[A bougie-guide for drainage of the common bile duct across the stump of the cystic duct].
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Common Bile Duct↗
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Cystic duct remnant carcinoma with widespread invasion along the extrahepatic bile duct wall: dynamic CT findings.
We report a case of remnant cystic duct carcinoma with widespread invasion along the common bile duct wall. Thin-slice dynamic computed tomography showed circumferential wall thickening of the extrahepatic bile duct (from the common hepatic duct to the intrapancreatic common bile duct) and the remnant cystic duct. Pathologically, the extrahepatic bile duct wall was thickened due to submucosal tumor infiltration by cystic duct papillary adenocarcinoma.
Aged↗
Mirizzi syndrome secondary to an adenoma of the cystic duct.
Bile duct adenomas are uncommon lesions that can cause obstructive jaundice. We report the unusual case of a 54-year-old man who developed Mirizzi syndrome secondary to a bile duct papillary adenoma located in the cystic duct remnant. A case report is presented, together with a review of extrahepatic bile duct adenomas published in the English-language literature, with special attention directed toward the clinical manifestations, locations, and prognosis of these tumors. Bile duct adenomas are very rare tumors. Although cholangiography can detect many of these lesions, few cases were correctly diagnosed preoperatively. Most lesions were located in the distal common bile duct or at the ampulla of Vater. Pathologic examination often revealed foci of carcinoma in situ, dysplasia, or atypia. Local resection was performed in most cases. There were no previous case reports of extrinsic common bile duct obstruction caused by tumors within the cystic duct. We describe here a very rare, acalculous variant of Mirizzi syndrome secondary to a solitary papillary adenoma of the cystic duct. In general, bile duct adenomas are uncommon lesions that are difficult to diagnoses preoperatively. These tumors usually present with jaundice secondary to intraluminal biliary obstruction. These lesions are premalignant and should be managed by complete surgical resection.
Adenoma↗
The utilization of cystic duct cholangiography.
The patient records at two hospitals were reviewed to ascertain the incidence of unsuspected common duct stones and to evaluate the patterns of utilization of routine and selective intraoperative cystic duct cholangiography. The incidence of unsuspected common duct stones discovered only by cystic duct cholangiography was 4.3 per cent. Unnecessary common duct exploration was performed on 5.3 per cent of patients undergoing routine cystic duct cholangiography because of false-positive cholangiograms. The use of routine and preexploratory cystic duct cholangiography was significantly different at the two hospitals studied. Choledochotomy without preexploratory cystic duct cholangiography resulted in unnecessary common bile duct explorations in 44 per cent of patients. Although routine cystic duct cholangiography will identify unsuspected common duct stones, it is associated with an equal incidence of unnecessary common duct exploration. Preexploration cholangiography is an essential procedure which diminishes unnecessary choledochotomy and facilitates accurate demonstration of biliary tract pathology.
Cholangiography↗
Immediate cystic duct occlusion using an endoluminal absorbable polyglycolic acid screw.
Endoscopic in situ occlusion of the cystic duct and ablation of the gallbladder could constitute a useful alternative to cholecystectomy in certain patients. The purpose of this study was to examine the feasibility of endoluminal occlusion of the cystic duct using a biodegradable polyglycolic acid screw and simultaneous gallbladder mucosal ablation with a Sotradecol-ethanol mixture. Eight pigs had operative cholecystotomy. A polyglycolic acid screw was twisted into the cystic duct after the proximal cystic duct mucosa was thermally ablated using electrocautery. Cholecystography confirmed occlusion of the cystic duct. Synchronous ablation of the gallbladder mucosa was then done by instilling absolute alcohol and 2% Sotradecol. The gallbladder was drained. Animals were sacrificed on days 14, 28, and 42. All animals survived operation and showed no untoward effects. Postmortem gross inspection showed gallbladders were shrunken and surrounded with adhesions from adjacent tissue. Cholangiography and cholecystography confirmed occlusion of the cystic duct in 6 of 8 pigs (75%). Histopathologic examination showed extensive areas of mucosal necrosis mixed with small areas of epithelial regeneration. Immediate occlusion of the cystic duct is possible using an endoluminal polyglycolic acid screw.
Animals↗
Clinicopathological analysis of cystic duct carcinoma.
BACKGROUND/AIMS: Gallbladder carcinoma is the most common malignancy of the biliary tract, while the clinical features of cystic duct carcinoma remain unexplored. METHODOLOGY: Clinicopathological data of 8 cases of cystic duct carcinoma were retrospectively analyzed. RESULTS: The sample included 5 men and 3 women, with a mean age of 66+/-10 years (range, 49-79 years). Clinical manifestations included jaundice (n=6) and/or abdominal pain (n=6). Two of the patients presented as acute cholecystitis. Preoperative work-ups included ultrasonography (n=8), computed tomography (n=7), and endoscopic retrograde cholangiography (n=6)/or magnetic resonance cholangiography (n=2). Meanwhile, the preoperative diagnoses included cystic duct neoplasms (n=3), common hepatic duct neoplasms (n=4), and gallstones with acute cholecystitis (n=1). Radical procedures, including cholecystectomy, resection of extrahepatic bile duct, and lymph node dissection, were performed in six patients, while palliative cholecystectomy was performed in the remaining two. Notably, five of eight cases displayed lymph node metastasis along the hepaticoduodenal ligament. Median survival was 15 months (range, 6 to 26 months). Two cases with no lymph node metastasis were alive and disease free at 23 months and 26 months, respectively. CONCLUSIONS: Cystic duct carcinoma is rare. Neoplasm of the cystic duct should be suspected in patients presenting with cystic duct obstruction accompanied by distended nonfunctioning gallbladder without evidence of stone impaction in the cystic duct. The prognosis of cystic duct carcinoma remains dismal. However, for those patients in whom tumors are detected in early stage, curative radical resections possibly provide the chance of potential curable.
Aged↗
[Anatomic variants of the cystic duct and cysticohepatic junction: diagnosis with MR cholangiography].
The cystic duct are variable in length, course and site of termination. A knowledge of the variable anatomy of the cystic duct and cysticohepatic junction is important in biliary surgery, because failure to recognize anatomic variations may result in a significant ductal injury. Magnetic resonance cholangiography (MRC) is a recently developed technique that demonstrates the biliary tree noninvasively and without injection of contrast material. Anatomic variants of the cystic duct and cysticohepatic junction that may increase the risk of bile duct injury in biliary surgery are frequently identified with MRC. MRC will be a noninvasive and a useful technique in the diagnosis of anatomic variants of the cystic duct and cysticohepatic junction.
Cystic Duct↗
Percutaneous obliteration of the cystic duct with a holmium:yttrium-aluminum-garnet laser: results of in vitro and animal experiments.
OBJECTIVE: The purpose of this study was to investigate the feasibility of using a holmium:yttrium-aluminum-garnet laser to permanently occlude the cystic duct in order to isolate the gallbladder from the biliary-enteric circulation and prevent gallstone formation. MATERIALS AND METHODS: To determine the optimal laser parameters (power and pulsing rate) for cystic duct thermocoagulation, 20 freshly excised porcine gallbladders with intact cystic ducts underwent low-energy (0.075-0.085 J/pulse) or high-energy (0.20-0.25 J/pulse) thermocoagulation. Histopathologic examination was done to determine the extent of cystic duct injury. After in vitro experiments, percutaneous transcholecystic laser thermocoagulation of the cystic duct was performed on 23 anesthetized domestic pigs (four controls). Cholangiograms immediately after laser thermocoagulation were obtained to assess cystic duct occlusion. Animals were sacrificed for histopathologic correlation immediately after laser thermocoagulation (n = 4), 72 hr later (n = 4), and 6 weeks later (n = 15). RESULTS: In the in vitro studies, all 10 cystic ducts in the high-energy group were occluded, while only four in the low-energy group were occluded. At histology, all cases in both groups showed circumferential injury to the cystic duct wall without injury to the cystic artery or vein. In the in vitro experiments, the cystic duct was successfully cannulated in 21 (91%) of 23 animals. Cholangiography after thermocoagulation showed occlusion of the cystic duct in 16 (84%) of 19 cases. Immediately after laser thermocoagulation, the cystic duct mucosa was circumferentially destroyed, whereas after 72 hr necrosis of the cystic duct wall and periductal tissues had occurred. By 6 weeks, all pigs had complete cystic duct fibrosis without injury to the common bile duct. CONCLUSION: Holmium:yttrium-aluminum-garnet laser thermocoagulation of the cystic duct can be performed easily, results in immediate cystic duct occlusion, and leads to permanent fibrous ductal obliteration by 6 weeks.
Animals↗
Does routine cystic duct cholangiogram during laparoscopic cholecystectomy prevent common bile duct injury?
Between November 1989 and September 1992, the author performed 1,000 laparoscopic cholecystectomies. Three common bile duct injuries occurred (0.3%). Selective cystic duct cholangiograms were performed for diagnosis and management of common bile duct stones. A total of 102 cholangiograms (10%) were done. Only eight of these cholangiograms were done for anatomical verification in the face of severe chronic or acute cholecystitis. Five were cystic duct cholangiograms, resulting in two common bile duct injuries. To avoid the problem of common bile duct injury in cases of obscure anatomy where clarification was needed, a cholecystocholangiogram was done for duct identification in three subsequent cases without event. The third common bile duct injury occurred early in the learning experience without benefit of the cholangiogram.
Cholangiography↗
Investigation of the functional three-dimensional anatomy of the human cystic duct: a single helix?
Clinical research into the formation of gallstones has indicated that the anatomy of the cystic duct is one of a number of factors contributing to the formation of gallstones. The cystic duct allows low-viscosity hepatic bile to enter the gallbladder under low pressure and the expulsion of a more viscous gallbladder bile, but little is known about this transport mechanism and the effect of anatomical variations in structure. This article describes the variation in geometry of the cystic duct, obtained from acrylic resin casts of the neck and first part of the cystic duct in gallbladders removed for gallstone disease and obtained from patients undergoing partial hepatectomy for metastatic disease. The data obtained allowed us to formulate a number of standard terms for describing cystic duct morphology and demonstrate that the term "spiral valve" is only partially correct when describing the duct anatomy. In over half of the casts, spiraling was not the dominant feature of the cystic duct. Additionally, the term valve implies active resistance to flow in one direction, whereas the internal baffles of the cystic duct would serve to regulate bile flow in both directions. These data are useful for realistic 3D modeling of fluid-structure interactions of the flow of bile in the human cystic duct.
Bile Ducts↗
Tuberculosis of the cystic duct lymph node.
Tuberculosis of the cystic duct lymph node associated with cholelithiasis is rare. We report a case of a 40 year-old woman with this pathology. She presented with anorexia, biliary colic, postprandial fullness and fever. Imaging studies revealed cholelithiasis and several visible portal lymph nodes. Cholecystectomy was performed and histopathological examination showed tuberculosis of the cystic duct lymph node without affecting the gallbladder. The presence of gallstones and lymphadenopathy in computed tomography, associated with persistent fever and symptoms that resemble cholecystitis, should cause suspicion of tuberculosis. However, diagnosis is usually achieved by microscopic appearance of caseating granulomas and isolation of Mycobacterium tuberculosis. The treatment in this case consisted of cholecystectomy and antitubercular chemotherapy.
Adult↗
Impact of tumor spread to the cystic duct on the prognosis of patients with gallbladder carcinoma.
INTRODUCTION: The importance of gallbladder carcinoma spread to the cystic duct has not yet been described. Although the cystic duct is contiguous with the gallbladder, it is located in the hepatoduodenal ligament and differs in structure from the gallbladder. The incidence and prognostic significance of cancer spread to the cystic duct in patients with gallbladder cancer is unclear. METHODS: Surgical specimens from 42 patients who underwent resection for advanced gallbladder carcinoma were examined retrospectively. RESULTS: Altogether, 13 (31%) of the patients had cancer spread to the cystic duct. The incidences of perineural invasion, lymph node metastasis, and venous invasion were significantly higher in these patients than in the other 29 patients without cancer spread to the cystic duct (P = 0.027, 0.034, and 0.034, respectively). The 3- and 5-year survival rates of these 13 patients were significantly lower than those of the other 29 patients (15.4% vs. 51.0% and 7.7% vs. 46.6%, respectively, P < 0.0001 each). Multivariate analysis using the Cox proportional hazard model identified positive cancer spread to the cystic duct and depth of invasion (beyond serosa) as significant independent indicators of a poor prognosis. CONCLUSIONS: Cancer spread to the cystic duct is an indicator of poor prognosis in patients with gallbladder carcinoma. This may be due to the high incidence of concomitant perineural invasion and lymph node metastasis associated with cancer spread.
Adenocarcinoma↗
Tape ligature of cystic duct and fundus-down approach for safety laparoscopic cholecystectomy: outcome of 500 patients.
It is important to identify the structure of Calot's triangle at the time of cystic duct isolation to decrease intraoperative bile duct injury. Isolation of the cystic duct is the first dangerous technique in laparoscopic cholecystectomy. In conventional open cholecystectomy, the fundus-down approach (retrograde) is a more common procedure than the approach in the reverse direction. Similarly, the fundus-down approach is safe and has benefits of reducing common bile duct injury. We report the easy and safe contrivance for laparoscopic cholecystectomy with taping of the cystic duct followed by resection of the gallbladder with the fundus-down approach, performed for 500 patients. The identified cystic duct was ligatured temporarily with Teflon tape. Then, fundus of the gallbladder was isolated with the fundus-down approach except for Calot's triangle. The tape was used for pulling down the cystic duct and Calot's triangle was easily visible. The cystic duct was cut off only after the confirmation of no bile duct injury. Thanks to this tape procedure, there was no bile duct injury in our 500 cases. We recommend this tape ligature of the cystic duct with the fundus-down approach to decrease the incidence of common bile duct injury.
Adolescent↗
The role of extracorporeal shock wave lithotripsy combined with endoscopic management of impacted cystic duct stones in patients with high surgical risk.
BACKGROUND/AIMS: Cholecystoscopic lithotripsy can be an alternative procedure for the treatment of impacted cystic duct stones in patients who are high risk for surgery. Conventional methods, including electrohydraulic lithotripsy (EHL), occasionally fail due to the inability to access or capture the impacted stones in the narrow, spirally long cystic duct. Using extracorporeal shock wave lithotripsy (ESWL) may be more effective to disintegrate cystic duct stones. The aim of the study is to evaluate the role of ESWL in the endoscopic treatment of impacted cystic duct stones in patients with high operative risk. METHODOLOGY: Eleven patients with impacted cystic duct stones who were at high risk for surgery were included in this study. All of them had had a failed initial attempt of percutaneous transhepatic cholecystoscopic lithotripsy (PTCCS-L) followed by percutaneous transhepatic cholecystostomy. Patients underwent ESWL to disintegrate cystic duct stones with endoscopic removal of fragmented stones. RESULTS: Complete removal of cystic duct stones was achieved in 9 of 11 patients (81.8%). One of the 9 patients (11.1%) was treated solely with ESWL, but the other 8 patients (88.9%) required cholecystoscopic removal of residual fragmented stones after ESWL. Fragmented stones passing through the cystic duct impacted in ampullary region in 3 patients after ESWL. Two patients required transpapillary removal of stones. CONCLUSIONS: Endoscopic stone removal after ESWL for impacted cystic duct stones is a difficult and time-consuming procedure. But, it seems to be a relatively safe alternative to surgery in patients with high surgical risk.
Adult↗
Where to incise and/or divide the cystic duct.
The study concern was to establish the position of cystic duct incision/division in circumstances of laparoscopic cholecystectomy. Seventy consecutive human cadavers were dissected. Corrosion casting (50) and post-mortem cholangiography (20) were employed. Cystic duct length was 34.6 mm, and in 88.6% cases its length was 1-5 cm. Mean cystic duct diameters next to the gallbladder neck, within the valve and 5 mm proximal to the junction with the common hepatic duct were 1.95, 0.42 and 1.85 mm, respectively. Lateral cysto-hepatic junction was identified in 78.6%, spiral in 10% and parallel in 10%. In 90% cases the cysto-hepatic junction is within 4 cm of the hepatic duct junction. One case (1.43%) of cystic duct entering the right hepatic duct was identified. The valve of Heisteri consisted of three spiral turns in 73% of the cases with a range from 0 to 5. In 3/70 specimens the spiral valve did not exist.
Adult↗
Laparoscopic management of enlarged cystic duct.
After laparoscopic exploration of the common bile duct, or when a patient has acute cholecystitis, the cystic duct is sometimes edematous and too large to be ligated safely with an Endoclip. In such cases, ligation of the cystic duct with an Endoloop offers a solution to the problem. The standard technique for application of an Endoloop consists of dividing the cystic duct and then applying the Endoloop. This becomes more difficult if, after the cystic duct is divided, loss of traction on the common bile duct results in retraction of the divided cystic stump outside of the laparoscopic field of view. To avoid this difficulty, the authors apply an Endoloop with the grasping forceps on the cystic duct before the duct is divided so that it cannot retract from operative view and for this task developed an instrument that allows simultaneous introduction of both grasping forceps and the Endoloop through a single port.
Acute Disease↗
Choledochal obstruction by cystic duct stone. Mirizzi's syndrome.
Two patients with high-grade common bile duct obstruction from an impacted cystic duct stone are described. A low-lying cystic-choledochal duct juncture or contiguity of a large cystic duct with the common hepatic duct are usual preexisting anatomic conditions. Known as Mirizzi's syndrome, this uncommon phenomenon needs to be considered when clinical and intraoperative findings indicate obstruction of the common bile duct by stone, but bidirectional exploration of the common bile duct or location of an elusive calculus after choledochotomy proves unexpectedly difficult.
Aged↗
Double cystic duct found by intraoperative cholangiography in laparoscopic cholecystectomy.
We report a rare case of double cystic duct in a 74-year-old woman. The patient complained of mild epigastric discomfort, and several stones were discovered by ultrasonography and computed tomography. Any anomalies of the biliary tract were undetectable in the preoperative examinations without direct cholangiography. Laparoscopic cholecystectomy was performed. After clipping the cystic duct close to the gallbladder, as usual, serial intraoperative cholangiography was performed and unexpectedly showed the inflow of contrast medium into the gallbladder via another cystic duct arising from the right hepatic duct, thus revealing one gallbladder and two cystic ducts, one of which joined the common hepatic duct and the other the right hepatic duct. There was only one cystic artery that arose from the right hepatic artery and accompanied the primary cystic duct to be distributed to the gallbladder. The existence of contrast medium in the resected specimen was confirmed by radiography. No complications occurred during or after laparoscopic cholecystectomy. This is the first report of double cystic duct found in laparoscopic cholecystectomy. We recommend routine preoperative or intraoperative cholangiography.
Aged↗