Duct Orifice Research Articles

Comparative endonasal analysis of the inferior lateral wall of the nasal fossae in adults with and without epiphora

AbstractPurpose The development of endonasal dacryocysto‐rhinostomia is associated with the advent of nasal video endoscopia which enables a perfect visualization of the surgical site. As the inferior turbinate bones are close to the lacrimonasal duct orifice at the level of Hasner’s valvula, anatomic variations of endonasal structures could be associated with the occurrence of epiphora.Methods The results of nasal endoscopia between a group of adult patients with epiphora (n=35) and a control group of patients (n=19) without epiphora were compared. The endoscopic examination concentrated on changes of the inferior part of the nasal fossae and particularily on the inferior meatus and inferior turbinate bones. A non parametric Mann Whitney test was performed to compare the findings in the two groups.Results Neither the edema of the inferior turbinate bones nor the visibility of the inferior meatus were associated with epiphora due to lacrimonasal duct stenosis (avec p >0.05). It appeared that there are major anatomic variations of the nasal fossae between two patients but also between either side of the same patient. The lack of difference observed between the two groups of patients could be due to the major anatomic variations observed in the nasal fossae.Conclusion No particular correlation between anatomical changes of the lateral wall of the nasal fossae and the existence of lacrimonasal duct stenosis was found. However it remains essential to perform preoperative nasal endoscopy in order to detect a possible cause of lacrimonasal duct stenosis and thus evaluate the feasibility of surgery.

Risk factor analysis and procedural modifications for biliary stricture after adult living donor liver transplantation

BACKGROUND: We undertook a retrospective assessment of risk factors for biliary stricture after adult living donor liver transplantation (LDLT) and evaluated risk reduction following the implementation of modified surgical procedures. METHODS: Between June 1997 and December 2009, 85 adult patients underwent LDLT. Up to September 2006, we performed duct-to-duct hepaticocholedochostomy (D-D) in 38 patients and Roux-en-Y hepaticojejunostomy (R-Y) in 24 patients. Risk factors for biliary stricture were analyzed for these patients. We then performed D-D in 23 patients using modified procedures and assessed the resultant outcomes. RESULTS: D-D was a significant risk factor in the 62 patients who underwent LDLT before September 2006. Despite this result, we decided to employ only D-D for subsequent cases. Since the presence of multiple graft bile duct orifices was a significant risk factor in the 38 patients who underwent D-D, we used modified procedures after October 2006 to address grafts with multiple bile duct orifices. The procedures included: 1) inserting a biliary tube from the common bile duct; 2) placing the tip of tube beyond the anastomosis; 3) inserting the tubes in all the anastomoses if multiple; and 4) maintaining the tube for 6 months postoperatively. The incidence of biliary stricture after D-D was significantly less frequent with the use of these procedures (before: 36%; after: 13%). CONCLUSIONS: In our early experience, D-D was a significant risk factor for biliary stricture after adult LDLT. Although we are now employing only D-D, our procedural modifications seem promising for preventing biliary stricture after D-D.

Stensen Duct Relocation After Cheek Mucosa Tumor Resection

Cheek mucosa cancer might surround Stensen meatus requiring preservation and relocation of the duct. Sialodochoplasty is necessary to avoid subsequent stricture, cheek swelling, and obstructive sequelae that could make following oncologic follow-up difficult. We report a simple successful technique of parotid duct cannulation and relocation in a 77-year-old woman who underwent cheek mucosa tumor resection for squamous cell carcinoma and free fasciocutaneous forearm reconstruction. Ability of milk clear saliva from the duct orifice after 6 weeks from surgery was assessed clinically, and no fistula or swelling was experienced. Stensen duct cannulation and relocation are a useful adjunctive procedure in the treatment of oral mucosa cancer, preserving salivary gland function while not compromising cancer resection.

Mo1298 Self-Expandable Metallic Stent With High Axial Force is the Risk Factor of Cholecystitis

Cholecystitis and pancreatitis after biliary self-expandable metallic stent (SEMS) placement are un-resolved serious complications. Our previous retrospective analysis demonstrated tumor involvement to the orifice of cystic duct (OCD) as a risk factor for cholecystitis (Isayama H. Clin Gastroenterol Hepatol. 2006). Subsequently, we reported the measurement of radial force (RF) and axial force (AF), characteristics of SEMSs (Isayama H. Gastrointest Endosc. 2009) and its impact on clinical outcomes including high AF as a risk factor for post-SEMS placement pancreatitis (Kawakubo K.

Is Microsurgical Technique Useful in Biliary Reconstruction of Living Donor Liver Transplantation?

IntroductionBiliary reconstruction remains the “Achilles' heel” of living donor liver transplantation (LDLT). In the last decades, the technical aspects of biliary reconstruction have been debated for their impact on biliary complications in LDLT. A microsurgical technique in biliary reconstruction is more attractive. Patients and methodsFrom December 2010 to June 2011, 15 primary LDLTs underwent duct-to-duct biliary reconstruction using a microscopic technique. External stents were inserted in all patients. All procedures were performed under a microscope by a single transplant microsurgeon. ResultsThe time consumed for bile duct reconstruction using the microscopic technique was 35 minutes. There were 8 grafts with a single bile duct orifice and seven with two orifices. The average duct size was 3 mm in patients with two orifices and 5 mm in those with a single orifice. There was no bile leak or biliary stricture associated with the biliary reconstruction over a median 5-month follow-up. There were two cases of bile leakage from the cut hepatic surface. ConclusionThe microscopic technique reduced early biliary complications. However, further technical advances are needed to decrease the time consumptions for the procedure.

Foreign Body Reaction to Facial Dermal Fillers: Case Report

We present a patient who developed a delayed granulomatous reaction after injections of hyaluronic acid and bovine collagen glutaraldehyde that were introduced 6 and 4 years, respectively, previous to her present visit. She was a healthy 65-year-old woman, who was seen in November 2010 at the Columbia University Salivary Gland Center with a tentative diagnosis of a left buccal facial swelling caused by a "blocked parotid duct." The swelling was only slightly painful and had developed 1 month previously after a periodontal surgical procedure that involved the maxillary left quadrant. Questioning indicated that the swelling did not fluctuate in size nor had it changed its configuration since its sudden inception 2 days after the periodontal surgery. Visibly, the swelling was slightly erythematous. Palpation caused only mild discomfort and revealed the swelling to be quite firm in tone. The lesion involved the left facial buccal tissues, with its extraoral center corresponding to the intraoral location of the parotid duct orifice. The swelling was diffuse, with no definitive outline. It measured approximately 3 cm horizontally and 3.5 cm in height. Posteriorly, palpation of the left parotid gland revealed the gland to be painless, normal in tone, and not swollen. No swelling or discomfort was evident on the right side. No trismus was present.

Clinical, statistical and chemical study of sialolithiasis

Introduction Sialolithes are initiated by localized deposition of calcified material in the salivary glands. And that may even cause various symptom especially swelling and pain. This study purposes to collect statistical data of sialolithiasis for clinical analysis. Materials and Methods Among forty seven patients who have visited Seoul National University Dental Hospital during 2004-2009, patients' age, sex, location and size of stone, radiodensity of stone, symptom, surgical procedure were investigated. Statistical correlation between size, location, symptom was evaluated. Chemical composition was analyzed for 3 sialolithes. Results The average age was 41.4 years. Sialolithiasis had slight female predilection (57.4%). Most cases occurred in the submandibular glands (91.5%). And most cases had radiopaque features (95.8%). The average size was 7.17 mm. The most frequent location of the stones were the duct orifice and the submandibular gland hilum (16 cases in each), followed by the middle part of the duct (n=8), the intraglandular area (n=4), and the proximal part of the duct (n=3). Eleven cases were asymptomatic. Thirty six cases had complaints of pain, swelling, hardness, and decrease in saliva flow (multiple symptoms). Various methods of surgery was performed. Two cases were self-removed. Thirty seven cases underwent procedure involving stone removal alone. Six cases underwent gland extirpation, and two cases underwent ductoplasty. Conclusion There was no statistical correlation between size, location, and symptoms. Sialolith was composed of Ca (58.5-69.3%), P (30.7-35.7%), organic material, and trace inorganic material.

Does ductal lavage assert its role as a noninvasive diagnostic modality to identify women at low risk of breast cancer development?

ObjectiveDuctal lavage (DL) involves evaluation of the ductal system of the breast for detection of intra-ductal carcinomas and precursor lesions by collecting breast epithelial cells using a small-gauge catheter inserted into a ductal orifice on the nipple. The aim of this survey was to analyze cytologic features of samples obtained from low-risk women with DL and to elucidate the efficacy of this diagnostic modality in evaluating fluid production, cannulating and determining atypical breast epithelial cells.MethodsInto this prospective study were consecutively registered 80 women between ages 28 to 67. Nipple aspiration was performed to identify all fluid-yielding ducts. According to the grading of specific features the interpretation of the sample included: normal/benign (category, 0), mild atypical (category, I), markedly atypical (category, II) or malignant (category, III) disorders.ResultsNinety five percent (316/334) of the nipple aspirate fluid samples were classified as category 0, 4.8% (16/334) as category I and 0.2% (2/334) as category II changes. Category III disorders were not detected. Therefore, in 80% of the women examined results were within normal limits while 17.5% of the participants presented mild atypical and 2.5% markedly atypical rates.ConclusionDL collection procedure proved to be rapid as well as acceptable by the women studied. It retains the advantage over other methods of nipple aspirate fluid in that it is easy to perform, thereby removing most clinician variability. It also helped low risk women to discriminate those with breast disorders that require additional investigation, further follow-up or administration of preventive medication.

Double Duct to Mucosa Pancreaticojejunostomy for Bifid Pancreatic Duct following Pylorus Preserving Pancreaticoduodenectomy: A Case Report

Bifid pancreatic duct represents a relatively rare anatomical variation of the pancreatic ductal system, in which the main pancreatic duct is bifurcated along its length. This paper describes the challenging surgical management of a 68-year-old male patient, with presumptive diagnosis of periampullary malignancy who underwent a successful double duct to mucosa pancreaticojejunostomy for bifid pancreatic duct. Following pylorus preserving pancreaticoduodenectomy, careful intraoperative inspection of the cut surface of the residual dorsal pancreas identified the main in addition to the secondary pancreatic duct orifice. Bifid duct anatomy was confirmed via intraoperative probing and direct visualization of the ductal orifices. A decision was made for the performance of an end-to-site double duct to mucosa pancreaticojejunostomy. Postoperative outcome was favorable without any complications. Although bifid pancreatic duct is relatively rare, pancreatic surgeons should be aware of this anatomical variation and be familiar with the surgical techniques for its successful management. Lack of knowledge and surgical expertise for dealing with this anatomical variant may lead to serious, life threatening postoperative complications following pancreatic resections.

ACUTE SUPPURATIVE PAROTITIS TREATMENT BY DIODE LASER COMBINED WITH ER:YAG LASER

The diode laser combined with Er:YAG laser is a new treatment modality for acute sialadenitis. A 78-year-old woman with acute suppurative parotitis was treated by traditional probe to the duct orifice with oral antibiotics for 2 weeks. The symptoms and signs did not subside after treatment. The Er:YAG laser was used to reduce severe infection and inflammation and low level laser therapy (LLLT) was applied to relieve pain sensation during incision and drainage. Less scar formation and obstruction was observed after the laser treatments. Purulent secretions from the Stensen duct was noted after milking the parotid gland. The symptoms and signs were significantly relieved after combined laser treatments. The patient experienced no pain during the course of treatment. No recurrence of the symptoms and signs was noted after 1-year follow-up, and the prognosis was very good. The hemostatic properties of the diode laser enable better control of the surgical field and faster healing of the wound lesions. The bactericidal effect of Er:YAG lasers has been proved by many researchers, and has been shown to reduce infection and inflammation for better wound healing. The combined laser therapy of diode and Er:YAG lasers is recommended in treating acute sialadenitis.

Efficacy of three different infrared wavelength lasers on strawberry hemangioma in face

Objective To observe the effect of treatment and cosmetology in cbildren patients with strawberry hemangioma (SH) on face by three kind of infrared wavelength lasers.Methods In 300 children patients aged from 5 to 12 years with SH on face were randomly divided into a semi con ductor laser group (100 cases),a Nd ∶ YAG laser group (100 cases) and a CO2 laser group (100 cases).The parameters of laser were the same in the three groups,such as 10 W,light spot 0.2 cm in diameter and 318 W/cm2.According to size of area in the semiconductor laser and Nd ∶ YAG laser groups SH were coagulated by semiconductor laser and Nd ∶ YAG laser,and in the CO2 laser group it were gasified by CO2 laser,respectively.Children patients with SH were followed up for observation of cicatrzation and evaluation of the effect of therapeutics and cosmetology at six months after laser treatment.Results The cure rates were 89 ％ in the semiconductor laser group,83 ％ in the Nd ∶ YAG laser group and 69 ％ in the CO2 laser group (P＜0.05).The excellent and faworahle rates of cosmetic effect were 87.0 ％ in the CO2 laser group,86.5 ％ in the semiconductor laser group and 57.8 ％ in the Nd ∶ YAG laser group (P＜0.01).The analysis also showed that average therapeutic time,operative time and quantity of bleeding in the semiconductor laser group were less than that of in the Nd ∶ YAG laser and CO2 laser groups (P＜0.01).Conclusions The semiconductor laser (wave length 830 nm and power 318 W/cm2) for the treatmet of children patients with SH on face has many advantages,such as higher cure rate,shorter operative time,less bleeding in operation and better cos metic effects.It might become a first selective therapy for children patients with SH on face. Key words: Laser; Strawberry hemangioma; Efficiency; Cosmetic effect

Skene’s gland revisited: function, dysfunction and the G spot

Despite Skene’s gland being described over 300 years ago, and the frequent performance of surgery on and around these glands, it is remarkable how little we know about what they do and potential problems associated with them. Infection in these glands was described with gonorrhoeal infection in 1672 by Regnier de Graaf (1641–1693), which was long before Skene [1] described them in 1880. Controversy exists on the function of Skene’s glands, their role in sexual function, female orgasm and ejaculation, and even their anatomy. What is their role in the causation of urogynecological symptoms such as urethral pain and sexual dysfunction? Urogynaecological surgery in this area is commonplace for the treatment of urethral or paraurethral pathology, urinary incontinence or vaginal prolapse. What effect can this have on their function and sexual function more generally? In a histopathological study Wernert et al. [2] described Skene’s gland as a group of glands arranged in long ductal structures situated in the caudal two thirds of the urethra “mainly in the dorsal and lateral mucosal stroma but extending in some cases to the smooth musculature of the septum urethrovaginale”. These glands are not always present and were found in only two thirds of the 33 women they studied. They are “tubuloaveolar formations on long ductal structures” and resemble male prostate glands prior to puberty and androgenic stimulation. They contain prostate-specific antigen (PSA) and prostatic acid phosphatase (PAP) on immunostaining [2]. A more recent study [3] has confirmed the presence of prostate-specific antigen reactivity in the paraurethral tissues and in the “superficial layer of the female secretory (luminal) cells of the female prostatic glands and membranes of secretory and basal cells and membranes of cells of pseudostratified columnar epithelium of the ducts”. These ductal structures run longitudinally around the distal urethra located on the anterior vaginal wall. The literature is unclear on whether the glands open through a single or multiple orifices either into the distal urethra (similar to the male prostate) or a single duct orifice onto the left and right sides of the external urethral orifice. However it is my experience in asymptomatic women (Fig. 1) or where there is infection and abscess formation (Fig. 2), there is a single duct external to the urethral meatus. The distal urethra and vagina have an intimate relationship with the clitoris, both anatomically and functionally. The clitoris consists of an exterior glans, a midline densely neural nonerectile structure that is continuous with the erectile tissue of the paired bulbs and crura, which surround the distal urethra and vagina. The distal urethra, vagina and clitoris have a shared vasculature and nerve supply (the dorsal nerve to the clitoris) and form a tissue cluster described by O’Connell et al. [4] as the “locus of female sexual function and orgasm”. These tissues around the distal urethra become engorged with sexual arousal, but there is debate whether secretions are produced during coitus by Skene’s gland, or if ejaculation with orgasm occurs, similar to the male prostate. Heath [5] proposed that a large amount of lubricating fluid can be secreted from this gland similar to a “female ejaculation" when stimulated from inside the vagina and to such an extent that it can be mistaken for urine and coital urinary incontinence. If this does occur, it is an uncommon cause Related articles can be found at doi:10.1007/s00192-011-1461-9 and doi:10.1007/s00192-011-1488-y.

Impact of three-dimensional analysis of multidetector row computed tomography cholangioportography in operative planning for hilar cholangiocarcinoma

Background A detailed evaluation of portal triad structures, especially the biliary anatomy at the hepatic hilus, is essential to ensure curative resection for hilar cholangiocarcinoma. Methods Patients underwent 3-dimensional analysis using multidetector row computed tomography cholangioportography preoperatively. The number of bile duct orifices in the cut end of the hilar plate was estimated and compared with the actual number of bile ducts. Furthermore, the estimated length of the surgical margin and its relationship to the pathological margin status was evaluated. Results The number of bile duct orifices was correctly estimated in 14 of 19 patients. Of 18 hepatic ducts in which the estimated length of the hepatic side surgical margin was calculated 17 hepatic ducts (94.4%) were diagnosed pathologically as margin negative. Conclusions This investigatory technique has the advantages of precise visualization of anatomic structures and multidirectional assessment of biliary branches and vessels, allowing improved operative planning for the treatment of hilar cholangiocarcinoma.

Topography of the nasolacrimal duct on the lateral nasal wall in Koreans

The aim of this study was to describe in detail the gross anatomy of the nasolacrimal apparatus in relation to the lateral nasal wall by the various steps of cadaver dissection and to measure the distances of surgically important landmarks from relevant structures to improve the safety and efficiency of endoscopic surgical procedures. Thirty-six half-heads of embalmed Korean adult cadavers were dissected under a surgical microscope. After removal of the nasal septum, the lateral wall of the nasal cavity was examined. The orifice of the nasolacrimal duct (NLD) was most frequently observed in the form of a vertical sulcus in 14 cases (39%) and the lacrimal fold was present in 28 cases (77.8%). A total of 15 morphometric items between the orifice of the NLD and the adjacent anatomical structures were measured. The location of the orifice of the NLD was observed at a mean of 17.5 ± 3.1 mm from the limen nasi, 22.8 ± 4.8 mm from the anterior nasal spine, and 21.4 ± 3.5 mm from the axilla of the middle nasal concha. In the positional relationships, the most frequent finding was that the lacrimal sac was posterior to the axilla of the middle nasal concha in 23 cases (64%), and overlap of the NLD with the maxillary line was observed in 24 cases (67%). This study was conducted to accumulate anatomic data on the lacrimal sac and duct with regard to the positional relationships among the surrounding structures to establish the information for use in endoscopic dacryocystorhinostomy.

A Rare Variation of the Biliary Tree of Relevance to Live Liver Donation

To the Editor: An appreciation of the potential anatomical variations of the vascular and biliary systems is essential for donor safety in the context of live donor hepatectomy (1, 2). We previously reported that variant biliary anatomy was present in a substantial proportion of donors with trifurcated portal veins (2, 3). The present report describes two rare cases of biliary anomaly with an independent bifurcation of a branch of segment 2 (B2) from the anterior or posterior bile duct. A 38-year-old male was admitted to our hospital to serve as a live donor for his sister, who had fulminant cryptogenic hepatic failure. Preoperative three-dimensional computed tomography (CT) of the donor did not demonstrate any anomalies of the portal vein, hepatic vein, or hepatic artery. Based on imaging and volume analysis of the liver, the donor underwent left hepatectomy with the caudate lobe. Intraoperative cholangiography demonstrated that B2 bifurcated independently from a branch of segment 7 (B7) (Figure 1A). Therefore, the left-lobe graft contained two bile duct orifices (B2 and B3). Intraoperative cholangiography confirmed that there was no bile leakage and that there was no biliary stenosis of the posterior branch. (A–C) Intraoperative cholangiography demonstrated that B2 independently bifurcated from B7 (case 1, A) or from the anterior branch (case 2, C). Magnetic resonance cholangiography demonstrated variant biliary anatomy, with B2 independently bifurcating from the anterior branch in case 2 (B). A 48-year-old male was admitted to our hospital to serve as a live donor for his wife, who had end-stage primary biliary cirrhosis. Preoperative three-dimensional CT of the donor demonstrated trifurcation of the portal vein, but there were no anomalies of the hepatic vein or hepatic artery. Magnetic resonance cholangiopancreatography (MRCP) demonstrated biliary anomaly with B2 bifurcating independently from an anterior branch (Figure 1B). Based on preoperative volume analysis, the left-lobe graft volume was considered to be too small for the recipient. Further, use of a right-lobe graft was complicated by the possibility that it possesses more than two bile duct orifices as well as two portal veins (anterior and posterior branches), which would increase the complexity of harvesting and of reconstruction. By contrast, the posterior segment graft had one bile duct orifice and portal vein with sufficient liver volume for the recipient. Therefore, the posterior segment graft was utilized for transplantation. The donor underwent posterior segmentectomy. Preoperative MRCP and intraoperative cholangiography demonstrated that B2 bifurcated from anterior branch (Figure 1C). The posterior segment graft had a single bile duct orifice and a single portal vein as well as a hepatic artery of the posterior branch and a right hepatic vein. Live donor liver transplantation requires careful graft selection to reduce the risk of complications. Biliary anomalies, which are sometimes associated with trifurcation of the portal vein, can complicate graft selection and donor surgery. This is the first report to describe independent B2 bifurcation from the anterior or posterior bile duct in a live donor. In donors with this anomaly, both the right and left-lobe grafts have multiple bile ducts. As illustrated in case 2 from the present report, the posterior graft represents a viable alternative for transplantation, provided graft volume is adequate. Preoperative evaluation of the biliary system has not been routinely utilized in our institution. Since dynamic CT may not detect important biliary variations, preoperative MRCP may be required to accurately characterize biliary anatomy, even in donor candidates without trifurcated portal veins. Based on the cost-benefit of this approach, we now routinely perform preoperative MRCP in all live donors in our institution. The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.

Removal of proximally migrated pancreatic stent using needle knife and capture forceps (with video)

Pancreatic stent (PS) is used as a preventative tool for postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. For this purpose, one-side flap, one-side pig-tailed, or stick-shaped PS is widely used. This type of PS is thought to stay at ampulla while fasting and bowel arrest maintaining smooth pancreatic juice excretion, and then spontaneously migrated toward intestinal lumen after the restart of food intake. However, by a subtle mistake in usage, it may cause critical situation. We currently document a case of proximal migration of the PS and its’ rescue technique by needle-knife incision of the pancreatic duct orifice and stent removal using capture forceps.

Proximally migrated pancreatic stent successfully removed using needle-knife and forceps: Complication after precut papillotomy assisted by pancreatic stenting

Pancreatic stent-assisted ampullary precut papillotomy is a rescue method for cases with difficult bile duct cannulation during endoscopic retrograde cholangiopancreatography (ERCP). We describe a case in which post-ERCP pancreatitis (PEP) developed due to the proximal migration of pancreatic stent, after precut papillotomy. Removal of the migrated pancreatic stent was achieved after needle-knife incision of the pancreatic duct's orifice followed by retrieval of the stent using rat-tooth forceps, which resulted in rapid resolution of the PEP. Caution is needed when pancreatic stent is placed after papillary incision. Needle-knife incision of the pancreatic duct orifice followed by forceps removal is an effective technique for rescuing pancreatic stent migration.

Nasolacrimal duct orifice cysts in adults: A previously unrecognized, easily treatable cause of epiphora

Nasolacrimal duct orifice cysts in adults: A previously unrecognized, easily treatable cause of epiphora

Duodenal obstruction following papillary stenosis: a rare complication after endoscopic sphincterotomy

An 80-year-old man was admitted for abdominal pain and jaundice. Abdominal computed tomography and endoscopic retrograde cholangiopancreatography (ERCP) revealed an impacted bile duct stone in the duodenal papilla with biliary and pancreatic duct dilatation. We safely performed an endoscopic sphincterotomy (EST) and stone extraction. Eighteen months later, the patient was readmitted with jaundice. ERCP showed retraction of the duodenal papilla with stenosis of the biliary and pancreatic duct orifices ([Fig. 1]).

Predictors of Xerostomia after Head and Neck IMRT: Beyond the Parotid Glands

Predictors of Xerostomia after Head and Neck IMRT: Beyond the Parotid Glands