Flowcharts for the management of biliary tract and ampullary carcinomas

No strategies for the diagnosis and treatment of biliary tract carcinoma have been clearly described. We developed flowcharts for the diagnosis and treatment of biliary tract carcinoma on the basis of the best clinical evidence. Risk factors for bile duct carcinoma are a dilated type of pancreaticobiliary maljunction (PBM) and primary sclerosing cholangitis. A nondilated type of PBM is a risk factor for gallbladder carcinoma. Symptoms that may indicate biliary tract carcinoma are jaundice and pain in the upper right area of the abdomen. The first step of diagnosis is to carry out blood biochemistry tests and ultrasonography (US) of the abdomen. The second step of diagnosis is to find the local extension of the carcinoma by means of computed tomography (CT), magnetic resonance imaging (MRI), magnetic resonance cholangiopancreatography (MRCP), percutaneous transhepatic cholangiography (PTC), and endoscopic retrograde cholangiopancreatography (ERCP). Because resection is the only way to completely cure biliary tract carcinoma, the indications for resection are determined first. In patients with resectable disease, the indications for biliary drainage or portal vein embolization (PVE) are checked. In those with nonresectable disease, biliary stenting, chemotherapy, radiotherapy, and/or best supportive care is selected.     

The relationship between gallbladder disease and smoking and drinking habits in middle-aged Japanese

Background: Background: Few studies have investigated the association between smoking and ultrasonographically diagnosed gallbladder (GB) disease, and their results were uncertain. This study was conducted to examine the association between smoking and drinking and GB diseases. Methods: A total of 9947 subjects (age, 30–69 years; 4953 men and 4994 women) voluntarily received a paid medical check-up at our center in Yamanashi Prefecture in Japan. All of the subjects underwent abdominal ultrasonographic (US) examination, a demographic check, and a biochemical test, and answered a self-administered questionnaire asking about smoking habits and alcohol consumption. Of the 9947 subjects, 483 had gallstones, 819 had gallbladder polyps, and 169 were in a state of postcholecystectomy. We compared the findings in this group with the findings in 8417 people (4144 males and 4273 females) with normal gallbladder. Results: Multiple regression analysis among males showed that cigarette smoking was inversely related to GB polyps (odds ratio, [OR], 0.76; 95% confidence internal [CI], 0.59–0.98 and OR, 0.74; 95% CI, 0.56–0.98, respectively, for current and ex-smokers). Ex-smokers a showed positive association with the postcholecystectomy state (OR, 2.56; 95% CI, 1.18–5.52). Light drinkers showed an inverse relation to GB stones (OR, 0.69; 95% CI, 0.49–0.99), and heavy drinkers showed an inverse relation to GB polyps (OR, 0.68; 95% CI, 0.51–0.90). Current drinkers showed an inverse relation to the postcholecystectomy state (OR, 0.48; 95% CI, 0.28–0.83). Conclusions: Cigarette smoking was inversely related to gallbladder polyps in males and was positively related to the postcholecystectomy state. Drinking was inversely related to gallstones, GB polyps, and the postcholecystectomy state in males. Received: July 19, 2001 / Accepted: November 2, 2001     

Macroscopic and stereomicroscopic diagnosis of superficial flat-type early carcinomas of the gallbladder

Superficial flat early carcinomas of the gallbladder are rarely detected clinically. We previously reported that these carcinomas display granular, flat, or gastric area-like surface mucosal patterns. However, these patterns are also seen in some non-neoplastic conditions. To more definitively differentiate carcinomas from non-neoplastic lesions, we analyzed the stereomicroscopic structure of macroscopically granular, flat, or gastric area-like mucosal lesions with a methylene-blue contrast technique. Sixteen superficial flat early carcinomas and 65 non-neoplastic flat lesions from surgically resected gallbladders were studied by stereomicroscopy. The fine mucosal structures were classified into three patterns: grooved, pitted, or papillary, each of which was further subdivided into regular and irregular. The frequency of the grooved (52.2%) and papillary (52.2%) patterns was significantly higher in the carcinomas than in the non-neoplastic lesions (24.7% and 1.3%, respectively). The pitted pattern was present in 69.6% of the carcinomas and in 53.2% of the nonneoplastic lesions (the difference was not significant). In the grooved and pitted patterns, the irregular subtypes predominated in the carcinomas (100% and 81.3%, respectively), while the regular subtypes were more frequent in the non-neoplastic lesions (84.2% and 97.6%, respectively). Stereomicroscopic examination of the fine mucosal structures of flat lesions of the gallbladder is very useful in differentiating carcinomas from nonneoplastic lesions. Presented, in part at the annual meeting of the Japanese Society of Gastroenterology, May 1995, Yokohama, Japan     

苦参碱对上消化系肿瘤临床药理作用的研究进展

苦参碱能防治大鼠胃癌前病变以及乙基硝基亚硝基胍诱发大鼠原发性胃癌,也能防治人胃癌MKN-45细胞、SGC-7901细胞、BG823细胞、人胰腺癌BxPC-3细胞移植瘤在裸鼠或大鼠体内生长。经体外实验发现,苦参碱能浓度相关地抑制人胃癌SGC-7901细胞、MGC803细胞、BGC823细胞、MKN-45细胞、NCI-N87细胞、AGS细胞、人胰腺癌BxPC-3细胞、CFPAC-1细胞、人胆管癌QBC939细胞、人胆囊癌GSC-SD细胞、人食管癌Eca109细胞、Escl细胞的增殖并诱导其凋亡。经体内外实验结果发现,苦参碱能增强化疗药抗人胃癌SGC-7901细胞作用。综述苦参碱对消化系肿瘤临床药理作用的研究文献,并对其研究进展做了分析。     

Gallbladder gangrene after percutaneous vertebroplasty,an uncommon presentation of vascular complication: a case report and analysis of the causes

We present a case of an 81-year-old man with gallbladder gangrene after percutaneous vertebroplasty (PV) that was successfully treated via laparoscopic cholecystectomy (LC). The patient underwent multilevel, thoracic PV for painful osteoporotic compression fractures. PV performed at the T6 level was complicated by severe abdominal pain owing to direct embolization of the right T6 segmental artery with penetration of bone cement into the radicular artery beneath the pedicle. Cement leakage, especially arterial embolization of cement into the general circulation, is a known potential complication following PV. Serious complications related to PV augmentation procedures, such as vertebroplasty and kyphoplasty, are rare and most often result from local cement leakage or venous embolization. Combined with this case report, we reviewed the literature regarding the unusual occurrence of direct arterial cement embolization during PV and analyzed the causes to alert clinicians to this potentially rare vascular complication.     

超声造影评价胆囊息肉样病变形态特征的临床研究

目的：通过与常规超声技术对比,明确超声造影技术在评价胆囊息肉样病变形态特征的优势和临床价值。方法：收集我院2016年3月到2018年7月因囊息肉样病变行胆囊切除患者146例纳入研究。研究对象于胆囊切除术前分别进行胆囊常规超声及超声造影检查。根据手术病理结果,将胆囊息肉分为胆固醇性息肉组与腺瘤性息肉组。分析并记录胆囊息肉常规超声特征、患者年龄、性别、胆囊结石、息肉数量、息肉内血流、息肉最大径大小以及息肉基底部宽度并进行统计分析。两组间计量资料采用t检验,等级资料采用χ_²检验。采用多因素回归分析明确鉴别胆囊腺瘤的独立风险因素。P <0.05认为差异有统计学意义。结果：经手术病理证实104例为胆固醇性息肉,42例为腺瘤性息肉。胆固醇组与腺瘤组间在年龄、性别、胆囊结石以及息肉数量方面无统计学差异(p>0.05),息肉内血流、息肉最大径在两组间有统计学差异(p<0.05)。两组间超声测量基底部宽度与超声造影测量基底部宽度均有统计学差异(p<0.05)。两组内超声测量基底部宽度与超声造影测量基底部宽度有统计学差异(p<0.05)。多因素回归分析证实息肉内血流、超声造影测量息肉基底部宽度是与腺瘤性息肉相关的独立风险因素(p<0.05)。 结论：超声造影技术能够更准确反应胆囊息肉形态特征,有助于鉴别胆固醇性息肉与腺瘤性息肉。     

Nuclear cyclin D1 overexpression is a critical event associated with cell proliferation and invasive growth in gallbladder carcinogenesis

Cyclin D1 overexpression is remarkably frequent in several human carcinomas and is believed to be a critical event in oncogenesis. We examined cyclin D1 expression, p53 expression, and the Ki-67 labeling index by immunostaining in human gallbladder mucosa in conditions varying from normal to malignant tissue. We also examined K-ras codon 12 mutations in these tissues with a two-step polymerase chain reaction. Nuclear cyclin D1 overexpression was observed in 48% of carcinomas occurring independently of adenoma, but not in adenomas, carcinomas arising in adenomas, or nonneoplastic lesions. Cytoplasmic cyclin D1 overexpression was observed in about 15% of abnormal specimens, irrespective of the type of epithelial abnormality. Carcinomas showing nuclear cyclin D1 overexpression had significantly higher Ki-67 labeling indexes than those with no overexpression. Moderately to poorly differentiated adenocarcinomas showed a higher incidence of nuclear cyclin D1 overexpression than papillary to well differentiated carcinomas. Specimens with cyclin D1 overexpression showed a high incidence of lymph permeation, venous permeation, and lymph node metastasis. We conclude that nuclear cyclin D1 overexpression is a critical event importantly associated with cell proliferation and invasive growth in gallbladder carcinogenesis, and that cyclin D1 immunostaining may become a useful marker for evaluating gallbladder carcinomas. Received: March 9, 1999 / Accepted: July 23, 1999     

Radioactive choline metabolism in guinea pig gallbladder

Acetylcholine may be released from gallbladder intrinsic nerves in response to cholecystokinin stimulation. This study characterized metabolites of [¹⁴C]choline produced in the gallbladder and released during incubation, with or without cholecystokinin-octapeptide. Radiolabeled [¹⁴C]choline was applied to the mucosal or muscle surface of intact guinea pig gallbladders in an organ bath. After radiolabeling, gallbladders were incubated with or without the contractile agonist cholecystokinin-octapeptide. Metabolites of [¹⁴C]choline were identified in gallbladder tissue and incubation buffers using HPLC and thin-layer chromatography. The major metabolites of [¹⁴C]choline were betaine and phosphocholine. [¹⁴C]Phosphocholine was incorporated slowly into [¹⁴C]phosphatidylcholine. [¹⁴C]Choline was released into buffers during incubation. [¹⁴C]Acetylcholine constituted less than 1% of radiolabel in the gallbladder. There was no identifiable [¹⁴C]acetylcholine released in buffers. Cholecystokinin-octapeptide did not affect choline metabolism. These studies showed that choline in the gallbladder is metabolized along pathways similar to those in the liver. Gallbladders released mostly choline, rather than acetylcholine, even during hormonally induced contraction.This project was supported by the Research and Development Office of the Department of Veterans Affairs.     

Percutaneous transhepatic gallbladder stenting for recurrent acute acalculous cholecystitis after failed endoscopic attempt

Endoscopic gallbladder stenting is useful palliative therapy for acute cholecystitis in high‐risk patients. Although the success rate of endoscopic gallbladder stenting is 79%–100%, an alternative method has not been reported. We succeeded in employing a method for percutaneous gallbladder stenting (PTGS) and herein describe this new method. A patient with acute acalculous cholecystitis related to ischemic atherosclerotic vascular disease, cholangitis due to Lemmel syndrome, and severe congestive heart failure underwent PTGS through the cystic duct from the gallbladder to the duodenal papilla, because an endoscopic method failed in the treatment of Lemmel syndrome. Because we were unable to place endoscopic transpapillary gallbladder drainage, percutaneous transhepatic gallbladder drainage (PTGBD) was performed and both the cholecystitis and cholangitis ceased. PTGS was performed as an alternative to endoscopic gallbladder stenting. Access to the cystic duct and gallbladder was obtained by the PTGBD route, using a guidewire (0.035‐inch diameter) and seeking catheter (6.5 Fr) under fluoroscopic control. A 7‐Fr 12‐cm double‐pigtail biliary polyethylene stent was placed. The patient remained asymptomatic for 3 months after the PTGS until he died, of an acute recurrent myocardial infarction. This new PTGS placement is an alternative treatment for symptomatic gallbladder disease in patients with increased operative risk when the endoscopic method is unsuccessful.