Hepatic Duct Research Articles

Novel specialized guidewire for bridging deployment into the right hepatic duct via endoscopic ultrasound-guided hepaticogastrostomy for malignant hilar biliary obstruction.

Novel specialized guidewire for bridging deployment into the right hepatic duct via endoscopic ultrasound-guided hepaticogastrostomy for malignant hilar biliary obstruction.

Oral N-acetylcysteine ameliorates liver fibrosis and enhances regenerative responses in Mdr2 knockout mice

Cholangiopathies are poorly understood disorders with no effective therapy. The extrahepatic biliary tree phenotype is less studied compared to the intrahepatic biliary injury in both human disease and Mdr2−/− mice, the established cholestatic mouse model. This study aimed to characterize the extra hepatic biliary tree of Mdr2−/− mice at various ages and to determine if injury can be repaired with the antioxidant and glutathione precursor N-acetyl-L-Cysteine treatment (NAC). We characterized extra hepatic bile ducts (EHBD)s at various ages from 2 to 40 weeks old FVB/N and Mdr2−/− mice. We examined the therapeutic potential of local NAC ex vivo using EHBD explants at early and late stages of injury; and systematic therapy by in vivo oral administration for 3 weeks. EHBD and liver sections were assessed by histology and immunofluorescent stains. Serum liver enzyme activities were analyzed, and liver spatial protein expression analysis was performed. Mdr2−/− mice developed progressive EHBD injury, similar to extrahepatic PSC. NAC treatment of ex vivo EHBD explants led to improved duct morphology. In vivo, oral administration of NAC improved liver fibrosis, and decreased liver enzyme activities. Spatial protein analysis revealed cell-type specific differential response to NAC, collectively indicating a transition from pro-apoptotic into proliferative state. NAC treatment should be further investigated as a potential therapeutic option for human cholangiopathies.

056. Impacted CBD Stones in Ampula Vater Evacuated by Transduodenal Approach in A 48-year-old Patient at Prof. Dr. IGNG Ngoerah Hospital in 2024

Background: Cholecystolithiasis and choledocholithiasis are common biliary disorders that can lead to significant complications if left untreated. Among these complications, the formation of impacted CBD stones, particularly at the Ampulla of Vater, poses a unique clinical challenge. The Ampulla of Vater is the anatomical site where the common bile duct (CBD) and pancreatic duct converge, and its obstruction can lead to biliary colic, cholangitis, or pancreatitis. Urgent stone removal is critical for improving the patient’s condition. Case: A 48-year-old male patient presents to the emergency department with right upper abdominal pain since 10 days ago accompanied with icteric sclera since 10 days ago. There was nausea and vomiting when eating high-fat foods. The stools were brownish in color, the urine color was similar to tea color. The patient regularly takes UDCA 3 x 250 mg IO, simvastatin 1 x 20mg IO, curcuma 3 x1 tab IO, lansoprazole 2 x 30mg IO. Physical examination showed icteric eyes, jaundice, liver enlargement 2 fingers below costae arch with positive Murphy's sign. Complete blood examination showed leukocytosis, decreased hemoglobin, hypokalemia, as well as increased direct bilirubin, total bilirubin, and indirect bilirubin. BOF result showed sentinel loop on the right umbilical region suspected inflammatory process. MRI impression of choledocholithiasis causing dilatation of EHBD and IHBD proximal aspect without signs of cholangitis, hepatomegaly, simple cyst of left kidney (Bosniak I). Abdominal ultrasound with the conclusion of cholecystitis with dilatation and thickening of the ductus cysticus wall suspicious of inflammation, dilatation of the right and left IHBD, common hepatic duct, to the proximal common biliary duct, the presence of distal obstruction cannot be evaluated because it is covered by intestinal shadows, mild prostatic hypertrophy accompanied by prostate calcification. After Cholecystectomy and Explore CBD transduodenal, the patient was placed with thoracic drain with good outcome. Conclusion: The transduodenal approach to evacuating impacted CBD stones at the Ampulla of Vater is a valuable technique that can yield excellent outcomes in select cases. This case report underscores the importance of a tailored approach based on individual patient anatomy and stone characteristics.

Imaging of Ischemic Cholangiopathy Following Donation after Circulatory Death Liver Transplant.

Ischemic cholangiopathy (IC) is the leading cause of inferior long-term outcomes following donation after circulatory death (DCD) liver transplant. Biliary strictures related to IC are nonanastomotic strictures (NASs) by definition and involve the donor hepatic ducts proximal to the anastomosis, compared with postsurgical anastomotic strictures that form due to fibrotic healing. IC-related NASs can be microangiopathic with patent hepatic artery or macroangiopathic with occluded or stenotic hepatic artery. Recently, IC with NASs have been described to have four distinct patterns at imaging: diffuse necrosis, multifocal progressive, confluence dominant, and minor form, which correlate clinically with graft prognosis. Severe IC can lead to ductal wall breakdown with subsequent bile leaks that can cause significant patient morbidity, with imaging playing a vital role in diagnosis and guiding intervention. IC also predisposes the transplanted liver to biliary stasis and subsequent formation of stones, casts, and sludge. Some cases of posttransplant biliary stricturing are not IC but are a sequela of reflux cholangitis seen with choledochojejunal anastomosis. Other biliary findings in the posttransplant liver can be explained by sphincter of Oddi dysfunction that results from denervation. The authors describe and comprehensively categorize the various IC types and their imaging patterns at MRI and MR cholangiopancreatography, review the prognostic significance of these imaging patterns, and discuss imaging features of additional biliary complications associated with IC after DCD liver transplant. ©RSNA, 2024 Supplemental material is available for this article.

041. A Case of Cholangiocarcinoma in A Young Adolescent

Background: Cholangiocarcinoma usually occurs in 50-70 years age group. Recent study showed an increased incidence in younger age group. We describe a case of Cholangiocarcinoma in an adolescent girl in order to understand its natural history. Case: A 16 year old girl presented with 2 months history of jaundice, itchyness, right upper quadrant abdominal pain, pale stool and dark urine. Initial investigation showed : Total Bilirubin 8.87, (Direct 3.53, Indirect 12.40), SGOT 75, SGPT 56, ALP 240, GGT 59, Hepatitis B and C negative, AFP 1.96, CA19-9 3.1, and CEA 5.1. Imaging showed dilated hepatic duct with 1.5cm mass in mid-Common Bile Duct (CBD). Due to unforeseen personal circumstances, surgery was done 16 months from onset of complaints. Tumor was found at junction of cystic duct + CBD. The CBD and Gallbladder was resected (with frozen section), lymph node dissected along hepatic artery, Roux-en-Y hepaticojejunostomy anastomosis and Jejuno-Jejunostomy anastomosis was performed. Histopathology showed Cholangiocarcinoma grade 2 with perineural + lymphovascular invasion, and malignant cells’ perineural invasion at proximal margin. She underwent adjuvant chemotherapy (Gemcitabine + Cisplatin). CT scan 6 months post Chemotherapy showed 3cm lesion in CBD. After a further 2 months of chemotherapy, CT evaluation showed no residual mass left. Conclusion: This highlight that despite significant time lapse from onset of symptoms, surgery with curative intent may still be considered. Secondly, chemotherapy is an extremely important part of the treatment, especially in presence of malignant cells at resection margin.

Intravenous injection versus transhepatic intracholecystic injection of indocyanine green (ICG) to outline biliary tree during laparoscopic cholecystectomy

BackgroundTo potentially lessen injuries and associated complications, fluorescence cholangiography has been suggested as a technique for enhancing the visualization and identification of extrahepatic biliary anatomy. The most popular way to administer indocyanine green (ICG) is intravenously, as there is currently little data on ICG injections directly into the gallbladder. In order to visualize extrahepatic biliary anatomy during laparoscopic cholecystectomy (LC), we compared the two different ICG administration techniques. We also examined variations in visualization time, as well as the effectiveness, benefits, and drawbacks of each modality.MethodsIn this prospective randomized clinical study, 60 consecutive adult patients with chronic and acute gallbladder disease were included. Our study conducted from 2022 to 2024 in Surgical Department of Theodor Bilharz Research Institute. Thirty patients underwent LC with intravenous ICG administration (IV-ICG), thirty patients received a direct injection of gallbladder through transhepatic ICG (IC-ICG) and Preoperative, intraoperative, and postoperative patient data were examined.ResultsIn terms of their perioperative and demographic features, the groups were similar. Without a statistically significant difference, the IV-ICG group’s total operating time was less than that of the IC-ICG group (p 0.140). Compared to the transhepatic IC-ICG method, IV-ICG was more accurate in identifying the duodenum and the common hepatic duct (p = 0.029 and p = 0.016, respectively). In the transhepatic IC-ICG and IV-ICG groups, the cystic duct could be identified prior to dissection in 66.6% and 73.3% of cases, respectively, and this increased to 86.6% and 93.3% following dissection. In the transhepatic IC-ICG group, the common bile duct was visible in 93.3% of cases; in the IV-ICG group, it was visible in 90% of cases. Two cases in the IC-ICG group and every case following IV-ICG administration had liver fluorescence (6.6% versus 100%; p < 0.001).ConclusionThe current study shows that for both administration methods, ICG-fluorescence cholangiography can be useful in identifying the extrahepatic biliary anatomy during Calot’s triangle dissection. By avoiding hepatic fluorescence, the transhepatic IC-ICG route can increase the bile duct-to-liver contrast with less expense and no risk of hypersensitivity reactions than the intravenous ICG injection method. We recommend to use both techniques in case of acute cholecystitis with cystic duct obstruction. In cases of liver cirrhosis, we recommend transhepatic IC-ICG as IV-ICG is limited.

A case of hepatocellular carcinoma arising from the intraductal hepatic bile duct without parenchymal lesion.

Hepatocellular carcinoma (HCC) rarely presents as an intraductal tumor with no parenchymal lesions. Here, we present a case of HCC arising from an intrahepatic bile duct. A 74-year-old man who had been treated with direct-acting antiviral therapy for hepatitis C virus infection was referred to our hospital because of elevated serum prothrombin levels induced by vitamin K absence II (PIVKA-II). Initial imaging revealed no findings suspicious of HCC; however, repeat CT six months later revealed dilation of the intrahepatic bile ducts in the lateral segment of the liver. Cholangiography revealed a significant stricture of B3, and biopsy suggested adenocarcinoma. A left hepatectomy was performed with a preoperative diagnosis of intrahepatic cholangiocarcinoma. Although a surface nodule on the lateral segment of the liver, suspicious for intrahepatic metastasis, was found intraoperatively, radical resection was performed. Histopathological examination revealed a tumor filling the intrahepatic bile duct from the stump to the peripheral bile duct, with no infiltration into the liver parenchyma. The surface nodule is a dilated peripheral bile duct filled with a tumor with no extrabiliary invasion. Immunohistochemistry suggested HCC. No tumor lesions were observed in the hepatic parenchyma, and the tumor was finally diagnosed as HCC stemming from the biliary epithelium.

Efficacy of Intraoperative vs Preoperative Indocyanine Green Administration for Near-Infrared Cholangiography During Laparoscopic Cholecystectomy: An Open-Label, Non-Inferiority, Randomized Controlled Trial.

Near-infrared fluorescence cholangiography (NIRFC) improves the clinical effects of laparoscopic cholecystectomy. However, the administration of indocyanine green (ICG) remains controversial. Both the intraoperative (IS, 0.05mg) and preoperative (PS, 0.25mg/kg body weight, 1 day before operation) strategies have been shown to be superior to standard strategy (2.5mg, intraoperative). This trial was designed to determine whether IS offers non-inferior visualization of biliary ducts compared to PS. A total of 168 eligible patients undergoing laparoscopic cholecystectomy were enrolled in this non-inferiority, open-label, randomized controlled trial at Zhujiang hospital between August 2023 and November 2023. Participants were randomized in a 1:1 ratio into PS and IS groups after stratification by BMI and inflammation level. The fluorescence visualization of biliary structures was assessed by comparing the signal-to-background ratio (SBR) and surgeon evaluations. The common bile duct-liver SBR did not significantly differ between IS and PS groups (3.0±0.8 vs 3.1±1.2; p=0.636). The liver fluorescence intensity (FI) of the IS group was significantly lower than that of the PS group (46.3±12.9 vs 70.4±26.2; p<0.01). The visualization score of common hepatic ducts was significantly greater in the IS than in the PS group (4.1±0.7 vs 3.7±0.6; p＜0.01). The critical view of safety (CVS) was achieved more rapidly in the IS group compared to the PS group (9.4 vs 11.0 minutes, p<0.01). While IS did not improve the SBR, it significantly reduced the FI of the liver background, potentially enhancing the surgeon's subjective perception and thereby increasing the visualization score. Compared to PS, IS offers greater convenience and is more effective in facilitating CVS exposure.

MiR-182-5p promotes the proliferation and invasion of hilar cholangiocarcinoma cells by inhibiting FBXW7

BackgroundHilar cholangiocarcinoma (HCCA) is a common type of cholangiocarcinoma (CHOL) that originates from the right and/or left hepatic duct near the biliary tract confluence. The objective of this study is to investigate the impact of miR-182-5p on the proliferation and invasion of HCCA cells and identify a potential target for HCCA treatment.MethodsHCCA tissues were collected and HCCA cells were cultured. miR-182-5p and F-box and WD repeat domain containing 7 (FBXW7) were detected. After transfection of miR-182-5p inhibitor into HCCA cells, cell proliferation and invasion were detected by cell counting 8-kit and Transwell assay. FBXW7 expression was detected by Western blot. The targeted relationship between miR-182-5p and FBXW7 3’UTR was verified by dual-luciferase report assay. si-FBXW7 and miR-182-5p inhibitor were transfected into cells for combined experiments. HCCA cells with lowly-expressed miR-182-5p were injected into nude mice to establish the xenograft tumor model, and subsequent observations were made on tumor growth and gene expression changes.ResultsmiR-182-5p exhibited high expression levels in both HCCA tissues and cell lines. Inhibiting miR-182-5p effectively suppressed the proliferation and migration of HCCA cells. miR-182-5p bounded to FBXW7 3 ‘UTR and inhibited FBWX7 expression. Suppressing FBXW7 expression partially reversed the inhibitory effect of miR-182-5p inhibitor on HCCA cell proliferation and invasion. Silencing miR-182-5p could inhibit the HCCA growth in vivo.ConclusionmiR-182-5p promoted the proliferation and invasion of HCCA cells by targeting and inhibiting FBXW7 expression.

Hepatic Hilum Variations and Their Clinical Considerations in the Liver: A Systematic Review and Meta-Analysis.

Background: The liver has a region called the hepatic hilum (HH) where structures enter and exit: anteriorly, the left and right hepatic ducts; posteriorly, the portal vein; and between these, the left and right hepatic arteries. The objective of this review is to know how variants in structures of the hepatic hilum are associated with clinical alterations of the liver. Methods: The databases Medline, Scopus, Web of Science, Google Scholar, CINAHL, and LILACS were researched until January 2024. The methodological quality was evaluated with an assurance tool for anatomical studies (AQUA). The pooled prevalence was estimated using a random effects model. Results: A total of six studies met the selection criteria established in this study for meta-analysis. The prevalence of hepatic hilus variants was 9% (CI = 5% to 13%), and the heterogeneity was 83%. The other studies were analyzed descriptively and with their respective clinical considerations in the presence of the variant, such as the high incidence of the Michels type III variant; among the portal vein variants, the type III variant of the Cheng classification stands out and in biliary anatomy, and the IIIa variant stands out according to the Choi classification. Conclusions: This review allowed us to know in detail the anatomical variants of HH; the structure with which the greatest care should be taken is the hepatic artery because of the probability of metastatic processes due to increased blood distribution in the hepatic lobules. Finally, we believe that new anatomical and clinical studies are needed to improve our knowledge of the relationship between HH variants and liver alterations or surgeries.

Proximity predicament: a rare case of hydatid cyst in the porta hepatis region

Hydatid cysts near the porta hepatis present notable medical challenges due to their intricate positioning and potential influence on crucial structures within the liver and its vicinity. While relatively rare, their presence can lead to intricate medical scenarios because of their proximity to vital liver and bile duct structures, but their occurrence can present complex medical situations due to their proximity to critical structures in the liver and bile ducts. We present an unusual case of a 33-year-old male with no known comorbidities presented to the outpatient department of general surgery with pain, insidious in onset and gradually progressive, in the right hypochondrial region for the past 3 months, along with mild fever, reduced appetite, and weight loss of 3 kg. Managing hepatic cysts, especially when near the porta hepatis, poses significant diagnostic challenges. Imaging scans revealed multiple hypodense lesions suggestive of hepatic cysts, with the largest one measuring 5 cm × 8 cm in segment VI. Native post-contrast lesions were also observed in the right lower lobe. Although hepatic duct dilation was not observed, the presence of a cyst near the porta hepatis an atypical site for hydatid cyst, complicated potential PAIR procedures (puncture, aspirate, injection, re-aspirate), raising concerns about the risk of damaging vital structures like the hepatic artery or major bile duct. A multidisciplinary approach engaged interventional radiology to evaluate PAIRS feasibility. PAIRS was performed successfully, except for the cyst near the porta hepatis to avoid complications. Despite this, the patient continued to experience abdominal discomfort post-operation, although liver function tests improved in the postop period. This case underscores the uncommon occurrence of hydatid cysts near the porta hepatis and highlights the need for additional research to comprehend its prevalence and causes. Further investigation is crucial to enhance our understanding of the epidemiology and optimal management strategies involving PAIRS in such challenging cases.

Hepatic adenosquamous carcinoma with sarcomatous transformation: a case report and review of the literature.

Adenosquamous carcinoma (ASC) with the presence of a sarcomatous component is exceptionally uncommon in intrahepatic cholangiocarcinoma (iCCA). We report a case of hepatic ASC with rhabdoid transformation, one variation of sarcomatous change. A 72-year-old man was admitted to our hospital after being diagnosed with a 45mm-diameter neoplastic lesion in the right hepatic duct on abdominal computed tomography. Laboratory findings showed increases in AST, ALT, ALP, gamma-GT, CA19-9 and DUPAN-II. The patient then underwent an extended right hepatectomy. Histopathologically, the tumor was composed of an ASC component within an abundant fibrous stroma and a sarcomatoid carcinoma component. By immunohistochemistry, keratin 7 and keratin 19 were expressed by all tumor cells. Expression of keratin 5/6, p40 and p63 was restricted to the squamous component. The sarcomatoid component was immunoreactive for vimentin with no loss of INI1 expression. This component also showed a loss of membranous E-cadherin expression and a reduction of membranous β-catenin expression. Staining for desmin, myoglobin and HepPar1 was negative in any tumor cells. The patient died of liver failure 3months after surgery. This report aims to provide a better understanding of the clinicopathological characteristics and disease progression of the rare variants of iCCA to aid diagnosis and treatment.

Surgical anatomy of the cystic artery: A systematic review with meta-analysis

BackgroundThe current evidence-based systematic review with meta-analysis presents a detailed overview of the cystic artery (CA) surgical anatomy, including its origin, number, topography, and morphometry. Moreover, the surgical implications of these variants are further discussed. MethodsAccording to the Evidence-Based Anatomy Workgroup and PRISMA 2020 guidelines, the systematic review was performed using four online databases. The Anatomical Quality Assurance Tool was used to evaluate the risk of bias. Meta-analysis was performed with the R programming software. The pooled prevalence and pooled mean of different CA parameters were calculated. ResultsThe CA most commonly originated from the right hepatic artery (a pooled prevalence of 85.75 %). Other described origins (in order of frequency) were the aberrant right hepatic artery, the common hepatic, the left hepatic, the gastroduodenal, the superior mesenteric, and the middle hepatic arteries. The CA was single in 88.59 %, while it can be identified as double, triple, or absent. Most commonly, it was located inside the cystohepatic triangle in 83.83 %. Most commonly, it was superomedially to the cystic duct (77.80 %) and posteriorly to the common hepatic duct (35.08 %). The CA pooled mean length was 21.34 mm, and its diameter was more commonly over 1 mm. ConclusionThe CA surgical anatomy is paramount when operating on the gallbladder. The CA's altered anatomy and adjacent area could lead to confusion, iatrogenic injury, and prolonged surgical time. The CA depicts high morphological variability; therefore, surgeons should consider the typical anatomy and possible (usual and unusual) variants.

Feasibility of open cholangioscopy with disposable flexible endoscopes.

To determine the feasibility of open cholangioscopy using disposable flexible endoscopes in canine cadavers and describe the surgical approach. Ex vivo experimental cadaveric study. Eight canine cadavers. Cadavers ranging from 5.8 to 43.8 kg underwent open transcholecystic cholangioscopy using a disposable flexible endoscope with a 3.8 mm outer diameter and 1.2 mm working channel and the surgical approach was described. The most distal anatomical region of the biliary tree towards the duodenal papilla that was visualized with the endoscope was recorded in each cadaver. A 2.7 mm rigid endoscope and a 1.9 mm flexible endoscope were also trialed and findings recorded. Endoscopic tools were trialed and their usage recorded. The disposable flexible endoscope was feasible for visualization of the junction of the common bile duct, cystic duct, and hepatic ducts in all eight dogs. Cholangioscopy using a 2.7 mm rigid endoscope did not provide further distal visualization. The 1.9 mm flexible endoscope was able to traverse down to the level of the major duodenal papilla in a 43.8 kg cadaver. Use of certain endoscopic tools can be considered through the disposable flexible endoscope although fluid instillation was affected. A 3.8 mm disposable flexible endoscope could be placed through an open transcholecystic approach to provide intraluminal endoscopic evaluation up to the level of the junction of the common bile duct, cystic duct, and hepatic ducts in dogs without cholecystic disease. Open transcholecystic cholangioscopy with a disposable flexible endoscope could provide a low-cost diagnostic and therapeutic tool in cases of obstructive biliary disease up to the level of the common bile duct.

Case report : lemmel syndrome-aggravated by consumption of fatty food

Introduction and Importance: One of the very rare causes of obstructive jaundice, Lemmel’s syndrome is caused due to biliary mechanical compression by a juxtapapillary diverticulum. It is defined as obstructive jaundice due to juxtapapillary diverticulum in the absence of cholelithiasis, periampullary tumours or other detectable obstacles. It is extremely rare syndrome therefore studies need to be done for proper diagnosis and management. Case Presentation: Our patient, a 73-year-old woman, gave a history of recent acute right hypochondriac pain that had subsided the day before. Lab investigations were performed and liver enzymes were found to be significantly raised. An endoscopy followed by an endoscopic ultrasound was performed for further diagnosis which showed the diverticulum outpouching from the duodenum. MRCP was then performed which revealed a dilated common bile duct and common hepatic duct, with tapering at the distal end, most likely to be a stricture. Lemmel syndrome was identified based on the clinical presentation and imaging results. A dilated common bile duct, and two large duodenal diverticula with interdiverticular papilla was discovered during the patient’s endoscopic ultrasound which was performed by the gastrointestinal team. Clinical Discussion: Duodenal diverticula are the second most common site of diverticula after colon with an incidence of 1-5% in radiological series3. Lemmel’s syndrome is a rare cause of obstructive jaundice associated with juxtapapillary diverticulum. With a low incidence rate, only a few cases of Lemmel’s syndrome are reported with the first case reported in 1934 by Lemmel.4 Imaging techniques such as barium meal, EUS, ERCP, or magnetic resonance cholangiopancreatography are used to confirm the diagnosis. Our observations demonstrate that the diverticulum which is often found on the medial wall of the second half of the duodenum and contains bezoar, compresses the distal common bile duct laterally. Nowadays, ERCP and EUS are used to confirm the diagnosis.5 Only symptomatic periampullary duodenal diverticulum(PDD) requires conservative or surgical therapy. The first line of treatment for biliopancreatic PDD problems is endoscopic sphincterotomy, which is 95% effective.6 Conclusion: Lemmel syndrome occurs due to the compression of the common bile duct by a duodenal diverticulum. Imaging including CT scan and MRCP are important for the diagnosis of this syndrome. Treatment modalities are not the same for each patient, however.

A Study On The Variations Of Structures Passing Through The Porta Hepatis Of Liver

Background: The porta hepatis is a deep transverse fissure on the inferior surface of the liver, between the quadrate lobe anteriorly and the caudate process posteriorly. The major structures traversing in it are the portal vein, the hepatic artery and the hepatic duct. There are a lot of variations in the arrangement of structures passing through porta hepatis. Having knowledge of these variations becomes important to help in the existing knowledge so as to avoid complications during surgical and radiological interventions. The present study was carried out to study the arrangement and number of structures passing through porta hepatis and to report any variation thereof. Materials and methods: 40 formalin fixed adult cadaveric livers obtained from the Department of Anatomy, JNIMS, Imphal were studied. Porta hepatis was carefully dissected to observe a) arrangement, b) number of structures (artery, vein and duct) and c) the combination of the above structures. Results: There was consistent arrangement of the structures in porta hepatis with ducts, arteries and veins antero-posteriorly in all the livers studied. The most common finding had the combination of 1 vein, 2 arteries and 1 duct seen in 16 specimens (40%). Maximum number of arteries observed was 4 in 1 specimen (2.5%), vein was 2 in 3 specimens (7.5%) and duct was 2 in 7 specimens (17.5%). Various combinations of structures were observed and the porta hepatis with maximum number of structures passing through had the combination of 2 veins, 3 arteries and 2 ducts seen in 1 specimen (2.5%). Conclusion: The present study highlights the various combinations of the structures at the porta hepatis and will be therefore useful for the radiologists and surgeons dealing with this region.

S4003 Cystic Duct Take Off From the Right Main Hepatic Duct: Case of an Interesting Anatomic Variant

S4003 Cystic Duct Take Off From the Right Main Hepatic Duct: Case of an Interesting Anatomic Variant

Application of indocyanine green during laparoscopic cholecystectomy in elderly and senile patients

Aim. To evaluate an effect of fluorescence cholangiography for intraoperative identification of extrahepatic bile ducts on the treatment outcomes of patients with cholelithiasis.Materials and methods. The study included 71 cholelithiasis patients who underwent laparoscopic cholecystectomy with fluorescence cholangiography and 69 cholelithiasis patients who underwent standard laparoscopic cholecystectomy. The study analyzed intraoperative damage of extrahepatic bile ducts and arteries, duration of surgery, conversion rate, need for colleague assistance, incidence of postoperative complications, hospital length of stay, and outcomes.Results. Fluorescence of the vesicular duct was achieved in 100% of patients, of the common bile duct – in 91%, and of the common hepatic duct – in 64%. A correlation between the number/type of complications and the application of ICG-diagnostics was found statistically significant (p &lt;0.001, p = 0.012), thereby indicating the advantages of the method. The colleague-surgeon assistance was required in the ICG group 35 times less than in the standard surgery group (OR = 0.029; 95% CI = 0.003–0.319). A 34-minute reduction in surgery duration (linear regression) can be expected when performing ICG-guided surgery.Conclusion. The application of fluorescence cholangiography reduces the probability of postoperative complications, in particular, biliary leakage with the necessity of reoperation. Due to the method, a surgeon appears able to complete the operation independently without colleague assistance. Treatment outcomes, incidence of bile duct injuries, and conversion rate are yet to be investigated.

Assessment of the biliary branching pattern of the caudate lobe in perihilar cholangiocarcinoma using ENBD-CT cholangiography.

Preoperative recognition of the anatomy of caudate biliary branches is important for the safe and complete resection of perihilar cholangiocarcinoma (PHC). In the present study, we identified these branches using an endoscopic nasobiliary drainage tube (ENBD). Between January 2012 and October 2022, 89 patients with suspected PHC underwent computed tomographic (CT) cholangiography through ENBD and caudate biliary branching patterns were examined. Multidetector raw CT (MDCT) scans on 85 patients with PHC without biliary drainage were also investigated. The caudate biliary branches detected by each modality were evaluated. ENBD-CT cholangiography detected 206 caudate branches (2.44 branches/patient), while MDCT identified 62 branches (0.78 branches/patient). ENBD-CT cholangiography showed that 89 caudate branches drained into the left hepatic duct (LHD), 87 into the posterior hepatic duct (Bpost), and 30 into the right hepatic duct. LHD and Bpost were the common roots of the caudate branches. Some branches (20%) joined the contralateral hepatic duct across the left-right border, but not the anterior hepatic duct or infraportal-type Bpost. ENBD-CT cholangiography clearly showed the caudate biliary branches in patients with PHC after biliary drainage.

Clinical implications of aberrant anatomy of the common hepatic duct in liver surgery: a systematic review and meta-analysis.

Knowledge of anatomical variants that affect the hepatic duct (HD) are of particular clinical relevance during hepatobiliary surgical procedures. More specifically, the aberrant anatomy of the common HD is the most common anatomical variation affecting the biliary tree. Below, we describe different classifications of anatomical variants that affect this canal. According to Huang's classification, variations are determined depending on the insertion of the right posterior hepatic duct (RPHD). Medline, Scopus, Web of Science, Google Scholar, CINAHL, and LILACS databases were investigated until January 2024. The methodological quality was assessed with an anatomical studies assurance tool (AQUA). Pooled prevalence was estimated using a random effects model. For the subgroup analysis, Student's T-test was used. The prevalence rate of aberrant hepatic duct (AHD) was 15% (confidence interval [CI] of 7-22%). The first subgroup had cadavers and images. For the cadavers, the prevalence was 15.83% (CI: 11.22-18.3%), while the images had a prevalence of 22.06% (CI: 18.12-25.33%). This subgroup analysis showed no statistically significant difference between these groups (p = 0.127). The second subgroup comprised the continents where the included studies were from. In this subgroup, no statistically significant differences were found (p = 0.613). Finally, regarding the right or left laterality of the HD variant, there were no statistically significant differences (p = 0.089). A AHD corresponds to a finding that can occur in a significant percentage of our society, which could be an accidental discovery during surgeries or present asymptomatically throughout life and be a cadaveric discovery later. We believe it is important for surgeons to have prior knowledge of the possible variants of HD to prevent possible complications during and after surgery.