Thermal bile duct and duodenal protection during pancreatic cryoablation

Aim

To examine whether thermo-perfusion of the bile duct and duodenum may protect these organs during cryoablation of adjacent pancreatic tissue.

Study design

Cryoablation of the pancreatic tissue, adjacent to the common bile duct and duodenum was performed in two groups of pigs. In the experimental group, the bile duct and duodenum were protected during the cryo-procedure by intraluminal perfusion of warm saline. In the control group, cryoablation was performed without thermo-protection.

Results

All three animals in the control group developed duodenal perforation and abscesses and died within a week. All the pigs in the experimental group survived and on re-operation 14 days after the first procedure were found to have normal duodenum and bile duct adjacent to the cryoablated pancreatic tissue. Histological examinations confirmed these results.

Conclusion

The present study confirms the feasibility and efficacy of thermo-protection of the duodenum and common bile duct during cryoablation of the head of the pancreas.     

Exogenous and endogenous contribution to nitrogen fluxes in the digestive tract of pigs fed a casein diet. I. Contributions of nitrogen from the exocrine pancreatic secretion and the bile

The aim of the present work was to study the endogenous contribution of the exocrine pancreatic and biliary secretions to the total endogenous nitrogen production in the pig. Three growing Large White pigs weighing 45 +/- 2.5 kg were fitted with permanent fistulae in the pancreatic duct, the bile duct and the duodenum. They were adapted to a semi-synthetic casein diet for 14 d before surgery. In a 7-d post-operative period and an 8-d experimental period, they were fed the same diet. Secretion rates were recorded, total nitrogen and TCA (trichloroacetic acid) insoluble nitrogen were determined in representative pancreatic juice and bile samples. Daily pancreatic juice and bile flow rates were very similar: 1,850 and 1,820 ml, respectively. The amount of endogenous total nitrogen secreted in the intestinal lumen was 3.6 g per day: 1.9 g N through pancreatic secretion and 1.7 g N through bile secretion. Pancreatic nitrogen increased after meal intake, whilst the kinetics of nitrogen production in the bile were not affected. Throughout the experiment, the mean percentage of TCA insoluble nitrogen was 78.1% in pancreatic juice and 72.3% in bile.     

Anatomo-stereologic characteristics of the mucous membrane of the major duodenal papilla

In 55 men and 60 women who had had not any pathology in their biliary-pancreato-duodenal system during life, microrelief of the mucous membrane in the major duodenal papilla has been studied by means of light and scanning electron microscopy. It is defined by variants of fusion of the common bile duct and the pancreatic duct in the papilla. Three main variants of the ducts fusion are defined and, respectively, three main varieties of the structure of the mucous membrane folds. When the ducts flow into the same orifice separately, the mucous membrane relief is even, parvigranular and there are no fold-valves. In the common major duodenal papilla, the architectonics of the mucous membrane resembles the valve that acts as a block-outlet mechanism.     

Studies on the microvascularization of the digestive tract by scanning electron microscopy of vascular corrosion casts. 2. Bile duct in guinea pigs.

The microvascularization of the bile duct was studied in 20 adult guinea pigs (Cavia porcellus) using microvascular corrosion casts in the scanning electron microscope. The main supplying and draining vessels are located in the adventitial layer; from there they form the subepithelial capillary network. The microangioarchitecture of the common bile duct is reminiscent of that of the cystic and hepatic ducts. The diameter of these ducts is 1,000 microns on average. The microvascular arrangement in the bile duct suggests a probable involvement of the capillaries in the absorption of bile hormones.     

Effect of ML-236B (compactin) on biliary excretion of bile salts and lipids, and on bile flow, in the rat

To assess the importance of de novo cholesterol synthesis for bile salt formation, the effects of ML-236B (an inhibitor of 3-hydroxy-3-methylglutaryl-coenzyme A reductase) on biliary excretion of bile salts and lipids were studied in rats with permanent catheters in bile duct, heart and duodenum. In rats having their bile diverted continuously for 8 days, duodenal administration of ML-236B (50 mg/kg) caused an immediate transient choleresis, which subsided after 2 h. Concomitant with the choleresis concentrations of bile salt, phospholipid and cholesterol fell, but this decrease was maintained for 6 h. Consequently, ML-236B inhibited biliary output salts and lipids from the second till the sixth hour after injection. The kinetics of biliary excretion of intravenously injected [14C]taurocholate were not affected by ML-236B administration. In rats having their biliary catheter connected to the duodenal catheter, or in rats with prolonged bile diversion but treated with mevalonolactone, ML-236B again caused a transient choleresis (having subsided after 2 h), but now did not affect biliary excretion of bile salts and lipids. It is concluded that (1) ML-236B causes a transient bile salt-independent choleresis, (2) ML-236B depresses excretion of bile salts and lipids by blocking mevalonate synthesis and not by blocking the bile salt or lipid transport, (3) biliary excretions of phospholipids and cholesterol partly depend on excretion of bile salt, and (4) in rats with a prolonged total bile diversion newly formed mevalonate is a major substrate for bile salt synthesis.     

Intraductal polypoid growth variant of pancreatic acinar cell carcinoma metastasizing to the intrahepatic bile duct 6 years after surgery: a case report and literature review

We present the first reported case of intraductal polypoid growth (IPG) variant of pancreatic acinar cell carcinoma (ACC) metastasizing to the intrahepatic bile duct. A 58-year-old Japanese woman had previously presented with obstructive jaundice and a 7.0 cm mass in the pancreatic head. She underwent biliary drainage for 2 months followed by pancreatectomy. Histological examination revealed a carcinoma with acinar pattern, immunohistochemically positive for trypsin, and acinar cell carcinoma was diagnosed. IPGs were prominent in the main pancreatic duct and its tributaries, extending into the intrapancreatic bile duct with tumor casts in the lumen. Imaging examinations 6 years later revealed a growing lesion within the intrahepatic bile duct. Needle biopsy examination suggested metastasis of ACC, and she underwent chemoradiation therapy and partial hepatectomy. Histological examination demonstrated ACC confined to the intrahepatic bile duct. The localization of metastasis and slow growth may indicate indolent biologic behavior of the IPG variant.     

Gross anatomy of the liver, biliary tree, and pancreas in the black-tailed prairie dog (Cynomys ludovicianus)

The gross anatomy of the liver, extrapetatic biliary tree, sphincter of Oddi, and pancreas in the black-tailed prairie dog (Cynomys ludovicianus), a widely used animal model for investigations into biliary physiology, pathophysiology, and pathology, was studied in 10 animals. The liver consists of 4 lobes, the left lateral, median, right lateral, and caudate. The gallbladder lies on the ventral surface of the right lobule of the median lobe. The cystic and hepatic ducts unite to form the common bile duct which enters the duodenum approximately 5 mm distal to the pylorus. The lower end of the common duct dilates forming an ampulla which is surrounded proximally by a band of circular muscle fibres which constitute the choledochal sphincter. The pancreatic duct opens separately into the duodenum approximately 80 mm from the pylorus. Earlier physiologic studies have demonstrated that the choledochal sphincter has intrinsic motility distinct from the duodenum.     

Bile secretion in the fistulated pig: effect of the method used for bile reinfusion

The aim of this work was to investigate the effects on bile secretion of flow rate and site of reinfusion of the collected bile to the animal. Thirty-two pigs weighing 50 +/- 3 kg at the beginning of the experiment were fitted with a reentrant fistula in the lower common bile duct and in the upper duodenum. Bile collected from the bile duct was reinfused in four different ways (four groups of 8 animals each): into the duodenum or the lower common bile duct at a constant flow rate using a peristaltic pump, or into the duodenum or the lower common bile duct at a rate mimicking the flow rate of the secretion using an automatic apparatus. Reinfusing the bile into the lower common bile duct at a rate mimicking the secretion rate provided a daily bile acid production about 21% higher than the level recorded with the other three methods. This was mainly due to a higher bile acid concentration since the bile flow was only slightly affected by the treatment.     

磁共振胰胆管成像联合增强扫描在壶腹周围病变中的价值

目的探讨磁共振胰胆管成像（MRCP）在壶腹周围病变中的应用价值。方法采用重T2加权MR水成像技术对63例患者行MRCP检查,图像经三维最大信号强度投影（3DMIP）后处理。结果63例患者中,3例为正常,60例发现不同程度病变,其中肿瘤患者36例（9例肝门区原发性胆管细胞癌、2例肝门转移癌、5例原发性肝癌、4例肝外胆管癌、5例壶腹癌、8例胰头癌、3例十二指肠癌）,灵敏度为93．2％;结石患者16例（6例胆总管结石、6例胆囊结石、4例肝总管结石）,灵敏度为89．5％;炎症患者8例（3例胆管炎、3例胰腺炎、2例十二指肠憩室合并感染）,灵敏度为83．2％。均与病理或临床诊断无统计学差异（P〉0．05）。结论MRCP可准确显示胆管梗阻部位,明确病变性质,对非梗阻性胆胰疾病,MRCP可显示病变与周围脏器的毗邻关系,但不能脱离MRI平扫和增强,是后者的一种有效补充。     

改良单层胰肠吻合术在胰十二指肠切除术带蒂大网膜包埋中的应用

目的:探讨带蒂大网膜包埋的改良单层胰肠吻合法重建消化道的胰十二指肠术的临床疗效。方法:回顾性分析2012年9月-2014年12月在我院行胰十二指肠切除术带蒂大网膜包埋改良单层胰肠吻合术的34例患者的临床资料。统计患者的手术时间、胰肠吻合时间、术后出血量、住院时间以及并发症的发生情况。结果:(1)手术平均时间(2.9±1.4)h,胰肠吻合平均时间(14±2.1)min,术后平均出血量(380±60)m L。所有患者经治疗后均治愈出院,住院时间平均(13.0±2.4)天。(2)术后并发症发生率为8例(23.5%),其中胰瘘2例(5.8%),为A级胰瘘;腹部感染3例(8.8%);腹腔出血2例(5.8%);胃排空延迟1例(2.9%)。无手术死亡者,无因严重并发症需要再次手术者。术后病理学诊断胰头癌18例,胆总管下癌8例,壶腹部癌5例,十二指肠乳头癌3例。结论:带蒂大网膜包埋的改良单层胰肠吻合能够减少术后胰瘘、出血、感染等并发症,提高手术成功率,值得临床进一步推广。     

Mast cell responses to Hymenolepis microstoma infection in mice

Murine mast cells (MC) responded strongly to Hymenolepis microstoma infection. Starting day 7 postinfection (PI) and continuing until the end of the experiment (35 days PI), significantly larger numbers of MC were present in both the duodenum and bile duct of infected mice than in uninfected controls. In animals challenged with 5 cysticercoids 2 wk after primary infection, the MC response in the duodenum, but not in the bile duct, was of even greater degree than in naive hosts. The majority of MC in the duodenum of infected and challenged mice were intraepithelial mucosal MC, whereas in the bile duct the majority were connective tissue MC. Hypertrophy of the duodenal submucosa and of the bile duct wall was noticeable in all infected and challenged hosts. Worms in primary infections were not affected by the host response, but none of the worms in the challenge dose became established. It is postulated that the type of MC involved in specific immune response of the host is the intraepithelial MC, whereas the cell type participating in general inflammatory events is the connective tissue MC.     

Pathways of absorption of retinal and retinoic acid in the rat

The chemical and anatomical pathways of absorption of dietary retinal, retinoic acid, and retinol were examined in rats containing lymph, bile, and duodenal cannulae. The experiments were designed to maintain physiological conditions to the greatest possible extent. In each rat an uninterrupted flow of bile into the duodenum was maintained by connecting the duodenal cannula to the bile duct of a second rat. Labeled vitamin A compounds were introduced into the duodenum in very small amounts (7-14 micrograms) in the form of a bile-lipid mixture resembling normal intestinal contents. Under these conditions, most (70-80%) of the radioactivity recovered after the feeding of labeled retinol or retinal was found in the lymph, predominantly in saturated retinyl esters. In contrast, 92-95% of the radioactivity recovered after the feeding of labeled retinoic acid was found in the bile, and was contained in a mixture of polar metabolites, most of them more polar than free retinoic acid. Two-thirds of the small amount of radioactivity found in lymph after retinoic acid-(14)C feeding was in the form of free retinoic acid. The results indicate that under normal conditions the major pathway of retinal absorption involves its reduction to retinol, which is then esterified and transported via the lymphatics in a manner similar to that of dietary retinol. A small proportion of retinal is apparently normally oxidized, and is then transported via the portal vein and excreted in the bile in a manner similar to that of dietary retinoic acid. The relative importance, in quantitative terms, of these two pathways of retinal metabolism can vary, depending on the status of the animal.     

Endoscopic papillotomy and removal of gall stones.

Endoscopic papillotomy was attempted in 59 patients with extrahepatic obstruction of the biliary duct system and was actually performed in 50 patients. A special high-frequency diathermy knife was introduced via a duodenoscope into the terminal common bile duct and the roof of the papilla was incised. In 33 out of 39 patients with choledocholithiasis the stones passed into the duodenum spontaneously or were removed endoscopically. Papillary stenosis without ductal stones was successfully treated with this method in eight out of 11 patients. One perforation of the duodenocholedochal junction occurred and was repaired surgically. Endoscopic papillotomy and stone extraction is a relatively safe and effective method of treating extrahepatic jaundice.     

The effect of oleate on pancreatic and bile secretion in the conscious rat

The effects of sodium oleate infused into either the duodenum or the terminal ileum on bile and pancreatic secretion were examined in the conscious rat. Rats were prepared with cannulae draining pure bile and pancreatic juice separately, and with an ileal and two duodenal cannulae. A 40 mM taurocholate solution containing 7 mg/ml bovine trypsin was infused into the duodenum throughout the experiment to replace diverted bile-pancreatic juice to maintain the normal regulation of pancreatic secretion. The intraduodenal infusion of sodium oleate significantly increased pancreatic juice flow, protein, and bicarbonate outputs, whereas it did not affect bile secretion. Intravenous infusion of proglumide (300 mg/kg/hr) did not inhibit pancreatic secretion stimulated by intraduodenal infusion of sodium oleate. An intravenous infusion of atropine (100 micrograms/kg/hr) attenuated protein and fluid secretions but not that of bicarbonate in response to intraduodenal oleate. In contrast, the intraileal infusion of oleate had no effect on pancreatic secretion, whereas it decreased bile flow, bicarbonate, and bile salt outputs. In conclusion, sodium oleate introduced in the duodenum stimulates pancreatic secretion but oleate in the terminal ileum inhibits bile secretion.     

The protective effect of thromboxane synthetase inhibitor UK 38485 against bile duct ligation induced liver injury

In order to elucidate the relation between tissue eicosanoids and liver injury due to bile duct obstruction, we have examined the effects of iloprost, a stable analogue of prostaglandin I₂ (PGI₂), and UK 38485 (UK), an inhibitor of thromboxane synthetase, on prostaglandin E₂ (PGE₂) and leukotriene C₄ (LTC₄) in guinea pig liver. 56 male guinea pigs were divided into the following groups: (i) sham operations (SHAM), (ii) bile duct ligated (BDL) group, (iii) guinea pigs given UK (5 μg/kg body wt intraperitoneally 10 min, 8 h and 16 h after bile duct ligation), and (iv) guinea pigs treated with iloprost (ILO) (2 μg/kg body wt intraperitoneally 10 min, 8 h and 16 h after bile duct ligation). Liver damage was assessed by blind quantitation of liver cell necrosis. Bile duct ligation caused an increase in tissue PGE₂-like activity and a decrease LTC₄-like activity. But the most pronounced elevation of PGE₂ was observed in ILO treated group. The LTC₄-like activity level improved significantly in the UK-treated BDL group compared with the BDL only and ILO treated animals. Also, UK was found to be beneficial in preventing the liver cell necrosis due to cholestasis. It is concluded that the ratio of PGE₂/LTC₄ in liver is a valuable marker for cholestatic injury.     

Distribution of opioidergic,sympathetic and neuropeptide Y-positive nerves in the sphincter of Oddi and biliary tree of the monkey,Macaca fascicularis

Summary The opioidergic, sympathetic and neuropeptide Y-positive innervation of the sphincter of Oddi (common bile duct sphincter and pancreatic duct sphincter), as well as other segments of the extrahepatic biliary tree was studied in the monkey by use of immunohistochemistry. Methionine-enkephalin-positive nerves were seen to innervate the smooth muscle of all portions of the sphincter of Oddi and also local ganglion cells. No methionine-enkephalin-positive nerves could be detected in the common bile duct, pancreatic duct or gallbladder. Tyrosine hydroxylase-positive nerves occurred between smooth muscle bundles and also ran to local ganglion cells as well as along the common bile duct. Neuropeptide Y-positive nerves were observed within smooth muscle of the sphincter of Oddi (all portions), common bile duct, pancreatic duct and gallbladder. No evidence of any differential innervation of the pancreatic duct and common bile duct sphincters could be detected with these markers.     

Hepatic bile and pancreatic exocrine secretions evoked by gastrointestinal peptides in sheep

The secretory response of hepatic bile and exocrine pancreas to gastrointestinal peptides has been studied in chronically cannulated sheep. Pancreatic juice flow and protein output were evoked dose dependently by intraportal injection of secretin, CCK-8, caerulein, VIP and neurotensin. However, biliary secretion was evoked by only secretin. Biliary and pancreatic exocrine secretions were enhanced by delivered gastric juice into the duodenum as followed by the increased plasma concentration of immunoreactive secretin (IRS). Results suggest that secretin is the major peptide that regulates pancreatic exocrine secretion and hepatic bile production in the sheep.     

A case report of an ampullary tumor presenting with spontaneous perforation of an aberrant bile duct and treated with totally laparoscopic pancreaticoduodenectomy

ABSTRACT: BACKGROUND: This case report discusses a patient who presented with bile peritonitis due to spontaneous perforation of an aberrant bile duct that originated in the triangular ligament of the liver. It was associated with an ampullary tumor and treated with total laparoscopic pancreaticoduodenectomy (TLPD). Case report A 58-year-old male patient was admitted to the emergency department of Medical Park Gaziantep Hospital in September 2009 with acute abdominal findings. He underwent an urgent laparoscopy, and, interestingly, bile peritonitis due to the rupture of an aberrant bile duct in the triangular ligament was noted. After laparoscopic treatment of the acute conditions, the follow-up examinations of the patient showed the finding of obstructive jaundice. Endoscopic retrograde cholangio-pancreatography revealed a 1-cm polypoid mass located at the ampulla of Vater (duodenal papilla) with possible extension to the ampullary sphincter. A stent was inserted for temporary biliary drainage, and subsequent endoscopic biopsy showed the pathological finding of adenocarcinoma. After waiting for a 1-month period for the peritonitis to heal, the patient underwent pyloruspreserving TLPD and was discharged without any major complications on postoperative day 7. CONCLUSION: In patients with bile peritonitis, it should be considered that the localization of the perforation may be in an aberrant bile duct localized at the triangular ligament and the etiology may be associated with an obstructing periampullary tumor. Laparoscopic pancreaticoduodenectomy is a feasible operative procedure in carefully selected patients. This technique can achieve adequate margins and follows oncological principles. Randomized comparative studies are needed to establish the superiority of minimally invasive surgery over traditional open surgery.     

The major intrinsic pancreatic ducts of the rhinoceros

A first-time account is given of the parenchymal subdivisions and related duct system of the pancreas in Didermocerus, Diceros and Ceratotherium. In each of these rhinoceros forms a small, superficial portion only of the caput pancreatis is drained by a Santorini duct opening directly into the duodenum. The remainder of the pancreatic parenchyma is drained principally by a transverse and an ascending duct, from whose union arises a short Wirsung duct which enters the duodenum through an intermediary Vaterian ampulla situated within a prominent papilla duodeni.     

Giardiasis in guinea pigs: a case report

During the quarantine of 15 guinea pigs acquired from a breeder in February 1983, several became weak and moribund, and one died. A tremendous number of Giardia sp. bodies were detected from stamp smear preparations of the duodenal contents of some necropsied animals in this group. Histopathological examinations of the intestine revealed slight inflammatory changes and cystic enlargement of the crypts in the duodenal and jejunal mucous membranes. From these findings and the fact that other major pathogenic organisms were not detected, this disease was diagnosed as giardiasis in guinea pigs.