Ductal Anatomy Research Articles

Physician Controlled Wire Guided Cannulation of the Minor Papilla

Objective: Cannulation of the minor papilla (MiP) can be challenging. Historically, specialty accessories and small caliber guidewires have been advocated for approaching the MiP. New short-wire ERCP platforms allow physicians to control the guidewire, and have facilitated wire-guided ductal cannulation via the major papilla. The aim of this study is to describe the efficacy and safety of MiP cannulation using standard accessories and a wire-guided technique. Methods: All patients who underwent attempted MiP cannulation by 2 endoscopists (RA, JM) at 2 tertiary care medical centers between July 2005 and November 2008 were identified using institutional databases. These endoscopists exclusively employed the following cannulation technique. The MiP is identified, with or without the aid of secretin, and generally approached using a “long scope” position. Cannulation is attempted with a 4.4Fr tip sphincterotome loaded with a 0.035", 260cm guidewire. With the sphincterotome hovering in the duodenum, the physician-controlled guidewire is used to cannulate the orifice of the MiP, and then gently advanced 15-20 mm or until any resistance is met, using fluoroscopic guidance. The wire is secured and the sphincterotome advanced until it enters or abuts the MiP. Contrast is injected to delineate the dorsal duct anatomy. The wire is advanced more deeply into the dorsal duct and re-secured. The sphincterotome is passed deep into the dorsal duct. However, if the orifice doesn't permit passage of the sphincterotome, a needle knife is used to perform an access sphincterotomy alongside the guidewire. Electronic medical records were reviewed to assess for complications. Results: 24 patients were identified (14 women, mean age 46, 18 performed by RA). Procedure indications included recurrent acute pancreatitis in 17 patients (71%), idiopathic acute pancreatitis in 3 (13%), chronic pancreatitis in 1 (4%), and 3 patients had other indications. Pancreas divisum was suspected prior to the ERCP in 10 of 16 patients with prior imaging. Secretin was used in 9 patients (38%). MiP cannulation was successful in 23 patients (96%). Sphincterotomy followed by pancreatic stent placement (5-7 Fr) was performed in 20 patients (83%). The median procedure time (recorded in 18 patients) was 31 minutes. Complications occurred in 3 patients (13%), who developed mild post-ERCP pancreatitis. Conclusion: Physician-controlled wire-guided cannulation of the MiP using a 4.4Fr sphincterotome and 0.035" guidewire is an effective and safe technique that may obviate the need for specialty MiP accessories and small caliber guidewires. Further prospective evaluation of this technique is warranted.

Prevention of iatrogenic bile duct injuries in difficult laparoscopic cholecystectomies: is the naso-biliary drain the answer?

Prevention of iatrogenic injuries is of paramount importance in difficult laparoscopic cholecystectomies (LC). The objective of this study was to analyze the effectiveness of cholangiography using a pre-inserted endoscopic naso-biliary drain (ENBD) for navigation during difficult cholecystectomies. The study design was a retrospective case analysis. In 508 patients who underwent LC in a tertiary referral university hospital from 1996 through 2007, difficult cholecystectomy was anticipated in 26 patients due to possibly aberrant biliary anatomy (four patients), unclear cystic duct anatomy during magnetic resonance cholangiopancreatography (MRCP) and/or endoscopic retrograde cholangiopancreatography (ERCP) (three patients), and acute cholecystitis (19 patients). An ENBD was inserted during ERCP prior to LC for cholangiography (ENBDC) to facilitate safe dissection during LC. Prevalence of biliary complications was assessed as the main outcome measurement. The majority (68%) of the patients who underwent ENBDC had complicated cholecystitis. Advanced technical expertise was not required for insertion of an ENBD. In retrospect, ENBDC was useful in prevention of a possible catastrophe in 69% of cases. Open conversion was necessary in five patients and biliary complications occurred in five patients only in the non-ENBD group. There were no procedure-related complications. One limitation of the study was that it was not randomized and there was no comparison with patients without ENBDC. ENBDC is a useful and safe tool in the prevention of iatrogenic bile duct injuries in LC.

Hormonal abnormalities leading to disorders of sexual development

Normal human sexual development occurs in a highly regulated process that comprises three distinct phases: establishment of chromosomal sex, development of the sex-specific gonads and phenotypic differentiation of the internal ductal anatomy and external genitalia. The latter two phases are mediated by specific hormonal effector molecules, including anti-Müllerian hormone and testosterone, and their dysregulation often leads to the development of a phenotypic disorder of sexual differentiation. This review describes the hormonal mediators that are involved in sexual development and the disorders of sexual differentiation that arise from their dysfunction.

Imaging of the Pancreas With Secretin Enhancement

Magnetic resonance cholangiopancreatography is a noninvasive imaging technique for evaluation of the pancreatic duct and the biliary tree. Secretin is a polypeptide hormone that has numerous physiological effects, including stimulation of the pancreatic secretion of bicarbonate-rich fluid and transient increase in the tone in the sphincter of Oddi. As a result, secretin administration usually results in distention of the pancreatic duct; therefore, visualization of the pancreatic ductal anatomy is often substantially improved. Awareness of its value by referring clinicians and radiologists will increase its use in the future.

Transcatheter closure of patent ductus arteriosus: Evaluating the effect of the learning curve on the outcome

Background and Objectives:Initial experience with transcatheter closure of patent ductus arteriosus (PDA) using detachable coils and Amplatzer duct occluder devices is reported. We evaluated the outcome, complications, and influence of the learning curve, and also assessed the need of surgical backup for such interventional procedures.Methods:From January 2000 to December 2004, 121 patients underwent transcatheter closure of PDA. Aortic angiogram was performed to evaluate the size, position, and shape of the duct for appropriately choosing the occluder device type and size. A second aortic angiogram was performed 10 minutes after device deployment. Echocardiography was repeated at intervals of 24 hours, then at 1, 3, and 6 months after the procedure to assess complications. Stepwise multiple regression analysis was used to assess the role of experience in improving the outcome of the procedure.Results:Of 121 cases, four patients had pulmonary artery embolization of the occluder device which was successfully retrieved in the catheterization laboratory, while two others had embolization that required surgical intervention. Four patients had temporary residual leak, nine had protrusion of the device into the aorta without significant Doppler pressure gradient or hemolysis on follow-up, and five had partial hemodynamically insignificant obstruction to the left pulmonary artery. Statistical analysis showed that the effect of the learning curve and experience was responsible for 93% improvement in the procedural outcome over the five-year study period.Conclusion:Transcatheter occlusion of PDA is safe and effective alternative to surgery. Complications occurred in those with unfavorable duct anatomy and with the use of multiple coils. Surgical backup was important for such interventional procedures. Experience played a major role in the proper choice of device type and size which greatly influenced the outcome of the procedure.

Pig Pancreas Anatomy: Implications for Pancreas Procurement, Preservation, and Islet Isolation

Islet transplantation is emerging as a treatment option for selected patients with type 1 diabetes. The limited human islet supply from cadavers and poor islet yield and quality remain substantial impediments to progress in the field. Use of porcine islets holds great promise for large-scale application of islet transplantation. Consistent isolation of porcine islets is dependent on advances in pancreas procurement, pancreas preservation, and islet isolation, requiring detailed knowledge of the porcine pancreatic anatomy. The primary aim of this study was to describe the vascular and ductal anatomy of the porcine pancreas to guide and improve organ preservation and enzyme perfusion. Pancreata were removed by en bloc viscerectomy from 65 female Landrace pigs. Fifteen percentage of organs exhibited inconsistent vascular branching from the celiac trunk. All organs showed uniform patterns of branching at the superior mesenteric artery. The superior and inferior mesenteric veins merged to become the portal vein in all but one case in which the inferior mesenteric vein drained into the splenic vein. Ninety-seven percent of pancreata had three lobes: duodenal lobe (DL), connecting lobe (CL), and splenic lobe (SL); 39% demonstrated ductal communication between the CL and the other two lobes; 50% had ductal communication only between the CL and duodenal lobe; and 11% presented other types of ductal delineation. Accounting for the variations in vascular and ductal anatomy, as detailed in this study, will facilitate development of protocols for preservation, optimal enzyme administration, and pancreas distention and digestion, and will ultimately lead to substantial improvements in isolation outcomes.

CLINICAL UTILITY OF SECRETIN MRCP FOR PANCREATIC DISEASES

Introduction: Addition of secretin to MRCP (sMRCP) provides functional pancreatic assessment and greater detail of ductal anatomy. The clinical impact of sMRCP on the evaluation and management of various pancreatic conditions is not well-defined. Methods: Since 01/2005, 174 sMRCP studies were obtained for 5 indications: recurrent acute pancreatitis (N = 62), presumed chronic pancreatitis (36), poorly characterized abdominal pain (31), interrogation of operative anastomoses (28), and cystic lesions (17). Pre and post-secretin imaging findings were compared and impact of the functional component on clinical decision-making was analyzed. Results: Overall, use of sMRCP provided additive diagnostic value in 36% of cases. An anatomic basis for recurrent acute pancreatitis was identified based on post-secretin imaging in a quarter of cases. In chronic pancreatitis, sMRCP increased diagnostic confidence in 10 (32%) and identified 3 strictures not seen on traditional MRCP (10%). sMRCP never ruled in a pancreatic etiology in poorly characterized abdominal pain; in 10% (3/31), a normal sMRCP led to pursuit of non-pancreatic diagnoses. For interrogation of operative anastomoses, sMRCP either confirmed (43%) or negated (36%) the presence of a stricture in 79%. Anatomic detail of cystic neoplasms was clarified in 4 of 17 (24%) cases. In multivariate analysis, highest yield of sMRCP occurs in postoperative patients and those with a history of pancreatitis (p = 0.01). Conclusion: sMRCP is useful in the evaluation and management of selected pancreatic diseases, with highest yield for the postoperative setting or history of pancreatitis.

Intrahepatic Biliary Anatomy Derived From Right Graft Adult Live Donor Liver Transplantation

Objective The successful management of the bile duct in right graft adult live donor liver transplantation requires knowledge of both its central (hilar) and distal (sectorial) anatomy. The purpose of this study was to provide a systematic classification of its branching patterns to enhance clinical decision-making. Patients and Methods We analyzed three-dimensional computed tomography (3-D CT) imaging reconstructions of 139 potential live liver donors evaluated at our institution between January 2003 and June 2007. Results Fifty-four (n = 54 or 38.8%) donor candidates had a normal (classic) hilar and sectorial right bile duct anatomy (type I). Seventy-eight (n = 78 or 56.1%) cases had either hilar or sectorial branching abnormalities (types II or III). Seven (n = 7 or 5.1%) livers had a mixed type (IV) of a rare and complex central and distal anatomy. Conclusions We believe that the classification proposed herein can aid in the better organization and categorization of the variants encountered within the right-sided intrahepatic biliary system.

Biliary complications in liver transplantation

Biliary complications of living donor liver transplantation remain common. The complications of biliary leakage and stricture result in substantial recipient morbidity. A major focus of liver transplantation research is the prevention and reduction of these complications through identification of the multiple factors that are conducive to them. Such factors include the donor bile duct anatomy and quality, and the techniques of donor hepatectomy, recipient hepatectomy, and ductal reconstruction. A low threshold for re-exploration for possible bile leakage prevents development of uncontrolled sepsis. Return of good graft function can usually be expected after successful early endoscopic treatment. Contingent measures of percutaneous transhepatic dilatation and stenting, and revision hepaticojejunostomy have to be exercised with utmost care to avoid hepatic artery injury which may results in graft loss.

Comparison between T2-weighted MR and contrast-enhanced MR cholangiography in the evalutian of biliary anatomy in liver transplant donor candidates

Objective To compare conventional T2-weighted MR cholangiography (T2WI-MRC) with gadobenate dimeglumine enhanced T1-weighted MR cholangiography(CE-MRC) for evalution of biliary anatomy in liver transplant donor candidates. Methods Thirty-two healthy liver transplant donor candidates were examined with two MR cholangiogaphic methods. For T2WI-MRC, a three-dimensional turbo spin-echo sequence and oblique coronal heavily T2-weighted thick-slab turbo spin-echo imaging sequence were performed. For CE-MRC, three-dimensional fat-suppressed spoiled gradient-echo sequences were performed, with a time delay of 60 minutes following the administration of gadobenate dimeglumine. To compare the depiction of biliary duct anatomy and the artifact caused by intestinal liquid and breathing between the two methods. Intraoperative cholangiography was the reference-standard examination. Results The both methods depicted the biliary anatomy correctly in all 9 cases. The both methods showed the third branches of intrahepatic biliary duct clearly. T2WI-MRC showed interhepatic bihary duct before the third branches in 28 cases (87.5%), CE-MRC showed the same finding in 14 cases (43.8% ). T2WI-MRC showed common bile ducts intermitantly in 2 cases, which were normal in CE-MRC and intraoperative cholangiography. Intestinal liquid affected the image quality of biliary duct in 6 cases (18.8%) performed with T2WI-MRC, but none with CE-MRC. The artifacts caused by breathing were not obvious in the either method. Conclusion T2WI-MRC and CE-MRC both can be used to evaluate bihary anatomy of liver transplant donor candidates, but CE-MRC appears to be more accurate than T2WI-MRC. Key words: Liver transplantation; Contrast media; Magnetic resonance imaging; Comparative study

Miss Rate of Pancreas Divisum by Magnetic Resonance Cholangiopancreatography in Clinical Practice

Pancreas divisum is the most common congenital abnormality of the pancreatic anatomy. Magnetic resonance cholangiopancreatography has emerged as a noninvasive method of examining the pancreatic ductal anatomy. We aim to assess the sensitivity of MRCP for pancreas divisum. Patients with pancreas divisum at endoscopic retrograde cholangiopancreatography (ERCP) and who had prior MRCP between January 2001 and February 2006 were identified. Sensitivities were calculated for relevant subgroups with binomial 95% confidence intervals. Fisher exact P values were calculated. Four hundred five patients had divisum at ERCP; of these, 111 (27%) had undergone MRCP before ERCP. Seventy-two (65%) patients had MRCP at outside centers. Twenty-three of the 72 MRCPs at referring centers correctly reported divisum. In contrast, the sensitivity was higher for the 24 MRCPs without secretin at our institution: 16 (67%). The sensitivity in the secretin-stimulated group was 67% (10/15). However, this was not different from that of MRCP without secretin. Of note, 9 (18%) of the 49 negative outside MRCPs had divisum suspected by the gastroenterologist reviewing the MRCP images before ERCP. Pancreas divisum seems to be often missed on MRCP, even when secretin is used. The absence of secretin, use of suboptimal magnetic resonance techniques, and inexperienced pancreatic MRCP examiners are all possible contributing factors.

An Unusual Fetal Ductus Arteriosus Pathway

Received January 22, 2008, from the Children’s Heart Center, Las Vegas, Nevada USA (R.J.A., W.N.E., W.C., R.R.); Division of Cardiology, Department of Pediatrics (R.J.A., W.N.E., W.C., R.R.), and MaternalFetal Medicine Program, Department of Obstetrics and Gynecology (D.R.), University of Nevada School of Medicine, Las Vegas, Nevada USA; Department of Obstetrics and Gynecology, University Medical Center, Las Vegas, Nevada USA (D.R.); and Nevada Perinatal, Las Vegas, Nevada USA (J.M.). Manuscript accepted for publication February 12, 2008. Address correspondence to Ruben J. Acherman, MD, Children’s Heart Center, 3006 S Maryland Pkwy, Suite 690, Las Vegas, NV 89109 USA. E-mail: IAcherman@aol.com uctal tortuosity occurs normally with advancing gestational age.1 Early in gestation, the 2-dimensional echocardiographic high transverse thoracic view shows the ductus arteriosus as a straight channel from the main pulmonary artery to the descending aorta. As gestation progresses, the ductus normally curves to the left away from the aortic arch. We report a fetus that had unusual ductal tortuosity: curving to the right posterior to the ascending aorta and above the right pulmonary artery. We were asked to evaluate this fetus because obstetric sonography suggested a ductus arteriosus abnormality. Initial fetal echocardiography performed at 32 weeks’ gestation showed an unusual ductus arteriosus pathway turning toward the right behind the ascending aorta and above the right pulmonary artery (Figures 1–3). There was no evidence of ductal constriction on follow-up fetal echocardiograms. A healthy neonate was delivered at term. The postnatal echocardiogram showed a ductal anatomy similar to the prenatal findings. Additionally, the ductus arteriosus was aneurysmatic at its aortic end and constricted at its midportion. At 3 days of age, echocardiographic findings were normal without evidence of ductal flow. In summary, we report a previously undescribed fetal ductus arteriosus pathway in a patient that had no evidence of a prenatal or postnatal hemodynamic disturbance.

Real-time intraoperative assessment of the extrahepatic bile ducts in rats and pigs using invisible near-infrared fluorescent light

Currently, only x-ray fluoroscopy is available for visualization of the extrahepatic bile ducts intraoperatively. We hypothesized that with an appropriate fluorophore and imaging system, invisible near-infrared (NIR) light could be used for image-guided procedures on the extrahepatic bile ducts. We quantified the performance of three 800 nm NIR fluorophores, differing primarily in their degree of hydrophilicity, for real-time imaging of the extrahepatic bile ducts in rats and pigs: IR-786, indocyanine green (ICG), and the carboxylic form of IRDyetrade mark 800CW (CW800-CA). The signal-to-background ratio (SBR) of the common bile duct relative to liver and pancreas was measured as a function of the dose of contrast agent, injection site, and kinetics using an intraoperative NIR fluorescence imaging system described previously. Bile samples were examined by high performance liquid chromatography tandem mass spectrometry (HPLC/MS) to determine the chemical form of fluorophores in bile. Non-sulfonated (IR-786) and di-sulfonated (ICG) NIR fluorophores had poor efficiency and kinetics of excretion into bile. Tetra-sulfonated CW800-CA, however, provided sensitive, specific, and real-time visualization of the extrahepatic bile ducts after a single low-dose given either intraportally or intravenously via systemic vein. A SBR >/=2 provided sensitive assessment of extrahepatic bile duct anatomy and function for over 30 min post-injection, including the detection of millimeter-sized, radiolucent inclusions in pigs. CW800-CA remained intact chemically after secretion into bile. The combination of invisible NIR light and an IV injection of CW800-CA provides prolonged, real-time visualization of the extrahepatic bile duct, without ionizing radiation and without changing the look of the operative field.

Bile duct anatomy of the Anatolian Caucasian population: Huang classification revisited

Living donor liver transplantations (LDLT) donor candidates are being assessed with MRCP (magnetic resonance cholangiopancreatography) to identify their suitability for standard surgical techniques. Variations of the bile duct anatomy play an important role in donor selection and in the selection of the resection technique. If bile duct anatomy is misrecognized, complications may occur. Anatomic variations are classified according to the origin of the right posterior hepatic duct (RPHD). According to the so called Huang classification, type A1 is the most, and type A5 is the least frequent variation. These frequencies were initially validated on Chinese population. Later studies revealed significant variability in frequency for the so called trifurcation, the variation in which a common junction of RHPD, right anterior hepatic duct (RAHD) and left hepatic duct (LHD) (A2) exists. In this study we aimed to determine the bile duct anatomy variations for the Anatolian Caucasians. One hundred and thirty-four healthy subjects were investigated under 1.5 T MRI, with breath-hold (expiration) heavily T2-weighted turbo spin echo (TSE) static fluid imaging (TR/TE=8,000/800). The sequence has permitted three to five oblique coronal thick sections (40 mm) around a common axis. Sequences were repeated until anatomically interpretable images were obtained. Diagnostic images could not be obtained in 22 subjects. Radiologists who were fully experienced in LDLT assessment investigated these images, and classified them for the surgical variations of the bile duct anatomy. One hundred and twelve subjects (58 men, 54 women) who were classified were between 14 and 81 years of age (mean: 39.3; SD 14.1). According to Huang classification, 61 of them (55%) were classified as type A1 (normal right and left hepatic duct junction), 16 (14%) as type A2 (common junction of RAHD, RHPD and LHD), 24 (21%) as type A3 (aberrant drainage of RPHD to left main duct), and 11 (10%) as type A4 (aberrant drainage of RPHD to main hepatic duct). When subjects, in whom the distance (d) between RPHD insertion and the right and left hepatic duct junction is less than 1 cm, are classified as type A2, the type A1 prevalence decreases to 28%. For the entire population that distance was between 3 and 25 mm (mean: 9.8, SD: 4.8). Accordingly, the frequency of type A1 anatomy was 8-29% lower than the respective frequency in Chinese population. From the surgical perspective, close proximity (d<1 cm) of RPHD to right and left hepatic duct junction is considered as type A2 variation. According to that concept, type A1, usually accepted as the dominant anatomic variation, is encountered only in 28% of the Anatolian Caucasians. We have proposed a modified surgical classification in which Huang type 2 was subdivided into types K2a (close proximity) and K2b (trifurcating). The predominance of K2 types in the population of the study may necessitate the use of bench ductoplasty in many liver grafts.

Congenital Lacrimal Sac Fistula: Intraoperative Visualization by Polyvinyl Siloxane Cast

We report the intraoperative use of polyvinyl siloxane impression material to demonstrate the anatomy of the lacrimal sac, canaliculi, and lacrimal duct in a case of congenital lacrimal sac fistula. A 1-week-old boy was examined for tearing since birth. Examination revealed a left congenital lacrimal sac fistula. After a failed surgery to close the fistula with silicone intubation at 6 months of age, the patient underwent endonasal dacryocystorhinostomy performed at 14 months of age, aided by intraoperative injection of polyvinyl siloxane (trade name Reprosil) to mark and protect the nasolacrimal sac and facilitate endonasal visualization. A polyvinyl siloxane cast demonstrated the anatomy of the accessory canaliculus causing nasolacrimal duct obstruction. Postoperatively, the epiphora resolved and the fistula remained closed. The polyvinyl siloxane cast provides a 3-dimensional "ex vivo " model of the lacrimal sac, upper duct, and canalicular anatomy, and can be used in dacryocystorhinostomy surgery to identify and protect the lacrimal sac.

Magnetic Resonance Galactography: a Feasibility Study in Women with Prior Atypical Breast Duct Cytology

To the Editor: For women who inherit a high risk of developing breast cancer, early detection is a key strategy to reduce morbidity and mortality (1). Multiple studies have found that standard mammographic screening often fails to detect breast cancer early in women at high inherited risk of breast cancer, prompting inclusion of emerging methods such as magnetic resonance imaging (MRI) into high-risk screening protocols (2– 13). The evaluation of breast duct cells is also under investigation as a potential cancer risk assessment technique. Approximately 80 percent of breast cancers originate in the ductal system, and early changes of the ductal epithelium, which might predate malignant transformation, have been reported (14–16); for these reasons, analysis of duct cells is a rational approach to risk stratification and biomarker development. At this time, understanding of the normal breast ductal anatomy, including an appreciation of variation in the number of ducts per breast, continues to evolve (17). A prior anatomic study on mastectomy specimens has also reported wide variation in the proportion of breast volume drained by individual ducts (18). With increasing study of intraductal approaches, a better comprehension of ductal structure and the appearance of the ductal system on MRI has practical relevance. We undertook a pilot study of a novel technique, magnetic resonance (MR) galactography, which combines MRI and intraductal evaluation. Our goals were to map the breast ductal system, quantify the breast volume drained by individual ducts, and evaluate sources of prior cytologic atypia in high-risk women.

Congenital salivary fistula of accessory parotid gland: imaging findings

We report the imaging findings in a rare case of an accessory parotid gland fistula. An eight-year-old boy was presented with complaints of serous discharge from his left cheek since birth. As part of the radiological investigation, magnetic resonance imaging, computed tomography sialography with fistulography, and digital sialography with fistulography were performed. Magnetic resonance imaging demonstrated the exact location of an accessory parotid gland but failed to demonstrate the accessory duct. The presence of an accessory gland was well delineated on computed tomography fistulography and computed tomography sialography. Fistulography revealed a small accessory parotid duct and gland. No communication between the ductal systems of both glands was demonstrated. In such cases, pre-operative imaging (with sialography, magnetic resonance sialography and computed tomography sialography with fistulography) is helpful for exact delineation of the ductal anatomy. To the best of our knowledge, only four previous cases of congenital accessory parotid gland fistula have been reported in the English literature.

Comparação entre exames de imagem e achados operatórios em doadores para transplante hepático intervivos

Success in living donor liver transplantation is associated to donor vascular and biliar anatomy. Compare pre-operative and per-operative findings in living liver donors related to portal vein, hepatic artery, bile duct and hepatic venous drainage anatomy. Donors charts of living donor liver transplants done at Clinics Hospital of the Federal University of Paraná, Curitiba, PR, Brazil, were reviewed between March 1998 and August 2005. On the pre-operative period the anatomy was analysed through: celiac and mesenteric arteriography of the hepatic artery and portal vein (venous phase); magnetic resonance imaging of the venous drainage, portal vein and bile duct. Normality was determined based on data of the literature. Pre-operative findings were compared to per-operative findings. Portal vein and hepatic artery were studied in 44 patients, 16 females and 28 males, mean age of 33 years old. In 8 cases the left liver lobe was used to pediatric receptor, in 36 cases the right liver lobe was used to adult receptor. Bile duct anatomy was studied in 37 cases and venous drainage in 32. Over all, the findings related to pre-operative and per-operative anatomy were not coincident in 36.36% of the cases. In the case of hepatic artery, they were not coincident in 11.36%, in the case of the portal vein in 9.1%, in the case of the venous drainage in 9.37% and in the case of the bile duct in 21.6%. The pre-operative and per-operative findings related to vascular and bile duct donor anatomy are frequently different in living donor liver transplantation.

Treatment of pancreatic strictures

The diagnosis and treatment of patients with pancreatic strictures presents a multitude of clinical challenges. The etiology of pancreatic strictures is varied, including benign strictures subsequent to acute pancreatitis, trauma, postsurgical, post-endoscopic retrograde cholangiopancreatography (ERCP), and malignancy. Patients with strictures usually present with symptoms of recurrent pancreatitis, abdominal pain, weight loss, and/or steatorrhea. The absence of a prior history of pancreatitis or surgery increases the likelihood of malignancy. High-quality imaging studies of the pancreas, CT, MRI/magnetic resonance cholangiopancreatography, or endoscopic ultrasound (EUS) scanning are utilized for better definition. Imaging detects an associated mass and/or demonstrates the ductal anatomy. Invasive procedures such as ERCP are performed to better define the causal relationships of the patient's symptoms or to obtain tissue diagnosis. Treatment goals include ameliorating symptoms, dilating the stricture, and ruling out cancer. The risk of malignancy underlies much of the intervention, which includes serology, cytologic analysis, and serial imaging. EUS has become the procedure of choice to rule out a mass, to evaluate the parenchyma for evidence of chronic pancreatitis, and to obtain fine-needle biopsies for tissue confirmation. In symptomatic patients or patients with indeterminate strictures, ERCP is used for direct pancreatography, tissue acquisition, and endoscopic treatment. Endotherapy includes sphincterotomy, dilation, and stenting to provide drainage. We view ERCP as the optimal first-line treatment modality. ERCP offers the potential of curative treatment and is less invasive than surgery, especially as some patients' symptoms are not severe enough to justify surgery. If patients do not experience relief of symptoms after several sessions of endoscopic therapy, surgery is the logical next step for definitive, long-term treatment.

Dissectional and endoscopical anatomy of the lacrimal duct

Abstract Purpose: A better knowledge of the external and internal anatomy of the lacrimal duct isessential for any intervention. The induced prussure of the medial canthal ligament into the lacrimal sac might be considered as one of the reasons of epiphora. Methods: In this study, cadaver disection, trans‐canalicular and endonasol endoscopy are used to provide a better intuition of anatomy. Results: Concerning the medial canthal ligament, cadaver study of the lacrimal duct reveals that there are two portions: the posterior portion and anterior one which passes over the lacrimal sac and inserts on the lacrimal bone. The medial portion of the medial canthal ligament is connected by the medial part of the tarsus superior and inferior. There are fascial connections between the anterior part of the ligament and the lacrimal sac and between the anterior part of this ligament to the orbicular superior and inferior muscels.The lacrimal duct starts from the Punctum superius and inferius and terminates in the nose. The inferior opening of the duct comes in the nose on the level of the inferior turbinate.Collaps of the canaliculi or the lacrimal sac is investigated by trans‐canalicular endoscopy. It is observed that the pressure induced by medial canthal ligament into the lacrimal sac is the main reason of collps of the canaliculi or the lacrimal sac. Conclusions: Trans‐canalicular and endonasal endoscopy which are complementary to disectional anatomy, provid a better insight of the naso‐lacrimal duct anatomy and physiology. This knowledge is mandatory for any naso‐lacrimal duct interventions. Epiphora with exclusion of the other ethiology (allergy, foreign body) than obstruction, can be caused by collaps of the lacrimal sac due to pressure of the medial canthal ligament.