Reply to Matsushita et al. Regarding the Management of Anomalous Pancreaticobiliary Union

We thank Matsushita and his colleagues for their valuable comments on our paper. As the authors pointed out, there are reports emphasizing a significantly increased incidence of malignant change in the gallbladders and bile ducts of patients with anomalous pancreaticobiliary union (APBU) [1]. It is speculated that the pathogenesis of bile duct or gallbladder cancer in APBU patients involves the reciprocal reflux of bile and pancreatic juice. Complete biliary diversion procedures with bile duct resection are recommended for APBU patients with a dilated common hepatic duct and prophylactic cholecystectomy for those with an undilated common hepatic duct.

However, it is probable that both the increased incidence of APBU and the risk for malignant degeneration in the gallbladder and bile ducts are specific to Asian patients. There is not enough evidence documenting similar increased incidences in Caucasian patients [2] [3]. In Asian patients also, the risk of malignant degeneration varies according to the type of APBU: the risk of gallbladder cancer is reported to be higher in patients with a pancreatic duct opening into the common bile duct compared with those with a common bile duct opening into the pancreatic duct, as in our patient [4].

Therefore we think that there is not enough evidence to recommend prophylactic cholecystectomy in our patient. Complete biliary diversions with bile duct resection are serious surgical procedures. Complications such as strictures, recurrent cholangitis, and intrahepatic biliary stones may develop and the quality of life of the patients may worsen significantly. We think, therefore, that there should be strong evidence to recommend such surgical procedures in asymptomatic patients. We agree with Matsushita and his colleagues that clinicians should be alert concerning the development of gallbladder and bile duct carcinomas in APBU patients. We suggest that patients with APBU should be closely monitored, and surgery should be performed when laboratory tests or imaging procedures raise a suspicion of malignancy. But at present, we think that there is not enough evidence to recommend prophylactic surgical procedures in APBU patients of Caucasian ethnic origin.

References

• 1 Wang P H, Wu M S, Lin C C . et al . Pancreaticobiliary diseases associated with anomalous pancreaticobiliary ductal union.  Gastrointest Endosc. 1998;  48 184-189
• 2 Sharma S S. Pancreaticobiliary ductal union in cholangiocarcinoma.  Gastrointest Endosc. 1993;  40 171-173
• 3 Samavedy R, Sherman S, Lehman G A. Endoscopic therapy in anomalous pancreatobiliary duct junction.  Gastrointest Endosc. 1999;  50 623-627
• 4 Hu B, Gong B, Zhou D. Association of anomalous pancreaticobiliary ductal junction with gallbladder carcinoma in Chinese patients: an ERCP study.  Gastrointest Endosc. 2003;  57 541-545