Relationship between papilla-related variables and post endoscopic retrograde cholangiopancreatography pancreatitis: A multicenter, prospective study.

BACKGROUND AND AIM: Papilla with hooknose or long protruding shape may increase the difficulty of cannulation during endoscopic retrograde cholangiopancreatography (ERCP). However, the relationship between papilla anatomy and complications of ERCP has not been fully understood. We aimed to investigate the effect of major duodenal papilla morphology on post-ERCP pancreatitis (PEP) and the procedure of cannulation. METHODS: Patients with native papilla who underwent ERCP were recruited to this multicenter study. Papilla-related variables were collected, including the length of long axis (L), short axis (S) and opening width (OW), transverse fold, periampullary diverticulum (PAD), papilla location, orientation, swelling, and presence of duodenal stenosis. Demographic data and the procedure of cannulation were also prospectively evaluated. The primary outcome was PEP incidence. Multivariate analysis was used to identify high risk factors for PEP. RESULTS: Six hundred and fifty-eight patients were enrolled. Overall PEP incidence was 4.7% (31/658). The papilla of patients complicated with PEP had higher long to short axis (L/S) ratio (odds ratio [OR] 3.84, 95% confidence interval [CI]: 1.37-10.74, P = 0.010), higher long axis to opening width (L/OW) ratio (OR 1.35, 95%CI: 1.06-1.71, P = 0.014), more transverse folds (OR 2.53, 95%CI: 1.02-6.26, P = 0.044), and less periampullary diverticulum (OR 0.21, 95%CI: 0.06-0.70, P = 0.011). Multivariate analysis revealed that the indication of common bile duct stones, normal bilirubin, inadvertent pancreatic duct cannulation > 1, L/S ratio ≥ 1.5, and absence of PAD were independent risk factors for PEP. CONCLUSION: Besides patient-related and procedure-related factors, papilla-related variables, such as L/S ratio and PAD, can be considered as a third type of factors associated with PEP (Clinicaltrials.gov number: NCT03550768).

Ampulectomía transduodenal laparoscópica por tumor ampular / Laparoscopic transduodenal ampullectomy for ampullary tumor

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Microanatomical profiles on the lymphatic system in the human ampulla of Vater (immunohistochemistry and scanning electron microscopy).

BACKGROUND: Little information is available regarding microanatomy of lymphatic system in the ampulla of Vater, though it is of critical importance for an understanding of tumor progression via the lymphatics and determination of surgical strategy. The present study, therefore, aimed to demonstrate the distribution and microanatomical profiles on the lymphatic system in the ampulla. METHODS: The fine distribution and structure of the lymphatic vessels were investigated in the ampulla and the stomach by immunohistochemistry for lymphatic- (D2-40) and blood vascular- (CD31) specific markers and scanning electron microscopy. The densities of lymphatic and blood vessels were also compared. RESULTS: The duodenal papilla densely developed the lymphatics with distinct aspects of lymphatic capillaries, together with blood vessels. The density of lymphatic capillaries in the extramuscular layer in the ampulla was higher than those of both the other ampullary layers and the gastric extramuscular (subserosal) layer. CONCLUSIONS: The ampulla of Vater showed widespread lymphatic capillaries throughout the entire wall. The specific vascular system is suited to produce lymph everywhere and drain without via such a large vessel as lymphatic collector. This suggests that tumor cells invade the lymphatics and metastasize more easily in the ampulla than in the other gastrointestinal regions.

Fetal intraluminal portion of the sphincter of Oddi: a histological study using human fetuses

The sphincter of Oddi surrounds a common duct after joining of the bile and pancreatic ducts in the adult ampulla of Vater, but the fetal development of the submucosal portion of the sphincter is still obscure possibly because previous studies used horizontal or frontal sections. We examined serial sagittal histological sections of 12 human fetuses with 36-65 mm crown rump length or CRL (approximately 9-11 weeks) and semi-serial sections of the other 3 fetuses with 210-250 mm (25-30 weeks). Except for 1 fetus (36 mm CRL), fourteen fetuses carried the "intraluminal portion" protruding and floating in the duodenal lumen. Twelve of them had the sphincter extending to the anal side in the duodenal lumen, whereas two extended to the stomach side. The distal end of the sphincter seemed to detach from the duodenal mucosa at and around 9 weeks, and subsequently the common duct seemed to elongate freely without mucosal attachment in mid-term fetuses and, finally, become embedded again in the duodenal mucosa in the postnatal life. A possible discrepancy in growth rate between the sphincter muscle and duodenal mucosa was likely to allow the specific intermediate morphology, i.e., the intraluminal common duct. The fetal accessory papilla did not show such morphology. A minority of cases whose common duct extended to the stomach side might connect with abnormal union of the bile and pancreatic ducts

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MRI Findings of Intrinsic and Extrinsic Duodenal Abnormalities and Variations.

This pictorial review aims to illustrate the magnetic resonance imaging (MRI) findings and presentation patterns of anatomical variations and various benign and malignant pathologies of the duodenum, including sphincter contraction, major papilla variation, prominent papilla, diverticulum, annular pancreas, duplication cysts, choledochocele, duodenal wall thickening secondary to acute pancreatitis, postbulbar stenosis, celiac disease, fistula, choledochoduodenostomy, external compression, polyps, Peutz-Jeghers syndrome, ampullary carcinoma and adenocarcinoma. MRI is a useful imaging tool for demonstrating duodenal pathology and its anatomic relationships with adjacent organs, which is critical for establishing correct diagnosis and planning appropriate treatment, especially for surgery.

MDCT and MRI of the ampulla of Vater. Part I: technique optimization, normal anatomy, and epithelial neoplasms.

The purpose of this two-part article is to review the cross-sectional anatomy of the ampulla and periampullary region, to propose novel and optimized MDCT and MRI techniques that allow accurate evaluation of the ampulla of Vater, and to summarize the cross-sectional imaging features of benign and malignant ampullary conditions. In this first part, we will review the normal anatomy of the ampullary region, provide suggestions on how to optimize evaluation of the ampullary region by MDCT and MRI, and review the imaging features of select epithelial neoplasms of the ampulla. Familiarity with the normal ampullary anatomy and the pathologic conditions involving the ampulla, as well as the use of optimized MDCT and MRI techniques, may improve the diagnostic accuracy of radiologists facing ampullary abnormalities.

A study on the human pancreaticobiliary duct system and ampulla region with their clinical considerations.

INTRODUCTION: The purpose of this study is to present the variations of the pancreatic duct system and hepatopancreatic ampulla so that an awareness of these variations may help in surgical planning and prevention of ductal injury. METHODS: Forty human pancreatic specimens were used to study the duct pattern of the pancreas and the formation and mode of termination of the pancreatic ducts. Also, the patency of the main pancreatic ducts, length of the hepatopancreatic ampulla, and length of the main pancreatic duct were measured. RESULTS: The main pancreatic duct was patent in 37 out of 40 specimens, 2 specimens showed the embryonic type of the duct system, and one had the duct obliterated at its duodenal end. The mode of termination of the main pancreatic and common pancreatic ducts was divided into four types. Seventy-five percent specimens belonged to type I, followed by type II in 22.5 % and type III in 2.5 % of specimens. The length of the main pancreatic duct ranged from 11 to 21.2 cm, the average being 17.3 cm, and the length of the hepatopancreatic ampulla varied from 1 to 10 mm (1 to 2 mm-5 %, 3 to 8 mm-55 %, and more than 8 mm in 15 % of specimens), and it was absent in 25 %. CONCLUSION: Awareness of these anomalies may help in surgical planning and prevention of undue ductal injury.

MRI Findings of Intrinsic and Extrinsic Duodenal Abnormalities and Variations

This pictorial review aims to illustrate the magnetic resonance imaging (MRI) findings and presentation patterns of anatomical variations and various benign and malignant pathologies of the duodenum, including sphincter contraction, major papilla variation, prominent papilla, diverticulum, annular pancreas, duplication cysts, choledochocele, duodenal wall thickening secondary to acute pancreatitis, postbulbar stenosis, celiac disease, fistula, choledochoduodenostomy, external compression, polyps, Peutz-Jeghers syndrome, ampullary carcinoma and adenocarcinoma. MRI is a useful imaging tool for demonstrating duodenal pathology and its anatomic relationships with adjacent organs, which is critical for establishing correct diagnosis and planning appropriate treatment, especially for surgery.

Development of a novel and simple ex vivo biologic ERCP training model.

BACKGROUND: Training and teaching of ERCP in biologic models has gained importance over the past decade. However, many existing models are expensive, are not widely available, or rely on live animals. OBJECTIVE: We describe a novel and simple ex vivo, biologic model for hands-on teaching. DESIGN: Ex vivo porcine study. SETTING: Experimental endoscopy unit. METHODS: Experimental study using a custom-made ex vivo biologic ERCP simulation model. This model contains 2 new key concepts: (1) formation of a duodenal sweep by using the porcine stomach and (2) use of multiple neo-papillae for endoscopic sphincterotomy and biliary stent placement. The papilla was re-created with chicken heart, and the bile ducts were built from chicken trachea. Endoscopic sphincterotomy was performed by using a pull-type sphincterotome. Stenting was performed with Amsterdam-type plastic stents and guidewires. MAIN OUTCOME MEASUREMENTS: The following definitions were used to evaluate the model: successful implantation of the neo-papilla, stability of the neo-papilla to the neo-duodenum, successful removal of the neo-papilla, and damage to the model. The following endoscopic endpoints were evaluated: successful cannulation, cannulation time, difficulties in positioning the papilla, quality of the biliary sphincterotomy, and prosthesis placement. Procedure-related adverse events such as perforation were also assessed. RESULTS: Ten neo-papillae were consecutively used in 1 duodenalized stomach. The implantation and removal of the neo-papillae were easily and successfully accomplished in all 10 cases without any damage to the duodenalized stomach. The stability of the neo-papilla on the duodenal sweep was excellent in all cases. Cannulation, biliary sphincterotomy, and stent placement could be successfully performed in 100% of cases. There was no damage and were no technical problems with the model. There were no adverse events during endoscopy (ie, perforations, stent misplacement). LIMITATIONS: Pilot study. CONCLUSION: Although further studies are necessary, this simple, novel ex vivo model appears useful for training in sphincterotomy and bile duct cannulation. Because the neo-papillae are interchangeable, repetitive sphincterotomies and other interventions can be performed using a single porcine model.

Feasibility of endoscopic retrograde cholangiopancreatography in healthy cats.

Cats are predisposed to diseases of the biliary tract and the exocrine pancreas and these can be challenging to diagnose. In humans and dogs > 10 kg, endoscopic retrograde cholangiopancreatography (ERCP) has been successfully used to diagnose some of these disorders. The purpose of our study was to determine whether ERCP would also be feasible in cats using a pediatric duodenoscope. Four purpose-bred, clinically healthy, castrated domestic shorthair cats participated in two studies. Study 1 compared standard white light endoscopy with chromoendoscopy for localizing the major duodenal papilla. In Study 2 ERCP was performed. Repeated clinical examinations and measurements of serum feline pancreatic lipase immunoreactivity (fPLI) were performed before and up to 18 hours after interventions on all cats. Chromoendoscopy was subjectively judged to be superior for localizing the major papilla. Insertion of the ERCP catheter was best accomplished when cats were in dorsal recumbency. Complete ERCP was successful in two cats. In the other cats, either retrograde cholangiography or pancreatography was possible. Serum fPLI concentrations increased temporarily in two cats during Study 2 when measured immediately, 2, 4, and 18 h after ERCP. Peak fPLI concentrations were detected either immediately after ERCP or 2 h later. No clinical signs of complications were observed within 18 h after the procedures. Findings indicated that ERCP is technically demanding but feasible in healthy cats. Future studies need to determine whether the temporary increases in serum fPLI concentrations are clinically important and to investigate the utility of ERCP in feline patients.

Three-dimensional architecture of the ovine oviductal mucosa.

The objective of this work was to establish for the first time a complete three-dimensional model of the ovine oviductal mucosa. The oviducts of 15 cyclic ewes were examined combining the direct examination of the mucosa, by scanning electron microscopy (SEM) and histology, with the SEM observation of resin moulds of the oviductal lumen. Around the ostium abdominale, all longitudinal primary folds and wide secondary are seen to form cul-de-sacs, with their opening pointing in the ovarian direction were observed. At the connection of the ampulla to the isthmus, there is a sharp change in the morphology, from a high folded structure to a smoother one. In the utero-tubal junction, the primary folds broaden and become more voluminous, the lumen has a slit-like appearance, and secondary folds form cul-de-sacs with their opening oriented towards the uterus. The areas between the folds throughout the lumen of the oviduct show a high degree of complexity. The presence of crypts was observed in all the regions studied, branched in the ampulla and spiniform in the isthmus. Marked variations were observed in the oviductal epithelium depending on the oviductal segment and the basal or apical areas of the folds. The variations found regarding the phase of the oestrous cycle were similar to those described in studies of other species. The anatomy of the oviductal mucosa provides a complex system that seems to be designed to regulate the movement of fluids and the passage of cells within the oviductal canal.

Results of the Tokyo trial of prevention of post-ERCP pancreatitis with risperidone-2: a multicenter, randomized, placebo-controlled, double-blind clinical trial.

BACKGROUND: Our previous study suggested that a combination of ulinastatin and risperidone reduced post-ERCP pancreatitis (PEP) compared with ulinastatin alone. OBJECTIVE: The aim of this study was to evaluate the efficacy of risperidone alone for prevention of PEP. DESIGN: A multicenter, randomized, placebo-controlled, double-blind clinical trial. SETTING: Two academic hospitals and 5 referral hospitals in Tokyo and Saitama, Japan. PATIENTS: Patients undergoing therapeutic or interventional-diagnostic ERCP. INTERVENTION: The patients were randomized to receive 2 mg of oral risperidone or oral placebo at 0.5 to 2 hours before ERCP. MAIN OUTCOME MEASUREMENTS: The primary endpoint was the incidence of PEP. Secondary endpoints were the incidence of hyperenzymemia and enzyme levels (amylase, pancreatic amylase, lipase). Risk factors for PEP were evaluated. RESULTS: We initially enrolled 500 patients in the study (250 in the risperidone group and 250 in the placebo group), but 17 (11 in the risperidone and 6 in the placebo group) were excluded after randomization. PEP developed in 24 patients (10.0%) in the risperidone group and 21 patients (8.6%) in the placebo group (P = .587). Serum amylase levels at 3 hours after ERCP were lower in the risperidone group (P = .007 in a single test of hypothesis, significance removed by Bonferroni correction for multiple testing). In multivariate analysis, a small papilla of Vater, total procedure time ≥40 minutes, and stenosis of the intrahepatic duct were significantly associated with PEP. LIMITATIONS: Multiplicity of study centers and a relatively wide time range of drug administration time. CONCLUSION: Risperidone did not show a benefit in prevention of PEP in this trial. ( CLINICAL TRIAL REGISTRATION NUMBER: NCT000004592.).

The mucosal folds at the pancreaticobiliary junction.

PURPOSE: The structure and function of the mucosal folds in the terminal bile and pancreatic ducts and hepatopancreatic ampulla are poorly characterised. The distribution, muscularity, and innervation of these folds were investigated. METHODS: The pancreaticobiliary junction was excised from ten cadavers (five male, 66-90 years) and examined histologically by serially sectioning (4-µm thickness) along the length of the terminal bile and pancreatic ducts from the tip of the major duodenal papilla. Three surgical specimens (two male, 63-72 years) were also evaluated. Sections were stained with haematoxylin and eosin, anti-actin (smooth muscle), anti-S100 (innervation), and anti-cholecystokinin (CCK)-A receptor antibodies. ImageJ software was used to compare relative radial fold projection and semi-quantitatively assess the smooth muscle and nerve content. In one additional cadaver specimen, folds were examined by scanning electron microscopy. RESULTS: Mucosal folds in the terminal bile duct were arranged circumferentially in a lattice-like arrangement and were distributed over an average distance of 7.3 mm along the terminal bile duct compared to 4.2 mm along the pancreatic duct (P = 0.001), projected further into the lumen, and were more densely innervated than those in the terminal pancreatic duct. Folds in both ducts contained smooth muscle which was more prominent in folds nearest to the major duodenal papilla. Mucosal folds in cadaver and surgical specimens showed no evidence of CCK-A receptor immunoreactivity. CONCLUSIONS: This study demonstrates that the mucosal folds of the terminal bile and pancreatic ducts contain muscle and nerve fibres, suggesting an active rather than purely passive function.

Detection of the ampulla of Vater in small bowel capsule endoscopy: experience with two different systems.

OBJECTIVE: The aim of this study was to determine the detection rate of the ampulla of Vater (AoV) during small bowel capsule endoscopy (SBCE) examinations and compare the two SBCE systems used in our center. METHODS: SBCE procedures performed in our center from March 2005 to June 2011 were reviewed retrospectively. A single reviewer, following a detailed protocol, analyzed 30 min of each recording to identify the AoV. RESULTS: A total of 619 SBCE procedures were enrolled in the study, including 262 with a PillCam SB1, 148 with a PillCam SB2 and 209 with a MiroCam. AoV was identified in 59 SBCE examinations (9.5%), consisting of 28 with a PillCam SB1 (28/262, 10.7%), 13 with a PillCam SB2 (13/148, 8.8%) and 18 with a MiroCam (18/209, 8.6%) (P = 0.665). The AoV was visualized in 53.2 frames (median 12 frames, range 1-1056 frames); and the detection rate was low regardless of indication, patients' characteristics, SBCE system used or capsule transit parameters. Bile spout was associated with a higher AoV detection (P = 0.003). CONCLUSIONS: The persistently low AoV detection rate using two different SBCE systems underlines the weakness of non-steerable capsule endoscopy. Furthermore, if AoV detection is taken as a surrogate marker of small polyp detection, it becomes obvious both that non-steerable SBCE cannot replace a side-viewing endoscope in the evaluation of periampullary polyps in familial adenomatous polyposis and that it is an infallible method in other small bowel polyposis states.

Patency of accessory pancreatic duct and its relation with duodenal inter papillary distance.

A patent accessory pancreatic duct (APD), which acts as a safety valve, may prevent complications of endoscopic retrograde cholangiopancreatography. The interpapillary distance is probably the easiest parameter to assess the probability of APD patency. In previous studies, the patency of APD was correlated with other morphometric parameters of the accessory duct. The present study assessed the frequency of APD patency among south Indian adult cadavers of both sexes, and correlated it with the interpapillary distance. Duodeno-pancreas specimens collected from 100 cadavers with no recorded diseases of biliary pancreatic tree were studied by routine dissection method and dye injection technique. APD had a patent communication with the duodenum in 46 specimens, and was more frequent in men. The distance between the two duodenal papillae varied from 1.6-3 cm; 98% of the patent APD specimens had an interpapillary distance of ≥2 cm. We postulate that an duodenal interpapillary distance ≥2 cm suggests patency of APD.

Pancreatoduodenal junction: review of anatomy and pathologic conditions.

INTRODUCTION: The pancreatoduodenal junction is a small anatomic area where pathologic processes involving the distal bile duct, duodenum, pancreatic head, ampulla de Vater, and retroperitoneum converge. Differential diagnosis includes a spectrum of entities that ranges from anatomical variants to malignancies. PURPOSE: The aim of this paper was to review the anatomy and different pathologic conditions, whether tumoral, inflammatory, or congenital in origin, in this specific area that involves the pancreatic head, duodenum, duodenal ampulla, distal pancreatobiliary tract junction, and retroperitoneum. METHODS: Computed tomography (CT) and magnetic resonance (MR) help us to identify specific radiologic signs that allow to divide the pancreatic-duodenal junction abnormalities into three cathegories: (1) normal variants and congenital anomalies (pancreas divisum, santorinicele, annular pancreas,duodenal duplication cyst, choledocal cyst,...); (2) acquired non-tumoral: traumatic, iatrogenic, inflammatory (duodenal hematoma, duodenal iatrogenic perforation, groove pancreatitis, gastroduodenal artery pseudoaneurysm,...); (3) tumoral (pancreatic head adenocarcinoma, periampullary tumors, neuroendocrine pancreatic tumors, duodenal adenocarcinoma,...). The images illustrate morphologic aspects of these entities. RESULTS AND CONCLUSIONS: CT and MR are the most appropiate imaging modalities to evaluate pancreatoduodenal junction. Knowing the imaging features is crucial to reach the right diagnosis and treatment of the different entities that involve this anatomic area.