Classification of anatomical morphology of cystic duct and its association with gallstone

BACKGROUND Gallstones are common lesions that often require surgical intervention.Laparo-scopic cholecystectomy is the treatment of choice for symptomatic gallstones.Preoperatively,the anatomical morphology of the cystic duct(CD),needs to be accurately recognized,especially when anatomical variations occur in the CD,which is otherwise prone to bile duct injury.However,at present,there is no optimal classification system for CD morphology applicable in clinical practice,and the relationship between anatomical variations in CDs and gallstones remains to be explored.AIM To create a more comprehensive clinically applicable classification of the morphology of CD and to explore the correlations between anatomic variants of CD and gallstones.METHODS A total of 300 patients were retrospectively enrolled from October 2021 to January 2022.The patients were divided into two groups:The gallstone group and the nongallstone group.Relevant clinical data and anatomical data of the CD based on magnetic resonance cholangiopancreatography(MRCP)were collected and analyzed to propose a morphological classification system of the CD and to explore its relationship with gallstones.Multivariate analysis was performed using logistic regression analyses to identify the independent risk factors using variables that were significant in the univariate analysis.RESULTS Of the 300 patients enrolled in this study,200(66.7%)had gallstones.The mean age was 48.10±13.30 years,142(47.3%)were male,and 158(52.7%)were female.A total of 55.7%of the patients had a body mass index(BMI)≥24 kg/m2.Based on the MRCP,the CD anatomical typology is divided into four types:Type I:Linear,type II:n-shaped,type III:S-shaped,and type IV:W-shaped.Univariate analysis revealed differences between the gallstone and nongallstone groups in relation to sex,BMI,cholesterol,triglycerides,morphology of CD,site of CD insertion into the extrahepatic bile duct,length of CD,and angle between the common hepatic duct and CD.According to the multivariate analysis,female,BMI(≥24 kg/m2),and CD morphology[n-shaped:Odds ratio(OR)=10.97,95%confidence interval(95%CI):5.22-23.07,P<0.001;S-shaped:OR=4.43,95%CI:1.64-11.95,P=0.003;W-shaped:OR=7.74,95%CI:1.88-31.78,P=0.005]were significantly associated with gallstones.CONCLUSION The present study details the morphological variation in the CD and confirms that CD tortuosity is an independent risk factor for gallstones.

Malignant carcinoid tumor of the cystic duct:a rare cause of bile duct obstruction

BACKGROUND:Carcinoid tumors of the extrahepatic biliary tree are extremely rare malignancies,accounting for 0.2%-2%of all gastrointestinal carcinoid tumors,while carcinoids of the cystic duct are an uncommon entity and an extremely unusual cause of bile duct obstruction.METHODS:After an extensive literature review,we retrospectively analysed 61 cases of carcinoid tumor of the biliary tree as well as one additional case of a 60-yearold female with symptoms and laboratory/imaging examination findings compatible with those of a malignant biliary tract obstruction.At laparotomy,resection of the gallbladder and common bile duct was performed.Histological study revealed a well-differentiated neuroendocrine carcinoma of the cystic duct.The patient remained disease-free at 16 months.RESULTS:Our presentation is the seventh case reported in the world literature.Compared to cholangiocarcinoma,analysis of the reviewed group indicates an increased incidence of extrahepatic carcinoid tumors in younger persons along with a slight female predominance.Statistically,the most common anatomic location is the common bile duct,followed by the perihilar region and the cystic duct.Jaundice is the most common finding.Curative surgery was realized in the majority of cases and longterm disease-free survival was achieved when surgery was curative.CONCLUSIONS:Carcinoid tumors obstructing the biliary tree are extremely difficult to diagnose preoperatively,and nearly impossible to differentiate from non-neuroendocrine tumors.As surgery offers the only potential cure for both biliary carcinoids and cholangiocarcinoma,we recommend aggressive surgical therapy as the treatment of choice in every case of potentially resectable biliary tumor.

Anatomical variations of the cystic duct:Two case reports

Anatomical variations of the cystic duct often occur and may be encountered during cholecystectomy. Knowledge of the variable anatomy of the cystic duct and cysticohepatic junction is important to avoid significant ductal injury in biliary surgery. Here, we present two unusual cases with an anomalous cystic duct, namely, low lateral insertion and narrow-winding of the cystic duct. The first case was a 64-year-old man with cholelithiasis and chronic cholecystitis. During surgery, the entrance of the cystic duct was misidentified as being short and leading into the right hepatic duct. Further exploration showed multiple calculi in the right and common hepatic ducts. Cholecystectomy was completed, followed by T-tube drainage of the common and right hepatic ducts. Postoperative T-tube cholangiography demonstrated that the two T tubes were respectively located in the cystic and common hepatic duct. Six weeks later, the retained stones in the distal choledochus were extracted by cholangioscopy through the sinus tract of the T-tube. The second case was a 41-year-old woman, in which, preoperative endoscopic retrograde cholangiopancreatography (ERCP) revealed a long cystic duct, with a narrow and curved-in lumen. The patient underwent open cholecystectomy. Both patients were cured. The authors propose that preoperative ERCP or magnetic resonance cholangiopancreatography (MRCP), and intraoperative cholangiography or cholangioscopy constitute a useful and safe procedure for determining anatomical variations of the cystic duct.

Peroral cholangioscopy-assisted guidewire placement for removal of impacted stones in the cystic duct remnant

It is well known that impacted biliary stones are difficult to remove endoscopically.Among the many factors associated with failure of endoscopic therapy for removal of bile duct stones,impaction ranks high.One of the reasons behind failure of endoscopic therapy in such cases is that the impacted stone often does not allow passage of a guidewire.Recent introduction of a novel single-operator cholangioscopy system has made it possible for a single endoscopist to use cholangioscopy for evaluation and treatment of a wide variety of biliary disorders.This cholangioscopy system was used for placement of a guidewire in the cystic duct remnant with subsequent removal of an impacted stone which had prevented passage of a guidewire by conventional means.

Bile leakage after loop closure vs clip closure of the cystic duct during laparoscopic cholecystectomy:A retrospective analysis of a prospective cohort

BACKGROUND Laparoscopic cholecystectomy(LC)is one of the most frequently performed surgical procedures.Cystic stump leakage is an underestimated,potentially life threatening complication that occurs in 1%-6%of the patients.With a secure cystic duct occlusion technique during LC,bile leakage becomes a preventable complication.AIM To investigate the effect of polydioxanone(PDS)loop closure of the cystic duct on bile leakage rate in LC patients.METHODS In this retrospective analysis of a prospective cohort,the effect of PDS loop closure of the cystic duct on bile leakage complication was compared to patients with conventional clip closure.Logistic regression analysis was used to develop a risk score to identify bile leakage risk.Leakage rate was assessed for categories of patients with increasing levels of bile leakage risk.RESULTS Of the 4359 patients who underwent LC,136(3%)underwent cystic duct closure by a PDS loop.Preoperatively,loop closure patients had significantly more complicated biliary disease compared to the clipped closure patients.In the loop closure cohort,zero(0%)bile leakage occurred compared to 59 of 4223(1.4%)clip closure patients.For patients at increased bile leakage risk(risk score≥1)rates were 1.6%and up to 13%(4/30)for clip closure patients with a risk score≥4.This risk increase paralleled a stepwise increase of actual bile leakage complication for clip closure patients,which was not observed for loop closure patients.CONCLUSION Cystic duct closure with a PDS loop during LC may reduce bile leakage in patients at increased risk for bile leakage.

Simultaneous liver mucinous cystic and intraductal papillary mucinous neoplasms of the bile duct:A case report

Cystic hepatic neoplasms are rare tumors,and are classified into two separate entities:mucinous cystic neoplasms(MCNs)and intraductal papillary mucinous neoplasms of the bile duct(IPMN-B).We report the case of a 56-year-old woman who presented with abdominal pain and jaundice due to the presence of a large hepatic multilocular cystic tumor associated with an intraductal tumor.Partial hepatectomy with resection of extrahepatic bile ducts demonstrated an intrahepatic MCN and an intraductal IPMN-B.This is the first report of the simultaneous occurrence of these two histologically distinct entities in the liver.

Congenital Absence of the Cystic Duct: A Rare but Significant Anomaly

Cholecystectomy is the most common digestive tract surgery performed worldwide and injury to the bile duct leads to both acute and chronic sequelae. The incidence of bile duct injury is increased in the presence of severe inflammation and is compounded by congenital abnormalities of the biliary tract. Congenitally absent cystic duct is one such rare anomaly with significant surgical implications. So far only nine clear cases of congenitally absent cystic duct have been reported. In this report we describe two additional cases of a congenitally absent cystic duct and provide a comprehensive discussion of the clinical significance, and appropriate surgical management of this anomaly.

Cystic Enlargement of the Bile Duct: Case Report and Review of Literature

Congenital cystic dilatations of the bile duct are rare malformations representing 1 per 13,000 births with a female predominance. Diagnosis of this pathology is based on radiological imaging especially radiological investigations conducted on an ultrasound coupled with Computed tomography (CT) scan and especially a bili-MRI which allows the analysis of the bile duct malformations and the anomalies of the pancreaticobiliary junction. We will discuss in this clinical case the various radiological aspects of cystic dilatations of the biliary duct.

Cystic malformation of cystic duct:10 cases and review of literature

AIM:To evaluate cystic malformations of the cystic duct.METHODS:Over a 2-year period,we came across 10 cases of cystic malformation of the cystic duct among patients who were investigated in our radiology department with ultrasonography,multidetector computed tomography,or magnetic resonance imaging for abdominal complaints.Radiological diagnosis of cystic malformation of the cystic duct was made on the basis of a dilated,nonvascular cystic structure near the porta hepatis,and visualization of a clear communication with either the gallbladder,normal caliber cystic duct and/or common bile duct(CBD) on at least one imaging modality.RESULTS:Four of 10 patients had saccular dilatation of the cystic duct.Six patients had fusiform dilatation of the cystic duct,and two of these had only mild fusiform dilatation.Two patients had associated CBD dilatation and one had associated cystic duct calculi and malignancy.CONCLUSION:Cystic malformations of the cystic duct should be recognized as a distinct type of choledochal cyst and should be added as type Ⅵ cyst in Todani's classification.

New classification of the anatomic variations of cystic artery during laparoscopic cholecystectomy

AIM： To investigate the anatomic variations in the cystic artery by laparoscopy, and to provide a new classification system for the guidance of laparoscopic surgeons.METHODS： Six hundred patients treated with laparoscopic cholecystectomy from June 2005 to May 2006 were studied retrospectively, The laparoscope of 30° （Stryker, American） was applied, Anatomic structures of cystic artery and conditions of Calot＇s triangle under laparoscope were recorded respectively,RESULTS： Laparoscopy has revealed there are many anatomic variations of the cystic artery that occur frequently. Based on our experience with 600 laparoscopic cholecystectomies, we present a new classification of anatomic variations of the cystic artery, which can be divided into three groups： （1） Calot＇s triangle type, found in 513 patients （85.5%）; （2） outside Calot＇s triangle, found in 78 patients （13%）; （3） compound type, observed in 9 patients （1.5%）.CONCLUSION： Our classification of the anatomic variations of the cystic artery uncontrollable cystic artery extrahepatic bile duct injury. will be useful for decreasing hemorrhage, and avoiding extrahepatic bile duct injury.

Cystic duct cancer: Should it be deemed as a type of gallbladder cancer?

BACKGROUND According to the latest American Joint Committee on Cancer and Union for International Cancer Control manuals,cystic duct cancer(CC)is categorized as a type of gallbladder cancer(GC),which has the worst prognosis among all types of biliary cancers.We hypothesized that this categorization could be verified by using taxonomic methods.AIM To investigate the categorization of CC based on population-level data.METHODS Cases of biliary cancers were identified from the Surveillance,Epidemiology,and End Results 18 registries database.Together with routinely used statistical methods,three taxonomic methods,including Fisher’s discriminant,binary logistics and artificial neuron network(ANN)models,were used to clarify the categorizing problem of CC.RESULTS The T staging system of perihilar cholangiocarcinoma[a type of extrahepatic cholangiocarcinoma(EC)]better discriminated CC prognosis than that of GC.After adjusting other covariates,the hazard ratio of CC tended to be closer to that of EC,although not reaching statistical significance.To differentiate EC from GC,three taxonomic models were built and all showed good accuracies.The ANN model had an area under the receiver operating characteristic curve of 0.902.Using the three models,the majority(75.0%-77.8%)of CC cases were categorized as EC.CONCLUSION Our study suggested that CC should be categorized as a type of EC,not GC.Aggressive surgical attitude might be considered in CC cases,to see whether long-term prognosis could be immensely improved like the situation in EC.

Systematic review of cystic duct closure techniques in relation to prevention of bile duct leakage after laparoscopic cholecystectomy

AIM To study the effect of different techniques of cystic duct closure on bile leakage after laparoscopic cholecystectomy(LC) for biliary disease.METHODS A systematic search of MEDLINE, Cochrane and EMBASE was performed. Rate of cystic duct leakage(CDL) was the primary outcome. Risk of bias was evaluated. Odds ratios were analyzed for comparison of techniques and pooled event rates for non-comparative analyses. Pooled event rates were compared for each of included techniques.RESULTS Out of 1491 articles, 38 studies were included. A total of 47491 patients were included, of which 38683(81.5%)underwent cystic duct closure with non-locking(metal)clips. All studies were of low-moderate methodological quality. Only two studies reported separate data on uncomplicated and complicated gallbladder disease. For overall CDL, an odds ratio of 0.4(95%CI: 0.06-2.48)was found for harmonic energy vs clip closure and an odds ratio of 0.17(95%CI: 0.03-0.93) for locking vs non-locking clips. Pooled CDL rate was around 1% for harmonic energy and metal clips, and 0% for locking clips and ligatures. CONCLUSION Based on available evidence it is not possible to either recommend or discourage any of the techniques for cystic duct closure during LC with respects to CDL,although data point out a slight preference for locking clips and ligatures vs other techniques. No separate recommendation can be made for complicated gallbladder disease.

Instrumental detection of cystic duct stones during laparoscopic cholecystectomy

Residual cystic duct stones (CDSs) after cholecystectomy have been recognized as a cause of post cholecystectomy pain. This study was undertaken to determine the incidence of CDSs during laparoscopic cholecystectomy(LC). A cohort of 330 consecutive patients (80 males and 250females) undergoing LC between November 2006 and May2010 was studied. Their age ranged between 16 and 88 years(median 50, IQR: 36.62). The data were prospectively collected of preoperative liver function tests, imaging, the presence of intraoperative CDSs, and common bile duct stones at on-table cholangiogram. CDSs were detected intraoperatively in 64 of the 330 patients (19%). Ultrasound failed to detect CDSs in any of these cases. Deranged liver function tests were noted in 73% of the patients with CDSs and in 57% without CDSs Common bile duct stones were detected in 9% (29) of the 330patients. CDSs occur commonly at routine cholecystectomy, and preoperative investigations are not helpful in their diagnosis As CDSs may lead to postoperative morbidity, they should be actively sought out during surgery if present.

Managing injuries of hepatic duct confluence variants after major hepatobiliary surgery:An algorithmic approach

AIM:To investigate injuries of anatomy variants of hepatic duct confluence during hepatobiliary surgery and their impact on morbidity and mortality of these procedures. An algorithmic approach for the management of these injuries is proposed. METHODS:During a 6-year period 234 patients who had undergone major hepatobiliary surgery were retrospectively reviewed in order to study postoperative bile leakage. Diagnostic workup included endoscopic and magnetic retrograde cholangiopancreatography (E/MRCP), scintigraphy and fistulography. RESULTS:Thirty (12.8%) patients who developed postoperative bile leaks were identified. Endoscopic stenting and percutaneous drainage were successful in 23 patients with bile leaks from the liver cut surface. In the rest seven patients with injuries of hepatic duct confluence, biliary variations were recognized and a stepwise therapeutic approach was considered. Conservative management was successful only in 2 patients. Volume of the liver remnant and functional liver reserve as well as local sepsis were used as criteria for either resection of the corresponding liver segment or construction of a biliary-enteric anastomosis. Two deaths occurred in this group of patients with hepatic duct confluence variants (mortality rate 28.5%). CONCLUSION:Management of major biliary fistulaethat are disconnected from the mainstream of the biliary tree and related to injury of variants of the hepatic duct confluence is extremely challenging. These patients have a grave prognosis and an early surgical procedure has to be considered.

Diagnosis and management of cystic duct leakage after laparoscopic cholecystectomy: report of 3 cases

BACKGROUND; Operative complications after laparo- scopic cholecystectomy (LC) vary. Abdominal pain and other symptoms caused by fluid accumulation in the opera- tive area are not uncommon. Cystic duct (CD) leakage is one of the main sources of the fluid. This study was to eva- luate the procedures used in the diagnosis and management of CD leakage after LC. METHOD: The clinical materials of 3 patients with CD leakage after LC were studied retrospectively. RESULTS: Three female patients underwent LC for chronic cholecystitis associated with stones. Their clinical symp- toms were worsened of pre-existed cardiac arrhythmia, bile draining out from drainage tube, and biliary spillage from umbilical incision, respectively. Final diagnosis was made at the 1st, 2nd and 20th post-operative day. Two of the 3 patients were treated laparoscopically. Their opened CD stumps were closed with an endo-loop, with the abdomen irrigated and drained. The other patient was drained with the percutaneous technique, and a biliary stent was inserted under endoscopy. All patients recovered well. CONCLUSIONS: The clinical manifestations of CD leakage are different. Ascites can be found by B-ultrasound. Final diagnosis is dependent on magnetic resonance cholangiog- raphy and/or endoscopic retrograde cholangiopancreatog- raphy. Minimally invasive techniques can be applied to this complication safely and effectively. Reoperarion for closure of the opened CD stump can be fulfilled under laparosco- py. Endoscopic drainage must be accompanied with effec- tive abdominal drainage.

An Unusual and Previously Unreported Association between Tyrosinemia Type 1 and an Extremely Rare Variation of Congenital Cystic Dilatation: TODANI’s VI Cystic Duct Cyst: Report of a Case

Cystic duct cysts are rare lesions, and type VI of TODANI’s modified classification is the rarest subtype with only sporadic case reports in the literature. The following report describes the coexistence of this entity and type 1 tyrosinemia in a one month-old infant referred to our department for etiological investigations of prolonged neonatal cholestasis. To the best of our knowledge, we report herein the first case in the literature describing this association. Cystic duct abnormalities should be considered in the differential diagnosis of neonatal cholestases, however further investigations should be performed to exclude associated life-threatening conditions such as metabolic disorders including tyrosinemia.

Choledocholithiasis caused by anatomical variation of cystic duct: A case report

Laparoscopic cholecystectomy(LC)has gradually become the first choice for the treatment of cholecystolithiasis in recent years.Iatrogenic bile duct injury(IBDI)is an important clinical problem in LC.The anatomical variation of the cystic duct increases the probability of IBDI and the difficulty of operation.We present a case of a 44-year-old male with a anatomical variation of the cystic duct complicated with cholecystolithiasis and choledocholithiasis,who successfully underwent choledocholithotomy,choledochoscopic exploration and T-tube drainage surgery.The patient recovered well and was discharged home on postoperative day 10.The T-tube was removed at 1 month postoperatively after cholangiography examination of no choledocholithiasis left.

Topical nitrate drip infusion using cystic duct tube for retained bile duct stone:A six patients case series

A retained bile duct stone after operation for cholelithiasis still occurs and causes symptoms such as biliary colic and obstructive jaundice.An endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy(EST),followed by stone extraction,are usually an effective treatment for this condition.However,these procedures are associated with severe complications including pancreatitis,bleeding,and duodenal perforation.Nitrates such as glyceryl trinitrate(GTN) and isosorbide dinitrate(ISDN) are known to relax the sphincter of Oddi.In 6 cases in which a retained stone was detected following cholecystectomy,topical nitrate drip infusion via cystic duct tube(C-tube) was carried out.Retained stones of 2-3 mm diameter and no dilated common bile duct in 3 patients were removed by drip infusion of 50 mg GTN or 10 mg ISDN,which was the regular dose of intravenous injection.Three other cases failed,and EST in 2 cases and endoscopic biliary balloon dilatation in 1 case were performed.One patient developed an adverse event of nausea.Severe complications were not observed.We consider the topical nitrate drip infusion via C-tube to be old but safe,easy,and inexpensive procedure for retained bile duct stone following cholecystectomy,inasmuch as removal rate was about 50% in our cases.

On the mechanical behavior of the human biliary system

This paper reviews the progress made in understanding the mechanical behaviour of the biliary system. Gallstones and diseases of the biliary tract affect more than 10% of the adult population. The complications of gallstones, i.e. acute pancreatitis and obstructive jandice, can be lethal, and patients with acalculous gallbladder pain often pose diagnostic difficulties and undergo repeated ultrasound scans and oral cholecystograms. Moreover, surgery to remove the gallbladder in these patients, in an attempt to relieve the symptoms, gives variable results. Extensive research has been carried out to understand the physiological and pathological functions of the biliary system, but the mechanism of the pathogenesis of gallstones and pain production still remain poorly understood. It is believed that the mechanical factors play an essential role in the mechanisms of the gallstone formation and biliary diseases. However, despite the extensive literature in clinical studies, only limited work has been carried out to study the biliary system from the mechanical point of view. In this paper, we discuss the state of art knowledge of the fluid dynamics of bile flow in the biliary tract, the solid mechanics of the gallbladder and bile ducts, recent mathematical and numerical modelling of the system, and finally the future challenges in the area.

Mirizzi syndrome in an anomalous cystic duct:A case report

Mirizzi syndrome is a rare complication of gallstone disease,and results in partial obstruction of the common bile duct or a cholecystobiliary fistula. Moreover,congenital anatomical variants of the cystic duct are common,occurring in 18%-23% of cases,but Mirizzi syndrome underlying an anomalous cystic duct is an important clinical consideration. Here,we present an unusual case of typeⅠMirizzi syndrome with an uncommon anomalous cystic duct,namely,a low lateral insertion of the cystic duct with a common sheath of cystic duct and common bile duct.