Clinical problems in the surgical treatment of pancreaticobiliary maljunction

Abstract

Abstract:The results of surgical treatment of pancreaticobiliary maljunction at our department are described. The 67 patients who underwent surgery for this disease were divided by age into an adult group (45 patients, aged 16 years and over) and a pediatric group (22 patients, aged less than 16 years). The incidence of concomitant carcinoma before surgery and the incidence and severity of postoperative cholangitis were compared between these two groups. In addition, the cell proliferating activity of the biliary tract epithelium in cancer-free patients was compared between the two groups, using the proliferating cell nuclear antigen labeling index (PCNA LI). Ten patients (all adults) were diagnosed with cancer (gallbladder carcinoma in 7 and bile' duct carcinoma in 3) before surgery. The surgical techniques used for reconstruction in the cancer-free patients were: in the adult group, hepaticoduodenostomy in 9 patients, Roux-en-Y hepaticojejunostomy in 17, jejunal interposition in 8, and another technique in 1. In the pediatric group, hepaticoduodenostomy was performed in 17 patients, Roux-en-Y hepaticojejunostomy in 3, and jejunal interposition in 2. Postoperative cholangitis occurred in 6 adults (including 2 with severe form) and 1 child (mild case). The PCNA LI of the biliary tract epithelium was high compared to control findings in the biliary tract epithelium of 10 adult patients without pancreaticobiliary maljunction. In the adult group with dilated extrahepatic bile ducts (n = 10 examined) this index was 11.4% for the bile duct epithelium (control, 1.5%) and 12.7% for the gallbladder epithelium (control, 1.4%). In the adult group with non-dilated extrahepatic bile ducts (n -5 examined) it was 5.9% for the bile duct epithelium and 13.1% for the gallbladder epithelium. In the pediatric group (n = 10 with extrahepatic bile duct dilatation) it was 7.5% for the bile duct and 9.7% for the gallbladder epithelium. (Differences from control values were all significant.) These results suggest that surgery for this disease should be performed as early as possible and that extrahepatic bile duct excision and biliary reconstruction should be performed whether or not extrahepatic bile ducts are dilated. Offprint requests to." H. Hara

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

“…Correlations between the Ki67-LI or the proliferating cell nuclear antigen (PCNA)-LI of nonneoplastic GB mucosa and BD morphology have not been clarifi ed. 5,19,22 In our study, the Ki67-LI of the nonneoplastic GB mucosa was similarly high in both the D-type and N-type patients. The Ki67-LI of the nonneoplastic BD mucosa in the D-type patients tended to be higher than that in the N-type patients, which corresponds well to previous fi ndings.…”

“…[4][5][6][7][8] The fi ndings of the present study suggest that increased cell proliferation activity causes HE, followed by the development of AE and cancer in the GB epithelium of both D-type and N-type AAPB patients and in the BD epithelium of D-type patients. Metaplastic changes such as PGM and IM probably play some roles in this process.…”

“…The Ki67-LI of the nonneoplastic BD mucosa in the D-type patients tended to be higher than that in the N-type patients, which corresponds well to previous fi ndings. 5,6,19 The frequency of p53 protein overexpression in noncancerous GB and BD epithelium has been reported to be 11%-33% and 56%-75% in D-type patients, and 38%-43% and 13%-14% in N-type patients, respectively. 20,23 Although the number of our cases was limited, our data also suggest a low incidence of p53 protein overexpression in the nonneoplastic BD epithelium in N-type patients.…”

“…2,4 It is controversial whether or not prophylactic excision of the extrahepatic bile duct is necessary for AAPB patients without a dilated BD. 2,[4][5][6][7][8] Stagnation of pancreatic juice mixed with bile in the dilated BD or the gallbladder (GB) probably plays an important role in carcinogenesis in GBCa and BDCa. 9,10 Hyperplastic epithelium (HE) is frequently seen in the biliary tract, especially in the GB of AAPB patients.…”

Clinical presentations and outcomes of pancreaticobiliary maljunction in different pediatric age groups

“…This discrepancy could be explained by the different age spans of patients selected in the two studies. In any case, the length of the common channel is of concern because a relatively long common channel could be an important risk factor for the development of biliary tract cancer [ 18 , 19 ]. Although the diameter of the CBD increases with age [ 12 ], infantile patients with PBM exhibited a larger maximum diameter of the CBD than older patients (> 3 years old).…”