Preoperative evaluation of ampullary neoplasm with EUS and transpapillary intraductal US: a prospective and histopathologically controlled study

BACKGROUND: Endoscopic papillectomy is performed in selected patients with ampullary neoplasm, and, thus, accurate preoperative tumor staging is indispensable for its application. DESIGN: Prospective and histopathologically controlled study. SETTING: Single center. PATIENTS AND INTERVENTIONS: EUS and transpapillary intraductal US (IDUS) were performed in 40 patients with ampullary neoplasm before surgery (n = 30) or endoscopic papillectomy (n = 10). Ductal infiltration by a tumor into the bile duct (BD) or the pancreatic duct (PD) was also evaluated. The indication for endoscopic papillectomy was determined by findings obtained by EUS and IDUS. These findings were compared with histologic features of the resected specimens. MAIN OUTCOME MEASUREMENTS AND RESULTS: Thirty-three patients had adenocarcinoma (14 pT1, 11 pT2, 8 pT3-4) and 7 had adenoma. Tumor depiction by EUS and IDUS was achieved in 95% and 100% of the patients, respectively. The diagnostic accuracy of EUS and IDUS in T staging was 62% and 86% in adenoma and pT1, 45% and 64% in pT2, and 88% and 75% in pT3-4, respectively. The overall accuracy by EUS and IDUS in T staging was 63% and 78%, respectively (P = .14). In 10 patients who underwent endoscopic papillectomy, the accuracy of IDUS in T staging with EUS and IDUS was 80% and 100%, respectively. Ductal infiltration into the BD and the PD was correctly assessed in 88% and 90% by EUS and in both BD and the PD in 90% by IDUS, respectively. Ductal infiltration was correctly diagnosed by EUS and IDUS in all patients who had a papillectomy. CONCLUSION: Although IDUS had a tendency of overestimation in tumor staging for ampullary neoplasm, it can provide useful information for making therapeutic decisions, especially in cases appropriate for endoscopic papillectomy.     

Clinical factors predictive of spontaneous remission or relapse in cases of autoimmune pancreatitis

BACKGROUND: The rates of spontaneous remission and relapse of autoimmune pancreatitis (AIP) are not known. OBJECTIVE: To study the clinicopathologic factors predictive of remission and relapse in cases of AIP. DESIGN: Retrospective study. PATIENTS: Of the 20 patients with AIP, complete response to steroid therapy was recognized in 12 patients, and the remaining 8 patients improved without steroid therapy. Seven patients experienced a relapse. RESULTS: Patients who were seronegative for immunoglobulin (Ig) G4, had no obstructive jaundice, no diabetes mellitus, no swelling of the duodenal papilla, negative staining of the duodenal papilla for IgG4, and focal pancreatic swelling showed a greater tendency toward spontaneous remission (P < .05). The results of multivariate analysis revealed that negative staining of the duodenal papilla for IgG4 was the only independent predictor of spontaneous remission of AIP (odds ratio [OR] 1.395, P = .0304). Seropositivity for IgG4, diffuse swelling of the pancreas, and the presence of stricture in the lower part of the bile duct were significantly associated with a relapse of AIP (P < .05) according to the results of univariate analysis, whereas the results of multivariate analysis revealed only diffuse pancreatic swelling as an independent predictor of a relapse of AIP (OR 26.197, P = .0331). CONCLUSIONS: Endoscopic findings are of useful prognostic value, because patients with AIP and with negative staining of the duodenal papilla for IgG4 appeared to have a higher frequency of remission without steroid therapy. Patients with AIP and with diffuse pancreatic swelling were found to be at an increased risk of relapse after the initial steroid administration.     

Cap-assisted ERCP in patients with a Billroth II gastrectomy

BACKGROUND: ERCP is difficult in patients with a Billroth II gastrectomy because of anatomical changes. OBJECTIVE: Cap-assisted ERCP can improve the cannulation rate and the success rate of stone removal. DESIGN: Case series. SETTING: A tertiary referral center. PATIENTS AND INTERVENTIONS: Ten consecutive patients with bile-duct stones (9) or a distal common bile duct stricture (1), who had previously undergone Billroth II gastrectomy and were referred for ERCP, were analyzed for the outcome of their ERCP. All procedures were carried out with a cap-fitted regular forward-viewing endoscope. MAIN OUTCOME MEASUREMENTS: Ability to perform afferent loop intubation and bile-duct cannulation. RESULTS: Of 10 patients in whom ERCP was attempted, afferent loop intubation and selective bile-duct cannulation were achieved in all patients (100%). Endoscopic sphincterotomy (EST) was successful in all 10 patients (100%). All stones were removed by EST alone in 7 patients and by both EST and endoscopic papillary balloon dilation in 2 patients. There were no serious complications in the patients. LIMITATIONS: Small sample size, single-center experience. CONCLUSIONS: Diagnostic and therapeutic ERCP with a cap-fitted regular forward-viewing endoscope was successful in all patients with a prior Billroth II gastrectomy. The high rate of successful ERCP was achieved by improving afferent loop intubation and bile-duct cannulation with a cap-fitted endoscope.     

Glucagon-like peptide-1 and its receptor agonist exendin-4 modulate cholangiocyte adaptive response to cholestasis

BACKGROUND & AIMS: Cholangiopathies are characterized by progressive dysregulation of the balance between proliferation and death of cholangiocytes. In the course of cholestasis, cholangiocytes undergo a neuroendocrine transdifferentiation and their biology is regulated by neuroendocrine hormones. Glucagon-like peptide-1 (GLP-1), secreted by neuroendocrine cells, sustains beta-cell survival in experimental diabetes and induces the neuroendocrine transdifferentiation of pancreatic ductal cells. GLP-1 receptor (GLP-1R) selective agonist exendin-4 is used in humans as a novel therapeutic tool for diabetes. The aim of this study was to define if GLP-1 modulates cholangiocyte biologic response to cholestasis. METHODS: Expression of GLP-1R in cholangiocytes was determined. Effects on cholangiocyte proliferation of the in vitro and in vivo exposure to GLP-1 or exendin-4, together with the intracellular signals, were then studied. Synthesis of GLP-1 by cholangiocytes and the effects of GLP-1R blockage on their growth were also determined. RESULTS: Cholangiocytes express the GLP-1 receptor, which is up-regulated in the course of cholestasis. GLP-1 and exendin-4 increase cholangiocyte growth both in vitro and in vivo. The GLP-1R signal is mediated by the phosphatidyl-inositol-3-kinase, cAMP/Protein Kinase A, and Ca(2+)-CamKIIalpha but not by the ERK1/2 and PKCalpha pathways. Proliferating cholangiocytes synthesize GLP-1: neutralization of its action by GLP-1R antagonist blunts cholangiocyte response to cholestasis. CONCLUSIONS: GLP-1 is required for the cholangiocyte adaptive response to cholestasis. Cholangiocytes are susceptible to the activation of GLP-1R and respond with increased proliferation and functional activity. Exendin-4 availability for employment in humans and these data may open novel perspectives for the medical treatment of cholangiopathies.     

Histological study of gallbladder and bile duct epithelia in patients with anomalous arrangement of the pancreaticobiliary ductal system: comparison between those with and without a dilated common bile duct

Background We histologically evaluated the epithelia of the gallbladder (GB) and bile duct (BD) in patients with anomalous arrangement of the pancreaticobiliary ductal system (AAPB), with regard to the shape of the common BD (CBD). Methods The GB and BD were studied histologically using surgical materials from 44 patients with AAPB: 27 with a dilated CBD (D-type) and 17 with a nondilated CBD (N-type). Results GB cancer and BD cancer were found in 11.1% and 3.7% of D-type and 17.6% and 0% of N-type respectively. Hyperplastic epithelium and atypical epithelium of the GB were frequently seen in both D-type (46%, 46%) and N-type (82%, 70%), while such epithelia of the BD were only seen in D-type (10%, 35%). The Ki67 labeling index of the nonneoplastic epithelium of the GB was high in both D-type (13.0%) and N-type (9.7%), though that of the BD was high in D-type (12.5%) but low in N-type (1.8%). The prevalences of pyloric gland metaplasia, intestinal metaplasia, and p53 protein overexpression of the nonneoplastic epithelium did not show any significant differences between D-type and N-type. Conclusions It is suggested that the BD epithelium of N-type probably has a lower potential for developing malignancy than that of D-type, while the GB epithelia of both D-type and N-type have a high potential for developing malignancy. This might support the selection of simple cholecystectomy as the treatment of choice in AAPB patients of N-type, although further investigation of the BD epithelium is required in a larger number of such patients.     

Sarcoplasmic ATP-sensitive potassium channel blocker HMR1098 protects the ischemic heart: implication of calcium, complex I, reactive oxygen species and mitochondrial ATP-sensitive potassium channel

The aim of this study was to investigate the effects of HMR1098, a selective blocker of sarcolemmal ATP-sensitive potassium channel (sarcK(ATP)), in Langendorff-perfused rat hearts submitted to ischemia and reperfusion. The recovery of heart hemodynamic and mitochondrial function, studied on skinned fibers, was analyzed after 30-min global ischemia followed by 20-min reperfusion. Infarct size was quantified on a regional ischemia model after 2-h reperfusion. We report that the perfusion of 10 microM HMR1098 before ischemia, delays the onset of ischemic contracture, improves recovery of cardiac function upon reperfusion, preserves the mitochondrial architecture, and finally decreases infarct size. This HMR1098-induced cardioprotection is prevented by 1 mM 2-mercaptopropionylglycine, an antioxidant, and by 100 nM nifedipine, an L-type calcium channel blocker. Concomitantly, it is shown that HMR1098 perfusion induces (i) a transient and specific inhibition of the respiratory chain complex I and, (ii) an increase in the averaged intracellular calcium concentration probed by the in situ measurement of indo-1 fluorescence. Finally, all the beneficial effects of HMR1098 were strongly inhibited by 5-hydroxydecanoate and abolished by glibenclamide, two mitoK(ATP) blockers. This study demonstrates that the HMR1098-induced cardioprotection occurs indirectly through extracellular calcium influx, respiratory chain complex inhibition, reactive oxygen species production and mitoK(ATP) opening. Taken together, these data suggest that a functional interaction between sarcK(ATP) and mitoK(ATP) exists in isolated rat heart ischemia model, which is mediated by extracellular calcium influx.     

Chronic Extrahepatic Bile Duct Dilatation: Sonographic Screening in the Patients with Opioid Addiction

Objective

One of the best known side effects of using opium is spasm of the sphincter of Oddi, which may increase the diameter of the extrahepatic bile ducts. Ultrasound is the first imaging modality used for evaluating the biliary system because it is commonly available and noninvasive. The principal objective of this study was to measure the common bile duct (CBD) diameter via ultrasonography in opium addicts and to evaluate the relation between the CBD diameter and the period of addiction.

Materials and Methods

This research was an analytical-cross sectional study that was done on 110 opium addicts that were admitted to a drug treatment center. The diameter of the CBD in these cases was measured by ultrasonography and the results were analyzed with other factors like age, the period of addiction and the laboratory findings.

Results

According to the findings, there is a significant increase in the range of the CBD diameter in comparison with normal bile ducts. Also, the mean diameter of the CBD in the different age groups showed a significant difference (p < 0.0001) and there was a significant relation between the CBD diameter and the period of addiction (p < 0.001, r = 0.74); so, with the increased length of the addiction period, the mean CBD diameter increases.

Conclusion

Opium addiction is one of the factors that causes extrahepatic bile duct dilatation, so in these cases, if no obstructing lesion was found on ultrasound examination and the serum bilirobine and alkaline phosphatase levels are normal, then further evaluation is not needed.     

奉节县2004—2008年居民户碘盐监测结果分析

目的全面、准确地掌握奉节县居民食用合格碘盐的情况,确保碘缺乏病防治措施的有效实施,为持续消除碘缺乏病工作提供科学依据。方法按照《重庆市碘盐监测方案》规定的抽样方法及盐碘测定方法对居民户食用盐进行监测。结果2004—2008年监测居民户家庭食用盐每年360份,共1800份,碘含量均数为30．75mg／kg,变异系数为21．06,年份间碘含量差异有统计学意义（F=13．755,P〈0．05）,呈明显线性下降趋势（R=0．12,P〈0．05）;碘盐覆盖率为99．39％,碘盐合格率为94．69％,合格碘盐食用率为94．11％,非碘盐率为0．61％,年份间差异均无统计学意义（P〉0．05）。结论奉节县实现基本消除碘缺乏病阶段目标后,居民合格碘盐食用率保持在90％以上,成果巩固。各级政府应持续重视,完善监督监测机制,确保碘盐质量,以实现消除碘缺乏病的目标。     

Prognostic significance of fascin expression in extrahepatic bile duct carcinomas

Extrahepatic bile duct (EBD) carcinoma is an aggressive cancer with a poor prognosis. Fascin is an actin-bundling protein with roles in forming cell protrusions and mesenchymal and neuronal cell motility. Many human neoplasms up-regulate fascin. High fascin expression is thought to be a poor prognostic factor in some cancers; however, few data are available for the role of fascin in EBD carcinoma. We investigated fascin immunoreactivity in EBD carcinoma and tested it for correlations between fascin expression and clinicopathological parameters.Conventional tissue sections of 114 cases of EBD carcinomas were immunohistochemically analyzed for fascin expression.Fascin expression was tested by cytoplasmic staining. Negative, weak positive, and strong positive fascin staining was observed in 49 (43.0%), 32 (28.1%), and 33 cases (28.9%), respectively. Fascin expression in EBD carcinomas was significantly correlated with histological grade (P<0.0001), primary tumor (T) (P=0.002), TNM stage (P=0.036), lymphatic invasion (P=0.048), venous invasion (P=0.024), and adjacent organ invasion (P<0.0001). High fascin expression was a significant poor prognostic factor (P=0.0001) in EBD carcinoma. High fascin expression (P=0.004) and TNM stage (P=0.001) in EBD carcinoma were independent adverse prognostic factors.High fascin expression is significantly correlated with aggressive tumor phenotype in EBD carcinoma and is an independent poor prognostic factor in EBD carcinoma.