Bile Duct Anatomy Research Articles

Retraction: The effect and importance of extrahepatic bile duct anatomy variations in the etiology of holedocholithiasis (Sanamed. Online First, October 2022, DOI: 10.5937/sanamed0-40131)

This paper is retracted at the request of the authors due to the potential existence of a conflict of interest and disagreements between the authors and the head of the department where the research was conducted, regarding the holder of the authorship.

Ultrasound Еxamination of the Еxtrahepatic Bile Ducts in Children (Literature Review with our own Clinical Observations)

To study the normal sonographic anatomy of extrahepatic bile ducts, a polypositional ultrasound examination of 120 children aged 0 to 17 years was conducted. The technique of hepatoduodenal ligament ultrasound examination is described. The main sonographic visual indicators for studying the anatomical and topographic structure of extrahepatic bile ducts in children are denoted. The normative parameters of the common bile and common hepatic ducts in children of different age groups are presented.

Gallbladder cancer spreading into the aberrant cystic duct: First literature report.

Introduction and importanceAlthough variations from the standard anatomy of the extrahepatic bile ducts are common, duplication of the cystic duct draining a single gallbladder is an extremely rare variant. We herein describe the first report of gallbladder cancer spreading into the aberrant cystic duct.Case presentationA 60-year-old female presented with upper abdominal pain, and she was diagnosed with gallbladder cancer. Intraoperatively, she was found to have a duplicated cystic duct draining a single gallbladder, and her cancer had spread into the aberrant cystic duct entering the anterior right hepatic duct. Right hepatectomy with extrahepatic bile duct resection was performed to achieve R0 resection.Clinical discussionIn the English literature, 28 cases of duplicated cystic duct draining a single gallbladder have been reported. However, no cases of gallbladder cancer have been described in these previous reports.ConclusionWe report the first case of gallbladder cancer spreading into the aberrant cystic duct. To perform an oncologically adequate operation, exact assessment of the biliary tree is essential not only preoperatively but also intraoperatively.

Duplicated extrahepatic duct type Vb in a patient with gallstone pancreatitis

As rates of childhood obesity rise, the frequency of laparoscopic cholecystectomy to treat gallbladder disease in the pediatric population is increasing. Knowledge of biliary anatomy and its variants is vital to performing this operation safely. Duplication of the extrahepatic biliary tree is a rare but important variant. The significance of duplicated common bile duct anatomy is important as these variations may pre-dispose patients to stone formation and obstruction. Here we present the case of an 11-year-old girl with gallstone pancreatitis and a duplicated common bile duct. The patient underwent interval laparoscopic cholecystectomy following resolution of pancreatitis. A duplicated common bile duct type Vb was identified on intraoperative cholangiogram and subsequent endoscopic retrograde cholangiopancreatography.

Surgical anatomy of caudate bile ducts: An important technique to enhance enhance cholangiogram interpretation

Caudate bile ducts are routinely presented using negative images as X-ray-cholangiograms. Such information does not provide for instant surgical orientation of the relationships between caudate ducts and the liver itself-a paramount skill for successfully performing hilar cholangiocarcinoma resection and living donor/split transplantation. This study presents a 4-step procedure to prepare, dissect and present, high-quality, two-dimensional/three-dimensional (2D/3D) anatomical images of biliary caudate ducts in a surgically meaningful way. Fresh cadavers had arteries and veins injected with colored-silicone and ducts bile-stained to facilitate recognition. Dissections were performed under magnification with microsurgical instruments. Stepwise 2D and 3D images were acquired. Dissection of silicone-injected specimens under magnification allows identification of caudate structures, its portions and processes while preserving tridimensional arrangement of caudate vessels, biliary ducts and collectors. Such dissections can help enhance cholangiogram interpretation and favor its direct correlation to intraoperative findings. A procedure including: a) preparation of high-quality cadaveric livers; b) with silicone-injected vessels; c) dissected under surgical microscope; and d) documented using 2D and 3D images aimed at enhancing the clinical understanding of the anatomy of caudate ducts is presented. It has potential to enhance morphological and clinical understanding of caudate ducts, being useful to anatomists and surgeons alike.

Anatomic variations of the intra-hepatic biliary tree in the Caribbean: A systematic review.

BACKGROUNDIn the classic descriptions of the human liver, the common hepatic duct forms at the confluence of left and right hepatic ducts. Many authors have documented variations in the intra-hepatic ductal system, but to the best of our knowledge there has been no report on bile duct variations in Caribbean populations.AIMTo evaluate the variations in bile duct anatomy using magnetic resonance cholangiography (MRC) in unselected patients at a major hepatobiliary referral centre in the Eastern Caribbean. Knowledge of the intra-hepatic biliary anatomy is important to optimize service delivery for any physician treating liver and biliary disorders.METHODSThis study was carried out at a tertiary referral hospital for hepatobiliary diseases in the Eastern Caribbean. We retrospectively evaluated magnetic resonance cholangiograms in 152 consecutive patients at this facility over a two-year period from April 1, 2017 to March 31, 2019. Two consultant radiologists experienced in MRC interpretation reviewed all scans and described biliary anatomy according to the Huang’s classification. A systematic review of published studies was performed and relevant data were extracted in order to calculate the global prevalence of each biliary variant. The variants in our population were compared to the global population.RESULTSThere were 152 MRCs evaluated in this study in 86 males and 66 females. There were 109 (71.7%) persons with “classic” biliary anatomy (type A1) and variants were present in 43 (28.3%) persons. There was no statistical relationship between the presence of anatomic variants and gender or ethnicity. We encountered the following variants: 29 (19.1%) type A2, 7 (4.6%) type A3, 6 (3.95%) type A4, 0 type A5 and a single variant (quadrification) that did not fit the classification system. Compared to the global prevalence, our population had a significantly greater occurrence of A1 anatomy (71.7% vs 62.6%; P = 0.0227) and A2 trifurcations (19.1% vs 11.5%; P = 0.0069), but a significantly lower incidence of A3 variants (4.61% vs 11.5%; P = 0.0047).CONCLUSIONThere are significant differences in intra-hepatic biliary anatomy in this unselected Eastern Caribbean population compared to global statistics. Specifically, persons of Caribbean descent have a greater incidence of Huang A2 trifurcations and a lower incidence of Huang A3 variants.

Acute cholecystitis in a left sided gallbladder safely managed by laparoscopic surgery

Left-sided gallbladder (LSGB) is a rare bile duct abnormality, usually found during a cholecystectomy. Symptoms usually do not differ from those of a normally positioned gallbladder, making the preoperative diagnosis extremely uncommon. We report the case of an acute cholecystitis in a patient whit LSGB, safely managed with laparoscopic surgery. A 24-year-old male patient was admitted to our institution with clinical and radiological signs of acute cholecystitis. The intraoperative finding of an acute cholecystitis in a LSGB made us modify ports positioning and a cholangiograhy was done by direct puncture of the gallbladder before hilum dissection. After the cystic duct was identified, a transcystic cholangiography was performed which confirmed a complete and clear bile duct anatomy and laparoscopic cholecystectomy was safely completed. The intraoperative finding of a LSGB makes the surgeon change some aspects of the usual technique to perform a safe cholecystectomy as LSGB significantly increases the risk of common bile duct injuries. Meticulous dissection of the gallbladder hilum to achieve a critical view of safety and the systematic use of intraoperative cholangiography are extremely important to perform a safe laparoscopic cholecystectomy.

Morphometric Analysis of Common Bile Duct: A Cadaveric Study

Introduction: Though human beings look similar in their general anatomical appearances but during the investigation of a particular structure in detail, it is surprising how frequently we meet one sort or another type of variation. Literature reports that accurate dimensions of CBD are debatable. Therefore, determination of a spontaneous abnormality or atypical variation is important and reference range plays a significant role to classify the normal or abnormal duct. Materials and Methods: A total of thirty (30) cadavers were dissected at MGM Medical College Mumbai, India from Jan 2012 to March 2013 for anatomical features of the common bile duct-like their size, variations in the course and termination. Results: The length of the common bile duct varies 35.19 mm to 62.43 mm with Mean ± SD 46.92 ± 7.91 mm and diameter varied between 3.65 mm to 10.31 mm with mean value 6.50 ± 1.77. The correlation between length and diameter of common bile duct is statistically insignificant (p = 0.243) Conclusion: We established a reference range for the CBD length and diameter. Thus, the exact knowledge of the anatomy of the common bile duct is significant for successful hepato-biliary surgery and biliary pathology.

Impact of laparoscopic cholecystectomy on the complexity of endoscopic retrograde cholangiopancreatography.

A scarce number of researches discussed the impact of cholecystectomies on the anatomy of common bile duct (CBD) and intern if this will affect the difficulty of endoscopic retrograde cholangiopancreatography (ERCP). The objective of present study was to assess the impact of complicated cholecystectomy on the complexity and safety of the ERCP procedure. A total of 100 patients were enrolled after meeting the following inclusion criteria - study group (group A): 50 patients with previous history of complicated laparoscopic cholecystectomy and control group (group B): 50 patients with previous noncomplicated laparoscopic cholecystectomy. ERCP was performed and complexity was judged by a number of cannulation attempts, ERCP time, pancreatic cannulation and post-ERCP pancreatitis. The study revealed prolonged ERCP procedure duration in noncomplicated cholecystectomy (24.2 ± 8.5 min) and it was significantly more prolonged in complicated cholecystectomy (39.6 ± 10.7 min; P = 0.03). The trials of cannulation attempts were significantly higher in the study group with complicated cholecystectomy (P = 0.009). Pancreatic duct cannulation was frequently higher in the complicated cholecystectomy group (P = 0.03). Difficult or failed stone extraction was significantly prevalent in the complicated cholecystectomy group and the occurrence of post-ERCP pancreatitis (PEP) was significantly higher than the control group. ERCP after complicated laparoscopic cholecystectomy is more complex with increased duration liability of complications.

Surgical anatomy of caudate bile ducts: Silicon-injected cadaveric-livers dissected under magnification.

Backgrounds/AimsCaudate bile ducts are routinely presented using negative images as X-ray-cholangiograms. Such information does not provide for instant surgical orientation of the relationships between caudate ducts and the liver itself−a paramount skill for successfully performing hilar cholangiocarcinoma resection and living donor/split transplantation. This study presents a 4-step procedure to prepare, dissect and present, high-quality, 2D/3D anatomical images of biliary caudate ducts in a surgically meaningful way.MethodsFresh cadavers had arteries and veins injected with colored-silicone and ducts bile-stained to facilitate recognition. Dissections were performed under magnification with microsurgical instruments. Stepwise 2D and 3D images were acquired.ResultsDissection of silicone-injected specimens under magnification allows identification of caudate structures, its portions and processes while preserving tridimensional arrangement of caudate vessels, biliary ducts and collectors. Such dissections can help enhance cholangiogram interpretation and favor its direct correlation to intraoperative findings.ConclusionsA procedure including: a) preparation of high-quality cadaveric livers, b) with silicone-injected vessels, c) dissected under surgical microscope and d) documented using 2&3D images aimed at enhancing the clinical understanding of the anatomy of caudate ducts is presented. It has potential to enhance morphological and clinical understanding of caudate ducts, being useful to anatomists and surgeons alike.

Ten strategies to improve the efficacy of laparoscopic biliary surgery

Laparoscopic surgery is the gold standard treatment of symptomatic gallstones. For some, it is also the treatment of choice for choledocholithiasis. Certain special and rare circumstances regarding the number, size and location of bile duct stones or altered bile duct anatomy (embryonic or acquired), can be challenging to resolve with usual laparoscopic techniques. For these situations, we describe 10 surgical strategies that are relatively simple and inexpensive to apply, making them appropriate to be used in most surgical centers.

Importance of Imaging Plane of Gadoxetic Acid--Enhanced Magnetic Resonance Cholangiography for Bile Duct Anatomy in Healthy Liver Donors

PurposeThe purpose of this study was to compare the image quality and accuracy of axial vs coronal contrast-enhanced magnetic resonance cholangiography (CE-MRC) for assessing bile duct anatomy. MethodsData from 313 healthy donors who underwent axial and coronal CE-MRC before liver donation were retrospectively analyzed. Motion artifacts and bile duct visibility were assessed using 4-point scales, with scores ≥3 considered interpretable. The sensitivity and specificity of axial and coronal CE-MRC for diagnosing anatomic variations were compared, as were the proportions of correctly categorized biliary anatomic types. ResultsAxial CE-MRC provided better image quality than coronal CE-MRC in terms of both motion artifacts (3.83 vs 3.17; P < .001) and duct visibility (3.50 vs 3.17, P < .001), resulting in more interpretable images with axial than coronal CE-MRC (92.7% vs 82.1%; P < .001). Among 249 donors with interpretable images, coronal CE-MRC performed significantly better for identifying duct anatomic variation than axial CE-MRC (sensitivity, 96.9% vs 80.4%, P < .001; specificity, 100% vs 96.7%, P = .025). Coronal CE-MRC was significantly better than axial CE-MRC at correctly categorizing anatomic types of right posterior hepatic duct into left hepatic duct and accessory duct with incomplete right hepatic duct. ConclusionsWith interpretable image quality, coronal CE-MRC performed better than axial CE-MRC for evaluating bile duct anatomy.

Pathophysiology and Imaging Findings of Bile Duct Necrosis: A Rare but Serious Complication of Transarterial Therapy for Liver Tumors.

Simple SummaryBile duct necrosis (BDN) is rare but serious complication of transarterial therapy for liver tumors. During development of BDN, ischemia of the peribiliary vascular plexus (PBP) induces the disruption of the bile duct epithelial protection mechanism, causing necrosis of the surrounding tissue by the detergent action of exuded bile acids, and eventually a biloma forms. Once BDN starts, persistent tissue damage to the surrounding bile duct is induced by imbibed bile acids, and portal vein thrombosis may also be observed. On CT images, BDN shows similar findings to intrahepatic bile duct dilatation, and, therefore, it is sometimes misdiagnosed. Clinicians should be aware that although BDN and biloma can usually be treated conservatively, in the presence of symptoms such as moderate or severe infection or interval growth of the biloma, prompt treatment is essential to avoid lethal abscess formation and sepsis.Bile duct necrosis (BDN) with biloma formation is a type of ischemic bile duct injury that is one of the serious complications associated with transarterial therapies, such as transcatheter chemoembolization therapy (TACE), and radioembolization for hepatocellular carcinoma (HCC) and hepatic arterial infusion chemotherapy (HAIC) for metastatic liver cancer from colorectal carcinoma. In terms of the occurrence of BDN and subsequent biloma formation, ischemic injury to the peribiliary vascular plexus (PBP), the supporting vessel of bile duct epithelium, is thought to be intimately associated. In this paper, we first describe the anatomy, blood supply, and function of the intrahepatic bile duct, and then illustrate the pathophysiology of BDN, and finally present the imaging findings of BDN. Under the process of BDN formation, ischemia of the PBP induces the disruption of the bile duct epithelial protection mechanism that causes coagulation and fibrinoid necrosis of the surrounding tissue by the detergent action of exuded bile acids, and eventually a biloma forms. Once BDN occurs, persistent tissue damage to the surrounding bile duct is induced by imbibed bile acids, and portal vein thrombosis may also be observed. On pre-contrast and contrast-enhanced computed tomography (CT), BDN shows similar findings to intrahepatic bile duct dilatation, and, therefore, it is sometimes misdiagnosed. Differentiation of imaging findings on CT and ultrasound (US)/magnetic resonance (MR) imaging/MR cholangiopancreatography (MRCP) is important for correct diagnosis of BDN.

Diez estrategias para mejorar la eficacia de la cirugía biliar laparoscópica

Laparoscopic surgery is the gold standard treatment of symptomatic gallstones. For some, it is also the treatment of choice for choledocholithiasis. Certain special and rare circumstances regarding the number, size and location of bile duct stones or altered bile duct anatomy (embryonic or acquired), can be challenging to resolve with usual laparoscopic techniques. For these situations, we describe 10 surgical strategies that are relatively simple and inexpensive to apply, making them appropriate to be used in most surgical centers.

ANATOMICAL VARIATION OF INTRAHEPATIC BILIARY DUCT IN CADAVERIC LIVER

Background: Hepatobiliary system has many variations. Use of cadavers, intraoperative data and various imaging modalities are the commonly employed techniques for determining the anatomy of intrahepatic bile ducts. The vivid picture of hepatobiliary system is a must for hepatobiliary surgery and identification of frequency distribution of typical and atypical pattern and different types of atypical pattern are vital. This study aimed to uncover its frequency distribution and also to recognize the variations therein.&#x0D; Methods: An observational study was conducted in the Department of Anatomy, Kathmandu Medical College Teaching Hospital from July 2013 to June 2014 by taking 50 complete human cadaveric livers without evidence of injuries or previous operations. Livers were dissected, duct traced, colored, photographed and the findings were entered in a proforma.&#x0D; Results: Out of 50 dissected livers, 32 showed typical pattern (Type A, 64%) whereas 18 liver showed atypical pattern of confluence (36%). The type B pattern was seen in 6 (12%) and type C was seen in 8 of them (16%). Of these 8 cases, subtype C1 was observed in 6 livers (12%) and subtype C2 was found in 2 livers (4%). Type D was seen in 3 livers (6%). and all of them were of the subtype D1. There were no cases of subtype D2 and of type E. Type F was observed in a single case (2%).&#x0D; Conclusions: An accurate knowledge of the anatomical variations of the intrahepatic biliary tree is important for a successful hepatobiliay surgery.

Anatomical variation of intrahepatic biliary duct in cadaveric liver

Background: Hepatobiliary system has many variations. Use of cadavers, intraoperative data and various imaging modalities are the commonly employed techniques for determining the anatomy of intrahepatic bile ducts. The vivid picture of hepatobiliary system is a must for hepatobiliary surgery and identification of frequency distribution of typical and atypical pattern and different types of atypical pattern are vital. This study aimed to uncover its frequency distribution and also to recognize the variations therein.&#x0D; Methods: An observational study was conducted in the Department of Anatomy, Kathmandu Medical College Teaching Hospital from July 2013 to June 2014 by taking 50 complete human cadaveric livers without evidence of injuries or previous operations. Livers were dissected, duct traced, colored, photographed and the findings were entered in a proforma.&#x0D; Results: Out of 50 dissected livers, 32 showed typical pattern (Type A, 64%) whereas 18 liver showed atypical pattern of confluence (36%). The type B pattern was seen in 6 (12%) and type C was seen in 8 of them (16%). Of these 8 cases, subtype C1 was observed in 6 livers (12%) and subtype C2 was found in 2 livers (4%). Type D was seen in 3 livers (6%). and all of them were of the subtype D1. There were no cases of subtype D2 and of type E. Type F was observed in a single case (2%).&#x0D; Conclusions: An accurate knowledge of the anatomical variations of the intrahepatic biliary tree is important for a successful hepatobiliay surgery.

Intraoperative fluorescence angiography and cholangiography with indocyanine green in hepatobiliary surgery

Intraoperative fluorescence angiography and cholangiography with indocyanine green (ICG) are increasingly used in routine hepatobiliary surgery. Its usage is manifold. It improves and facilitates navigation especially in minimal invasive and robotic surgery and therefore increases the safety of the surgical intervention. In laparoscopic cholecystectomy for example, the bileduct anatomy can be easily visualized, even in complicated cholecystitis or anatomical variants without being too time consuming. ICG fluorescence also enables the visualization of vascular structures and perfusion. Anatomical liver resections, for example in hepatocellular carcinoma (HCC), can be performed easily as liver segments and territories can be identified. Anatomical resection is becoming more important, e.g. in the treatment of HCC. Another useful application is the intraoperative detection of bile leakages after liver resection. In particular, the intraoperative control of a biliodigestive anastomosis is possible with ICG fluorescence cholangiography and therefore reduces morbidity. Even primary and secondary liver tumors can be detected with ICG fluorescence. Whereas well-differentiated HCCs homogeneously take up ICG, poorly differentiated HCCs and metastases do not: however, in these cases the adjacent liver parenchyma stores ICG more intensively than healthy liver tissue, which creates aring-like fluorescence pattern. To conclude, the use of ICG fluorescence in hepatobiliary surgery is diverse but in Germany it is still at the beginning compared to other countries.

A Biliary Tract-Specific Near-Infrared Fluorescent Dye for Image-Guided Hepatobiliary Surgery.

Despite advances, visual inspection, palpation, and intraoperative ultrasound remain the most utilized tools during surgery today. A particularly challenging issue is the identification of the biliary system due to its complex architecture partially embedded within the liver. Fluorescence guided surgical interventions, particularly using near-infrared (NIR) wavelengths, are an emerging approach for the real-time assessment of the hepatobiliary system. However, existing fluorophores, such as the FDA-approved indocyanine green (ICG), have significant limitations for rapid and selective visualization of bile duct anatomy. Here we report a novel NIR fluorophore, BL (Bile Label)-760, which is exclusively metabolized by the liver providing high signal in the biliary system shortly after intravenous administration. This molecule was identified by first screening a small set of known heptamethine cyanines including clinically utilized agents. After finding that none of these were well-suited, we then designed and tested a small series of novel dyes within a prescribed polarity range. We validated the molecule that emerged from these efforts, BL-760, through animal studies using both rodent and swine models employing a clinically applicable imaging system. In contrast to ICG, BL-760 fluorescence revealed a high target-to-background ratio (TBR) of the cystic duct relative to liver parenchyma 5 min after intravenous injection. During hepatic resection surgery, intrahepatic ducts were clearly highlighted, and bile leakage was easily detected. In conclusion, BL-760 has highly promising properties for intraoperative navigation during hepatobiliary surgery.

Donor ductal anomaly is not a contraindication to right liver lobe donation

BackgroundData of living-donor liver transplantation (LDLT) suggested that donor ductal anomaly may contribute to postoperative biliary complications in recipients and in donors. This retrospective study aimed to determine if the occurrence of postoperative biliary stricture in donors or recipients in right-lobe LDLT (RLDLT) is related to donor biliary anatomy type. MethodsWe analyzed our RLDLT recipients’ clinical data and those of their graft donors. The recipients were divided into 2 groups: with and without postoperative biliary stricture. The 2 groups were compared. The primary endpoints were donor biliary anatomy type and postoperative biliary complication incidence; the secondary endpoints were 1-, 3- and 5-year graft and patient survival rates. ResultsTotally 127 patients were included in the study; 25 (19.7%) of them developed biliary anastomotic stricture. In these 25 patients, 16 had type A biliary anatomy, 3 had type B, 2 had type C, 3 had type D, and 1 had type E. In the 127 donors, 96 (75.6%) had type A biliary anatomy, 13 (10.2%) had type B, 6 (4.7%) had type C, 10 (7.9%) had type D, and 2 (1.6%) had type E. Biliary stricture was seen in 2 donors, who had type A biliary anatomy. None of the recipients or donors developed bile leakage. No association between the occurrence of postoperative biliary stricture and donor biliary anatomy type was found (P = 0.527). ConclusionsThe incidence of biliary stricture in donors or recipients after RLDLT was not related to donor biliary anatomy type. As postoperative complications were similar in whatever type of donor bile duct anatomy, donor ductal anomaly should not be considered a contraindication to donation of right liver lobe.

The role of intraoperative cholangiography in patients undergoing laparoscopic cholecystectomy for acute gallstone pancreatitis: is magnetic resonance cholangiopancreatography needed?

Intraoperative cholangiography is sporadically used in patients undergoing laparoscopic cholecystectomy to delineate common bile duct anatomy and exclude retained stones. In patients with acute gallstone pancreatitis, intraoperative cholangiography may reduce the need for preoperative magnetic resonance cholangiopancreatography. A retrospective review of a prospectively collected patient database was undertaken over a 15-year period. The primary objective was to evaluate intraoperative assessment of the common bile duct with intraoperative cholangiography in patients with acute gallstone pancreatitis. A total of 2215 patients underwent laparoscopic cholecystectomy between October 1998 and December 2013; 113 patients (of whom 77 were women) with a mean age of 54 years (range 16-88 years) were diagnosed with acute gallstone pancreatitis. Of these, 102 patients (90%) underwent laparoscopic cholecystectomy with intraoperative cholangiography, which was normal in 89 cases. Thirteen patients had choledocholithiasis on intraoperative cholangiography, 11 of whom were managed with concomitant trans-cystic duct exploration and clearance. Two patients required postoperative endoscopic retrograde cholangiopancreatography. In patients diagnosed with acute gallstone pancreatitis, it is reasonable to proceed directly to surgery using intraoperative cholangiography on the same admission as the definitive assessment of the common bile duct. This negates the need for magnetic resonance cholangiopancreatography and can translate into cost savings and reduced length of stay.