Duct Orifice Research Articles

Feasibility of Double-Deployment Small-Diameter Covered Metallic Stent for Malignant Distal Biliary Obstruction (with Video)

Background/Objectives: Covered self-expandable metallic stents (CSEMS) are commonly used to treat malignant distal biliary obstructions. A 10-mm CSEMS carries the risk of obstructing the pancreatic and cystic duct orifices by adhering to the bile duct; therefore, postoperative pancreatitis and cholecystitis are reported to occur at a certain frequency. We have adopted a new drainage technique for malignant distal biliary obstruction called ‘‘double-slim SEMS stenting” (DSS), where two small-diameter CSEMS are placed side-by-side. We aimed to compare the efficacy and safety of biliary drainage using DSS with those of conventional CSEMS. Methods: In total, 50 patients who underwent endoscopic biliary drainage for malignant distal biliary obstructions between April 2019 and March 2022 at Hyogo Medical University Hospital were enrolled. Patients were divided into DSS and Conventional groups, and the technical success rate, clinical success rate, adverse events, success rate for reintervention, recurrent biliary obstruction (RBO) rate, and time to RBO (TRBO) were evaluated. Results: There were no significant differences in patient characteristics between the DSS (n = 20) and Conventional groups (n = 30). The technical and clinical success rates were 100% in the DSS group. The incidence of adverse events was not significantly different between the two groups (DSS/Conventional: 10.0% [2/20]/20.0% [6/30]) (p = 0.34). No acute cholecystitis was observed in the DSS group. The incidence rates of RBO were 30% (6/20) and 43% (13/30) in the DSS and Conventional groups, respectively (p = 0.92). The median TRBO in the DSS group was 378 days, while the TRBO in the Conventional group was 195 days (p = 0.03), resulting in significantly longer TRBO in the DSS group. Conclusions: DSS emerges as a viable and safe approach for biliary drainage in malignant distal biliary obstruction, demonstrating a lower incidence of adverse events and longer TRBO compared to conventional CSEMS.

Stensen's Duct Dynamic Anatomy Assessed with Sialography.

Objectives: The presence of a catheter required for contrast infusion during sialography obscures imaging of the distal duct. Static imaging via cone beam computed tomography and magnetic resonance sialography fails to address changes that occur dynamically to the anatomy of the flexible salivary ductal system. We aim to identify dynamic changes to the parotid gland by introducing a novel approach to analyze the full extent of Stensen's duct based on dynamic infusion digital sialography. Methods: Retrospective chart review of a single-center consecutive series of 409 parotid sialograms performed between April 2008 and June 2023 permitted selection of a contemporary series including seven normal sialograms and seven sialograms with stricture(s). Dynamic (fluoroscopic) infusion (iopamidol/gadolinium) sialograms were assessed through blinded review by two radiologists employing the institution's picture archiving and communication (PACS) system (©2023 Koninklijke Philips N.V., Amsterdam, Netherlands). Measurements determined changes, in two dimensions, to the angle of the masseteric bend and duct length while the catheter was in place (repose), during catheter withdrawal (stretch), and during recoil after withdrawal. Differences in median lengths and angles of Stensen's duct between the three time points were compared using Wilcoxon matched-pairs signed rank and Mann-Whitney tests. Results: Fourteen patients [median age (IQR), 55 years (24.7); 10 women] were evaluated. The median angle of the masseteric bend was 117.7° in repose versus 155.4° during catheter withdrawal (P < .001, n = 14). The median distance measured from the Stensen's duct orifice to the first major ductal bifurcation was 81.5 mm (IQR = 12.3) in repose. The median percent increase in length from repose to stretch was 6.3% (P < .001, n = 14). Conclusions: Dynamic infusion digital sialography with fluoroscopic recording during catheter removal permits assessment of the distal duct unobstructed by the presence of a catheter. The technique also identifies the dynamic nature and varying length and angulation of Stensen's duct.

Visibility of the biliary orifice after precut papillotomy: Comparison between white light imaging and texture and color enhancement imaging.

Precut papillotomy is performed in cases of difficult biliary cannulation, but identification of the biliary orifice is difficult. Texture and color enhancement imaging (TXI) can enhance the structure, color, and brightness. This study compared TXI and white light imaging (WLI) in visibility of biliary orifices. We retrospectively examined 20 patients who underwent bile duct cannulation using both WLI and TXI after precut papillotomy at our center between 2021 and 2022. On WLI and TXI images displayed in random order, bile duct orifice on precut-incision surface of each image was independently evaluated by eight evaluators. Single-indication accuracy rate of biliary orifices, visibility score rated on a 4-grade scale, and color difference between the biliary orifice and the surrounding tissue were examined. The single-indication accuracy rate was higher in TXI compared to WLI (50.6% vs. 35.6%, odds ratio 2.26 [95% CI: 1.32-3.89], p = .003). The time to indicate the biliary orifice was comparable between TXI and WLI (median, 9.7 s [range, 2.6-43] vs. 10.9 s [1.5-64], p = .086). Furthermore, the visibility score was higher in TXI than in WLI (median, 3 [interquartile range, 2-3] vs. 2 [2, 3], p < .001), and the color difference between the biliary orifice and surrounding tissue in TXI was more pronounced than in WLI (median, 22.9 [range, 9.39-55.2] vs. 18.0 [6.48-43.0]; p < .001). TXI enhanced the color difference and visibility of the biliary orifice after precut and improved single-indication accuracy rate, suggesting that it could be useful for biliary cannulation after precut papillotomy.

Developing a model for aqueous deficient dry eye secondary to periglandular cicatrizing conjunctivitis

PurposeThe current study used various techniques to develop a rabbit animal model of lacrimal gland damage caused by scarring conjunctivitis in the periglandular area. MethodsLeft eyes of New Zealand white rabbits were injected with 0.1 ml of 1M NaOH subconjunctivally around superior and inferior lacrimal gland orifices (Group 1, n = 4), touched with 1M NaOH for 100 s to the superior and inferior fornices with conjunctival denuding (Group 2; n = 4), and electrocauterization to the ductal opening area (Group 3; n = 4). The ocular surface staining, Schirmer I, lacrimal gland, and conjunctival changes were observed at baseline,1, 4, 8, and 12 weeks. The degree of glandular inflammation, conjunctival fibrosis (Masson Trichrome), and goblet cell density (PAS) were also assessed. ResultsAt 12 weeks, the lacrimal glands of group 1 rabbits with periglandular injection showed severe inflammation with mean four foci/10HPF and a significant mean reduction in the Schirmer values by 7.6 mm (P = 0.007). Lacrimal glands had diffuse acinar atrophy, loss of myoepithelial cells, and ductular dilatation. The overlying conjunctiva showed fibrosis, goblet cell loss, and corneal vascularization in the inferotemporal quadrant. No lacrimal gland or ocular surface changes were observed in groups 2 and 3 at 12 weeks, except for localized subconjunctival fibrosis. ConclusionPeriglandular injection of 0.1 ml of 1M NaOH induced extensive lacrimal gland damage with reduced secretion and scarring in the subconjunctival plane compared to direct cauterization or direct NaOH contact to the ductal orifices of the rabbit lacrimal gland.

Risk factors and treatment strategies for cholecystitis after metallic stent placement for malignant biliary obstruction: a multicenter retrospective study

Background and study aimsCholecystitis can occur after self-expandable metallic stent (SEMS) placement for malignant biliary obstructions (MBO). Furthermore, the best treatment option for cholecystitis has not been determined. Here, we aimed to identify the risk factors of cholecystitis after SEMS placement and determine the best treatment option. Patients and MethodsIncidence, treatments, and predictive factors of cholecystitis were retrospectively evaluated in 1,084 patients with distal MBO (DMBO) and 353 patients with hilar MBO (HMBO) who underwent SEMS placement at the 12 institutions from January 2012 to March 2021. ResultsCholecystitis occurred in 7.5% of patients with DMBO and 5.9% of patients with HMBO. The recurrence rate was significantly lower (p=0.043), and the recurrence-free period was significantly longer (p=0.039) in endoscopic procedures than in percutaneous procedures for cholecystitis treatment. Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) was better in terms of technical success, procedure time, and recurrence-free period than endoscopic transpapillary gallbladder drainage. The cases with obstruction across the cystic duct orifice by tumor (p=0.015) and those with obstruction by stent (p=0.037) were the independent risk factors for cholecystitis in DMBO. The cases with multiple SEMS placements (OR 11, 95% CI 0.68–190, p=0.091) and those with gallbladder stones (OR 2.3, 95% CI 0.92–5.6, p=0.075) had a higher risk for cholecystitis in HMBO. ConclusionsThe incidences of cholecystitis after SEMS placement for DMBO and HMBO were comparable. EUS-GBD is the optimal treatment option for patients with cholecystitis after SEMS placement for MBO.

A modified Blumgart method using a homemade crochet needle facilitates pancreaticojejunostomy in laparoscopic pancreaticoduodenectomy: a retrospective cohort study

BackgroundAmong the safest procedures for anastomosis in pancreaticoduodenectomy, Blumgart pancreaticojejunostomy is associated with low rates of postoperative pancreatic fistula (POPF) and postoperative complications. However, this technique is difficult to perform during laparoscopic pancreaticoduodenectomy (LPD). This study presents a modified Blumgart method using a homemade crochet needle to facilitate laparoscopic pancreaticojejunostomy and evaluates its safety and reliability.MethodsFrom February 2019 to October 2022, 96 LPD surgeries with the new technique were performed by the same surgeons in the Second Affiliated Hospital of Zhejiang University School of Medicine. The operative details (operative time, pancreaticojejunostomy time, POPF rate, postoperative complication rate, mortality rate) were analyzed along with clinical and pathological indicators (pancreatic duct diameter, pancreatic texture, and histopathological findings).ResultsThere were 54 men and 42 women with a mean age of 63.38 ± 10.41 years. The intraoperative bleeding volume, operative time and postoperative length of hospital stay were 198.43 ± 132.97 mL, 445.30 ± 87.05 min and 13.68 ± 4.02 days, respectively. The operation time of pancreaticojejunostomy was 66.28 ± 10.17 min. Clinically relevant POPFs (grades B and C) occurred in 14.6% of patients. Only one patient had postoperative abdominal hemorrhage and was cured after reoperation. There were no operative or in-hospital deaths. With our proposed modification, the pancreatic duct and jejunal orifice are aligned correctly during duct-to-mucosa (DTM) after the application of external traction through the homemade crochet needle. The space between the posterior wall of pancreatic remnant and jejunal loop can be exposed by adjusting the tension of the external threads, which can facilitate DTM.ConclusionsA modified Blumgart method using a homemade crochet needle could be technically feasible and safe during LPD. A randomized control trial is needed to confirm these findings.

Lipoid Proteinosis, Its Symptoms, and Oral Manifestations: A Case Report and Review of Literature

Introduction: Lipoid proteinosis (LP), also known as Urbach-Wiethe disease, is an autosomal recessive disorder characterized by the deposition of glycoproteins in mucous membranes, skin, and organs. Symptoms typically begin in childhood, persist throughout life, and encompass hoarseness, skin inflammation, scarring, and ulcers, resulting in a waxy appearance. Oral manifestations present as white plaques and ulcers, significantly impacting the oral cavity. To date, approximately 400 cases have been reported worldwide. Case Presentation: Herein, we present the case of a 36-year-old female diagnosed with LP who sought a dental implant evaluation. Her medical history revealed tooth decay, which necessitated extractions, and she had previously undergone maxillary implant placement and mandibular bone grafting. Upon general examination, the patient exhibited voice hoarseness, hyperkeratosis on the elbows and hands, and papules on the fingers. Oral examination revealed firm and fibrotic mucosa, papillomatosis, and limited mouth opening. Hyposalivation and the absence of the left parotid duct orifice were noted. No significant abnormalities were observed on the eyelids or face. Salivary gland assessment indicated a reduced flow rate (1 ml in 5 minutes). This case highlights the importance of conducting a comprehensive evaluation and tailoring management strategies to the individual needs of patients with LP. Conclusions: Lipoid proteinosis is a rare mucocutaneous disorder characterized by a slow and benign course, with varying prevalence in different regions. Early recognition of oral symptoms is crucial, as they often precede skin and neurological manifestations. Although typical oral signs usually include tongue firmness and an inability to protrude, these were not observed in the present case. Xerostomia and dental agenesis, though uncommon, have been reported in previous cases, consistent with the findings of the present case, although different areas of the oral cavity might be involved in some instances.

Adverse events of self-expandable metal stent placement for malignant distal biliary obstruction: a large multicenter study

Background and aimEndoscopic placement of self-expandable metal stents (SEMSs) for malignant distal biliary obstruction (MDBO) may be accompanied by several types of adverse events. The present study analyzed the adverse events occurring after SEMS placement for MDBO. MethodsThe present study retrospectively investigated the incidence and types of adverse events in patients who underwent SEMS placement for MDBO between April 2018 and March 2021 at 26 hospitals. Risk factors for acute pancreatitis, cholecystitis, and recurrent biliary obstruction (RBO) were evaluated by univariate and multivariate analyses. ResultsOf the 1425 patients implanted with SEMS for MDBO, 228 (16.0%) and 393 (27.6%) experienced early adverse events and RBO, respectively. Pancreatic duct without tumor involvement (p = 0.023), intact papilla (p = 0.025), and SEMS placement across the papilla (p = 0.037) were independent risk factors for acute pancreatitis. Tumor involvement in the orifice of the cystic duct (OCD) was an independent risk factor for cholecystitis (p < 0.001). Fully and partially covered SEMSs were independent risk factors for food impaction and/or sludge. Fully covered SEMS was an independent risk factor for stent migration. Uncovered SEMS and laser-cut SEMS were independent risk factors for tumor ingrowth. ConclusionsPancreatic duct without tumor involvement, intact papilla, and SEMS placement across the papilla were independent risk factors for acute pancreatitis, and tumor involvement to the OCD was an independent risk factor for cholecystitis. The risk factors for food impaction and/or sludge, stent migration, and tumor ingrowth differed among types of SEMS.

Prophylactic endoscopic gallbladder stenting for cholecystitis after covered metal stent placement for distal biliary obstruction.

Acute cholecystitis is occasionally observed after biliary drainage using a covered self-expandable metal stent (CSEMS) for distal biliary obstruction (DBO). Gallbladder drainage prior to CSEMS placement may reduce cholecystitis. This study aimed to examine the preventive effect of endoscopic gallbladder stenting (EGBS) on cholecystitis with CSEMS. We retrospectively analyzed patients with DBO who underwent CSEMS placement across the orifice of the cystic duct between November 2014 and October 2021 and were negative for cholecystitis on biliary drainage. Prophylactic EGBS was attempted before CSEMS placement. The incidence of cholecystitis was compared between patients with and without EGBS. A total of 286 patients (128 men; median age, 75 years) were included in this study. EGBS was attempted in 32 patients before CSEMS placement, and technical success was achieved in 24 (75%) patients. Adverse events were noted in three patients (9.4%; penetration of cystic duct in one and acute pancreatitis in two). The cumulative incidence of cholecystitis was significantly lower in patients with EGBS than in those without EGBS (1 [4.2%] vs. 56 [21.4%]; p=0.045. In multivariable analysis, EGBS was a significant protective factor against cholecystitis (hazard ratio, 0.11; 95% confidence interval, 0.01-0.79; p=0.028). Although the transpapillary approach to the gallbladder is not easy for patients with DBO, EGBS is effective in preventing cholecystitis associated with CSEMS.

The submandibular sialolithiasis in an eight-year-old child: a case report

Sialolithiasis is a commonly encountered disease of the salivary glands and represents up to 30-50% of all salivary gland diseases. However, the condition is rarely encountered in the paediatric population. The formation of a salivary stone is believed to be secondary to the deposition of calcium salts around a nidus, which is commonly associated with desquamated epithelial tissue or sloughing from a recent bacterial infection. Patients with submandibular sialolithiasis usually present with acute swelling over the neck associated with pain, fever, and purulent intraoral discharge. The calculi were located on the right in 100.0% of paediatric patients. Moreover, 20.0% of paediatric patients exhibited sialoliths in the glands. In this paper, we present the case of an 8-year-old male child who presented with a history of swelling over the right submandibular region since four months and had not responded to the conservative treatment given for the last four months. On examination, a small, rounded salivary calculus was found at the Wharton duct orifice near the papilla. A minimally invasive surgical procedure of intraoral excision of the calculus was done, and the patient was prevented from undergoing surgical excision of the gland. A large number of relatively small and distal sialoliths in paediatric patients can be removed using intraoral retrieval under local or general anesthesia. The clinical evaluation of the entire salivary tract with a high index of suspicion helps in early diagnosis and avoids the development of an abscess and other complications that may require surgical excision of the gland.

A novel approach of intraoperative cholangiography in laparoscopic left lateral sectionectomy in living donor liver transplantation.

Accurate division of bile duct during laparoscopic donor hepatectomy in living donor liver transplantation is essential. We here present a novel approach to achieve cholangiography via the bile duct stump of segment IV (B4 stump) during laparoscopic donor hepatectomy in adult-to-pediatric living donor liver transplantation. Donors who underwent laparoscopic left lateral sectionectomy (LLLS) from January 2022 to April 2022 in our liver transplant center were retrospectively analyzed. A total of 32 donors were eventually enrolled into this study. Cholangiography via the B4 stump was performed in 11 donors (B4 group) while indocyanine green (ICG) fluorescence guiding was performed in 21 donors (ICG group). Perioperative data were collected and compared between groups. Cholangiography by catheterizing the B4 stump was successfully performed in all 11 donors in the B4 group. The mean time of this procedure was 12.82 ± 9.11min. Compared to the ICG group, it was more likely to acquire single bile duct orifice on graft in the B4 group (B4: 10/11, 90.91% vs ICG: 9/21, 42.86%) and it was significantly different (p = 0.030). The donors' complications (Clavien-Dindo grade III-IV) were not significantly different. There was one donor developed intraperitoneal effusion in B4 group, while two donors (one bile leakage and one biliary stricture) developed biliary tract related complications in the ICG group. A Roux-en-Y was performed to solve the biliary stricture in the ICG group. The recipients' outcomes were not significantly different between groups. Cholangiography via the B4 stump catheterization is feasible and safe in identifying the bifurcation of bile duct during LLLS.

Features of the Peribiliary Glands of the Extrahepatic Biliary Tract in the Elderly and Long-Living Individuals

The aim of the study was to analyse histologically and morphometrically the peribiliary glands of the extrahepatic biliary tract in the elderly and long-living people.Material and methods. The study included wholemounts of the gallbladder, the cystic, hepatic and common bile ducts obtained from the corpses of both sexes aged 22 to 35 years (n=16) and older than 76 years (n=39). Macro-microscopy was used to evaluate the number, localization, sizes and shape of the glands, the area of the lumen of the excretory duct orifices, the area of the initial section of the glands, the number of initial (terminal) parts and the proportion of epithelial parenchyma in their composition.Results. With age, there is a decreased proportion of "complexly branched" glands with a significant number of initial sections and excretory ducts of the 1st order. The proportion of "simple" glands, with one initial section increases to 70.2–78.3% in the senile age, while it is 41.0–52.1% in people of mature age. In long-living people, there is an increased number (up to 70–85%) of glands with ampullar extensions of the common excretory duct. The total number, density of gland localization, the length and width of the initial section of the peribiliary glands tend to decrease from the period of mature age to longevity. In senile age, the size and quantitative parameters of the glands stabilize, and do not modify in long-living people.Conclusion. The results of the morphological analysis demonstrate that there is no progression of involutive changes in the peribiliary glands of the extrahepatic biliary tract from senile age to the period of longevity. In some cases, long-living individuals manifest compensatory-adaptive reactions, such as an increased severity of the epithelial parenchymal component in the composition of the glands and an increased proportion of glands with an ampullar expansion of the common excretory duct.

Successful hemostasis using a self-assembling peptide hydrogel for bleeding after endoscopic papillary large-balloon dilation.

Adverse bleeding events can occur after endoscopic papillary large-balloon dilation (EPLBD) [1], though not as frequently as after endoscopic sphincterotomy. Post-EPLBD bleeding often originates from sites deeper than the bile duct orifice, such as lacerations of the bile duct wall, and the origin of bleeding may not be identified; therefore, it is often difficult to stop the bleeding. A novel self-assembling peptide hydrogel (PuraStat; 3-D Matrix, Tokyo, Japan) was recently developed as a hemostatic agent [2] [3] [4]. We present a case of hemostasis of massive post-EPLBD bleeding achieved with this hydrogel.

Intraperitoneal rupture of the hydatid cyst disease: Single-center experience and literature review.

The primary aim of this study was to present our experience on intraperitoneal rupture of the hydatid cyst in guidance of literature data. Demographical, clinical, radiological and postoperative follow-up data of 29 patients who underwent surgical treatment in our institution with an indication of intraperitoneal rupture of the hydatid cyst from January 2003 to July 2020 were analysed retropectively. Among the 29 patients with an age range of from 16 to 79 years ( median= 39, IQR=25.5), 16 were male (55.2%) and 13 were female (44.8%). Intraperitoneal rupture of the hydatid cyst was spontaneous in 21 (72.4%), traumatic in 7 (24.13%) (2 of them were iatrogenic) and was due to shotgun in one patient. Vast majority of the patients were admitted to the emergency department in the first 24 hours after the onset of sign and symptoms. WBC varied from 8.600 to 30.900/mm3 (median=12.100, IQR=5.7). Ruptured cysts were localised in liver (n=25, 86.2%), in spleen (n=2, 6.89%) or in pelvis (n=2, 6.89%) and diameter varied from 40 to 200 mm (median= 90, IQR=50). Among the cysts ruptured in liver, 19 (76%) of them were localised in right lobe. Among the ruptured cysts of liver, 20 (80%) of them underwent conservative surgery (partial pericystectomy etc), remaining 5 patients (20%) underwent a radical surgical treatment (pericystectomy etc). A biliary orifice was diagnosed during surgical exploration in either cyst cavity or cut surface of liver in 12 (48%) of the patients. Patients with a dilated common bile duct or a visible biliary duct orifice in cystic cavity underwent common bile duct exploration and T-tube drainage procedure (n=6, 24%). One patient died on postoperative day one, due to cardiopulmonary complications secondary to cyst rupture. All along the postopeartive follow-up of median 1416 days, seven (24.1%) patients were diagnosed for diseased recurrence. Intraperitoneal rupture of the hydatid cyst is a life-threatening complication of hydatid cyst disease, for which diagnosis without delay and timing of surgical treatment is essential. Anaphylactic shock cases require rapidly initiation of medical treatment against allergic reactions. Despite scolocidal agents, vesicular spread into peritoneal cavity account for the major risk factor for disease recurrence. Hence, abdominal cavity should be explored cautiously.

Progressively enlarging midline cystic mass of the floor of the mouth in an infant

A 6-month-old infant arrived with parents for evaluation of an anterior floor of mouth swelling. The birth history was unremarkable, and the parents stated that the swelling had been present since birth. During the past few months, the oral swelling had enlarged progressively; however, the parents denied observing any difficulties with feeding or breathing. The parents noted no other medical abnormalities. On examination, a large, distensible mass was palpated at the anterior floor of the mouth. The overlying mucosa had a bluish tinge, and both submandibular duct orifices were present, patent, and laterally displaced by the lesion. There were no palpable neck masses. Magnetic resonance imaging of the face was performed 1 month before at an outside hospital and revealed a 1.5- × 1.7- × 1.8-cm, well-defined, predominantly cystic, lesion located within the root of the tongue (Figure 1). There was a small, enhancing, soft-tissue nodule ventrally. Dr. Trinh is a resident, Division of Oral and Maxillofacial Pathology, Columbia University Irving Medical Center, New York, NY. Dr. Lee is a resident, Division of Oral and Maxillofacial Surgery, Columbia University Irving Medical Center, New York, NY. Dr. Eisig is the chairman, Division of Oral and Maxillofacial Surgery, Columbia University Irving Medical Center, New York, NY. Dr. Peters is an assistant professor, Division of Oral and Maxillofacial Pathology, Columbia University Irving Medical Center, New York, NY.

A Single Institution Cadaveric Study on Anatomical Variation of the Sublingual Gland Duct.

The purpose of this study was to conduct a cadaveric dissection study on the anatomical variation of the sublingual (SLG) excretory ducts and dictate an improved understanding of the anatomical communication between the SLG duct and submandibular (SMG) ducts. This study is carried out by standardized dissection of anterior floor of mouth in 6 formalin-fixed adult cadavers in Silent Mentor Workshop University Malaya in August 2020. The cadavers had no trace of scars, adhesions, signs of trauma or operation. SMG duct opening was identified lateral to the lingual frenulum through a papilla in the floor of mouth behind the lower incisor tooth. A horizontal incision line was done over floor of mouth just lateral to the opening. SMG duct and SLG was traced and skeletonized. Any presence of major duct arising from the SLG and its communication with SMG duct were investigated. We found there are 3 patterns of SLG excretory duct variants; (1) One major (Bartholin's) duct which open independently at its own orifice adjacent to the orifice of the Wharton's duct of SMG. (2) One major (Bartholin's) duct which joined into the Wharton's duct of SMG. (3) Absent of a major duct arising from SLG. The overall mean diameter of SLG ducts were 1.3 ± 0.41and the mean length of SLG ducts were 18.5 ± 6.55. The overall mean diameter of SMG ducts was 2.6 ± 0.74 and the mean length of SMG ducts were 46.5 ± 6.57. Excretory ductal system of SLG showed great variations, not only between the different cadavers but also within the different sides of the same cadaver. Awareness of potential anatomical variations can aid in the accurate diagnosis and treatment of patients with salivary gland pathology as well as help surgeons reveal potential risk factor and avoid complications during surgical procedures in the floor of mouth.

Prophylactic EUS-guided gallbladder drainage prevents acute cholecystitis in patients with malignant biliary obstruction and cystic duct orifice involvement: a randomized trial (with video)

Patients with distal malignant biliary obstruction (MBO) and cystic duct orifice tumoral involvement have an increased risk for the development of acute cholecystitis after self-expandable metallic stent (SEMS) placement. We aimed to determine whether primary EUS-guided gallbladder drainage prevents acute cholecystitis in these patients. This was a single-center, randomized control trial in patients with distal MBO enrolled from July 2018 to July 2020. Patients were randomized into 2 groups: an interventional group treated with conventional ERCP biliary drainage with SEMS placement and subsequent primary EUS-guided gallbladder drainage (EUS-GBD) and a control group treated with conventional biliary drainage alone. The primary outcome of the study was the occurrence of post-treatment acute cholecystitis, assessed for≤12 months or until death. The secondary outcomes were hospitalization length and median survival time. Forty-four patients were included in the study: 22 in each group. Five patients in the control group (22.7%) and none in the intervention group experienced acute cholecystitis. The median hospitalization time was significantly lower in the interventional group than in the control group (2 days vs 1 day, P= .017). There was no difference in the observed median survival rates in the primary EUS-GBD group (2.9 months) and the control group (2.8 months) (P= .580). In this single-center study of patients with unresectable MBO and occlusion of the cystic duct orifice, prophylactic EUS-GBD demonstrated a reduced incidence of acute cholecystitis.

Efficacy of pancreatic duct stenting to prevent postendoscopic retrograde cholangiopancreatography pancreatitis after covered self-expandable metal stentdeployment.

Although covered self-expandable metal stents (CSEMSs) are associated with the risk of postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis due to pancreatic duct (PD) orifice obstruction, they are often used for biliary drainage treatment in malignant biliary obstruction (MBO). This study aimed to investigate the efficacy of PD stenting in preventing post-ERCP pancreatitis after CSEMS implantation. This retrospective cohort study analyzed 554 patients with transpapillary CSEMS for MBO. Patients with noninitial deployment, benign disease, CSEMS deployment above the papilla, surgically altered anatomy, uncovered self-expandable metal stents, multiple thin self-expandable metal stents, and unavailable procedure videos were excluded. Logistic regression analysis estimated the association between PD stenting and post-ERCP pancreatitis incidence. We adjusted for age, sex, pancreatitis history, prophylactic rectal nonsteroidal anti-inflammatory drug use, naïve papilla, MBO etiology, and prolonged biliary cannulation time. Among 554 patients, 67 (12.1%) experienced post-ERCP pancreatitis. Post-ERCP pancreatitis was recorded in 13.7% of patients in the non-PD stenting and 4.3% in the PD stenting groups. Pancreatic duct stenting was associated with lower risks of post-ERCP pancreatitis (odds ratio [OR] 0.28; 95% confidence interval [CI] 0.099-0.79; P = 0.028). In multivariable analysis, the association between PD stenting and lower post-ERCP pancreatitis incidence was consistent (OR 0.19; 95% CI 0.062-0.58; P = 0.0034). Pancreatic duct stenting could reduce the risk of post-ERCP pancreatitis after CSEMSs.

Use of texture and color enhancement imaging to identify the pancreatic duct orifice in a patient with a pancreaticojejunal anastomotic stricture.

An endoscopic approach to pancreaticojejunal anastomotic stricture (PJAS) using a balloon enteroscope in patients who have undergone pancreaticoduodenectomy is challenging [1] [2] [3]. Identification of the pancreatic duct orifice is often difficult because of complete PJAS. Herein, we report the case of a patient with a PJAS in whom a texture and color enhancement imaging (TXI)-equipped new-generation endoscopy system (EVIS X1; Olympus Medical Systems, Japan) [4] was used, which facilitated identification of the pancreatic duct orifice.

Biliary Tract Exploration After Laparoscopic Left-sided Hepatectomy: A Comparative Study of Left Hepatic Duct Orifice Versus Common Bile Duct Approach.

Laparoscopic left-sided hepatectomy (LLH) and additional biliary tract exploration are effective methods to treat left-sided hepatolithiasis (LSH) combined with extrahepatic bile duct stones. Although biliary tract exploration through common bile duct (CBD) incision has been widely accepted, the safety and effectiveness of the left hepatic duct (LHD) orifice approach after LLH is still in debate. One hundred and forty-four patients with LSH who underwent LLH and biliary tract exploration in our institution from April 2014 to September 2021 were enrolled in the retrospectively study. They were divided into 3 groups: LHD group (n=67), CBD/T-tube group (n=58), and CBD/PC group (n=19). Patients' demographic characteristics, intraoperative, and postoperative outcomes were retrospectively analyzed. LHD group exhibited a shorter operative time (202.8±42.2 vs. 232.7±47.5min, P =0.000), time to first bowel movement (2.3±0.5 vs. 2.9±0.7d, P =0.000) and postoperative hospital stay (7.5±2.1 vs. 9.8±5.2d, P =0.001) compared with the CBD/T-tube group. The lithotomy time in the LHD group was significantly longer than that in the CBD/T-tube group (33.6±7.3 vs. 29.0±6.3min, P =0.000) and CBD/PC group (33.6±7.3 vs. 28.7±3.7, P =0.006). Intraoperative blood loss, blood transfusion rate, initial stone clearance rate, and stone recurrence rate all had no significant differences between the 3 groups (all P >0.05). LHD group showed less rate of electrolyte imbalance than that of the CBD/T-tube group (3.0% vs. 19.0%, P =0.004) but it was equivalent to the CBD/PC group ( P >0.05). The type of biliary tract exploration (odds ratio: 5.43, 95% confidence interval: 0.04-0.95, P =0.032) as independent predictors of electrolyte imbalance. No reoperation and mortality occurred in the 3 groups. The conversion rate was comparable among 3 groups (1.5% vs. 1.7% vs. 0, all P >0.05). No significant difference in stone recurrence rate was seen (1.5% vs. 3.4% vs. 0, all P >0.05). Biliary tract exploration through LHD orifice after LLH is a safe and effective treatment for selected patients with LSH, with an advantage over the T-tube drainage in the field of operative time, the incidence of electrolyte imbalance, recovery of gastrointestinal function, and postoperative hospital stay.