Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Tokyo 113-8677, Japan.
World J Gastroenterol. 2012 Jul 14;18(26):3409-14. doi: 10.3748/wjg.v18.i26.3409.
To clarify the strategy for early diagnosis of pancreaticobiliary maljunction (PBM) without biliary dilatation and to pathologically examine gallbladder before cancer develops.
The anatomy of the union of the pancreatic and bile ducts was assessed by using endoscopic retrograde cholangiopancreatography (ERCP). Patients with a long common channel in which communication between the pancreatic and bile ducts was maintained even during sphincter contraction were diagnosed as having PBM. Of these, patients in which the maximal diameter of the bile duct was less than 10 mm were diagnosed with PBM without biliary dilatation. The process of diagnosing 54 patients with PBM without biliary dilatation was retrospectively investigated. Histopathological analysis of resected gallbladder specimens from 8 patients with PBM without biliary dilatation or cancer was conducted.
Thirty-six PBM patients without biliary dilatation were diagnosed with gallbladder cancer after showing clinical symptoms such as abdominal or back pain (n = 16) or jaundice (n = 12). Radical surgery for gallbladder cancer was only possible in 11 patients (31%) and only 4 patients (11%) survived for 5 years. Eight patients were suspected as having PBM without biliary dilatation from the finding of gallbladder wall thickening on ultrasound and the diagnosis was confirmed by ERCP and/or magnetic resonance cholangiopancreatography (MRCP). The median age of these 8 patients was younger by a decade than PBM patients with gallbladder cancer. All 8 patients underwent prophylactic cholecystectomy and bile duct cancer has not occurred. Wall thickness and mucosal height of the 8 resected gallbladders were significantly greater than controls, and hyperplastic changes, hypertrophic muscular layer, subserosal fibrosis, and adenomyomatosis were detected in 7 (88%), 5 (63%), 7 (88%) and 5 (63%) patients, respectively. Ki-67 labeling index was high and K-ras mutation was detected in 3 of 6 patients.
To detect PBM without biliary dilatation before onset of gallbladder cancer, we should perform MRCP for individuals showing increased gallbladder wall thickness on ultrasound.
阐明无胆管扩张的胰胆管合流异常（PBM）的早期诊断策略，并在癌症发生前对胆囊进行病理检查。
采用内镜逆行胰胆管造影术（ERCP）评估胰胆管汇合处的解剖结构。在胰胆管之间的共同通道较长的情况下，即使在括约肌收缩时也保持沟通的患者被诊断为 PBM。其中，胆管最大直径小于 10mm 的患者被诊断为无胆管扩张的 PBM。回顾性调查了 54 例无胆管扩张的 PBM 患者的诊断过程。对 8 例无胆管扩张或癌症的 PBM 患者的胆囊切除标本进行了组织病理学分析。
36 例无胆管扩张的 PBM 患者出现腹痛或背痛（n=16）或黄疸（n=12）等临床症状后被诊断为胆囊癌。仅 11 例（31%）患者可行根治性胆囊癌手术，仅 4 例（11%）患者存活 5 年。8 例患者因超声发现胆囊壁增厚而怀疑为无胆管扩张的 PBM，通过 ERCP 和/或磁共振胰胆管成像（MRCP）确诊。这 8 例患者的中位年龄比胆囊癌的 PBM 患者年轻 10 岁。所有 8 例患者均行预防性胆囊切除术，未发生胆管癌。8 例切除胆囊的壁厚度和黏膜高度明显大于对照组，7 例（88%）、5 例（63%）、7 例（88%）和 5 例（63%）患者分别检测到增生性改变、肥厚性肌层、浆膜下纤维化和腺肌增生，6 例中有 3 例 Ki-67 标记指数高，3 例检测到 K-ras 突变。
为了在胆囊癌发生前发现无胆管扩张的 PBM，我们应该对超声显示胆囊壁增厚的个体进行 MRCP 检查。
