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.     

ERCP治疗急性胆源性胰腺炎

急性胆源性胰腺炎(ABP)是消化内科常见急腹症之一,是急性胰腺炎中最常见的类型,占急性胰腺炎每年发病人数的40%-60%,病死率较高,常规药物治疗不能从根本上解除病因,易导致复发,手术治疗风险较大,创伤较大,费用较高,住院时间较长,易引起其术后并发症,不利于患者恢复。而经内镜逆行胰胆管造影(ERCP)作为一种内镜与放射技术相结合的诊断治疗方法,对胆管内结石并发急性胰腺炎的诊断率是最高的,诊断结石的敏感性大于95%。在20世纪70年代被认为是急性胆源性胰腺炎的禁忌症,近年来随着ERCP技术的不断发展和广泛应用,ERCP已成为治疗胆胰疾病的一种安全有效的技术。ERCP可清除胆管结石,从而达到通畅胆道,减少胆汁向胰管反流,迅速改善患者病情,阻断病情进展的目的,并有效缩短住院时间,减轻患者痛苦,减少复发和改善总体预后,为广大ABP患者带来了福音,此外,还能减少患者住院费用,节省医疗资源,对于个人及社会均具有积极意义,值得推广。     

Pancreatic Duct Patterns in Acute Pancreatitis: A MRI Study

Objectives

To study the MRI findings of the pancreatic duct in patients with acute pancreatitis.

Materials and Methods

A total of 239 patients with acute pancreatitis and 125 controls were analyzed in this study. The severity of acute pancreatitis was graded using the MR severity index (MRSI) and the Acute Physiology And Chronic Healthy Evaluation II(APACHE II) scoring systems. The number of main pancreatic duct (MPD) segments visualized, and both MPD diameter and pancreatic duct disruption were noted and compared with the severity of acute pancreatitis.

Results

The frequency of MPD segment visualization in the control group was higher than that in the acute pancreatitis group (p<0.05). The number of MPD segments visualized was negatively correlated with the MRSI score (p<0.05) and the APACHE II score (p<0.05). There was no difference in the MPD diameter between the acute pancreatitis and control groups or among the patients with different severities of acute pancreatitis (p>0.05). The prevalence of pancreatic duct disruption was 7.9% in the acute pancreatitis group. The prevalences of pancreatic duct disruption were 4.8% and 15.3% in the mild and severe acute pancreatitis groups based on the APACHE II score, respectively, and were 0%, 5.7% and 43.5% in the mild, moderate and severe acute pancreatitis groups according the MRSI score, respectively. The prevalence of pancreatic duct disruption was correlated with the severity of acute pancreatitis based on the APACHE II score (p<0.05) and MRSI score (p<0.05).

Conclusion

The pancreatic duct in acute pancreatitis patients was of normal diameter. The number of MPD segments visualized and visible pancreatic duct disruption on MRI may be supplementary indicators for determining the severity of acute pancreatitis.     

Pancreatic duct occlusion in the rat: report and assessment of a new technique

Temporary reduction of the exocrine pancreatic secretion may be desirable in various experimental models. In the rat this can be achieved by obstructing the connection between the pancreas and the duodenum. A new, simple technique of pancreatic duct occlusion using metal hemostatic clips is described. The reduction of secretion produced by the procedure was assessed by measuring duodenal protein, amylase, and trypsin during stimulation with cholecystokinin. Stimulated duodenal amylase activity 1 and 4 weeks following duct occlusion was reduced by approximately 80% compared with sham-operated controls, whereas proteolytic activity was reduced by 96 and 60%, respectively. The magnitude and duration of pancreatic insufficiency achieved by this technique is equivalent to that achieved with more complicated methods.     

Common bile duct obstruction caused by the hydatid daughter cysts

Echinococcosis is a human parasitary disease. In 2002, 29 new cases of liver echinococcosis were recorded in Croatia. Liver is the most common site of hydatid cysts. Nine patients with echinoccocal liver disease were operated in our department in 2002. Here we present a case where a patient with verified hydatid cyst in the left liver lobe developed high fever, jaundice, nausea, vomiting and pain in the upper abdomen. The symptoms were initially ascribed to the acute cholangitis. After unsuccessful antibiotic treatment, computerized tomography and endoscopic retrograde cholangiopancreatography (ERCP) were performed, demonstrating daughter cysts in the common bile duct. During ERCP, papilotomy was made and daughter cysts were extracted. Hydatid cyst was surgically removed, and a communication between the cyst and left hepatic duct was noted during surgery. Pericystectomy, choledochotomy, removal of remaining daughter cysts from the common bile duct, and sutures of left hepatic duct were performed. The patient recovered fully after the surgery. One of the possible complications of the liver hydatid cysts is the communication between cyst and the biliary tree. Such communications are usually asymptomatic, but symptoms can also mimic acute cholangitis and jaundice, which may lead to the misdiagnosis of the patient's condition.     

复发性胆源性胰腺炎的临床特征及危险因素分析

目的:研究复发性胆源性胰腺炎(RGP)的临床特征及危险因素。方法:选择从2012年1月至2017年1月在本院接受治疗的80例RGP患者作为观察组,另选同期在本院接受治疗的胆源性胰腺炎(GP)患者86例作为对照组,分析观察组患者的临床特征及两组患者的致病因素,采用Logistic回归分析RGP的危险因素。结果:在RGP患者的临床特征中,复发次数均较多,平均达到(3.21±0.23)次。发病诱因则主要是胆囊结石、胆总管结石及高脂血症;临床症状主要是黄疸、呕吐、恶心、腹痛、腹胀;并发症主要包括胆管炎、胰腺脓肿以及腹水;临床体征主要有出血征象、腹肌紧张、腹部压痛等。观察组的男性、重度胰腺炎、合并胆总管结石、胆胰管开口狭窄、有高脂血症、手术治疗的患者致病率分别高于对照组,并且观察组急性生理与慢性健康评分(APACHE-Ⅱ)明显高于对照组,差异均有统计学意义(P0.05)。由多因素Logistic回归分析可知,导致RGP的危险因素有男性、高APACHE-Ⅱ评分、重度胰腺炎、合并胆总管结石、胆胰管开口狭窄、有高脂血症以及手术治疗。结论:RGP患者的临床特征具有一定的规律性,其中男性、高APACHE-Ⅱ评分、重度胰腺炎、合并胆总管结石、胆胰管开口狭窄、有高脂血症以及手术治疗是导致RGP发生的危险因素。     

Receptor strategies in pancreatitis.

A variety of receptors on pancreatic acinar and duct cells regulate both pancreatic exocrine secretion and intracellular processes. These receptors are potential sites of action for therapeutic agents in the treatment of pancreatitis. Cholecystokinin (CCK) receptor antagonists, which may reduce the level of metabolic "stress" on acinar cells, have been shown to mitigate the severity of acute pancreatitis in a number of models. Not all studies have shown a benefit, however, and differences may exist between different structural classes of antagonists. Because increased pancreatic stimulation due to loss of feedback inhibition of CCK has been proposed to contribute to the pain of some patients with chronic pancreatitis, CCK receptor antagonists could also be of benefit in this setting. Somatostatin and its analogs diminish pancreatic secretion of water and electrolytes and have been effective in treating pancreatic fistulas and pseudocysts. These agents are also being evaluated for their ability to reduce pain in chronic pancreatitis (perhaps by reducing ductal pressure by diminishing secretory volume) and mitigating the severity of acute pancreatitis (possibly by reducing the metabolic load on acinar cells). Recently described secretin receptor antagonists may also have therapeutic value as a means of selectively inhibiting pancreatic secretion of water and electrolytes.     

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.     

Effects of growth and maturation on biliary structures of guinea pigs

The biliary system and major duodenal papilla of male guinea pigs were examined in vivo using intravital microscopy. Study of the photomicrographs and videotape recordings indicated that biliary organs changed with age and growth of the guinea pigs. Physiological data including the frequency of sphincteric contractions were recorded and efforts were made to correlate these data with changes in structure thought to be due to maturation. The volume of smooth muscle in the bile duct sphincter (measured using histological sections) increased with age as did surface area of the mucosa. The bile duct was separate from the pancreatic duct in each of 28 guinea pigs. Study of the guinea pig extrahepatic biliary system (EBS) allowed the isolated examination of effects of maturation on bile duct capacity. The anatomical reason for this is that the ampulla of the bile duct emptied into the duodenum (independently of the pancreatic duct) at the major duodenal papilla. The duct of the pancreas entered the duodenum distally (caudally) to the major duodenal papilla on the minor duodenal papilla. The separation of biliary and pancreatic ducts simplified the making of casts of the EBS. It is important to consider this feature in selection of a model for studies of bile duct function in living animals. Three anatomical techniques were selected to focus from differing perspectives on growth-related changes that occurred among the EBS of neonatal, juvenile and adult animals. These techniques were: The capacity (volume) of bile contained within the EBS was determined using plastic casts of the system.(ABSTRACT TRUNCATED AT 250 WORDS)     

Development of the islets, exocrine pancreas, and related ducts in the Nile tilapia, Oreochromis niloticus (Pisces: Cichlidae)

Pancreatic development and the relationship of the islets with the pancreatic, hepatic, and bile ducts were studied in the Nile tilapia, Oreochromis niloticus, from hatching to the onset of maturity at 7 months. The number of islets formed during development was counted, using either serial sections or dithizone staining of isolated islets. There was a general increase in islet number with both age and size. Tilapia housed in individual tanks grew more quickly and had more islets than siblings of the same age left in crowded conditions. The pancreas is a compact organ in early development, and at 1 day posthatch (dph) a single principal islet, positive for all hormones tested (insulin, SST-14, SST-28, glucagon, and PYY), is partially surrounded by exocrine pancreas. However, the exocrine pancreas becomes more disseminated in older fish, following blood vessels along the mesenteries and entering the liver to form a hepatopancreas. The epithelium of the pancreatic duct system from the intercalated ducts to the main duct entering the duodenum was positive for glucagon and SST-14 in 8 and 16 dph tilapia. Individual insulin-immunopositive cells were found in one specimen. At this early stage in development, therefore, the pancreatic duct epithelial cells appear to be pluripotent and may give rise to the small islets found near the pancreatic ducts in 16-37 dph tilapia. Glucagon, SST-14, and some PPY-positive enteroendocrine cells were present in the intestine of the 8 dph larva and in the first part of the intestine of the 16 dph juvenile. Glucagon and SST-14-positive inclusions were found in the apical cytoplasm of the mid-gut epithelium of the 16 dph tilapia. These hormones may have been absorbed from the gut lumen, since they are produced in both the pancreatic ducts and the enteroendocrine cells. At least three hepatic ducts join the cystic duct to form the bile duct, which runs alongside the pancreatic duct to the duodenum.     

Inflammation of ectopic pancreatic tissue as unusual cause of duodenal perforation--a case report

Ectopic pancreatic tissue, also known as a pancreatic rest, is an uncommon congenital anomaly defined as extrapancreatic tissue located far from the pancreas and without any connection via vascular or anatomical means to it. Such tissue may occur throughout the GI tract but has a propensity to affect the stomach and the proximal small intestine. The majority of patients with pancreatic ectopia are asymptomatic, but when symptoms occur, they can be presented in a variety of ways. We report a patient with acute surgical abdomen due to a duodenal perforation caused by inflammation of ectopic pancreatic tissue in duodenum and stomach. Histology of the resected duodenum and stomach demonstrated heterotopic pancreatic tissue acute inflammation without atypia, suggesting "pancreatitis of the duodenum and stomach". To date, there have been a few reports describing perforation of the stomach due to heterotopic pancreas. Therefore, the present case was considered to be a very rare case of this disorder. To conclude, heterotopic pancreas should always be considered in the differential diagnosis of acute abdomen.     

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.     

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.     

Proteomics portrait of archival lesions of chronic pancreatitis

Chronic pancreatitis is a chronic inflammatory disorder of the pancreas. The etiology is multi-fold, but all lead to progressive scarring and loss of pancreatic function. Early diagnosis is difficult; and the understanding of the molecular events that underlie this progressive disease is limited. In this study, we investigated differential proteins associated with mild and severe chronic pancreatitis in comparison with normal pancreas and pancreatic cancer. Paraffin-embedded formalin-fixed tissues from five well-characterized specimens each of normal pancreas (NL), mild chronic pancreatitis (MCP), severe chronic pancreatitis (SCP) and pancreatic ductal adenocarcinoma (PDAC) were subjected to proteomic analysis using a "label-free" comparative approach. Our results show that the numbers of differential proteins increase substantially with the disease severity, from mild to severe chronic pancreatitis, while the number of dysregulated proteins is highest in pancreatic adenocarcinoma. Important functional groups and biological processes associated with chronic pancreatitis and cancer include acinar cell secretory proteins, pancreatic fibrosis/stellate cell activation, glycoproteins, and inflammatory proteins. Three differential proteins were selected for verification by immunohistochemistry, including collagen 14A1, lumican and versican. Further canonical pathway analysis revealed that acute phase response signal, prothrombin activation pathway, and pancreatic fibrosis/pancreatic stellate cell activation pathway were the most significant pathways involved in chronic pancreatitis, while pathways relating to metabolism were the most significant pathways in pancreatic adenocarcinoma. Our study reveals a group of differentially expressed proteins and the related pathways that may shed light on the pathogenesis of chronic pancreatitis and the common molecular events associated with chronic pancreatitis and pancreatic adenocarcinoma.     

Management of necrotizing pancreatitis.

A comprehensive management plan is presented for patients with severe acute pancreatitis. These patients may have pancreatic or peripancreatic necrosis or pancreatic fluid collections. Multiple organ failure often develops in patients with severe pancreatitis. We therefore recommend that all patients with acute pancreatitis be evaluated for pancreatic anatomy and function. If a patient is seriously ill, a computed tomographic (CT) scan with vascular enhancement should be done. Meanwhile, vigorous fluid replacement is necessary using Swan-Ganz monitoring. Patients with necrosis do not need surgical intervention unless the clinical course or CT scan-guided aspiration shows infection. The objective of an operation should be to remove all infected tissue and fluid. A preoperative CT scan with vascular enhancement should be used as a guide during the operation to ensure that all foci of infected necrosis or fluid are eliminated. We have found that open packing and irrigation with sodium oxychlorosene are helpful in patients with extensive necrosis or those who become infected early after the onset of symptoms. In all, 40% to 50% of patients treated by closed drainage will require reoperation because of incomplete debridement. Persistent sepsis is an indication for reoperation.     

Histopathology findings in common marmosets (<Emphasis Type="Italic">Callithrix jacchus</Emphasis> Linnaeus, 1758) with chronic weight loss associated with bile tract obstruction by infestation with <Emphasis Type="Italic">Platynosomum</Emphasis> (Loos, 1907)

Chronic weight loss in marmosets is often associated with wasting marmoset syndrome (WMS), an important disease that occurs in callitrichid colonies around the world. Even though its etiology is very difficult to determine, particular variables, such as weight loss, diarrhea and alopecia, associated or not with infestation in the pancreatic ducts with Trichospirura leptossoma (Nematoda: Thelazioidea), seem to be linked with the syndrome. This study investigated the histopathology of the lungs, duodenum, liver, gallbladder, extrahepatic bile ducts and pancreatic ducts of six common marmosets (Callithrix jacchus) suffering from severe non-diarrheic weight loss. Three individuals died naturally and the other three were euthanized. Microscopic findings showed the presence of adult flukes (Platynosomum) in the liver. These flukes, which provoke common infection in cats, were also observed inside the gallbladder as well as in the intra and extrahepatic bile ducts in common marmosets. Portal fibrosis was observed in two animals, which developed chronic fibrosing hepatopathy (biliary pattern, grade 3). The disease progresses without diarrhea and without pancreatic lesions or infestation. With the progression, the animals presented with ascending cholangitis, cholestasis and portal fibrosis, sometimes culminating in secondary biliary cirrhosis. Therefore, this infirmity, associated with chronic weight loss in common marmosets, could be another etiological factor linked with WMS.     

Acute pancreatitis: proteinase-activated receptor-2 as Dr. Jekyll and Mr. Hyde

"Proteinase-activated" receptor-2 (PAR-2) is a G protein-coupled transmembrane receptor with seven transmembrane domains activated by trypsin. It has been shown in the pancreatic tissue that PAR-2 is involved in duct/acinary cells secretion, arterial tonus regulation and capillary liquid content turnover under physiological conditions. These above mentioned structures play an important role during the development of acute pancreatitis and are profoundly influenced by a high concentration of trypsin enzyme after its secretion into the interstitial tissue from the basolateral aspect of acinar cells. Among the other factors, it is the increase of interstitial trypsin concentration followed rapidly by PAR-2 action on pancreatic vascular smooth muscle cells that initiates ischemic changes in pancreatic parenchyma and that finally leads to necrosis of the pancreas. Consequent reperfusion perpetuates changes leading to the acute pancreatitis development. On the contrary, PAR-2 action on both exocrine and duct structures seems to play locally a protective role during acute pancreatitis development. Moreover, PAR-2 action is not confined to the pancreas but it contributes to the systemic vascular endothelium and immune cell activation that triggers the systemic inflammatory response syndrome (SIRS) contributing to an early high mortality rate in severe disease.     

Serine proteases mediate inflammatory pain in acute pancreatitis

Acute pancreatitis is a life-threatening inflammatory disease characterized by abdominal pain of unknown etiology. Trypsin, a key mediator of pancreatitis, causes inflammation and pain by activating protease-activated receptor 2 (PAR(2)), but the isoforms of trypsin that cause pancreatitis and pancreatic pain are unknown. We hypothesized that human trypsin IV and rat P23, which activate PAR(2) and are resistant to pancreatic trypsin inhibitors, contribute to pancreatic inflammation and pain. Injections of a subinflammatory dose of exogenous trypsin increased c-Fos immunoreactivity, indicative of spinal nociceptive activation, but did not cause inflammation, as assessed by measuring serum amylase and myeloperoxidase activity and by histology. The same dose of trypsin IV and P23 increased some inflammatory end points and caused a more robust effect on nociception, which was blocked by melagatran, a trypsin inhibitor that also inhibits polypeptide-resistant trypsin isoforms. To determine the contribution of endogenous activation of trypsin and its minor isoforms, recombinant enterokinase (ENK), which activates trypsins in the duodenum, was administered into the pancreas. Intraductal ENK caused nociception and inflammation that were diminished by polypeptide inhibitors, including soybean trypsin inhibitor and a specific trypsin inhibitor (type I-P), and by melagatran. Finally, the secretagogue cerulein induced pancreatic nociceptive activation and nocifensive behavior that were reversed by melagatran. Thus trypsin and its minor isoforms mediate pancreatic pain and inflammation. In particular, the inhibitor-resistant isoforms trypsin IV and P23 may be important in mediating prolonged pancreatic inflammatory pain in pancreatitis. Our results suggest that inhibitors of these isoforms could be novel therapies for pancreatitis pain.     

Lymphoplasmacytic sclerosing pancreato-cholangitis: a case report and review of the literature

Autoimmune pancreatitis is a rare but important cause of pancreatitis that is becoming increasingly recognized in the West. Lymphoplasmacytic sclerosing pancreatitis (LPSP) is a benign form of chronic pancreatitis characterized clinically by infrequent attacks of abdominal pain, jaundice, and weight loss, and pathologically by focal or diffuse chronic or lymphoplasmacytic inflammatory infiltrates centered around pancreatic ducts and ductules, accompanied by obliterative phlebitis, acinar atrophy, and interstitial fibrosis. It has been described alone or as a part of the spectrum of autoimmune gallbladder and biliary tract disease, with clinical, radiological, and pathological overlap reported with primary sclerosing cholangitis. It has been described as "primary sclerosing pancreatitis," "sclerosing cholangitis," "non-alcoholic duct destructive chronic pancreatitis," and "autoimmune pancreatitis." We report a case of LPSP that mimicked pancreatic adenocarcinoma and was subsequently treated with a pylorus-preserving Whipple procedure. This may point towards a primary biliary autoimmune process involving the pancreatic duct, causing a benign form of chronic pancreatitis that may be difficult to characterize pre-operatively to avoid surgery. This case typifies the growing awareness of this relatively recently characterized clinical entity, its similar presentation to pancreatic carcinoma, and the importance for LPSP to be included in the differential diagnosis of pancreaticobiliary disease. Finally, we review the literature.     

棕黑锦蛇消化系统和呼吸系统的解剖

目的解剖观察东北体型最大的棕黑锦蛇。了解其消化系统和呼吸系统的基本形态结构及特点。方法采自辽宁东部丹东市和桓仁县棕黑锦蛇共6条,其中雌性3条,雄性3条。采用福尔马林固定后．沿腹面正中线部位将皮肤从泄殖孔剪至颏部。对消化和呼吸系统进行观察和测量。结果消化系统和呼吸系统的基本形态结构与其它蛇类相似。但也有其特点：上颌的两侧左右各有两排细小的牙齿,胰管在十二指肠壁外与胆总管汇合共同开口于十二指肠。呼吸系统主要由气管和肺构成。气管位于食管腹面,末端连接正常的右肺,末端一侧则连接着退化的左肺。右肺长囊状,明显分为呼吸部和气囊部。左肺很小,呈卵圆形囊状。结论由于生活习性和生存环境的不同,各蛇种在漫长的进化过程中也表现形态结构方面的不同。