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PubMed1988

Long-term occlusion of the porcine cystic duct by means of endoluminal radio-frequency electrocoagulation.

Recurrent cholelithiasis must be expected after gallstone removal without cholecystectomy. Chemical gallbladder ablation may offer prevention but requires preliminary cystic duct occlusion. Radio-frequency (RF) electrocoagulation of the cystic duct was performed in 15 pigs to induce occlusion by a controlled thermal epithelial injury. A flexible coagulation catheter was placed into the cystic duct lumen under fluoroscopic control by means of either subhepatic cholecystostomy or direct, percutaneous transhepatic gallbladder puncture. Complete cystic duct occlusion was proved in 14 animals. Follow-up ranged from 1 to 17 weeks (mean, 11 weeks). Histologically, the RF technique induced an intense chronic inflammatory and fibroblastic reaction, which eventually obliterated the coagulated cystic duct segments. There was no epithelial regeneration or recanalization of the fibrotic cystic duct segments. The adjacent structures, particularly the cystic artery, were intact in all specimens.

Animals↗
PubMed1997

Is biliary lithogenesis affected by length and implantation of cystic duct? Study of 270 patients with endoscopic retrograde cholangiopancreatography.

The gallbladder seems to play an important role in lithogenesis. Moreover, the morphology and the implantation of the cystic duct may also influence this process. Our purpose was to evaluate if the length and the implantation of the cystic duct may affect the formation of gallstones. Between April 1992 and March 1994, 270 patients who underwent endoscopic retrograde cholangiopancreatography were included in the study, and the radiological length of the cystic duct was carefully recorded. Patients were divided into two groups: I, absence of lithiasis: 113 patients (65 men, 48 women); and II, gallbladder lithiasis or lithiasis in the common bile duct with or without gallbladder lithiasis: 157 patients (73 men, 84 women). A statistically significant difference was observed among the two groups regarding the insertion of the cystic duct: implantation on the left side of the common bile duct represented a risk factor of lithiasis. The length of the cystic duct was not directly implicated. Hypokinesis of the gallbladder is currently recognized as being a major factor in the initial steps of lithogenesis, but the implantation of the cystic duct can play an important role by increasing cystic duct resistance and causing a reduced washout effect of the gallbladder contents, including cholesterol crystals.

Adult↗
PubMed1983

Isolated cystic dilatation of the cystic duct.

Presented was an unusual case of congenital cystic dilatation of the extrahepatic biliary tract in which the cystic changes were confined solely to the cystic duct. There was concomitant common bile duct obstruction secondary to inflammation and mass effect from the cyst. Management consisted of cholecystectomy, excision of the cyst, common bile duct exploration, examination of the ampullary region by duodenotomy, and choledochoduodenostomy.

Bile Duct Diseases↗
PubMed1989

Percutaneous transcatheter occlusion of cystic duct stump in postcholecystectomy bile leakage.

Postoperative cystic duct fistula is an uncommon complication after cholecystectomy. Nonoperative management includes endoscopic retrograde or percutaneous transhepatic biliary drainage, and percutaneous catheter drainage of fluid collections. Transcatheter occlusion of the leaking cystic duct remnant proved a valuable alternative treatment when biliary stenting failed for technical reasons.

Aged↗
PubMed1991

Cholecystcholangiography during laparoscopic cholecystectomy: cholecystcholangiography or cystic duct cholangiography.

Laparoscopic cholecystectomy is being used more frequently in the treatment of symptomatic cholelithiasis. The procedure as originally described was performed with cystic duct cholangiography. An alternate technique of performing cholangiography is cholecystcholangiography. Because of the objections that have been voiced concerning direct gallbladder injections namely, reliability of the technique, quality of the studies, and the risk of forcing stones into the common bile duct this study was performed. Subjects were 25 consecutive patients who underwent cholecystcholangiography during laparoscopic cholecystectomy. A standard technique was developed and used. Studies were graded from 0 to 5 depending upon quality with 5 being the best and 0 the worst. A 5 consisted of visualization of all of the biliary tract structures and the duodenum and a 0 consisted of visualization of only the gallbladder. Acceptable studies (graded 3, 4, or 5) were obtained in 20 patients (80%). An inability to obtain an acceptable study could usually be determined prior to contrast injection. Accordingly there would be no time delay in proceeding directly to cystic duct cholangiography. In our patients, 48% had stones in the gallbladder smaller than the caliber of the cystic duct. Based upon the results of this study we believe that cholecystcholangiography is the technique of choice for intraoperative cholangiography during laparoscopic cholecystectomy. In patients in whom this technique is not feasible the surgeon should proceed directly to cystic duct cholangiography. There was no added risk to the patient when cholecystcholangiography was performed. There was a benefit in terms of the ease of the procedure and the performance of the procedure over cystic duct cholangiography. The determination of ductal anatomy prior to cystic duct dissection may be important in minimizing the risk of ductal injury during laparoscopic cholecystectomy.

Adult↗
PubMed2005

Cystic duct directly joining the main pancreatic duct.

A unique anomaly of the direct union between the cystic duct and the main pancreatic duct is presented. A 19-year-old man with a history of repeated epigastralgia underwent endoscopic retrograde cholangiopancreaticography that showed a direct union between the cystic duct and the main pancreatic duct. No pancreaticobiliary maljunction was noticed. Cholecystectomy accompanied by resection of the long cystic duct was performed. The excised gallbladder showed cholesterolosis, chronic cholecystitis, and hyperplasia of the pseudopyloric glands microscopically. The patient has been well for 3 years since surgery.

Abdominal Pain↗
PubMed1991

Cystic duct occlusion by microwave tissue coagulator in rabbits.

In this preliminary study a flexible bipolar microwave electrode, 1.8 mm in diameter, was designed to occlude the cystic duct in 18 rabbits. Thermal model tests were performed to evaluate the effect of the antenna and to master the coagulating condition. Through surgical cholecystostomy, the antenna was inserted into the proximal cystic duct for various coagulation treatments. Cholecystography showed that the cystic duct was occluded minutes to hours after coagulation. Histologically, the microwave technique induced a chronic inflammation and fibrosis which eventually obliterated the coagulated cystic duct permanently. In group A (30 mA for 20 s) the cystic duct epithelium regeneration occurred and surrounding liver damage was limited, while in groups B (50 mA for 10 s) and C (70 mA for 6 s) no epithelium regeneration was observed and injury to the liver was mild to moderate. It was found that microwaves generated at 50 mA for 10 s to occlude the rabbit's cystic duct are effective and less injurious.

Animals↗
PubMedDate not supplied

Laparascopic cholecystectomy: cystic duct occlusion with titanium clips or ligature? A prospective randomized study.

During laparoscopic cholecystectomy (LC), cystic duct occlusion can be done with titanium clips or laparoscopically tied knots. However, till date, there is no randomized, controlled study reported in the literature that has prospectively compared the outcome using either of these methods. In the present study, 105 patients who were to undergo LC were randomly assigned to two groups. Group I comprised patients undergoing cystic duct occlusion with clips while group II comprised those undergoing cystic duct occlusion with knots. Our aim was to compare the postoperative outcome in both the cases. The incidence of overall bile leak following LC was 4 out of 105 (3.8%) while the leak rate following cystic duct occlusion with clips was 2 out 52 (3.9%), and that following ligature was 2 out of 53 (3.8%). The procedure using ligature took slightly longer time than that using clips. There was no significant difference in the postoperative outcome in either group. The use of ligature is a feasible, safe and cost-effective alternative to the use of titanium clips for cystic duct occlusion during LC.

Adolescent↗
PubMedDate not supplied

Safety of cystic duct clipping in healthy and cirrhotic livers: a cadaveric study.

BACKGROUND AND OBJECTIVES: Biliary leakage through the cystic duct stump due to clip dislodgement has been a concern since the advent of the laparoscopic cholecystectomy. The authors proposed a cadaveric model to test the safety of cystic duct clipping in a hypertensive biliary tract in healthy and cirrhotic livers. METHODS: Twenty fresh cadavers were studied (5 cirrhotic, 15 healthy). Open cholecystectomy was performed and the cystic duct clipped with commercially available titanium clips. The distal common bile duct was catheterized to allow infusion of water and pressure measurement. RESULTS: Increased pressure in the bile duct resulted in back diffusion into the liver, preventing reaching high-pressure levels. Only 1 clip was dislodged in this situation, in a cirrhotic liver with a large cystic duct. As a second experiment, the hepatic hilum was clamped to allow higher pressures of the biliary tree (500 mm Hg). In this situation, no clip was dislodged. CONCLUSIONS: We have established the safety of cystic duct clipping in healthy and cirrhotic livers; however, bigger clips or alternative methods to seal the duct may be necessary in larger ducts.

Adult↗
PubMed1997

[Extraction of cystic duct occlusion calculus in laparoscopic cholecystectomy].

Occluding stones left in the stumpf of the cystic duct may account for between 17% and 25% of the cases of post-cholecystectomy syndrome. When acutely inflamed or empyemic gallbladders are removed, an occlusive cystic duct stone must almost always be expected. When performing laparoscopic cholecystectomy, therefore, care must be taken to ensure that any stone occluding the cystic duct are detected and removed. After completely freeing the cystic duct to the point of its junction with the common bile duct, it is carefully "palpated" with a 5 mm forceps for the presence of stones. Any such present are pressed out of the duct through a transverse incision, and retrieved. Bile reflux through the incision in the duct indicates freedom from stones. Finally, intraoperative cholangiography can be performed.

Cholangiography↗
PubMed2002

Cystic duct carcinoma: a proposal for a new "working definition".

BACKGROUND: Farrar's criteria for cystic duct carcinoma (histopathological diagnosis of a carcinoma strictly limited to the cystic duct) have practical limitations. We propose new "working definition": a gallbladder tumor, the center of which is located in the cystic duct. PATIENTS AND METHODS: Between 1980 and 2000 we diagnosed cystic duct carcinoma in 31 patients, 28 of whom (90%) had increased serum bilirubin concentrations. Extrahepatic bile duct resection and cholecystectomy were performed in 10 patients; in others, extended right hepatectomy (16), right hepatectomy (3), and liver bed resection (2) were necessary as well for a potentially curative resection. Additional procedures were portal vein resection (10) and pancreatoduodenectomy (7). RESULTS: All tumors were adenocarcinomas. Depth of invasion was T2 in 3 patients, T3 in 12, and T4 in 16. Thirteen patients (42%) had lymph node metastasis. Curative resection was performed in 24 patients (77%). Hospital mortality was 5 of 31 (16%). Actuarial 5-year survival rate excluding hospital deaths was 22%. CONCLUSIONS: The proposed "working definition" avoids the problems associated with Farrar's criteria and describes a distinct patient group with an approximately equal proportion of men and women, advanced T stage, but a lower than expected frequency of lymph node metastasis. It establishes a basis for standard reporting of results.

Adenocarcinoma↗
PubMed1994

Cystic duct stabilization during laparoscopic exploration and stone removal.

A modification of the standard method for cystic duct stabilization is presented. A percutaneously placed suture is used to loop and stabilize the cystic duct. The suture is secured outside the abdominal wall at the skin level using a clamp. Percutaneous suture stabilization of the cystic duct provides an alternative method of common bile duct stabilization when laparoscopic choledochotomy is required. By using this method, we can easily stabilize the cystic duct without the need for additional trocars and simplify the use of the choledochoscope.

Cholecystectomy, Laparoscopic↗
PubMed2005

Painful cystic duct remnant diagnosed by endoscopic ultrasound.

Postcholecystectomy pain may remain unexplained and difficult to treat. This report describes three patients with constant postcholecystectomy abdominal pain that may have arisen from the cystic duct remnant or a neuroma of the cystic duct stump. In each case pain was exacerbated by pushing on cystic duct surgical clips with an EUS-guided needle, and temporarily abolished by an EUS-guided injection of bupivicaine and triamcinolone. Two patients underwent surgical resection of the cystic duct remnant and the third did not require further treatment. Two of the three patients had long-term improvement. EUS is a novel modality for assessing the cystic duct remnant and performing a therapeutic trial.

Abdominal Pain↗
PubMed1984

The muscle layer of the canine gallbladder and cystic duct.

The muscle layer of the canine gallbladder wall and cystic duct was found to be a three-dimensional meshwork of smooth muscle bundles which appear loosely and irregularly arranged on the mucosal aspect and consolidate to form a homogeneous plate-like layer on the serosal aspect. The muscle bundles are tightly woven around interspersed pockets of loose connective tissue in the gallbladder wall and gradually become loosely arranged with more prominent amounts of intervening connective tissue in the cystic duct. The muscle layer is thickest in the gallbladder wall and becomes progressively thinner out into the cystic duct. No anatomic sphincter was observed. Ultrastructural organization revealed individual muscle fibers to be of irregular profile, often branching, widely spaced with intervening collagen fibers, and having few cell-to-cell contacts.

Animals↗
PubMed1995

Ultrastructural changes of female Syrian hamster cystic duct epithelium as a result of sex steroid treatment.

In view of the lack of sufficient data regarding the morphology of the cystic duct and the extensive focus on the gallbladder, a preliminary examination of the cystic duct response to female sex steroid treatment was conducted to follow up a detailed ultrastructural study of the gallbladder epithelial response to a similar treatment. As observed in the gallbladder epithelium, the cystic duct epithelial cells of nulliparous Syrian hamsters demonstrate morphologic changes in response to female sex steroid treatment. Control (C) cystic duct epithelial cells are covered by short microvilli and each cell appears to exhibit a single vestigial cilium. Estrogen (E)- and estrogen + medroxyprogesterone (E + MP)-treatments induce differential duct cell morphologic changes. These changes are the result of steroid treatments in the significant decreasing sequence E > E + MP > C for nuclear volume, indentations and perinuclear lysosomal/lipofuscin bodies. Moreover E + MP-treatment results in larger cytoplasmic volume and more sloughing of apical cell excrescences than following E treatment. It is suggested that, similar to that in the gallbladder, the action of progestin is paramount in favoring cytoplasmic morphological changes in the cystic duct which, along with the alteration of mucus, cell sloughing, decreased bile acids and motility could also participate in the gallstone nucleation process as they are brought into the gallbladder with the incoming bile flow.

Animals↗
PubMedDate not supplied

Dilatation of the cystic duct in patients with obstructive jaundice.

BACKGROUND: It is well known that obstructive jaundice causes biliary dilatation, but sonographic (US) findings of the cystic duct in patients with obstructive jaundice are rarely reported. METHODS: We reviewed US findings in 25 such patients. RESULTS: US findings of dilated cystic duct could be divided roughly into two patterns: tortuous and tubular. The former pattern was a tortuously dilated cystic duct arising from the gallbladder neck, running predominantly deeply, turning anteromedially, and then joining the posterior face of the common hepatic duct. The latter pattern was a straight dilated cystic duct running parallel with the common hepatic duct, giving the appearance of a septated bile duct. CONCLUSION: A better understanding of the US findings of dilated cystic duct translates into improved biliary US diagnosis.

Adult↗
PubMed1990

Ablation of the cystic duct and the gallbladder. Experimental basis and initial clinical observations.

Bipolar radiofrequency electrocoagulation of the cystic duct by catheter can be performed safely and reproducibly using fluoroscopic control and induces endoluminal scar formation. The scar within the cystic duct forms a reliable barrier between the gallbladder and the biliary system and avoids recanalization of the cystic duct at a later date. Sclerotherapy of the isolated gallbladder with 95% ethanol and 3% STS can be performed without toxic or otherwise adverse effects and is suitable to ablate the porcine gallbladder. Initial clinical trials with this new technique on a small number of patients are promising and have demonstrated that the protocol can be applied safely to humans. The electrocoagulation technique by catheter appears suitable to ablate the human cystic duct. Follow-up evaluation of our first patients is under way and must determine whether our regimen is appropriate to ablate the human gallbladder on a long-term basis. Further development of this new approach may eventually enable definitive nonoperative treatment of cholecystolithiasis in selected patients.

Animals↗
PubMed1996

Cystic duct leak after laparoscopic cholecystectomy. A multi-institutional study.

BACKGROUND: Cystic duct leak is a rare complication of laparoscopic surgery. To study the incidence, presentation, and management of cystic duct leak (CDL) after laparoscopic cholecystectomy (LC) a retrospective study of centers doing large numbers of LC was done. METHODS: Patient information was obtained by a questionnaire sent to experienced laparoscopic surgeons. This queried demographic information, course of the original operation, presentation, diagnostic studies, and management of CDL after LC. RESULTS: Some 22, 165 LCs were performed by 24 surgeons; there were 58 cases of CDL (0. 26%); 21% of the surgeons reported no CDLs; 60% of CDLs occurred in the first 25% of each surgeon's experience, but CDLs continue to occur even in their most recent 10% of cases. Preoperative symptoms, prior surgery, and comorbid conditions did not predict CDL. Acute cholecystitis was present at initial surgery in 47%. Symptoms of CDL an average of 3.1 days post-LC were abdominal pain 78%, fever 26%, nausea 35%, vomiting 22%, abdominal distention 26%, and shoulder pain 12%. WBCs and LFTs were elevated in more than two-thirds of the cases. ERCP was most frequently used to diagnose CDL (53%) and was successful in 97%, although sonogram (40%) and HIDA scan (26%) and CT (26%) were also used. Management included ERCP and ductal decompression in 27 patients, percutaneous drainage in 13 patients, open laparotomy in 14, laparoscopy in three, and observation in two. Patients were discharged an average of 7.4 days post discovery of leak. Stents were removed an average of 30 days post ERCP. Ninety-four percent were complete cures. There was one post-treatment abscess. Two deaths due to multisystem failure unrelated to leak occurred. CONCLUSIONS: Cystic duct leak is rare and fairly easily diagnosed. It occurs more frequently during the learning curve, but also after much experience. ERCP and ductal decompression play a large role in treatment, but almost all standard methods of treatment yield successful outcomes with low morbidity.

Cholecystectomy, Laparoscopic↗