Duct Orifice Research Articles

Novel Treatment for Cheilitis Glandularis

Sir, In 1870, von Volkmann (1) introduced the term cheilitis glandularis (CG). He described a distinct, chronic inflammatory condition of the lower lip characterized by mucopurulent exudates from the ductal orifices of enlarged labial salivary glands. Historically, CG has been classified into three subtypes: simplex, superficial suppurative, and deep suppurative. However, it is now believed that these represent three stages in progression of a single disease entity. Conventional treatment consists of vermillionectomy or the administration of intralesional corticosteroids. Additional treatment with antibiotics is frequently necessary (2, 3). We report here on a patient with CG treated successfully with a combination of oral minocycline and tacrolimus ointment 0.1%, thereby avoiding invasive therapy.

Unilateral congenital cystic dilatation of the submandibular gland duct: MDCT findings

A male infant presented with unilateral cystic swelling in the floor of his mouth as a result of congenital stenosis of the orifice of duct of Wharton. Early diagnosis and treatment is important to avoid feeding difficulties and to prevent later complications. Multidetector computed tomography can be used as a diagnostic tool in order to differentiate congenital cystic lesions of the floor of the mouth.

Feasibility and safety of placement of a newly designed, fully covered self-expandable metal stent for refractory benign pancreatic ductal strictures: a pilot study (with video)

Painful chronic pancreatitis with main pancreatic ductal strictures is usually managed with endotherapy with a plastic stent. To date, the role of placement of metallic stents, especially uncovered ones in benign pancreatic ductal stricture, has been unsatisfactory as a result of stent dysfunction related to mucosal hyperplasia. We explored the feasibility and safety of temporary placement of a newly designed, fully covered self-expandable metal stent (FCSEMS) in painful chronic pancreatitis and refractory benign pancreatic ductal strictures. A prospective pilot and feasibility study. A tertiary academic center. Thirteen patients with chronic painful pancreatitis of alcoholic (8) or idiopathic (5) etiology. ERCP with temporary FCSEMS placement (2 months). Endoscopic removal of FCSEMSs was performed with a snare or rat-tooth forceps. End points were feasibility, safety, and morbidity. Successful FCSEMS placement was performed in all enrolled patients. After immediate placement of FCSEMS, 2 patients had mild acute pancreatitis related mainly to the stricture dilation procedure (Soehendra stent retriever or balloon dilation). Complications associated with stent placement included 5 migrations (39%, 1 proximal and 4 distal) and 2 incidents of cholestatic liver dysfunction associated with the compression of the bile duct orifice by expansion of FCSEMSs. In 1 patient with proximal migration, the stent was repositioned by an inflated retrieval balloon. Additional endoscopic biliary sphincterotomy with or without biliary stenting was performed in 2 patients with cholestatic liver dysfunction. There was no occurrence of pancreatic sepsis among any patients. FCSEMSs were removed from 9 of 9 patients without stent migration (100% [9/9] as per protocol, and 69% [9/13] as intention to treat, respectively). Improvement or resolution of the pancreatic ductal strictures was confirmed in all 13 patients on follow-up ERCP (2 months after stent placement), regardless of stent migration. Small patient populations without long-term follow-up. Two-month placement of FCSEMSs in patients with refractory benign pancreatic ductal strictures may be feasible and relatively safe. However, stent migration was not uncommon. A further investigation with ideal stent design may therefore be needed before recommending FCSEMSs as a therapeutic option for refractory benign pancreatic ductal strictures.

Inferior Meatus Dacryolith

Symptomatic nasolacrimal duct obstruction (NLDO) is a common problem that has the potential to significantly affect the quality of life of many patients. Referral patterns involving patients who are evaluated and often surgically treated without rhinologic examination have developed in most areas. We describe a patient with a diagnosis of NLDO who was found to have a large dacryolith obstructing the nasolacrimal duct orifice on endoscopic examination of the inferior meatus. The dacryolith was easily removed under endoscopic visualization in the office. The patient has had no recurrence of epiphora and was happy to be spared dacryocystorhinostomy (DCR). We believe that cases of NLDO that can be treated by addressing obstruction in the inferior meatus are more common than was previously recognized, and many of these cases undergo more advanced surgical interventions.

MR Cholangiography for Evaluation of Hilar Branching Anatomy in Transplantation of the Right Hepatic Lobe from a Living Donor

Our objective was to determine the utility of 3D T2 MR cholangiography (MRC) for biliary visualization and predicting the number of ductal orifices during right lobe harvesting for ductal anastomosis in liver donors for right lobe transplantation. This study was composed of 33 donors who underwent right lobectomy for transplantation. Preoperative MRC techniques included 2D T2 MRC, 3D T2 MRC, and 3D contrast-enhanced T1 MRC. Qualitative analyses were performed for ductal visualization in each technique. The accuracies for predicting the numbers of orifices during right lobe harvesting were evaluated for 2D T2 MRC alone and for various other combined sets. MRI definitions of the predicted number of ductal orifices were compared with surgical findings. Mean visualization scores of all ducts for 3D T2 MRC were significantly higher than for 2D T2 MRC and 3D contrast-enhanced T1 MRC. In predicting the number of orifices, all combined sets showed significantly higher accuracy than 2D T2 MRC. No significant difference in mean accuracies was observed within the comparison of the combined sets. Three-dimensional T2 MRC provided superior biliary visualization than 2D T2 MRC and 3D contrast-enhanced T1 MRC. For predicting the number of orifices, the combined set of 2D and 3D T2 MRC enabled better accuracy than 2D T2 MRC alone and produced comparable results to other combined sets.

Inferior Meatus Endoscopy and Treatment for Epiphora

Objective Epiphora can result from obstruction anywhere along the nasolacrimal (NL) system. The inferior meatus (IM) is not routinely evaluated despite the ease of nasal endoscopy. We propose the IM pathology is common in patients with epiphora, and surgery can be directed at the IM. Methods Consecutive patients referred for epiphora between July 2006 and July 2007 underwent endoscopic evaluation of the IM. All patients then underwent intervention to address the NL duct orifice obstruction. Results There were 14 patients, 11 females, mean age 53 years. Four patients had bilateral epiphora, for 18 total lacrimal systems. Two patients were treated in clinic, one for a dacryolith and one, a thick mucoid plug. At the time of surgery, 4 NL duct orifices were obstructed by a cyst. The remaining 12 nasolacrimal ducts were obstructed by hypertrophied mucosa. In 4, hypertrophic mucosa was found proximal to Hasner's valve, and 3 of these had early recurrent symptoms requiring revision (2 DCR's). 13 of 14 sides with pathology at Hasner's valve had resolution or dramatic improvement with patent NL ducts with inferior meatal treatment alone. Mean follow-up was 5 months. Conclusions Routine endoscopic evaluation of the inferior meatus in epiphora uniformly identified pathology at the NL duct orifice. At the time of surgery, identification of pathology at the NL duct orifice and distal NL duct portends a better outcome with endoscopic treatment of the IM, whereas identification of proximal NL duct obstruction had a poorer outcome with treatment through the IM.

Reducing biliary complications in adult-to-adult living donor liver transplantation using right lobe graft: experience of 124 cases

The aim of this paper is to summarize our experience of using right lobe liver grafts to reduce biliary complications in adult-to-adult (A-A) living donor liver transplantation (LDLT). From January 2002 to October 2007, 124 adult patients underwent living donor liver transplantation using right lobe grafts at the West China Hospital, Sichuan University Medical School, China. There was no death in all donors. Biliary reconstruction for 178 hepatic duct orifices from 124 donor grafts was performed which included 106 reconstructions of duct-to-duct anastomoses and 72 cholangiojejunostomy. Nine recipients had biliary complications including six bile leakages (four from the anastomotic site and two from the cut surface of the liver graft) and three biliary strictures. With the improved techniques for biliary reconstruction, we have achieved good results in 124 recipients of A-A LDLT. We ascribe our success to the introduction of microsurgical techniques and the use of fixed operators which help in decreasing the biliary complications of LDLT.

Cutaneous application of local anaesthetic–a useful help in galactography

Galactography is an important step in the diagnostic workup of abnormal nipple discharge. At times it is impossible to insert the cannula in the secreting duct and galactography cannot be performed. In such cases we tried applying local anaesthetic spray (LA) cutaneously to the nipple followed by a further insertion attempt. LA has enabled us to insert the galactography cannula in all patients so far. We concluded that after previous unsuccessful attempts, the presented technique may relax the duct orifice and therefore permit insertion of the galactography cannula into the secreting duct.

MR sialography: the effect of a sialogogue and ductal occlusion in volunteers

MR sialography using heavily T(2) weighted projection techniques relies upon saliva for image contrast, and the visualization of normal ducts is often limited. Methods used to increase the volume of intraductal saliva during imaging in order to improve duct visualization have not been previously evaluated. The effect of a sialogogue and passive ductal occlusion on the ability to visualize the main and intraglandular salivary gland ducts during MR sialography was investigated. Three-dimensional (3D) T(2) weighted MR sialograms were obtained from 12 healthy volunteers with and without the combined use of a sialogogue and passive ductal occlusion pad adjacent to the parotid duct orifice on one side. Two radiologists (in consensus) subjectively evaluated ductal visualization and image artefacts on the resulting blinded maximum intensity projections. The results demonstrate that main duct visualization was significantly improved (p<0.00001) by this technique, with no significant change seen in image artefacts. Although an improvement in intraglandular duct visualization was noted, this was not statistically significant (p = 0.05). Thus, the use of a sialogogue and passive ductal occlusion improves visualization of the main parotid duct in volunteers undergoing MR sialography. Further optimization and evaluation of this approach should lead to improvements in the MR sialography examination of patients.

Intraductal US in the assessment of tumor involvement to the orifice of the cystic duct by malignant biliary obstruction

Tumor involvement to the orifice of the cystic duct (OCD) is a risk factor for cholecystitis after metallic stent (MS) placement. ERCP and intraductal US (IDUS) were used to assess tumor involvement to the OCD. A prospective consecutive study. The University of Tokyo Hospital, Japan. Between January 2003 and May 2007, 34 patients with resectable malignant biliary obstruction underwent an ERCP and an IDUS before preoperative biliary drainage. ERCP and IDUS findings were confirmed via a histopathologic analysis of surgical specimens. An ERCP showed that the cystic duct was opacified in 22 of 34 patients (64.7%). Eight patients were diagnosed with OCD tumor involvement. In the remaining 12 patients, tumor involvement was impossible to evaluate via an ERCP. An IDUS identified tumor involvement to the OCD in all 34 patients. Tumor involvement to the OCD was diagnosed in 12 patients, including 4 patients with previously negative results during an ERCP. Tumor involvement was confirmed by histopathology of surgical specimens. The sensitivity and specificity of detection were 66.7% (8/12) and 63.6% (14/22), respectively, via ERCP, and 100% (12/12) and 100% (22/22), respectively, via IDUS. The small sample size. IDUS, in addition to ERCP, provides an accurate evaluation of tumor involvement to the OCD in patients with malignant biliary obstruction.

Bile Duct Imaging with Ultrathin Laser Scanning Catheterscope in a Swine Model

Peroral cholangioscopy is limited by the sharp bending required in accessing the bile duct. By significantly reducing the number of optical fibers in the shaft, a 4-meter long catheterscope was fabricated with 6-mm shaft bend radius. Contained in the shaft is a single optical fiber for laser illumination, less than 70 optical fibers for light collection, and electrical wires used to control optical scanning at the distal tip.A therapeutic duodenoscope was introduced into the esophagus of an anesthetized farm pig and passed to the duodenum. The bile duct orifice was located and cannulated with a sphincterotome. After contrast was injected, a 0.025" guidewire was passed into the intrahepatic bile ducts. The sphincterotome was exchanged over the guidewire for the catheterscope after a small sphicterotomy. Care was taken to avoid elevating the catheterscope at the shaft-tip junction during insertion. Unobstructed optical imaging was performed by removing the guidewire and slowly withdrawing the catheterscope, modifying its position within the bile duct by making small adjustments with the duodenoscope. Recent improvements in the catheterscope are (1) diameter of highly flexible shaft and rigid tip is reduced from 1.6 to 1.2 mm, (2) length of rigid tip is reduced from 13 to 9 mm, and (3) full-color 500-line image capture rate is increased from 15 to 30 frames/sec. Unchanged is the excellent color fidelity of imaging from only three narrow laser bands of light.In the future, catheterscopes will be fabricated with 4-way tip bending as a steerable “guidewire-with-eyes”. Direct visualization of the biliary ducts may eliminate the need for fluoroscopy and injection of contrast. Cannula-style tools are expected to be introduced over this catheterscope in both the biliary and pancreatic ducts for image-guided interventions in humans that may reduce the need for sphicterotomy.

Dose-Effect Relationships for the Submandibular Salivary Glands and Implications for Their Sparing by Intensity Modulated Radiotherapy

Submandibular salivary glands (SMGs) dysfunction contributes to xerostomia after radiotherapy (RT) of head-and-neck (HN) cancer. We assessed SMG dose-response relationships and their implications for sparing these glands by intensity-modulated radiotherapy (IMRT). A total of 148 HN cancer patients underwent unstimulated and stimulated SMG salivary flow rate measurements selectively from Wharton's duct orifices, before RT and periodically through 24 months after RT. Correlations of flow rates and mean SMG doses were modeled throughout all time points. IMRT replanning in 8 patients whose contralateral level I was not a target incorporated the results in a new cost function aiming to spare contralateral SMGs. Stimulated SMG flow rates decreased exponentially by (1.2%)(Gy) as mean doses increased up to 39 Gy threshold, and then plateaued near zero. At mean doses < or =39 Gy, but not higher, flow rates recovered over time at 2.2%/month. Similarly, the unstimulated salivary flow rates decreased exponentially by (3%)(Gy) as mean dose increased and recovered over time if mean dose was <39 Gy. IMRT replanning reduced mean contralateral SMG dose by average 12 Gy, achieving < or =39 Gy in 5 of 8 patients, without target underdosing, increasing the mean doses to the parotid glands and swallowing structures by average 2-3 Gy. SMG salivary flow rates depended on mean dose with recovery over time up to a threshold of 39 Gy. Substantial SMG dose reduction to below this threshold and without target underdosing is feasible in some patients, at the expense of modestly higher doses to some other organs.

Solitary Fibrous Tumor of the Oral Cavity: Case Report and Pathologic Consideration

A 94-year-old Caucasian man affected by senile dementia came under our observation due to a bulky mass of the oral cavity advancing from the labial rim. Due to his mental condition, the patient had always refused surgical treatment. On clinical examination the ovoid-shaped mass was located on the mucosa of the right cheek, approximately 1 cm below the Stensen’s duct orifice; it was reddish-brown in color, had a hard-elastic consistency, and bled easily during manipulation (Fig 1). The neoplasm, which had been present for about 5 years, slowly increased in volume reaching the dimensions reported above, thus causing dysphagia and bleeding due to the presence of superficial microlesions induced by chewing. The tumor was removed surgically with an easy enucleation from healthy cheek tissues. After the excision the mass measured 7.5 5 4 cm. (Fig 2). The patient was discharged after 3 days. Twenty-four months later, no recurrence was detected. Microscopically, the lesion did not appear to be encapsulated, however, it was well-demarcated (Fig 3),

Galactography without discomfort using lidocaine/prilocaine anesthetic cream

Galactography (ductography) is the technique of choice for studying pathologic nipple discharge. It is sometimes difficult or even impossible to perform cannulation of the ductal orifice because of the discomfort caused to the patient. To evaluate the efficacy of a eutectic mixture of local anesthetics (EMLA) containing lidocaine and prilocaine applied as a cream to reduce discomfort during galactography. 46 patients with abnormal nipple secretion underwent galactography. The patients were distributed in non-randomized form into two groups (A and B). Group A consisted of 19 patients who were treated without application of the anesthetic cream; group B consisted of 27 patients to whom the anesthetic cream was applied prior to galactography. Pain intensity was measured using a verbal description scale. Galactography was successfully performed in all cases in group B (n = 27) and in 15 cases (78.9%) in group A. In four patients from group A, it was initially impossible to cannulate the discharging duct because of patient discomfort and anxiety. The same patients were submitted to galactography 1 week later after application of the anesthetic cream to the areola/nipple area. In total, then, 31 cases (all 27 of group B plus four) registered 0 ( = no pain) on the verbal description scale after application of the cream. In the 19 patients of group A, the degree of pain registered was mild in 11 cases and discomforting in eight cases. The application of anesthetic cream over the areola/nipple area enables galactography to be performed without patient discomfort. It also reduces anxiety, allowing the radiologist to perform the procedure with confidence and safety, and without stress on the part of the patient or radiologist.

Endoscopic Examination on the Nasolacrimal Lesions

Epiphora, or watering eye, is commonly caused by lacrimal duct stenosis or obstruction. Lacrimal endoscopy is useful not only for observation of the inner lumen of the lacrimal duct but also for direct endoscopic probing of obstructive lacrimal lesions. In this procedure, a fine endoscopic probe can be introduced from the upper or lower punctum of the lids to the orifice of nasolacrimal duct (NLD) into the inferior meatus. The endoscopy procedure usually requires local anesthesia, through infratrochlear nerve block and nasal instillation. The occurrence and distribution of the obstruction sites of NLD were studied using endoscopy. The most frequent obstruction site was the lower portion of NLD. By using endoscopy and silicone tube intubation for NLD obstruction, the success rate of the treatment was improved much greater than without endoscopy. The future and limitations of lacrimal endoscopy are discussed.

Risk of pancreatitis following endoscopically placed large-bore plastic biliary stents with and without biliary sphincterotomy for management of postoperative bile leaks

Endoscopic transpapillary biliary stent placement is effective for closure of postoperative bile leaks. Large-bore stents (10 French) may transiently obstruct the adjacent pancreatic duct orifice causing acute pancreatitis. Endoscopic biliary sphincterotomy may reduce this risk, but it introduces separate risks of bleeding and perforation. The objective of this study was to compare complications after large-bore biliary stent placement (10 Fr) with and without sphincterotomy in patients with bile leaks. The institutional endoscopy database was queried to identify patients who had undergone endoscopic retrograde cholangiopancreatogrpahy (ERCP) for bile leak between March 1996 and August 2006. Procedural reports were reviewed for evidence of biliary sphincterotomy, cholangiographic and pancreatographic findings, transpapillary stent placement, and procedural complications. Patients with prior biliary sphincterotomy, choledochoenteric anastomosis, placement of multiple biliary stents and expandable metal biliary stents, biliary stents smaller than 10 Fr, and patients in whom a stent was not placed were excluded. The chi-square test was used for categorical variables. Probability <or= 0.05 was considered significant. The rate of pancreatitis (all mild) after large-bore biliary stent placement was greater when sphincterotomy was not performed than when sphincterotomy and stent placement were both performed (13% versus 2.4%). This difference was not statistically significant. (Chi(2) = 3.41; p = 0.1). Bleeding was observed in one patient who underwent sphincterotomy and large-bore stent placement (2.4%). No perforations occurred in either group. Although not statistically significant, there is a higher rate of post-ERCP pancreatitis after placement of large-bore biliary stents when sphincterotomy is not performed. The additional complications of biliary sphincterotomy did not offset the reduction in post-ERCP pancreatitis. When large-bore biliary stents are used in the treatment of bile leak, a biliary sphincterotomy may avoid pancreatitis. Randomized trials are needed to determine whether there is a significant difference in overall complication rate when large-bore stents are placed with and without biliary sphincterotomy.

Keratin and filaggrin expression in keratoacanthoma

To clarify the histogenesis of keratoacanthoma, we studied keratin (K) expression in keratoacanthoma (KA) using 10 different anti-keratin antibodies against K1, K7, K8, K10, K14, K15, K16, K17, K18 and K19 and anti-filaggrin (filament aggregating protein) antibody. In the centre of KA, K1 and K10 expressions were declined, and K14 and K16 were detected in the tumour cells, suggesting differentiation towards the outer root sheath beneath the orifice of the sebaceous duct. These results suggest that KA differentiates towards the outer root sheath beneath the opening of the sebaceous duct.

Role of three-dimensional imaging in operative planning for hilar cholangiocarcinoma

Complex, highly variable, anatomic relationships in the portal hilum complicate the surgical management at hilar cholangiocarcinoma. Preoperative three-dimensional (3D) imaging to stage the tumor and define anatomy may help in planning for curative resection. Between 2003 and 2006, 20 consecutive patients with hilar cholangiocarcinoma underwent preoperative multidetector row computed tomography (MDCT) cholangiography; 3D images of the portal vein, hepatic artery, and bile ducts were created and viewed simultaneously. Longitudinal tumor extension was evaluated by direct cholangiography and 3D cholangiography, and contiguous spread by 2D computed tomography (CT). Of 20 patients, 15 underwent surgical resection. Liver resection was planned based on 3D imaging that allowed visualization of the relationship between the tumor and the umbilical portion of the left portal vein, or the bifurcation of the anterior and posterior branch of the right portal vein. Preoperative and operative findings were compared. All patients tolerated 3D CT without serious complication. The accuracy rates of longitudinal tumor extension, using the Bismuth-Corlette classification system, were 85% (11/13) and 87% (13/15) with direct cholangiography and 3D cholangiography, respectively. The sensitivity, specificity, and accuracy rates were 100%, 80%, and 87% for portal invasion and 75%, 91%, and 87% for hepatic arterial invasion. The number of bile duct orifices in the cut end of the hilar plate was estimated correctly in 13 of 15 patients. There were no operative deaths. Potentially curative resection was achieved in 14 of 15 patients. 3D images provide accurate information about the relationship between hilar cholangiocarcinoma and adjacent vessels. This technique is a powerful new tool for improving the proportion of potentially curative resection.

Traumatic sialocoele—a case report

Objective: To present a case of sialocoele of the parotid gland secondary to trauma and outline its management. Methods: A 34-year-old patient with a penetrating injury of the parotid duct resulting in a sailocoele was treated with anticholinergics and probanthin initially. As the collection kept recurring, a cannula of appropriate size was introduced into the sialocoele via the stenson's duct orifice under local anaesthesia and sutured to the oral mucosa. Results: When the patient was decannulated 3 weeks later, the tract had completely epithilized as evidenced by excellent salivary flow on stimulation and the patient was free of any swelling or symptoms. Conclusion: Transoral cannulation of the sialocoele under local anaesthesia is a quick and effective means of managing chronic refractory sialocoeles when ductal anastomosis is precluded.

Nasolacrimal Duct Orifice Cysts in Adults: A Previously Unrecognized, Easily Treatable Cause of Epiphora

Epiphora is a common problem evaluated by ophthalmologists and otolaryngologists. It is typically the result of obstruction at some level of the nasolacrimal system, either the canaliculi, sac, or duct. Multiple etiologies exist, including scarring from infection or trauma, tumors, or masses. Cysts of the nasolacrimal duct orifice (dacryocystoceles) in the inferior meatus have been described in neonates, usually presenting as obstructive nasal masses shortly after birth. Nasolacrimal duct orifice cysts have not been described in the adult population in the medical literature. Three patients were identified with epiphora as a result of cysts in the inferior meatus at the opening of the nasolacrimal duct. All patients presented with constant epiphora and were referred for dacryocystorhinostomy by an ophthalmologist or an otolaryngologist. None of the patients had a previous history of nasolacrimal duct (NLD) surgery. One patient had previous endoscopic sinus surgery for nasal polyps. Cysts were identified by nasal endoscopy of the inferior meatus in all patients. All patients underwent endoscopic resection of the inferior meatus cyst to relieve the obstruction of the NLD. Two procedures were performed under general anesthesia and one under intravenous sedation. All patients had complete relief of epiphora and have had no evidence of recurrence of the symptoms or the cyst in 4 to 10 months follow-up. NLD orifice cysts are easily correctable causes of epiphora. Routine inferior meatus endoscopy should be routinely performed in patients with epiphora to identify whether on not this pathology is present prior to performing dacryocystorhinostomy.