Accessory Duct Research Articles

Retrograde tracing along "cystic duct" method to prevent biliary misidentification injury in laparoscopic cholecystectomy.

Bile duct injury remains the most serious complication of laparoscopic cholecystectomy (LC), the main cause was misidentification of cystic duct (CD). The aim of this study was to evaluate the effectiveness and security of retrogradetracing along "cystic duct" (RTACD) method for the prevention of biliary misidentification injury in LC. The conception of RTACD method was first described and then illustrated by simulation dissection with extrahepatic biliary structure charts. A total of 840 patients undergoing LC were selected. After the "CD" was separated during operation, its authenticity was identified by RTACD method according to its course and origin. The "CD" can be clipped/divided only when it was identified to be true CD. Among 840 patients, the initially separated "CD" was identified as actual CD in 831 cases, common hepatic (bile) duct in six cases, accessory right posterior sectoral duct in two cases, and right haptic duct in one case. LCs were successfully finished in 837 patients, and converted to open cholecystectomy in three cases. The average operation time was 64.23min (range 25-225min), and the average blood loss was 8.07ml (range 2-200ml). No biliary misidentification injury was found. All patients recovered smoothly. No jaundice or abdominal pain was noted in the patients during 1-19months follow-up. RTACD method is a safe and effective new technique of preventing biliary misidentification injury.

Conductos linguales accesorios y su relacion con la zona de colecta de hueso autógeno en la región mentoniana.


 
 
 
 
 INTRODUCTION: El involucramiento de los Conductos Linguales Accesorios, con sus correspondientes contenidos neurovasculares, durante la colecta de bloques óseos en la zona mentoniana puede ser la causa de complicaciones neurosensoriales y hemorrágicas.
 OBJECTIVE: El objetivo de este estudio es determinar, por medio del estudio de imágenes tomográficas de Haz Cónico de la región anterior de la mandíbula, las características anatómicas de estos conductos óseos dentro de los limites de esta zona donante de hueso autógeno en dicha zona.
 METHODOLGY: fueron evaluados 50 exámenes tomográficos de Haz Cónico de la región mentoniana,. En cada uno fueron identificados y analizados, cuando presentes, en sus características anatómicas de los Conductos Linguales Accesorios en la línea media. para determinar a que profundidad se presentan y si es posible obtener bloques óseos de 4 mm y 6 mm de espesor sin lesionar su integridad. Los valores fueron comparados entre grupos según sexo, edad y lado examinado.
 RESULTS: Cuando la línea media mentoniana es empleada para la obtención de tejido óseo, los Conductos Linguales Accesorios fueron afectados de 11.7% a 52% dependiendo del espesor, de 04 o 06 mm, del bloque colectado. No fueron detectadas variaciones significativas conforme al sexo, edad o lado estudiado. Conclusión: cuando están presentes los Conductos Linguales Accesorios, la región Anterior de la Mandíbula no debe ser considerada una zona quirúrgica segura. La planificación de la colecta de bloques óseos en la Región Mentoniana debe ser realizada empleando, exclusivamente, imágenes tomográficas de calidad apropiada.
 
 
 

Significance Of "Dominant" Uncinate Duct Dilatation In Ipmn: A New High-Risk Criterion

Presenter: Samer AlMasri MD | University of Pittsburgh Medical Center Background: The uncinate process of the pancreas has a dominant drainage ductal system that can either empty into the accessory or main pancreatic ducts. Although several autopsy series have outlined the anatomical footprints for this independent drainage system, current international consensus guidelines of intraductal papillary mucinous neoplasms (IPMNs) still consider it as a branch duct, even though it is the main drainage system for a once independent portion of the pancreas. We hypothesized that, in addition to the well-defined high-risk criteria of IPMNs, dilation of the “dominant” uncinate duct (UDD) is associated with advanced neoplasia (high grade dysplasia /invasive cancer = HGD/IC) on final resection pathology, and may therefore be classified as an independent high-risk criterion. Methods: A retrospective review of patients who underwent surgical resection of a pancreatic IPMNs between 2008-2019 at our institution was performed. Preoperative imaging studies (pancreas protocol CT and /or MRI) were reviewed by an abdominal radiologist who was blinded to the final pathological Results. In addition to the Fukuoka criteria, we recorded whether there was any UDD irrespective of the location of the primary lesion. Using multivariate logistic regression, the pathological significance of UDD was determined. Results: A total of 260 patients were identified. The mean age at diagnosis was 67.9 years and 49.2% were females. Of the entire cohort, 122 (47%) had HGD/IC and 138 (53%) had non-invasive (low/intermediate grade dysplasia) disease in the surgical specimen. UDD was noted in 59 (22.7%) patients, of which 36 (61%) had invasive disease on pathological evaluation (P < 0.003). On multivariate logistic regression for the entire cohort, adjusting for size, main duct dilation, presence of enhancing mural nodule, bilirubin level and demographics, UDD was an independent predictor of invasive disease (OR= 2.99, P < 0.04). Subgroup analysis was performed on patients with main/mixed duct IPMNs and branch duct IPMNs with high risk criteria confined to the dorsal pancreas (n=170, 66.4%) in order to determine the pathological significance of UDD in these remote lesions. Even in this subgroup of patients, UDD was a significant predictor of HGD/invasive cancer (OR= 7.6, P < 0.004), suggesting it may be associated with an aggressive field effect. Conclusion: This is the largest study to date evaluating the significance of uncinate “dominant” duct dilation in IPMNs, and shows it to be a high-risk feature associated with HGD/IC. This association persisted for IPMNs limited to the dorsal pancreas, suggesting UDD may be associated with an aggressive “field effect”. Although these findings warrant validation with larger prospective studies, we recommend this feature be considered an additional high-risk criterion in IPMN, irrespective of the location of the cystic lesion.

Anatomical Patterns of the Pancreatic Ductal System – A Cadaveric and Magnetic Resonance Cholangiopancreatography Study

Abstract Introduction Morphological variants of the pancreatobiliary system can predispose to chronic pancreatitis. The goal of the present study is to assess the prevalence of pancreatic duct patterns in the Indian population, both by cadaveric dissection and by magnetic resonance cholangiopancreatography (MRCP). Materials and Methods A total of 15 adult pancreas specimens of unknown age and gender, and 5 fetal pancreas specimens of different gestational ages with the intact second part of duodenum, were dissected by the piecemeal method. For clinical relevance, MRCP images of 103 clinically-diagnosed chronic pancreatitis patients irrespective of their etiology were obtained retrospectively from the existing database and studied. The anatomical patterns were classified as five different types based on the course of the main pancreatic duct and the accessory pancreatic duct and their openings into the duodenal wall, including variants like pancreas divisum and ansa pancreatica. Results In the cadaveric study, the main pancreatic duct was single with a straight course in 46.67% of the adult specimens, and in the MRCP study, the main pancreatic duct showed a descending course in 77.66% of the cases. The most common pattern was type III in both the cadaveric (80%) and radiological (55.33%) studies, and the accessory duct was absent on the MRCP in all type-III cases, while it ended blindly in the cadaveric specimens. Ansa pancreatica (type V) was observed in 1 adult specimen (6.7%), but not in the radiological study. Pancreas divisum (type IV) was observed in the 8 cases (7.76%) cases in the radiological study. Conclusion Knowledge of the anatomical variants of the pancreatic ductal system may be helpful for the radiologists during diagnostic and therapeutic interventional procedures.

Randomized Trial of Near-infrared Incisionless Fluorescent Cholangiography.

Incisionless near-infrared fluorescent cholangiography (NIFC) is emerging as a promising tool to enhance the visualization of extrahepatic biliary structures during laparoscopic cholecystectomies. We conducted a single-blind, randomized, 2-arm trial comparing the efficacy of NIFC (n = 321) versus white light (WL) alone (n = 318) during laparoscopic cholecystectomy. Using the KARL STORZ Image1 S imaging system with OPAL1 technology for NIR/ICG imaging, we evaluated the detection rate for 7 biliary structures-cystic duct (CD), right hepatic duct (RHD), common hepatic duct, common bile duct, cystic common bile duct junction, cystic gallbladder junction (CGJ), and accessory ducts -before and after surgical dissection. Secondary calculations included multivariable analysis for predictors of structure visualization and comparing intergroup biliary duct injury rates. Predissection detection rates were significantly superior in the NIFC group for all 7 biliary structures, ranging from 9.1% versus 2.9% to 66.6% versus 36.6% for the RHD and CD, respectively, with odds ratios ranging from 2.3 (95% CI 1.6-3.2) for the CGJ to 3.6 (1.6-9.3) for the RHD. After dissection, similar intergroup differences were observed for all structures except CD and CGJ, for which no differences were observed. Significant odds ratios ranged from 2.4 (1.7-3.5) for the common hepatic duct to 3.3 (1.3-10.4) for accessory ducts. Increased body mass index was associated with reduced detection of most structures in both groups, especially before dissection. Only 2 patients, both in the WL group, sustained a biliary duct injury. In a randomized controlled trial, NIFC was statistically superior to WL alone visualizing extrahepatic biliary structures during laparoscopic cholecystectomy. NCT02702843.

Pancreas divisum inversus.

Pancreatic duct variations are usually diagnosed incidentally, in particular when using magnetic resonance cholangiopancreatography (MRCP), the most accurate imaging modality for depicting the pancreatic ductal system. However, the frequency and the embryologic development of pancreatic variants have not been well investigated. The purpose of this prospective study was to investigate the frequency of pancreatic ductal variants, providing potential explanations of their embryologic basis. The pancreatic ductal anatomies of 202 patients with mean ± standard deviation (SD) age of 54 ± 27 years, 56% females, who underwent MRCP for different indications between April 2018 and March 2019, were prospectively collected. Normal pancreatic ductal variants were identified in 196 cases (97%), and variants of pancreas divisum in six cases (3%). In the type C variant of the normal pancreatic anatomy, found in 3% of the cases, the dorsal duct was joined to the ventral duct while the accessory duct did not communicate with the dorsal duct. Unlike the classic type C variant, in our cases, the accessory pancreatic duct (APD) was long (mean ± SD of 58 ± 8.5 mm) and originated in the lower portion of the pancreatic head, caudally to the duct of Wirsung. This was a new subtype of the type C variant or a new variant, which could be called "pancreas divisum inversus"; the APD could be called the isolated duct of Santorini. Reporting this new variant could increase knowledge regarding the pancreatic anatomy in order to avoid misdiagnosis and to help in better understanding pancreatic diseases and their relative treatment. Clin. Anat., 33:646-652, 2020. © 2019 Wiley Periodicals, Inc.

Duplication of the Common Bile Duct Associated with an Abnormal Pancreatico-Bile Duct Junction. Case Report and Literature Review

Duplication of the common bile duct (CBD) is an uncommon congenital anomaly of the extrahepatic biliary tree; less than 150 cases have been reported to date. The anomaly is characterized by the presence of two ducts—usually one main common bile duct and an accessory bile duct. We present one such case in a 7-year-old girl, where the proximal CBD divided into two separate channels for a short distance and re-united distally to open as a common channel into the second part of duodenum. The main pancreatic duct opened proximally into the medial limb of the anomalous CBD, forming an abnormal pancreatico-bile duct junction (APBDJ). According to the accepted classification, this is a Type Va CBD duplication. The patient also had cholelithiasis and calculi in the medial limb and distal common channel. Endoscopic retrograde cholangiopancreatography (ERCP) was performed, with removal of the gallstones, followed by laparoscopic cholecystectomy. Preoperative radiological imaging, such as ERCP and magnetic resonance cholangiopancreatography (MRCP) are strongly recommended for diagnosis of this condition. Surgery may not be needed for all patients and should be tailored to suit each individual case. This case is presented for its rarity, in the hope that it will contribute to the literature coverage.

1322 A Known Complication With a Delayed Presentation: A Rare Case of Biloma Formation Post-Cholecystectomy

INTRODUCTION: Biloma is an uncommon complication post cholecystectomy with a reported incidence of approximately 0.3-1.5%. While biloma formation is typically seen within weeks of surgery, there are very few documented cases of biloma formation seen years after an uncomplicated cholecystectomy, as seen in the case below. CASE DESCRIPTION/METHODS: A 35-year-old female with a medical history of cholelithiasis requiring cholecystectomy eight years prior presented with worsening dull right upper quadrant pain with early satiety and abdominal distention for two months. Vitals were stable with her exam notable for a palpable abdominal mass. Labs revealed a mild transaminitis. MRI demonstrated dilated bile ducts and a large 16.1 cm cystic lesion in the gallbladder fossa consistent with a biloma. 1.5 liters of proteinaceous material was drained by interventional radiology. Cultures and cytology were negative for an infectious or malignant process. HIDA scan revealed a bile leak for which she underwent an ERCP where two biliary stents were placed for a segmental duct leak. The patient clinically improved and was discharged home on antibiotics. Two outpatient ERCPs were performed, the first revealing a persistent small leak requiring stent exchange and the subsequent ERCP three months later demonstrating complete closure of the leak. DISCUSSION: A biloma is a demarcated collection localized outside the biliary tree often secondary to iatrogenic, traumatic and even spontaneous injury to the biliary tree. With the introduction of laparoscopic cholecystectomy, incidence of biliary injury has increased from 0.1% to about 0.3-1.5%. The pathophysiology is often secondary to either a leakage of bile from an improper closure of a cystic duct stump, transection of an accessory bile duct or duct of Luschka, or rarely from inadvertent injury of the segmental ducts. Presentation varies and can manifest with abdominal pain, nausea, fever and if large enough can result in obstructive jaundice. Diagnosis is typically 1-2 weeks post-surgery with few cases reported years post-op as seen here. Management is dependent on the size of the biloma and leak. Large bilomas often require percutaneous catheter drainage combined with ERCP with sphincterotomy and biliary stenting whereas small bilomas are treated conservatively. If refractory to endoscopic intervention, surgery may be warranted. We present this case to raise awareness of this uncommon, pathologic entity to help facilitate prompt diagnosis and treatment to avoid poor outcomes.

Bile Leak Following Laparoscopic Cholecystectomy

Bile leakage is a very dangerous condition after laparoscopic cholecystectomy and may lead to fatal complications and serious care should be taken to diagnose the cause as early as possible because it may be sign of bile duct injury which is a major concern to the surgeons as if it is not diagnosed early, it will lead to dangerous complications such as biliary peritonitis, hepatic failure and even death. Early diagnosis is important to decrease morbidity and mortality. This study aimed to determine the incidence of bile leakage, its types of management and the outcome in patients with gallstone who are submitted to laparoscopic cholecystectomy. This prospective study was done in Basrah Al-Sadr Teaching Hospital in a two-year period from October 2013 to October 2015 on 560 patients; they were 378 females and 182 males. All of them have symptomatic gallstones and underwent laparoscopic cholecystectomy. All converted cases to open cholecystectomy were excluded. From the total number of 560 patients, nine patients developed bile leak in early post-operative period, 6 of them have drains, the other three have no drain, and they were presented with signs and symptoms of intra-abdominal collection. The causes of leak were common bile duct (CBD) injury in 2 cases, accessory duct in 3 patients, leak from the gall bladder bed in 3 cases and one case iatrogenic from intra-hepatic drain. All the patients were treated conservatively except the two patients with CBD injury who were treated; one with the aid endoscopic retrograde cholangio-pancreatography (ERCP) and the other by re-exploration. In conclusion, bile leak is a serious complication after laparoscopic cholecystectomy, although it is not common but it is important to identify the site of leak and should be tre

Morphology and ultrastructure of salivary glands of male treehopper &lt;i&gt;Tricentrus brunneus&lt;/i&gt; Funkhouser (Hemiptera: Membracoidea)

The salivary glands of male treehopper Tricentrus brunneus Funkhouser comprise a pair of acinous principal glands each with an anterior lobe and a posterior lobe; a pair of elbow-shaped accessory glands. Every accessory gland connects with the principal gland via a thin accessory salivary duct. The anterior lobe contains three types of acini (I, II and III), whereas the posterior lobe possesses only one type of acinus (IV). Two efferent salivary ducts fuse into a common salivary duct. Different acinis cells are filled with secretory granules that are distinct in size, number, shape and electron-density, indicating a maturation process before secreted. Infoldings in different acini suggest dilution of substances before being secreted. The presence of microvilli in acinus IV and the accessory gland duct possibly indicates the undergoing maturation of secretions. Electron-dense fine granules existed in the accessory gland cells, possibly related to virus transmission.

Gallbladder Choledocholithiasis with Communicating Accessory Bile Duct Diagnosed Preoperatively

Gallbladder Choledocholithiasis with Communicating Accessory Bile Duct Diagnosed Preoperatively

Unusual Conditions Impairing Saliva Secretion: Developmental Anomalies of Salivary Glands.

Salivary glands (SG) arise from ectodermal tissue between 6 and 12th weeks of intrauterine life through finely regulated epithelial-mesenchymal interactions. For this reason, different types of structural congenital anomalies, ranging from asymptomatic anatomical variants to alterations associated with syndromic conditions, have been described. Notable glandular parenchyma anomalies are the SG aplasia and the ectopic SG tissue. Major SG aplasia is a developmental anomaly, leading to variable degrees of xerostomia, and oral dryness. Ectopic SG tissue can occur as accessory gland tissue, salivary tissue associated with branchial cleft anomalies, or true heterotopic SG tissue. Among salivary ducts anomalies, congenital atresia is a rare developmental anomaly due to duct canalization failure in oral cavity, lead to salivary retention posterior to the imperforate orifice. Accessory ducts originate from the invagination of the developing duct in two places or from the premature ventral branching of the main duct. Heterotopic ducts may arise from glandular bud positioned in an anomalous site lateral to the stomodeum or from the failure of the intraoral groove development, hindering their proximal canalization. These anomalies require multidisciplinary approach to diagnosis and treatment. While ectopic or accessory SG tissue/ducts often do not require any treatment, patients with SG aplasia could benefit from strategies for restoring SG function. This article attempts to review the literature on SG parenchyma and ducts anomalies in head and neck region providing clinicians with a comprehensive range of clinical phenotypes and possible future applications of bioengineered therapies for next-generation of regenerative medicine.

BILE LEAK FOLLOWING LAPAROSCOPIC CHOLECYSTECTOMY, A PROSPECTIVE STUDY

Abdulkareem Jabbar Ghadban Al-Ebadi Consultant General & Laparoscopic Surgeon, MB,ChB, CABS, FACS, SAGES, Al-Sadr Teaching Hospital, Basrah, Iraq. Abstract Bile leakage is a very dangerous condition after laparoscopic cholecystectomy and may lead to fatal complications and serious care should be taken to diagnose the cause as early as possible because it may be sign of bile duct injury which is a major concern to the surgeons as if it is not diagnosed early, it will lead to dangerous complications such as biliary peritonitis, hepatic failure and even death. Early diagnosis is important to decrease morbidity and mortality. This study aimed to determine the incidence of bile leakage, its types of management and the outcome in patients with gall stone who are submitted to laparoscopic cholecystectomy. This prospective study was done in Basrah Al-Sadr Teaching Hospital in a two-year period from October 2013 to October 2015 on 560 patients, they were 378 females and 182 males. All of them have symptomatic gall stones and underwent laparoscopic cholecystectomy. All converted cases to open cholecystectomy were excluded. From the total number of 560 patients, nine patients developed bile leak in early post-operative period, 6 of them have drains and the other three have no drain and they were presented with signs and symptoms of intra-abdominal collection. The causes of leak were: common bile duct (CBD) injury in 2 cases, accessory duct in 3 patients, leak from the gall bladder bed in 3 cases and one case iatrogenic from intra-hepatic drain. All the patients were treated conservatively except the two patients with CBD injury who were treated; one with the aid endoscopic retrograde cholangio-pancreatography (ERCP) and the other by re-exploration. In conclusion, bile leak is a serious complication after laparoscopic cholecystectomy, although it is not common but it is important to identify the site of leak and should be treated urgently especially by drainage to avoid more severe results which may lead to increased morbidity and mortality

Ansa pancreatica. Review of the literature

Ansa pancreatica is a reversed S-shaped pancreatic duct arising from the main pancreatic duct of Wirsung and ending at or near the minor duodenal papilla. Described for the first time in 1961, it is a rare anatomic variant of the pancreatic ducts system and is characterized by the absence of the accessory duct of Santorini. It probably serves as a counter measure after the accessory duct obliteration, in order to maintain sufficient pancreatic juice drainage. The literature concerning ansa pancreatica seems to be rather poor, compared to other anatomic variants and congenital anomalies of the pancreatic ducts. We tried to define the ansa pancreatica incidence among general population and highlight the possible differences between different populations, and to define its possible correlation with pancreatitis. The existing data correlate ansa pancreatica with recurrent acute pancreatitis and pancreatitis in alcoholics. Despite the lack of extended data, ansa pancreatica is a rare anatomic variant, proven to play an important role in certain clinical conditions.

Rare anatomic variations of the right hepatic biliary system.

To report rare and clinically significant anatomic variations in the biliary drainage of right hepatic lobe. Unique variations in the extra- and intrahepatic biliary drainage of right hepatic lobe were observed in 6 cadaveric livers during dissection on 100 formalin-fixed en bloc cadaveric livers. There was presence of aberrant drainage of right segmental and sectorial ducts in four cases and of accessory right posterior sectorial duct in two cases. We encountered some extensively complicated biliary drainage of right hepatic lobe, unsuccessful recognition of which can lead to serious biliary complications during hepatobiliary surgeries and biliary interventions.

A rare branching pattern of the celiac trunk associated with an accessory aberrant cystic duct

During routine educational dissection of the upper part of the abdominal cavity in a female cadaver (67 years old, Netherlands) a unique association of two rare biliary and vascular patterns was discovered. The gastroduodenal artery originated from the celiac trunk along with the right hepatic, gastric and splenic arteries, and gave origin to the accessory right and left hepatic vessels. The right hepatic artery took the course typical for the common hepatic artery; however, as a component of the portal triad, the artery was located behind the bile duct and portal vein. Next to the hilum of the liver, it branched off the cystic artery to the gallbladder and bifurcated into two segmental hepatic branches. The described hepatic vascular pattern was associated with the presence of an accessory aberrant cystic duct connecting the body of the gallbladder with the right anterior inferior segmental bile duct. The case is reported to emphasize the importance of a detailed preoperative investigation of the patients considered for open and laparoscopic procedures on the liver and gallbladder documenting the variability of both the biliary and vascular patterns.

Unusual Variations in Path of Accessory Submandibular Salivary Gland Duct in Comparison with Main Submandibular Salivary Gland Duct

Introduction: The submandibular gland is located bilaterally in the submandibular triangle. The main submandibular duct or Wharton’s duct, runs with lingual nerve to open in the sublingual papilla at the side of frenulum of the tongue. The aim of this study was to demonstrate the unusual variations of accessory submandibular duct in comparison with main submandibular salivary gland duct. Material &amp; Methods: Nineteen cadavers were dissected to study the submandibular salivary duct. Results: 15.7% incidence of variations were observed. We found that one submandibular region was having unusual path of accessory duct, it emerged from superficial part of the gland and crossed the superficial surface of mylohyoid muscle and bifurcated into two branches. These bifurcated branches of duct pierced the mylohyoid muscle to pass between mylohyoid and hyoglossus muscle. One branch of bifurcated accessory duct opened through papilla in the floor of the mouth behind the lower incisor tooth and second branch of the bifurcated duct anastomosed with the main duct (Wharton’s duct) to open in sublingual papilla. Wharton’s duct of this side followed its normal path to open in the sublingual papilla. Two specimens of submandibular region was observed with duplication of submandibular duct in each submandibular gland. One was main duct and second was accessory duct. Both ducts emerged separately from the deep part of submandibular gland and ended independently into sublingual papilla. Conclusion: Reporting of these variations are important for diagnostic imaging, anatomical teaching and to help surgeons while operating in this region.

Role of Salivary Duct Morphology in the Etiology of Chronic Obstructive Parotitis: Statistical Analysis of Sialographic Features and Computational Fluid Dynamics Analysis of Salivary Flow

The causes of some cases of chronic obstructive parotitis (COP) without obstructive factors are still unclear. The authors hypothesized that some morphologic features of salivary ducts might contribute to the development of COP. This study investigated the role of salivary duct morphology in the etiology of COP. The authors designed and implemented a case-and-control study. Cases were defined as patients with COP, diagnosed from September 2014 to May 2017 at the Affiliated Hospital of Stomatology of the Sun Yat-sen University (Guangzhou, China), and controls were healthy participants. The primary predictor variables were the occurrence of an accessory duct (AD), the number of branches uniting to form the Stensen duct (SD), the angle between the AD and the SD, and the angle between branches identified on sialographic computed tomograms. Data from the 2 groups were compared to investigate the association between these variables and COP. The χ2 test, Student t test, and logistic regression were computed, with significance set at a P value less than .05. Fluid dynamics analysis was used to analyze salivary flow field in models of salivary ducts with different morphologic features reconstructed from sialographic computed tomograms. The sample was composed of 39 patients with COP and 18 controls without COP. The 2 groups were not similar for incidences of an AD (71.8 vs 38.9%) and the angle between branches (96.5±26.0° vs 71.5±21.2°). There was no relevant difference between groups in the number of branches and the angle between the AD and the SD. The area of low velocity was larger in the model with the wider angle between branches. The results suggest that the presence of an AD and a wider angle between duct branches are associated with COP.

Hepaticocholecystic duct: A pitfall of cholecystectomy.

Key Clinical MessageThe anatomical variations of accessory biliary ducts account for up to 2% of the population. The two types of ducts are the: subvescical and hepaticocholecystic. The knowledge of such variations is extremely important during cholecystectomy in order to avoid possible postoperative complications such as biliary injury or choleperitoneum.

Morphological expression of the extrahepatic bile duct. A study in a sample of Colombian mestizo population

&#x0D; Background: The great variability of the extrahepatic bile duct (EBD) has clinical-surgical implications. The objective of this study was to characterize the morphological expressions of EBD.&#x0D; Methods and findings&#x0D; This descriptive study, done by injecting a semi-synthetic (Palatal GP40L 85%; styrene 15%) impregnated with mineral green dye into the gallbladder, to determine the anatomical characteristics and the biometrics of EBD in 33 blocks formed from the supra-mesocolic floor.The gallbladder presented a length of 66.9 ± 1.7 mm. The Hartmann´s Pouch was observed in 16 specimens (50%). The lengths of the cystic duct (CD), common hepatic duct (CHD) and common bile duct (choledoch duct) were 27.8 ± 1.6 mm, 28.6 ± 11.39 mm and 60.6 ± 11.6 mm respectively.&#x0D; The presence of accessory hepatic ducts (AHD) was found in three samples (9.1%). In 29 specimens (87.9%) the cystic duct presented medium length, while in 4 cases (12.1%) the CD was long (P &lt; 0, 05). The trajectory of the lateral oblique of CD was present in 23 cases (69.7%), with statistically significant differences in relation to the other trajectories of the CD (P &lt;0, 05). In 18 samples (55%) the cystic-hepatic union appeared at the level of the middle third of the EBD, while in 15 (45%) cases the union of the CD was low (P&lt;0,05).&#x0D; Conclusions&#x0D; The mathematical distribution of the segments of the EBD, carried out in this study, provides reliability to the assessment of the cystic-hepatic junction level. The presence of CHA and the level of the cysto-hepatic junction are important anatomical references, especially in emergency room procedures.