人胰胆管合流异常胆汁对胆管细胞的影响及其机理探讨

目的研究胰胆管合流异常(APBDU)患者的胆汁对人胆管细胞生长的影响,探讨APBDU与胆管癌发生的关系。方法应用四甲基偶氮唑蓝(MTT)比色法检测APBDU患者胆汁对胆管细胞增殖的影响,流式细胞仪测定其细胞周期分布及凋亡情况;Western blot法检测经APBDU胆汁处理的胆管细胞c-erbB-2蛋白表达水平的变化。结果APBDU患者胆汁与正常对照胆汁比较,能明显促进胆管细胞的增殖(P<0.05),这种促增殖作用可被环氧化酶COX-2抑制剂celecoxib或一氧化氮合成酶抑制剂L-NAME抑制;流式细胞仪分析经APBDU胆汁处理的胆管细胞其处于S期的细胞明显增多(P<0.001);Western blot法检测经APBDU胆汁处理的胆管细胞其c-erbB-2表达增多。结论APBDU患者的胆汁对正常胆管细胞增殖有促进作用,可能潜在致癌活性。     

Type classification of anomalous pancreaticobiliary junction by ERCP

The role of endoscopic retrograde cholangiopancreatography (ERCP) in the preoperative assessment of anomalous pancreaticobiliary junction was retrospectively evaluated in 74 consecutive patients (19 males and 55 females; aged 0–80 years). Sixty-three patients had congenital biliary dilatation and 11 did not. Type classification of congenital biliary dilatation was possible by ERCP alone in 45 patients (71%). The main causes of classification failure were previous bilio-enteric anastomosis and restriction of postural changes during ERCP due to general anesthesia in pediatric patients. Classification of anomalous junction was possible in 69 patients (93%). Technical difficulty in ERCP caused classification failure in 5 patients. Neoplastic lesions were found in 12 patients (16%) and all but 1 were correctly diagnosed by ERCP. We conclude that ERCP plays an important role in the preoperative diagnosis and type classification of anomalous pancreaticobiliary junction and congenital biliary dilatation.     

胰胆管连接异常患儿血清淀粉酶同功酶变化

为观察胰胆管连接异常(PBM)患儿血清淀粉酶同功酶谱变化并探讨其临床意义，采集30例先天性胆管。扩张症(CBD)患儿(囊形24例，梭形6例，均伴PBM)手术前、后血清及胆汁；另取30例正常儿童和12例急性胰腺炎成人血清作为对照，应用不连续缓冲系统薄膜电泳法进行酶谱分析。结果显示，正常对照组血清胰型淀粉酶同功酶仅存在P1和P2波峰；PBM患儿术前血清和胆汁的胰型淀粉酶同功酶除有Pl和P2外，均出现P3、P4、P5等异常波峰，血清和胆汁各波峰的出现率具相似性；急性胰腺炎组除有P1、P2和P3外，P4较少见，无P5波峰；PBM患儿血清酶学的异常在胰胆分流术后基本消失。提示：PBM患儿血清淀粉酶同功酶谱存在异常，具一定特异性。该异常证实PBM畸形存在胆-血返流，对PBM，尤其是胆管扩张不明显者有一定的诊断价值。     

Clinicopathology of pancreaticobiliary maljunction: relationship between alterations in background biliary epithelium and neoplastic development

Background/Purpose

Between 1988 and 2003, 38 patients underwent biliary resection for pancreaticobiliary maljunction (PBM). We reviewed the histopathologic findings for the surgically resected specimens to compare the clinical and pathologic features and assess the relationship between changes in the background biliary epithelium and the development of neoplasms.

Methods

Papillary hyperplasia (PHP) seen in the biliary epithelium of patients with PBM, was classified into grades 0–III in the gallbladder and grades 0–II in the extrahepatic bile duct, according to the extent, and was assessed for links with tumors in the same specimens.

Results

The incidence of gallbladder carcinoma was 13/21 in grades I–II, versus 0/16 in grade III, while the incidence of bile duct carcinoma was 4/20 in grade I versus 0/5 in grade II. Furthermore, these incidences for patients below age 50 years and age 50 or older were 1/18 versus 12/20, and 0/14 versus 6/17, respectively.

Conclusions

PHP of the biliary epithelium in PBM patients is an important precursor lesion, especially for gallbladder cancer, and the risk becomes greater with age, regardless of the type of pancreatobiliary junction (PBJ) and its location in the biliary tract.     

End-to-side choledochoduodenostomy: A widely applicable procedure for biliary reconstruction

End-to-side choledochoduodenostomy was originally used for reconstruction between the duodenum and the biliary tree in iatrogenic bile duct stricture. However, we believe the procedure could be applied for various biliary disorders. We have recently shown the high carcinogenicity of biliary epithelium in patients with pancreaticobiliary maljunction, and consequently we recommend excision of the bile duct, along with appropriate reconstruction of the biliary system to divert the flow of pancreatic juice from bile fluid, to prevent carcinoma in biliary epithelium even in patients without dilatation of the bile duct. The conditions causing primary or recurrent bile duct stones must be removed. We employed this procedure for biliary reconstruction in 42 patients with pancreatico-biliary maljunction and in 30 patients with various benign biliary diseases, such as bile duct stones and benign biliary stenosis. We also used the procedure for palliation in 6 patients with malignant tumors around the head of the pancreas. Among these 78 patients over 20 years, we experienced 5 cases of reflux cholangitis with anastomotic stenosis, for which conservative dilatation was required. This procedure of end-to-side choledochoduodenostomy could be widely applicable for biliary reconstruction in terms of its being simplicity, minimal invasiveness and the establishment of a single physiological route for bile flow into the duodenum.     

Association between anomalous pancreaticobiliary ductal union and adenomyomatosis of the gall-bladder

A frequent association of biliary tract carcinoma and anomalous pancreaticobiliary ductal union (APBD) is well recognized, especially gall-bladder carcinoma in undilated type APBD. However, little is known about the presence and incidence of adenomyomatosis (AMT) of the gall-bladder, a presumed premalignant lesion, in patients with APBD. This retrospective study was conducted to elucidate the clinical features and incidence of AMT in APBD patients with relation to undilated type and dilated type APBD. We reviewed the clinicopathological records of 30 patients with APBD (28 women and two men) encountered during the past 10 years. Among them, 22 patients underwent cholecystectomy and the resected specimens were subjected to histopathological examinations. Eleven cases of APBD patients were undilated type and 11 cases were dilated type. Adenomyomatosis was found in six (55%) of 11 undilated type and one (9%) of 11 dilated type, and fundal type was predominantly observed in six (86%) of seven AMT. An overall incidence of AMT in APBD patients was 32%. An undilated type of APBD is frequently associated with AMT and we believe, therefore, that clinicians should be aware of a possible coexistence of APBD and AMT.     

胰胆管合流异常及其相关疾病

胰胆管合流异常是一种胆管和胰管在十二指肠壁外汇合的先天性畸形。由于失去了Oddi括约肌的控制,胆汁和胰液可以相互返流从而引起胆总管扩张症,胆道结石,胆道肿瘤及其胆源性胰腺炎等疾病。     

Small Cell Carcinoma of the Gallbladder Arising in a Patient with Pancreaticobiliary Maljunction without Bile Duct Dilatation

We report a 36–year-old female patient with small cell carcinoma of the gallbladder with liver metastasis, that was associated with pancreaticobiliary maljunction (PBM) without bile duct dilatation. On admission, a gallbladder mass and multiple liver tumors were detected by US, CT and ERCP. Moreover, ERCP clearly demonstrated an abnormally long common channel between the pancreatic and bile ducts, indicating PBMwithout choledochal dilatation. US-guided biopsy of the tumor histopathologically confirmed small cell carcinoma. The serum neuron-specific enolase (NSE) level was very high. Transarterial chemo-embolization followed by systemic chemotherapy resulted in marked tumor reduction, but this was followed by rapid exacerbation. The patient died of the tumor 145 days after admission. The proposed mechanism of the car-cinogenesis of this rare gallbladder malignancy under the preexisting condition of PBM was discussed. (Dig Endosc 1999, 11: 246–249)