analysis of liquid chromatography mass spectrometry showed significant differences in bile components between the PBR and control groups, and 40 metabolites were screened by variable importance for the projection value (VIP > 1). The levels of phosphatidylcholine (PC) and PC (20:3(8Z,11Z,14Z)/14:0) decreased significantly, whereas the levels of lysoPC (16:1(9z)/0:0), lysoPC (15:0), lysoPC (16:0), palmitic acid, arachidonic acid, leucine, methionine, L-tyrosine, and phenylalanine increased.

CONCLUSIONS

Significant differences in bile metabolites were observed between the PBR and control groups. Changes in amino acids and lipid metabolites may be related to stone formation and mucosal inflammation.

Free fatty acids and triglyceride change in the gallbladder bile of gallstone patients with pancreaticobiliary reflux

Background

Pancreaticobiliary reflux (PBR) causes chronic inflammation of the gallbladder mucosa and changes in the bile components, which are known to promote gallstone formation. This study aimed to investigate the bile biochemistry changes in gallstone patients with PBR and provide new clues for research on the involvement of PBR in gallstone formation.

Methods

Patients undergoing surgery for gallstones between December 2020 and May 2021 were eligible for inclusion. The bile biochemistry (including amylase, lipase, triglyceride, cholesterol, free fatty acids [FFAs], alanine aminotransferase [ALT], aspartate aminotransferase [AST], alkaline phosphatase [ALP], and γ-glutamyl transferase [γ-GT]) of the included gallstone patients was analysed to determine correlations with PBR.

Results

In this study, 144 gallstone patients who underwent surgery were enrolled. Overall, 15.97 % of the patients had an increased bile amylase level, which was associated with older age and significantly higher bile levels of ALP, lipase, triglyceride, and FFAs. Positive correlations were observed between amylase and lipase, triglyceride, FFAs levels in the gallbladder bile. However, the bile levels of triglyceride, FFAs, and lipase were positively correlated with each other only in the PBR group and showed no significant correlation in the control (N) group. In addition, elevated bile FFAs levels were found to be an independent risk factor for gallbladder wall thickening.

Conclusions

In conclusion, PBR-induced increase in FFAs and triglyceride in the gallbladder bile is a cause of gallstone formation, and an increase in bile ALP suggests the presence of cholestasis in PBR.

Standardized Surgical Management for Cystic Dilation of the Bile Ducts Based on Clinical and Pathological Studies: A Narrative Review

The surgical method of complete/radical cyst excision plus Roux-en-Y hepaticojejunostomy remains the primary therapy and the only effective treatment for cystic dilation of the bile ducts (CDBDs). However, the incidence of long-term postoperative complications is still high, as is the reoperation rate, and the potential for postoperative malignant transformation still exists. In recent years, significant progress has been made in understanding the pathogenic mechanism and pathological changes of adult CDBDs. Based on which, the surgical procedures for CDBDs have been revised to further improve their effectiveness. The purpose of this review is to systematically summarize the latest concepts of the etiology and pathogenic mechanism and the pathological changes of adult CDBDs. Based on the findings of these clinical and pathological studies, a comprehensive theoretical system in the surgical treatment of CDBDs has been established, which corrects many previous theoretical misunderstandings. The specific surgical method for each type of CDBDs and the key technical notes are also described in detail. Using these principles, treatment outcomes for CDBDs can be significantly improved, and the current high complication rate, reoperation rate, and rate of postoperative malignant transformation can be reduced.

Metachronous biliary carcinoma with intraductal pancreatic adenocarcinoma 13 years after curative resection of hilar bile duct cancer

We report a case of a 68-year-old woman with metachronous bile duct cancer and a pancreatic adenocarcinoma. She had undergone extended left hepatic lobectomy for hilar bile duct carcinoma. However, when she was admitted to our hospital 13 years later for an annual follow-up, abdominal CT revealed a mass in the dilated remnant of her lower bile duct. This was diagnosed as a second primary tumour, a pancreaticoduodenectomy was performed and 15 months after the second operation, she remains recurrence-free. Nineteen cases of patients with metachronous bile duct carcinomas were identified in the literature and have been reviewed.