Search

Intraductal papillary or tubular neoplasms of the bile duct have recently been proposed as one of the pre-invasive lesions of cholangiocarcinoma. Herein, a total of 50 cases of intraluminal polypoid neoplasms of the bile ducts experienced in Khon Kaen University Hospital in Thailand were pathologically examined. These cases presumably had a history of infection of Opisthorchis viverrini. These neoplasms were histologically composed of high-grade intraepithelial neoplasm showing a tubular and/papillary pattern without invasion (20 cases), and with minimal and considerable invasion (15 and 15 cases, respectively). They were histologically classifiable into papillary type (10 cases), tubular type (20 cases) and papillotubular type (20 cases), and were phenotypically classifiable into gastric (17 cases), intestinal (17 cases) and pancreatobiliary types (16 cases). It was found that cases of papillary type and gastric or intestinal phenotype were less invasive, while those of tubular or papillotubular type and pancreatobiliary phenotype were more invasive. In conclusion, intraductal polypoid neoplasms in Thailand were well-differentiated papillary and/or tubular neoplasms including those with no or minimal invasion, and histological and phenotypic subclassifications seem to be useful for evaluation of the aggressive pathological behaviors of these neoplasms.

Background: Treatment or prevention of a benign biliary tree stricture is an unresolved problem. A novel self-expandable biodegradable polydioxanon biliary stent in a porcine model was studied., Materials and Methods: This new stent was used in 23 pigs. Feasibility and safety of surgical stenting, time of biodegradation, and histologic reaction in 2, 8, 13, and 20 wk of a follow-up were studied. All stents were inserted into a common bile duct through a duodenal papilla following small dilatation. After surgical evaluation of abdominal cavities, the pigs were sacrificed to remove common bile ducts with the stents. All bile ducts were assessed by macroscopic and histopathologic examination., Results: Self-expansion was correct in all cases. Neither bile duct obstruction nor postsurgical complications were observed. Macroscopic evaluation indicated lightening of the stent color in 2 wk, a partial disintegration in 8 wk, and a complete absorption in 13 and 20 wk. Histologic evaluation in general substantiated a mild-to-moderate inflammatory reaction in the lamina propria during the whole follow up and had no clinical consequences. No cholangitis, necrosis, abscess, or excessive fibroplasia was found in a hepatoduodenal ligament., Conclusions: Our results suggest that polydioxanon biodegradable self-expanding stents seem to be useful for biliary system implantation, offer a good biocompatibility, and completely degrade within 13 wk., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Introduction Peroral cholangioscopy (POC) enables direct visual examination of bile ducts, tissue sampling and therapeutic interventions. The authors aimed to evaluate the diagnostic utility of Spyglass POC for indeterminate biliary lesions and its usefulness in electrohydraulic lithotripsy (EHL) of bile duct stones not amenable to conventional endoscopic therapy. Methods A total of 141 consecutive patients (mean age 61 years (SD15); 62F), undergoing 149 attempted Spyglass procedures, in 3 UK tertiary referral centres between 2008 and 2010 were retrospectively enrolled. The authors estimate that >80% of all Spyglass procedures performed for indeterminate biliary lesions or EHL of stones in the UK are included. Brush cytology or POC-directed biopsies were obtained as clinically indicated. Patients were followed up for a mean of 9 months (7). The operating characteristics of POC for detecting malignant biliary lesions were calculated using a composite reference standard that included surgery, tissue sampling and follow-up. Bile duct clearance after POC-EHL was also determined using stone recurrence at follow-up as a reference standard. Results Indications for Spyglass procedures included 108/149 (72%) stricture assessment, 16/149 (11%) intraluminal mass assessment and 25/149 (17%) EHL for stones. The Spyglass cholangioscope could be inserted in the bile duct in 140/149 (94%) and adequate mucosal visualisation was achieved in 121/149 (81%). A diagnosis of cancer was made in 36/149 (24%). Brush cytology sampling was performed in 60/149 (40%) with 50/60 (83%) yielding sufficient samples. POC-directed biopsies were performed in 67/149 (45%) with 52/67 (78%) yielding sufficient samples. The sensitivity, specificity, positive and negative predictive values and accuracy of POC for the diagnosis of malignant lesions were 72%, 97%, 93%, 86% and 88%, respectively. 17 out of 36 (42%) malignant lesions were correctly identified at Spyglass POC (with/without tissue confirmation). In all 27 EHL procedures were performed in 25 patients. Bile duct clearance was achieved in 17/25 (68%) with a further 2/25 (8%) awaiting further procedures. There were 11/149 (7%) adverse events (8 cholangitis/sepsis, 1 postsphincterotomy bleed, 1 hypotension, 1 pancreatitis). Two adverse events were severe (1 death and 1 ITU admission both with sepsis) and one was moderate (sepsis). Conclusion In experienced hands, Spyglass POC is very accurate in the diagnosis of malignant biliary lesions and effective for the treatment of bile duct stones not amenable to conventional endoscopic therapy. The complication rate is comparable to that of conventional ERCP with sepsis being the most common adverse event. [ABSTRACT FROM PUBLISHER]

Routine experiences suggest that cholangiocarcinomas (CCAs) show different clinicopathological behaviors along the biliary tree, and hilar CCA apparently resembles pancreatic duct adenocarcinoma (PDAC). Herein, the backgrounds for these similarities were reviewed. While all cases of PDAC, hilar CCA, intrahepatic CCA (ICCA) and CCA components of combined hepatocellular-cholangiocarcinoma (cHC-CCA) were adenocarcinomas, micropapillary patterns and columnar carcinoma cells were common in PDAC and hilar CCA, and trabecular components and cuboidal carcinoma cells were common in ICCA and CCA components of cHC-CCA. Anterior gradient protein-2 and S100P were frequently expressed in perihilar CCA and PDAC, while neural cell adhesion molecule and luminal epithelial membrane antigen were common in CCA components of c-HC-CCA. Pdx1 and Hes1 were frequently and markedly expressed aberrantly in PDAC and perihilar CCA, although their expression was rare and mild in CCA components in cHC-CCA and ICCA. Hilar CCA showed a similar postoperative prognosis to PDAC but differed from ICCA and cHC-CCA. Taken together, hilar CCA may differ from ICCA and CCA components of cHC-CCA but have a similar development to PDAC. These similarities may be explained by the unique anatomical, embryological and reactive nature of the pancreatobiliary tract. Further studies of these intractable malignancies are warranted., (© 2014 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Cholangiocarcinoma (CC) of the biliary tract occasionally presents a predominant intraductal papillary growth in the bile ducts, called as biliary tract carcinoma (BTC) of papillary growth (PG) and intrahepatic CC (ICC) of intraductal growth (IG) type. Recently, intraductal papillary neoplasm of bile duct (IPNB) has been proposed as a pre-invasive biliary neoplasm. This study was performed to characterize pathologically BTC of PG type and ICC of IG type with respect to IPNB. It was found that 126 of such 154 CCs (81.8%) fulfilled the criteria of IPNB, while the remaining 28 cases showed different histologies, such as tubular adenocarcinoma and carcinosarcoma. These IPNBs occurred in old aged patients with a male predominance, and the left lobe was rather frequently affected in the liver. A majority of these cases were high grade IPNB (43 cases) and invasive IPNB (77 cases), while low grade IPNB was rare (6 cases). Pancreatobiliary type was predominant (48 cases) followed by gastric (30 cases), intestinal (29 cases) and oncocytic (19 cases) types. Mucus hypersecretion was found in 45 cases, and this was frequent in IPNB at the intrahepatic large bile duct and hilar bile ducts but rare at the extrahepatic bile ducts. Interestingly, 36 cases of high grade and invasive IPNBs contained foci of moderately differentiated adenocacinoma within the intraductal papillary tumor. In conclusion, a majority of ICC of IG type and BTC of PG type could be regarded as a IPNB lineage, and clinically detectable IPNBs were already a malignant papillary lesion.

Working knowledge of extrahepatic biliary anatomy is of paramount importance to the general surgeon. The embryologic development of the extrahepatic biliary tract is discussed in this article as is the highly variable anatomy of the biliary tract and its associated vasculature. The salient conditions related to the embryology and anatomy of the extrahepatic biliary tract, including biliary atresia, choledochal cysts, gallbladder agenesis, sphincter of Oddi dysfunction, and ducts of Luschka, are addressed., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Aim: To describe our patients affected with ectopic biliary tree gastrinoma and review the literature on this topic., Methods: Between January 1992 and June 2012, 28 patients affected by duodenopancreatic endocrine tumors in multiple endocrine neoplasia type 1 (MEN1) syndrome underwent surgery at our institution. This retrospective review article analyzes our experience regarding seventeen of these patients subjected to duodenopancreatic surgery for Zollinger-Ellison syndrome (ZES). Surgical treatment consisted of duodenopancreatectomy (DP) or total pancreatectomy (TP). Regional lymphadenectomy was always performed. Any hepatic tumoral lesions found were removed during surgery. In MEN1 patients, removal of duodenal lesions can sometimes lead to persistence or recurrence of hypergastrinemia. One possible explanation for this unfavorable outcome could be unrecognized ectopic localization of gastrin-secreting tumors. This study described three cases among the seventeen patients who were found to have an ectopic gastrinoma located in the biliary tree., Results: Seventeen MEN1 patients affected with ZES were analyzed. The mean age was 40 years. Fifteen patients underwent DP and two TP. On histopathological examination, duodeno pancreatic endocrine tumors were found in all 17 patients. Eighty-one gastrinomas were detected in the first three portions of the duodenum. Only one gastrinoma was found in the pancreas. The mean number of gastrinomas per patient was 5 (range 1-16). Malignancy was established in 12 patients (70.5%) after lymph node, liver and omental metastases were found. Three patients exhibited biliary tree gastrinomas as well as duodenal gastrinoma(s). In two cases, the ectopic gastrinoma was removed at the same time as pancreatic surgery, while in the third case, the biliary tree gastrinoma was resected one year after DP because of recurrence of ZES., Conclusion: These findings suggest the importance of checking for the presence of ectopic gastrinomas in the biliary tree in MEN1 patients undergoing ZES surgery., (© 2013 Baishideng Publishing Group Co., Limited. All rights reserved.)

Cholangiocytes are epithelial cells lining the biliary epithelium. Cholangiocytes play several key roles in the modification of ductal bile and are also the target cells in chronic cholestatic liver diseases (i.e., cholangiopathies) such as PSC, PBC, polycystic liver disease (PCLD) and cholangiocarcinoma (CCA). During these pathologies, cholangiocytes (which in normal condition are in a quiescent state) begin to proliferate acquiring phenotypes of neuroendocrine cells, and start secreting different cytokines, growth factors, neuropeptides, and hormones to modulate cholangiocytes proliferation and interaction with the surrounding environment, trying to reestablish the balance between proliferation/loss of cholangiocytes for the maintenance of biliary homeostasis. The purpose of this review is to summarize the recent findings on the mechanisms regulating cholangiocyte proliferation and the significance of the neuroendocrine regulation of cholangiocyte pathophysiology. To clarify the mechanisms of action of these factors we will provide new potential strategies for the management of chronic liver diseases.

Aim: To investigate the roles of peribiliary glands around the bile ducts in the pathophysiology of the biliary tract., Methods: The expression of fetal pancreatic markers, pancreatic duodenal homeobox factor 1 (PDX1) and hairy and enhancer of split 1 (HES1) and endodermal stem/progenitor (S/P) cell markers [CD44s, chemokine receptor type 4 (CXCR4), SOX9 and epithelial cell adhesion molecule (EpCAM)] were examined immunohistochemically in 32 normal adult livers (autopsy livers) and 22 hepatolithiatic livers (surgically resected livers). The latter was characterized by the proliferation of the peribiliary glands. Immunohistochemistry was performed using formalin-fixed, paraffin-embedded tissue sections after deparaffinization. Although PDX1 and HES1 were expressed in both the nucleus and cytoplasm of epithelial cells, only nuclear staining was evaluated. SOX9 was expressed in the nucleus, while CD44s, CXCR4 and EpCAM were expressed in the cell membranes. The frequency and extent of the expression of these molecules in the lining epithelia and peribiliary glands were evaluated semi-quantitatively based on the percentage of positive cells: 0, 1+ (focal), 2+ (moderate) and 3+ (extensive)., Results: In normal livers, PDX1 was infrequently expressed in the lining epithelia, but was frequently expressed in the peribiliary glands. In contrast, HES1 was frequently expressed in the lining epithelia, but its expression in the peribiliary glands was focal, suggesting that the peribiliary glands retain the potential of differentiation toward the pancreas and the lining epithelia exhibit properties to inhibit such differentiation. This unique combination was also seen in hepatolithiatic livers. The expression of endodermal S/P cell markers varied in the peribiliary glands in normal livers: SOX9 and EpCAM were frequently expressed, CD44s infrequently, and CXCR4 almost not at all. The expression of these markers, particularly CD44s and CXCR4, increased in the peribiliary glands and lining epithelia in hepatolithiatic livers. This increased expression of endodermal S/P cell markers may be related to the increased production of intestinal and gastric mucin and also to the biliary neoplasia associated with the gastric and intestinal phenotypes reported in hepatolithiasis., Conclusion: The unique expression pattern of PDX1 and HES1 and increased expression of endodermal S/P cell markers in the peribiliary glands may be involved in biliary pathophysiologies.

Cholangiocarcinomas (CCs) show intraluminal spread to bile ducts and periductal infiltration associated with vascular, lymphatic and perineural invasion in addition to direct penetration. Recently, the peribiliary gland networks located around the hilar and extrahepatic bile ducts have been reportedly to be involved in a variety of biliary diseases. However, the pathological features and roles of these networks in the carcinogenesis and progression of CCs remain to be explored. Recently, we experienced two cases of hilar CC showing a nodular sclerosing growth grossly and histologically well-differentiated adenocarcinomas, with an extensive involvement of the peribiliary gland networks. In situ like spread of carcinoma cells in the bile duct lumen was focal in one case and not identifiable in the other. In contrast, other 4 cases of ordinary hilar CC which were also well-differentiated adenocarcinomas, showed variable intraductal luminal spread and also extensive periductal infiltration irrespective of the peribiliary gland network. In conclusion, the present study showed a unique form of periductal spread of CCs with preferential and extensive involvement of the peribiliary gland networks.

Introduction: Advanced malignant tumours involving the head of the pancreas, gallbladder or extrahepatic bile ducts usually lead to the development of cholestasis. In such cases improvement of the quality of life of patients can be achieved with the decompression of jaundice. Endoscopic implantation of self-expanding or (seldom) rigid plastic stents into the biliary tree constitutes the most common technique allowing for restoration of bile duct patency. In some patients however the use of such a procedure is technically impossible. In this particular group percutaneous drainage of the biliary tree can constitute the only method of management., Aim: Presentation of our experience with the use of percutaneous ultrasound-guided drainage of the biliary tree in patients with mechanical jaundice resulting from malignant tumours., Material and Methods: There were 852 patients with mechanical jaundice resulting from malignant neoplasms treated in the 2(nd) Chair of Surgery of Jagiellonian University Medical College from January 1994 to December 2010. In 199 of them jaundice was decompressed by means of open - radical or palliative - surgical operations. In 539 patients endoscopic treatment was implemented while in 114 of them percutaneous ultrasound-guided drainage was performed., Results: In 5 patients percutaneous drainage was introduced to prepare them for radical surgical treatment, while in the remaining 109 it constituted the definitive way of management. The average hospitalization time for women was 6.5 days (range: 1-22 days) and proved to be twice as short as in men - 12.2 days (range: 1-38 days). The duration of percutaneous drainage prior to surgical treatment averaged 7.2 days (range: 6-10 days). Mean volume of the bile drained during the first day was 370 ml (range: 10-1300 ml), increased to 450 ml (range: 100-1150 ml) during the second day and reached 780 ml (range: 80-1600 ml) during the third day. Mean bilirubin level before the drainage was 320-23 µmol/l (range: 658-130.7 µmol/l) and decreased by half before discharge or before the operation, reaching on average 181.87 µmol/l (range: 14.5-343 µmol/l)., Conclusions: Complications of the percutaneous ultrasound-guided technique were found sporadically and resulted from leakage of the bile into the peritoneum.

Advances in technology have made possible the clinical application of magnetic resonance cholangiography, endoscopic, intra-operative and laparoscopic ultrasound in the study of the biliary tree, in addition to conventional magnetic resonance imaging and transabdominal ultrasound. The role of the conventional, as well as the newer techniques, in the diagnosis of bile duct disease and the limitations and pros and cons of each technique, will be the subject of the present discussion., (© 1998 The Official Publication of the Asian Pacific Association for the Study of the Liver and the Asian Pacific Association of Gastroenterology.)