Cystic Duct Research Articles

Morphological Parameters of Gallbladder are Correlated with Age

Introduction: Gallbladder issues are prevalent globally, particularly in Bangladesh, and become more common with age. Diagnosis involves clinical assessment and confirmation through noninvasive and invasive methods. Understanding gallbladder features is crucial for effective investigation, diagnosis, and management. Objectives: To find out relation between morphological parameters of human gallbladder with age. Materials and Methods: This cross-sectional descriptive study was conducted in the Department of Anatomy in collaboration with the Department of Forensic Medicine, Sylhet MAG Osmani Medical College, Sylhet from January 2014 to December 2014. Fifty human postmortem gallbladders were selected. Dead bodies autopsied within 36 hours of death. Considerable signs of decomposition or decomposed dead body, presence of gross gallbladder disease and any history of poisoning cases were excluded. All the specimens were examined to detect the length, breadth, weight and thickness of the gallbladder; and length and diameter of cystic duct. Results: The study included cadavers ranging in age from 11 to 55 years, with a mean age of 35.02 ± 19.98 years. Of the total, 29 (58.0%) were male, and 21 (42.0%) were female. The length and thickness of the gallbladder increased significantly with age, as did the length and diameter of the cystic duct. But the weight and breadth also change with age, although not significantly. Conclusion: The length and thickness of the gallbladder; the length and diameter of the cystic duct were varied with age; but no variation in weight and breadth. Medicine Today 2023 Vol.36 (1): 31-35

Post-partum thyroiditis with concurrent enlargement of thyroglossal duct cyst due to presumed thyroiditis within the cyst wall- a pathophysiological link or a coincidence?

Post-partum thyroiditis with concurrent enlargement of thyroglossal duct cyst due to presumed thyroiditis within the cyst wall- a pathophysiological link or a coincidence?

Papillary thyroid carcinoma arising from thyroglossal duct cyst: Report of three cases and review of the literature

Papillary thyroid carcinoma arising from thyroglossal duct cyst: Report of three cases and review of the literature

Simulation training of intraoperative complication management in laparoscopic cholecystectomy for novices—A randomized controlled study

BackgroundIntraoperative complications occur more often in laparoscopic cholecystectomies (LCs) than in open cholecystectomies. Since LC is a frequent training procedure, surgical residents should be trained to deal with intraoperative complications in a safe and controlled environment. This study aimed to determine whether structured training in coping mechanisms in complication management in LC benefits novices compared to no training in complication management. MethodsThe study included sixty medical students without prior experience in minimally invasive surgery. They were randomly assigned to the intervention or control group and worked in teams of two. Both groups completed multimodal skill training, including one ex-vivo porcine LC. The intervention group (n=30) was then informed about the complications that can occur during an LC and how to manage them using the Coping Mechanisms for Intraoperative Complication Management in Laparoscopic Cholecystectomy (COMIC-LC) tool specially developed for this study. Afterward, they performed two LCs receiving structured training in coping mechanisms for intraoperative complication management. The control group (n=30) performed two LCs, receiving no information about managing complications. Both groups performed two postinterventional LCs. Complication management of the two groups was evaluated using the COMIC-LC assessment score. ResultsThe intervention group demonstrated better management of intraoperative complications in LCs compared to the control group (gallbladder perforation: 8.5 vs. 3.0 points, p<0.001; injury to the liver parenchyma: 7.0 vs. 2.0 points, p<0.001; cystic artery injury: 8.0 vs. 5.0 points, p<0.001; cystic duct injury: 6.0 vs. 1.0, p<0.001). ConclusionStructured training in coping mechanisms for managing intraoperative complications during LC can improve complication handling and potentially reduce adverse events. Translation to clinical practice should be evaluated.

Sestamibi as an alternative to mebrofenin for the diagnosis of acute cholecystitis: An alternative option during supply chain disruption

PurposeTo determine the accuracy of Tc-99 m sestamibi for the diagnosis of acute cholecystitis during a supply chain disruption of mebrofenin. Material and methodsDuring a national shortage of Tc-99 m mebrofenin in 2019, our institution initiated sestamibi imaging for suspected cases of acute cholecystitis using a standard hepatobiliary imaging protocol. Forty-one patients underwent hepatobiliary imaging with sestamibi, 39 to assess for acute cholecystitis. The examinations were initially interpreted by one nuclear medicine physician and subsequently overread by 5 blinded nuclear medicine physicians (8–30 years’ experience). SPECT/CT was obtained for 8 of these patients at the discretion of the primary interpreter. An additional 23 asymptomatic patients (6 with prior cholecystectomy) underwent abdominal scintigraphy as a negative control to determine the normal time to sestamibi accumulation in the gallbladder. A composite reference standard was used (chart review by 3 physicians). Sensitivity, specificity, and positive (PPV) and negative (NPV) predictive values were calculated with and without SPECT/CT (mean ± 95%CI). ResultsOf 39 symptomatic patients, 17/39 had acute cholecystitis and 22 did not. The sensitivity, specificity, PPV and NPV for acute cholecystitis at planar imaging were 97.6 ± 4.6, 62.7 ± 5.2, 67.0 ± 3.6, and 97.3 ± 5.2 % (N = 39). The values changed to 95.7 ± 4.7, 77.9 ± 4.7, 72.1 ± 4.1, and 97.0 ± 3.3 % when control patients were included (N = 62). With SPECT/CT, these mildly improved to 98.8 ± 2.3 %, 69.1 ± 4.4 %, 71.3 ± 3.2 %, and 98.7 ± 2.6 % (N = 39), but not significantly different. On average, sestamibi activity was detected in the gallbladder in negative controls within 1 h. ConclusionTc-99 m sestamibi has excellent sensitivity and NPV for diagnosing acute cholecystitis and can serve as an alternative when mebrofenin is unavailable for evaluating cystic duct obstruction during shortages of standard agents.

Bilateral axillo-breast approach robotic thyroglossal duct cyst resection in an adolescent: a case report and literature review

Bilateral axillo-breast approach robotic thyroglossal duct cyst resection in an adolescent: a case report and literature review

Metastatic Papillary Thyroid Microcarcinoma Presenting as a Branchial Cleft Cyst in Young Female.

Though aetiology of lateral neck masses is complex, branchial cleft cyst is the second most common congenital lesions of the neck next only to thyroglossal duct cysts. Rarely ectopic thyroid tissue within a branchial cleft cyst may develop into primary papillary carcinoma, and even more rarely it may harbour metastases of primary thyroid papillary carcinoma. We report a rare case of lateral cystic neck mass in a 24-year-old female patient diagnosed as metastatic PTC. The patient was diagnosed after she underwent surgical excision of branchial cleft cyst. Later prospectively the patient underwent total thyroidectomy which revealed papillary thyroid micro invasive carcinoma.

Status of clipless laparoscopic cholecystectomy in a tertiary care hospital of Nepal: A descriptive cross-sectional study

Background &amp; Objectives: In this modern age, the preferred course of treatment for gallstone disease symptoms is laparoscopic cholecystectomy. For securing both the cystic duct and artery with a single ligation (SLAD), is a quicker and safe procedure. The study was aimed to determine the status of clipless laparoscopic cholecystectomy in a tertiary care hospital of Nepal. Materials and Methods: A total of 205 patients with gallstone, who underwent laparoscopic cholecystectomy at tertiary center of Nepal of age group 16 - 70 years were included. During the procedure the cystic duct and artery was tied with single ligation. Data were subjected to Microsoft excel 16 for analysis. Results: Laparoscopic cholecystectomy was performed in 205 patients with gallstone. Average age of patients was 31.54 yrs. There was female predominance in the study. The cystic duct and artery were tied in single ligature using nonabsorbable Silk 2-0. The mean time taken for ligation was 120.78 ± 26.92seconds. Bile leakage and intra-op bleeding were found in two patients without any mortality. Conclusion: In laparoscopic cholecystectomy, a viable and secure alternate technique for securing the cystic artery and duct is single ligation with the use of non-absorbable thread. Even though it is a common procedure, it has an additional benefit over clips when dealing with thick, edematous cystic artery and duct complexes. It lowers the threat of surgical morbidity and does not increase the intra operative time.

Papillary Carcinoma Developing from a Thyroglossal Duct Cyst: A Case Report

Background: Thyroglossal duct cyst is the most common midline congenital anomaly of the neck. Papillary carcinoma in the thyroglossal duct cyst and papillary carcinoma in the thyroid tissue can be seen together. In this article, we present a case of papillary carcinoma of the thyroglossal ductus cyst in a 43-year-old male patient. In the postoperative second year ultrasonography, our patient had multiple reactive lymph nodes in the submandibular region due to tooth infection and about 4x3 mm cystic nodule was detected in the thyroid left lobe. Total thyroidectomy was recommended to the patient when our patient wanted to exit long -term follow -up. In our case, although the focus of papillary carcinoma is less than 1 cm and the capsule is intact in the thyroglossal cyst material, the focus of 4 mm papillary carcinoma was found in the total thyroidectomy material. Even if the focus of papillary carcinoma in the thyroglossal cyst is smaller than 1 cm and the capsule is intact, it should be kept in mind that there may be a focus of papillary ca in the thyroid tissue and patients should not be excluded from follow-up.

Incidental finding of thyroglossal duct cyst in a neonate during endotracheal intubation: a case report

BackgroundThyroglossal Duct Cyst (TDC) is a common lesion of the midline neck, originating from an incomplete involution of the thyroglossal duct. It is typically observed in pre-scholar patients and surgery is the treatment of choice to prevent infections. Here reported a case of incidental diagnosis in a newborn patient.Case presentationa 3-week-old male baby was admitted to our hospital for weight loss and projectile vomits after breastfeeding. After a diagnosis of hypertrophic pyloric stenosis, the baby underwent pyloromyotomy. During the endotracheal tube placement, the anesthetist noticed the presence of a midline neck mass. The suspect of TDC was confirmed by an intraoperative ultrasound, so, despite the age of the patient, we proceeded with the excision of the lesion according to Sistrunk’s procedure to avoid future complications and anesthesia.Conclusionseven if TDC is a common lesion of pediatric patients, anecdotical neonatal cases were described in the literature, all of them symptomatic. An accurate physical examination and ultrasound are essential diagnostic tools to distinguish TDC from other middle neck lesions, particularly ectopic thyroidal tissue. Sistrunk’s procedure is the most effective surgical approach. When diagnosis is made in a newborn, we suggest postponing surgery, unless the baby requires general anesthesia for other surgical procedures, such as in our case.

Mirizzi Syndrome Secondary to Impacted Stone in A Low Inserted Cystic Duct Variant: Case Report

Abstract Introduction. Cystic duct anatomical variations are encountered frequently during surgical procedures. In this report, a female patient underwent laparoscopic cholecystectomy for acute cholecystitis and developed symptoms of obstructive jaundice subsequently, which was diagnosed as low insertion of the cystic duct and an impacted stone that was causing common hepatic duct obstruction. Case report. A 42-year-old female presented to the emergency room complaining of persistent right upper quadrant pain that was radiating to the back. White blood count (WBC) was slightly elevated with normal liver function tests (LFTs). An abdominal ultrasound was performed and confirmed cholelithiasis with no signs of acute cholecystitis or biliary dilatation. The patient underwent laparoscopic cholecystectomy as an emergency procedure for persistent biliary colic. Eight days later, the patient returned to the emergency room with obstructive jaundice and continued right upper quadrant pain with elevated WBC and LFTs. Further tests were conducted, and the patient was found to have a long cystic duct with a low insertion variant to the common hepatic duct. An impacted stone was identified in the cystic duct, referred to as Mirizzi syndrome Type I. The patient underwent endoscopic retrograde cholangiopancreatography (ERCP) several times, but the common bile duct could not be cannulated. In the last ERCP session, SpyGlass and electrohydraulic lithotripsy were performed with a balloon sweep. Conclusion. This case demonstrates the importance of understanding Mirizzi syndrome and cystic duct variation to achieve optimal treatment, and careful assessment and investigation are essential for proper diagnosis. In experienced hands, Mirizzi syndrome secondary to an impacted cystic duct stone can be managed successfully with ERCP, electrohydraulic lithotripsy, and SpyGlass.

Clinical characteristics and surgical outcomes of transcutaneous versus transconjunctival excision of Wolfring gland ductal cysts.

To analyze the clinicopathological characteristics and surgical outcomes of patients with Wolfring gland ductal cysts (WGDCs). A retrospective, consecutive, interventional comparative case series was performed over a period of 7 years. Data on demographic and clinical characteristics, pathological findings and outcomes of surgically excised cysts were collected. A comparison between the transconjunctival and transcutaneous approaches was also assessed. Forty-eight patients (48 eyelids) were included in the final analysis. The most common presenting symptom was painless eyelid swelling (81.3%). The median symptom duration was 11.5 months (IQR, 18.25). The upper eyelid was involved in 31 (64.6%) patients, 29/31 of whom had cysts in a medial or centromedial location. Forty-five (93.8%) cysts were bluish gray and transilluminable with clear contents on lid eversion and a median largest dimension of 22mm (IQR, 8). A transverse conjunctival fibrotic band was observed along the proximal tarsal border in the cyst area in all patients. Signs of chronic trachoma were noted in 38 (79.2%) patients. Preoperative significant ptosis was present in 28/31 (90.3%) of the upper eyelid cysts. Thirty cysts (62.5%) were excised through the skin, and 18 cysts (37.5%) were excised transconjunctivally. Intraoperative cyst rupture, the need for conjunctival grafting and postoperative residual upper lid ptosis were significantly greater in the transconjunctival group (p = 0.009, p < 0.001, and p = 0.016, respectively). The present study highlights the clinicopathological characteristics of a relatively large series of surgically excised WGDCs. Transcutaneous excision of WGDCs has proven to be an effective treatment with fewer adverse sequelae than the transconjunctival approach.

Three-dimensional magnetic resonance cholangiography is superior to two-dimensional single-shot magnetic resonance cholangiography for visualization and image quality of the feline and canine biliary tract: A postmortem study.

Magnetic resonance cholangiography (MRC) is an established diagnostic tool for noninvasive assessment of the biliary tract in humans. It has also been found to be feasible in companion animals, but no published studies have compared MRC sequences in veterinary medicine. The present study is part of a prospective, observational, analytical investigation on MR cholangiopancreatography performed on the donated bodies of 12 cats and eight dogs. The main aim of this study was to compare the images of 2D-SSh-TSE-MRC and 3D-TSE-MRC sequences for visualization and image quality of the feline and canine biliary tract. Both sequences are T2-weighted and noncontrast. Three independent readers scored the visibility of four segments of the biliary tract, namely the gallbladder (GB), cystic duct, common bile duct (CBD), and extrahepatic ducts, and the image quality of the two MRC sequences using five-point Likert scales. Wilcoxon signed-rank test was used to compare the scores between the MRC sequences separately for cats and dogs. Inter- and intraobserver agreements were measured using Gwet's AC2 with linear weighting. The 3D-TSE-MRC images were scored significantly higher than the 2D-SSh-TSE-MRC for both visibility and image quality (P<.001-.016 for cats, P=.008-.031 for dogs); the only exception was GB in dogs. In both cats and dogs, interobserver agreement for segment visibility and image quality ranged from slight to substantial in 2D-SSh-TSE-MRC and from poor to almost perfect in 3D-TSE-MRC. Most of the assessments (73% for segment visibility and 66% for image quality) had substantial to almost perfect intraobserver agreement. Findings from the current study support the use of 3D-TSE-MRC over 2D-SSh-TSE-MRC for evaluation of the feline and canine biliary tract, but further studies on live animals are warranted.

Does thyroglossal duct arborization play a role in the post-surgical outcome of Sistrunk procedure in children?

PurposeThe purpose of the present study is to analyze thyroglossal duct cyst (TGDC) histopathological features, with focus on “arborization”, in a cohort of pediatric patients who underwent surgical removal, and evaluate a possible correlation with clinical recurrences.MethodsA retrospective analysis of all patients who underwent surgical resection for TGDC at the division of Pediatric Surgery of the University of Pisa from 2015 to 2020 was performed; for each patient, the following data were recorded: age, sex, clinical presentation, localization, size of the lesion, diagnostic tools, histopathological features, perioperative complications, recurrence and follow-up.ResultsWith respect to arborization, following histopathological analysis 25/30 patients (83.3%) presented thyroglossal duct branching. After a median follow-up of 3.5 years, only 2 out of 30 patients (6.7%), one male and one female, respectively aged 4 y.o. and 6 y.o., presented recurrence within one year from first surgery.ConclusionSurgery for TGDC remains a challenge for pediatric surgeons, while arborization was present in most of our cases which underwent surgery. With respect to the role of arborization, our study did not highlight sufficient conclusive data regarding their role in recurrence: instead, it showed wide resection as satisfactory, being the arborization present in most of the cases at histopathology.

High-resolution ultrasound of thyroglossal cysts with special emphasis on the detection of cystic portions above the hyoid within the tongue base

Background: Thyroglossal duct cysts (TGDCs) within the tongue base represent a challenge for the surgeon and are often the cause of recurrence. Purpose: This study aimed to evaluate diagnostic performance of high-resolution ultrasound in TGDCs within the tongue base, compared to intraoperative findings. Furthermore, accuracy with which the detection of thyroid tissue in parts of the thyroglossal duct cyst was possible was investigated. Methods: A total of 50 patients with TGDCs were examined by high-resolution ultrasound. Every thyroglossal cystic lesion was examined for the presence of solid thyroid tissue with colour-coded duplex sonography and evaluated according to American Thyroid Association (ATA) guidelines. Ultimately, 45 of the 50 patients underwent surgery (Sistrunk procedure). Results: In 38/50 patients (76%), TGDCs were seen in their typical distal location inferior to the hyoid. Four patients (8%) had the thyroglossal duct cyst superior and inferior to the hyoid. The TGDC remnants only in the tongue base were recognised in 16% of cases (8 patients). Histological specimens revealed thyroid tissue within the TGDCs in 23 of the 45 patients (49%). Thyroid tissue was diagnosed preoperatively in 15 patients (65%) X2(1, N = 23) = 2.13, p = 0.144. One patient exhibited suspicious features for thyroid cancer, which was confirmed histologically as papillary thyroid carcinoma. Conclusion: High-resolution ultrasound represents quick, safe and reliable imaging for TGDCs on both sides of the hyoid bone (inferior and superior) with an impact on surgical planning. Furthermore, thyroid tissue within TGDCs can be revealed preoperatively and assessed for suspicious features.

Endoscopic lithotripsy for an impacted biliary stone at the confluence of the cystic duct and common bile duct using a novel drill dilator.

Endoscopic lithotripsy for an impacted biliary stone at the confluence of the cystic duct and common bile duct using a novel drill dilator.

CVS: An Effective Strategy to Prevent Bile Duct Injury

Background: Bile duct injuries have been substantially increased after the introduction of laparoscopic cholecystectomy (LC). These are accompanied by major morbidity and mortality. Studies have shown varying degrees of success in the reduction of bile duct injury (BDI) using the Critical View of Safety (CVS) technique. The aim of this study was to see the efficacy of the CVS technique as the sole method of dissection in laparoscopic cholecystectomy. Methods: 1647 cases of LC were done between January 2012 and January 2022 for a period of 10 years in two hospitals. All were operated by the CVS dissection technique and none by the infundibular technique. Cases included acute cholecystitis, chronic cholecystitis, gangrenous cholecystitis, empyema, and Gallbladder (GB) polyp. Results: The average operating time was 42 minutes and the range was 13 to 80 minutes. In 92% of cases, all 3 criteria of CVS were achieved. In the remaining 8% cases were either converted to open or operated by a division of GB or subtotal cholecystectomy was done. There was only one case of cystic duct stump leak requiring drainage and common bile duct stenting. Conclusion: The excellent outcome of our study suggests that the CVS method will be the gold standard technique in the dissection of the gallbladder in LC. Further dissemination of the technique is necessary to improve safety in LC.

How I Do It: Robotic Choledochoscopy.

As the use of the robotic platform increases among general surgeons, the amount of robotic cholecystectomies is expected to increase as well. The use of intraoperative cholangiography is valuable in assessing for choledocholithiasis. We describe our technique of performing robotic intraoperative cholangiograms with choledochoscopy. Out technique aids in efficiency since no undocking is required. Preoperatively, the decision to perform a cholangiogram is made based on physical exam, labs, and imaging findings. The procedure begins with obtaining a critical view of safety. The robotic arms are positioned in a manner that allows all 4 robotic arms to remain docked. A ductotomy is made and the cholangiocatheter is introduced. The cholangiogram images are then interpreted and if a stone is seen in the common bile duct we will then perform a transcystic common bile duct exploration using the SpyGlass Discover digital. A complete cholangiogram is then performed. The cystic duct is secured and the gallbladder is removed from the liver bed. The patients are watched overnight and discharged on postoperative day 1. A robotic approach to performing a transcystic common bile duct exploration is a safe and reproducible treatment method for choledocholithiasis. Our approach offers an advantage since no undocking is required.

Madany triangle; a new era of laparoscopic cholecystectomy

Background: Laparoscopic cholecystectomy (LC) has an increased incidence of extrahepatic biliary injury or bleeding. The common hepatic duct is on the medial border of the Calot triangle and at risk of injury. So, the authors describe a new safety triangle with a more critical view of safety that is far from dangerous. Patient and methods: Retrospectively, from December 2019 until March 2023, the authors reviewed the medical records for patients who underwent LC. Only 238 patients underwent cholecystectomy using a new technique in approaches to critical safety. The patients who had intraoperatively extensive gallbladder adhesion and improper visualization of the cystic duct were excluded from the study. Results: The female-to-male ratio was 5:1. The number of children who were less than 18 years old was 5. The prevalence of cholecystitis among children in this study was 2.1%. The mean operative time was 63 min. The comments indication of cholecystectomy was chronic cholecystitis (66.8%). Conclusion: The Madany triangle can be used during LC as a critical measure of safety.

Evaluation of the Validity of Endoscopic Transpapillary Gallbladder Drainage for Acute Cholecystitis Based on the Tokyo Guidelines 2018.

We evaluated the validity of endoscopic transpapillary gallbladder drainage (ETGBD) as a bridging therapy prior to elective Lap-C for the patients with acute cholecystitis (AC). The Tokyo Guidelines 2018 recommend early laparoscopic cholecystectomy (Lap-C) for patients with AC, however, some patients require the preoperative drainage because of inadequate for early Lap-C du to background and comorbidities. We performed a retrospective cohort analysis using data from our hospital records from 2018-2021. In total, 71 cases of 61 patients with AC underwent ETGBD. The technical success rate was 85.9%. Patients in the failure group had more complicated branching of the cystic duct. The length of time until feeding was started and until WBC levels normalized, and the length of hospital stay were significantly shorter in the success group. The median waiting period for surgery was 39 days in the ETGBD success cases. The median operating time, amount of bleeding, and length of postoperative hospital stay were 134 min, 83.2g, and 4 days, respectively. In patients who underwent Lap-C, the waiting period for surgery and the operating time were similar between the ETGBD success and failure groups. However, the temporary discharge period after drainage and the length of postoperative hospital stay were significantly longer in the patients with ETGBD failure. Our study revealed that ETGBD has equivalent efficacy prior to elective Lap-C despite some challenges that lower its success rate. Preoperativ ETGBD can improve patient quality of life by eliminating the need for a drainage tube.