Common biliary-pancreatic conduit stenosis induces pancreobiliary reflux.

A striking pancreatic juice reflux toward the biliary tree (PR) has frequently been found in subjects with common bile-pancreatic conduit (CBPC) and gallstone-induced acute pancreatitis (SAP). Our aim was to determine the role of the CBPC functional diameter as a potential trigger of PR. The CBPC was calibrated in three groups of patients: (A) patients with gallbladder stones using intraoperative direct cholangiometry (n = 24), (B) patients after surgical removal of common bile duct stones using postoperative cholangiometry via T-drain (n = 6), and (C) patients with SAP using the same procedures as in group B (n = 6). In all patients in groups B and C, aliquots of bile were collected and assayed for pancreatic amylase content. The mean functional diameter of the CBPC varied from 0.80 mm in patients in groups A and B to 0.47 mm in group C (p < 0.001). The bile samples of group B contained low concentrations of amylase, whereas high values could be found in all samples of group C. We conclude that PR is a frequent event occurring after bile duct revision concerning small amounts of pancreatic juice. However, CBPC functional stenosis as seen in patients with SAP obviously induces PR with high amounts of pancreatic juice.

Sphincter stenosis and gallstone migration through the biliary tract.

We have investigated whether stenosis or insufficiency at the duodenal papilla results from the passage of a gallstone through the biliary tract. In three groups of patients after cholecystectomy we studied meal-stimulated pancreatic enzyme activity in T-drain bile from the common bile duct. Group A had gallbladder stones only; group B had gallbladder stones and bile duct stones; and group C had an episode of acute gallstone-induced pancreatitis, which was taken as direct evidence for gallstone migration into the duodenum. Reflux of pancreatic juice into the common bile duct was absent in group A, was occasionally found in group B, and was strikingly increased in group C. We conclude that passage of a gallstone through the biliary tract causes functional stenosis of the sphincter of Oddi and allows for a common channel between the pancreatic duct and the common bile duct. It does not cause sphincter insufficiency as previously assumed.