Dilated Cystic Duct Research Articles

Heterotopic Pancreas Masquerading as Duplication Cyst of the Stomach A Case Report

Heterotopic pancreas is not an uncommon finding in surgical or autopsy specimens. It may be asymptomatic or produce mechanical obstruction, surface ulceration, and other rarer complications. Cystic dilation of pancreatic ducts within heterotopic pancreas has been reported. This case report gives the clinicopathologic findings of heterotopic pancreas in a 37-year-old woman. It illustrates how cystic dilation of the pancreatic duct in heterotopic pancreas may masquerade as gastric duplication.

ERCP, cholangiography, and laparoscopic cholecystectomy. The Society of American Gastrointestinal Endoscopic Surgeons (SAGES) opinion survey.

With the increased use of laparoscopic cholecystectomy (LC), the roles of preoperative ERCP and intraoperative cholangiography (IOC) may be changing. SAGES members were surveyed to define opinions regarding use of ERCP and cholangiography during LC. Thirty-seven percent of the surveys were returned. Most respondents (83%) performed LC, reporting data on 19,747 LCs. Conversion to open cholecystectomy was required in 4% of cases. Complications were reported in 1.7% patients. IOC was attempted in 51.2% cases and was successful in 73%. Routine IOC was only recommended by approximately 50% of respondents. However, 80% recommended IOC for patients with multiple small gallstones and a dilated cystic duct. If preoperative liver function tests (LFTs) were mildly elevated (1.5 x normal), only 56% of respondents recommended preoperative ERCP. However, 73% of respondents suggested preoperative ERCP for more severe LFT abnormalities. If preoperative ERCP demonstrated choledocholithiasis, most (85%) recommended endoscopic clearance of stones followed by LC. These opinions will be helpful in establishing practice standards for LC.

Hyperhidrotic, Painful Lesion

REPORT OF A CASE A 4-year-old boy presented with a lesion on the anterosuperior aspect of his left thigh. The lesion was noted for the first time 15 days after birth. A tender, erythematous, hyperpigmented lesion measuring 4×2 cm was seen on examination (Fig 1). A constant secretion of clear fluid originated from the surface of the lesion. A biopsy specimen showed dilated blood vessels with no extravasation of erythrocytes. In addition, a large number of eccrinelike glands with dilated (cystic) ducts was also seen (Fig 2). What is your diagnosis? Clinicians, local and regional societies, and residents and fellows in dermatology are invited to submit quiz cases to this section. Cases should follow the established pattern and be submitted double-spaced and in triplicate. Photomicrographs and illustrations must be clear and submitted as positive color transparencies. If photomicrographs are not available, the actual slide from the specimen will be acceptable.

The Cystic Duct Sign during Morphine-augmented Cholescintigraphy

Visualization of a "dilated cystic duct" during standard hepatobiliary imaging represents a potential source of false-negative cholescintigraphy. Intravenous morphine, commonly used to shorten study time and improve the specificity of hepatobiliary imaging, may, by virtue of its pharmacologic/physiologic actions, accentuate the appearance of a "dilated cystic duct." We present a case of transient cystic duct visualization following morphine administration in a patient with an obstructing cystic duct calculus.

Experience with Laparoscopic Cholecystectomy

Abstract: Laparoscopic cholecystectomy is rapidly replacing conventional cholecystectomy as the treatment of choice for gallbladder stone disease because of its lower morbidity. Our study began on 29th May, 1990 and continued until February 28th, 1991. 40 laparoscopic cholecystectomies were successfuly performed. 4 patients had an open cholecystectomy instead because of bleeding in 1, dense adhesions in 2 and Mirizzi's Syndrome in 1. The two technical measures taken to avoid common bile duct injury, were 1) exposure of both the cystic duct and cystic artery in the same field before clipping and division 2) demonstration of the continuity between the cystic duct and the Hartman's pouch. Technical difficulties often encountered were extensive adhesions, multiple or giant stones, inflamed gallbladder and a short or dilated cystic duct. There were 4 complications; one diaphragmatic injury resulting in a pneumothorax, one periumbilical subcutaneous emphysema and 2 mild bile leaks. On average, each patient required 1.3 intramuscular analgesic injections and spent 10 days recuperating in hospital. In Japan, many patients insist on staying longer in hospital. We believe that laparoscopic cholecystectomy will rapidly become the preferred treatment for gallbladder stone disease.

TYPE IVa CHOLEDOCHAL CYSTS: SURGICAL MANAGEMENT AND LITERATURE REVIEW

Type IVa choledochal cysts with cylindrical dilatation of the intrahepatic ducts constitute a relatively less recognized variety of choledochal cysts, and differ from cystic dilatation of intrahepatic ducts in their clinical manifestations and response to treatment. Five patients with type IVa choledochal cysts and cylindrical dilatation of major intrahepatic ducts who underwent cyst excision and Roux-en-Y hepaticojejunostomy are reported. The duration of symptoms was less than 1 year in all patients. Palpable abdominal mass and abdominal pain were present in 3 patients. The traid of jaundice, abdominal pain and mass was present in only 1 patient. The intrahepatic dilatation regressed after excision of the extrahepatic cyst just below the hilum of the liver. The surgical technique is described and the need for excision of the cyst is emphasized.

Obstructive dilatation of extrahepatic recipient and donor bile ducts complicating orthotopic liver transplantation: imaging and laboratory findings.

Biliary obstruction in liver transplants is most commonly due to stricture at the biliary anastomosis. The native common bile duct typically is normal. We retrospectively studied 28 patients with choledochocholedochostomy anastomoses who had marked native and donor extrahepatic bile duct dilatation associated with clinical evidence of biliary obstruction. Operative cholangiograms were compared with postoperative cholangiograms obtained a mean of 50 weeks (range, 2-246 weeks) later. Mean caliber of the native common bile duct increased from 7.5 +/- 2.0 mm on operative cholangiograms to 14.8 +/- 3.9 mm on postoperative cholangiograms (p less than .001). Mean caliber of the donor common hepatic duct increased from 5.9 +/- 1.3 mm on operative cholangiograms to 12.8 +/- 3.8 mm on postoperative cholangiograms (p less than .001). Dilatation of the cystic duct remnant was seen in 15 patients. All patients had surgical revision to choledochojejunostomy with improved results of liver function studies in most cases. Diffuse dilatation of native and donor extrahepatic bile ducts may develop in liver transplant recipients. Typical features include native and donor extrahepatic ducts greater than 12 mm in diameter and a dilated cystic duct remnant on postoperative cholangiography in a patient with otherwise unexplained hepatic dysfunction.

Migration of gall stones.

The factors influencing the migration of gall stones are ill understood. Altogether 331 patients undergoing cholecystectomy were studied prospectively. The diameters of the cystic and common bile ducts and of stones in the gall bladder and bile ducts were measured. Increasing pressure was applied to the freshly excised gall bladder in an attempt to evacuate stones through the cystic duct. Stones passed in 33 (60.0%) of patients with choledocholithiasis, 45 (67.2%) of patients with pancreatitis, and 7 (3.2%) of patients without either pancreatitis or choledocholithiasis. Stones migrated in 6 (3.0%) who had a normal cystic duct diameter (less than or equal to 4 mm) and in 46 (32.5%) with a duct over 4 mm diameter. Common bile duct stones were often larger than the diameter of the cystic duct and when reintroduced into the gall bladder would not migrate. The passage of debris (less than or equal to 1 mm) through the cystic duct bore no relation to the presence or absence of choledocholithiasis or a dilated cystic duct. Small stones (1-4 mm diameter) must migrate to initiate and facilitate further migration; some must increase in size in the common bile duct. Increased biliary pressure consequently dilates the duct system retrogradely, allowing larger stones to follow. Patients at risk of stone migration and thereby pancreatitis and jaundice have large ducts that can be detected by ultrasound assessment.

Operative cholangiography: Is there a statistical alternative?

Data from 424 patients who underwent cholecystectomy were analysed on a computer by both univariate and multivariate methods to determine the factors that identify patients with stones in the common bile duct. The presence of common bile duct stones was associated with increased age (p = 0.003), increased numbers of gallbladder stones (p < 0.0001), a diagnosis of acute cholecystitis (p = 0.06), and a history of jaundice (chi-square = 22.2; p < 0.001). A dilated common bile duct was the most significant indicator of the presence of stones (chi-square = 155.5; p < 0.0001), and a dilated cystic duct was second (chi-square = 47; p < 0.001). Using multivariate analysis, 89.5 percent of patients were correctly classified as having bile duct stones without the use of cholangiographic data (chi-square = 246.5; p < 0.0001). Common bile duct diameter and the number of gallbladder stones emerged as the most important variables; additional historical factors, including the presence of jaundice and pancreatitis did not add to their predictive value. If multivariate analysis was used without cholangiographic data, bile duct stones would be missed in 3 percent of patients and unnecessary explorations would be carried out in 7.5 percent.

Normal and obstructed main bile duct evaluated by a modified ultrasound technique.

A modified ultrasound technique for demonstration of the extrahepatic bile duct was used in 75 patients and 135 normal subjects. The right and left hepatic ducts, common hepatic duct, and on occasion a part of a dilated cystic duct could be demonstrated with a rate of success of 100 per cent in patients and 98.5 per cent in normal subjects. Usually, the biliary tract can be demonstrated only in part in the conventional supine position, while the modified technique often improved the demonstration of the entire duct and in some cases of a main bile duct that cannot be evaluated in the conventional supine position.

Prenatal morphology in meckel's syndrome (with special reference to polycystic kidneys and double encephalocele)

Prenatal morphology of Meckel's syndrome was studied in five fetuses of different gestational age, that had been aborted because ultrasonography and elevated amniotic AFP-levels indicated neural tube defect. Histologically, the enlarged polycystic kidneys were completely alike with respect to the type of involvement and differed only in the severity of changes. They could be identified at type III cystic kidneys according to the classification of Potter. Proliferation of hepatic bile ducts and slight cystic dilatation of pancreatic ducts is already evident in the youngest fetus. Additional cyst formation in the epididymis was found in one of the cases. Occipital encephalocele, located within an apical occipital bone defect was always associated with a second mostly occult encephalocele protruding through a separated defect of the basal occipital squame and of the first and second vertebral arch. It is assumed that double encephalocele represents a constant finding in Meckel's syndrome, indicating a specific pattern within the disturbance of neural tube closure.

Linear Eccrine Poroma

A 44-year-old woman had multiple papular lesions of 20 years' duration. The lesions were limited to the right lower extremity and were arranged in a linear fashion. They had the histologic appearance of eccrine poroma; however, thin intertwining strands of tumor cells extended down into the dermis in a pattern similar to that of premalignant fibroepithelioma. Also, bud-like proliferations of tumor cells were attached to the epidermis, analogous to those superficial basal cell epithelioma. A dilated cystic duct resembling that found in syringoma was present in the upper part of the dermis. To my knowledge, such a linear distribution of multiple eccrine poromas has not been reported in the dermatologic literature.

Cystic dilation of intrahepatic bile ducts. Presenting as gram-negative septicemia.

A rare case of cystic dilation of the intrahepatic bile ducts, without involvement of the choledochus was complicated by severe gram-negative septicemia, presented with an atypical clinical picture, and had a fulminating course. Although presenting in adult patients, it is assumed that, in accordance with the literature, this anomaly is congenital in origin. Secondary obstructive and infective factors, however, may influence the picture. The relative ineffectiveness of any treatment in these cases is mentioned, which contrasts with cases of solitary choledochal cyst.

Experimental Common Bile Duct Conduits

RETAINED biliary stones following common bile duct exploration continue to bother the surgeon, and although it is difficult to obtain accurate estimates of incidence, it is known to be considerable. 1 The incidence of retained stones rises sharply where cystic dilatation of intrahepatic or extrahepatic ducts has occurred; some of these patients have to undergo repeated operations for removal of retained concretions. It occurred to us to explore the feasibility of constructing temporary conduits from the dilated common bile duct to the skin of sufficient size that exploration of the duct could be carried out without resorting to laparotomy. Since the success of this endeavor would depend on the size of the conduit and the healing of the duct following removal, the experiment was designed for maximum size conduits. Procedures and Techniques Healthy mongrel dogs were used for experimental animals. The experiment was carried out in three stages. Stage 1.

Technique of common duct exploration.

IN THE SURGICAL therapy of chronic gall bladder disease with stones, the indications for common duct exploration are specific and clear cut. On this surgical service, the common duct is opened and explored at the time of cholecystectomy under the following circumstances: (1) concomitant obstructive jaundice at the time of operation; (2) one or more episodes of jaundice in the past history of the patient; (3) finding of a dilated common duct at the time of cholecystectomy; (4) presence of a dilated cystic duct with small calculi in the gall bladder, and (5) finding of enlargement of the head of the pancreas due to chronic pancreatitis. In the conduct of the operation under the circumstances enumerated above, the diseased gall bladder with its contained calculi is removed, with careful individual ligation of the cystic vessels and duct under direct vision. It has been found important to excise the entire cystic

The reformed gallbladder: clinical and roentgen aspects.

Disease of the dilated cystic duct remnant following cholecystectomy has been considered from both the clinical and roentgenological points of view. A recent case has been included as an illustration of the problem.