A Type V Aberrant Right Hepatic Duct Branching from the Cystic Duct: The Paramount Importance of Intraoperative Cholangiography in Supplementing the Critical View of Safety Technique in Laparoscopic Cholecystectomy.

In this report, we present a 38-year-old female with acute cholecystitis, in which an aberrant right hepatic duct draining directly into the cystic duct was revealed by intraoperative cholangiography during a laparoscopic cholecystectomy. This anomaly was classified as the class V variant using the Hisatsugu classification schema, which has an incidence of 1.02%. The use of Strasberg's critical view of safety has become ubiquitous in laparoscopic cholecystectomy. Intraoperative cholangiography provides and additional layer of safety, and should be considered as a routine practice, particularly when imaging to delineate biliary anatomic aberrancies has not been performed prior to surgery.

Anatomy variant symptomatic of the duplication of the common bile duct type IV.

INTRODUCTION: Duplicity of the common bile duct (BCBD) is an unusual congenital disorder. CASE REPORT: A 80-year-old woman with duplication of the common bile duct with retrograde endoscopic cholangiopancreatography (ERCP) who did not resolve the symptoms. DISCUSSION: Our case is a variant of type IV to the classification of DCBC. The MR cholangiography and presurgical ERCP allows assessment of the bile ducts, their caliber, and assessment of abnormalities. The treatment before DCBC will depend on the clinic and the type of opening of the CBCA. CONCLUSIONS: It is important to perform a pre-surgical study and during surgery with CIO.

INTRODUCCIÓN: La duplicidad del conducto biliar común (DCBC) es una alteración congénita insólita. CASO CLÍNICO: Mujer de 80 años con duplicación de la vía biliar común con colangiopancreatografía retrógrada endoscópica (CPRE) que no dilucida la clínica. DISCUSIÓN: Este caso es una variante del tipo IV de la clasificación de DCBC. La colangiorresonancia y la CPRE prequirúrgica permiten valorar las vías biliares, su calibre y las anormalidades. El tratamiento depende de la clínica y el tipo de apertura del conducto biliar común accesorio. CONCLUSIONES: Es importante realizar estudio prequirúrgico y durante la operación con colangiografía intraoperatoria.

Long-term outcomes of endoscopic treatment of aberrant hepatic duct injuries after cholecystectomy.

BACKGROUND AND AIMS: Right aberrant hepatic ducts are an anatomic variant with clinical relevance because of the risk of injury during cholecystectomy. Treatment options for aberrant hepatic duct injuries are not standardized. This study aims to analyze the long-term results of endoscopic treatment of aberrant hepatic duct lesions. METHODS: Patients who underwent ERCP for aberrant hepatic duct lesions were retrospectively identified. Demographic data, type of aberrant duct lesion according to the Strasberg classification, type of treatment (number of plastic stents inserted, treatment duration, and number of ERCPs), and adverse events were recorded. Follow-up was obtained by telephone contact or medical examinations. RESULTS: Between January 1996 and March 2019, 32 patients (78% women, mean age 51.7 years) with aberrant hepatic duct injuries underwent ERCP at our Endoscopy Unit. Six patients had Strasberg type B lesions, 11 patients had type C, and 8 patients had type E5, and 7 patients had a stenosis of the aberrant duct. A mean of 3.7 biliary plastic stents per patient were used; mean treatment duration was 6.3 months. All patients with isolated aberrant duct stenosis and 1 of 6 patients (17%) with type B Strasberg lesions achieved patency. Ten of 11 patients (91%) with type C Strasberg lesions achieved duct recanalization. After a mean follow-up of 109.3 ± 61.2 months, 29 of 32 patients (91%) were asymptomatic; 1 underwent surgery for recurrent cholangitis, 1 received a new endoscopic procedure because of cholangitis, and 1 reported episodic biliary colic without an increase in liver function test values and was successfully managed with a low-fat diet. CONCLUSIONS: An endoscopic approach to aberrant hepatic duct lesions after cholecystectomy can be considered an effective first-line therapy.

Anatomic Variations of the Right Hepatic Duct: Results and Surgical Implications From a Cadaveric Study.

BACKGROUND: Right hepatic duct, formed by the confluence of the anterior and posterior right sectorial ducts, joins left hepatic duct to form common hepatic duct. This fashion of confluence does not prevail in all cases. The sectorial ducts can aberrantly meet left duct and rest of the ducts from the left lobe of liver. Presence of such variation imposes clinical importance during peri-hilar, split liver transplant surgery or cholecystectomy. Nepalese population has not been explored before disregarding clinical necessity as MRI or cholangiography. METHODS: Descriptive cross sectional study was conducted in 107 cases dissecting the main portal fissure separating hemi liver and extrahepatic biliary confluences. Methylene blue dye was injected and bile duct wall was cut open to the study pattern of the confluence. Data analysis was done with Statistical Package for Social Sciences (SPSS) version 17. RESULTS: Normal variant of confluence was found in 72% cases, aberrant right posterior sectorial duct joins left hepatic duct in 9.3% and aberrant right anterior duct or low insertion of the right posterior sectorial duct was found in 1.9%. 9.3% of cases there is no true right hepatic duct often described as triple confluence. 0.9% cases showed no particular pattern of confluence where common hepatic duct is formed by multiple confluence. Quadrate lobe was found to be draining into right anterior sectorial duct in a single case. CONCLUSIONS: Right hepatic duct confluence pattern is variable and all the evidence occurs at the main portal fissure. Right sectorial duct may join the left duct avoiding normal confluence pattern. Right posterior sectorial duct may be inserted low in the common bile duct.

Todani Ic cystic dilatation of the bile duct.

The congenital dilation of the bile duct is an infrequent pathology in western countries and is associated with the female sex. It is usually diagnosed clinically with complementary tests and evaluated at an early age and also appears frequently in adults. These dilatations are grouped into five types according to Todani's classification, including type Ic (Figure 1). The treatment of choice for dilatations of the biliary duct Todani type I is the complete excision of the biliary tract due to the susceptibility of malignant degeneration. A reconstruction is performed via a hepaticojejunostomy with a Roux-en-Y loop. Although in non-malignant cases, a papillotomy with prophylactic stent placement using ERCP can be performed as an alternative. We present the case of a 54-year-old female with a history of high blood pressure, she was examined due to generalized abdominal pain which was unrelated to food intake. The blood test did not identify any alterations of interest. Ultrasound identified a fusiform dilation of the common bile duct occupied by lithiasis. ERCP was attempted due to choledocholithiasis, but the procedure was abandoned as it was not feasible to channel the duodenal papilla. The study was completed with NMR cholangiography (transverse plane [Figure 2] and coronal plane [Figure 3]), identifying a diffuse fusiform dilatation of the common bile duct and common hepatic duct, compatible with congenital cystic lesion Todani type Ic. Finally, the patient underwent a hepaticojejunostomy after sectioning of the main bile duct and extraction of choledocholithiasis.

Embryological etiology of pancreaticobiliary system predicted from pancreaticobiliary maljunction with incomplete pancreatic divisum: a case report.

BACKGROUND: The genesis of the "complex type" classification of pancreaticobiliary maljunction (PBM) is unclear, and the pancreaticobiliary anatomy is also varied according to each case. We encountered a patient with PBM and incomplete pancreatic divisum (PD). We herein discussed about the embryological etiology of pancreaticobiliary system predicted from PBM with incomplete PD. CASE PRESENTATION: A 67-year-old man was found to have a dilatation of the common bile duct (CBD) during a medical examination at 62 years of age. The dilatation of the CBD subsequently progressed, and he was admitted to our hospital for surgical treatment. Magnetic resonance cholangiopancreatography revealed a dilatation from the common hepatic duct to the middle bile duct with PBM. Endoscopic retrograde cholangiopancreatography from the papilla of Vater revealed the pancreatic main duct via the pancreatic branch duct, and PBM with dilatation of the CBD and incomplete PD were revealed. We performed an extrahepatic bile duct resection and hepaticojejunostomy because of high risk of malignant transformation. Taping and transection of the bile duct without dilatation on the pancreatic side were performed, and thereafter, two orifices of the common channel and ventral pancreatic duct were ligated. The level of amylase in the bile was 7217 IU/L, and a histological examination of the CBD showed an inflammatory change of CBD, not a malignant transformation. CONCLUSION: It is somewhat easy to identify the pancreatobiliary anatomy when the cause of embryology of both PBM and PD is thought to be an abnormal embryology of the ventral pancreas.

Accessory bile duct: a rare but important anatomical variant.

An 84-year-old man presented with pancreatic adenocarcinoma. Following neoadjuvant chemoradiation, the patient underwent a pancreaticoduodenectomy, complicated by early bile leak. Re-exploration and intraoperative cholangiogram identified an accessory common bile duct draining segment 5 of the right hepatic lobe, which was then ligated. The patient underwent a complicated postoperative course eventually developing sepsis secondary to biliary stasis. He elected for comfort measures and passed away secondary to complications of sepsis.

[Rare bile duct anatomy variant - Right bile duct intraparenchymal junction into the left bile duct]. / Az epeutak ritka anatómiai variánsa − A jobb ductus hepaticus intraparenchymalis csatlakozása a bal oldali ductus hepaticusba.

The authors present a case of a 67-year-old male patient, who previously had been diagnosed with a malignant liver tumor localized in segment II. He underwent bisegmentectomy (II and III) and partial IV segmentectomy. After the primary surgery jaundice developed, the level of bilirubin increased and after several imaging modalities reoperation was indicated. During the surgery a rare bile duct anatomy variant was found. The right hepatic duct joined the left duct in the parenchyma of the left lobe, and was ligated at the resection. As the liver hilum was not explored, the absence of the right duct was not discovered. Reconstruction of the biliary system was accomplished by a Roux-en-Y loop.

Heterotopic Gastric Mucosa in a Duplication Cyst of the Common Hepatic Duct Mimicking Cholangiocarcinoma.

Heterotopic gastric mucosa in biliary tract is a congenital anomaly that can prove significant clinical dilemmas. Here we report the case of a 28-year-old female patient presenting with jaundice, pruritus, and altered liver tests, with predominant cholestasis. Liver biopsy revealed histological changes suggesting large bile duct obstruction with advanced fibrosis. At imaging, common hepatic duct stricture due to an intraluminal enhancing mass was observed. Endoscopic retrograde cholangiopancreatography and upper echoendoscopy revealed a firm mass of the common hepatic duct with a complete obstruction, suspicious for cholangiocarcinoma. Fine-needle aspiration biopsy performed under echoendoscopic guidance revealed fundic type gastric mucosa. Despite histological result, radiological suspicion of malignancy together with advanced fibrosis prompted a segmental resection of biliary tract. At macroscopic examination, the common hepatic duct presented a focal pseudocystic appearance with a firm zone of subtotal stenosis. Histology revealed a duplication cyst lined by heterotopic fundic gastric mucosa. Heterotopic gastric mucosa of the biliary tract should be suspected in young patients without know risk factors for hepatobiliary malignancies. Imaging and careful histological examination are mandatory for optimal management. Liver fibrosis, secondary to chronic biliary obstruction may be a significant late complication.

Multidetector CT in detection of troublesome posterior sectoral hepatic duct communicating with cystic duct.

OBJECTIVE: To investigate whether multiple detector CT (MDCT) could detect troublesome aberrant posterior sectoral hepatic duct (PHD) communicating with cystic duct (CD). METHODS: The most troublesome bile duct anomaly during cholecystectomy is an aberrant PHD communicating with CD. It has been suggested that an unenhanced small duct between Rouviere's sulcus and CD on MDCT could be coincident to an aberrant PHD communicating with CD. A total of 224 patients who underwent laparotomy with complete lymph node dissection in the hepatoduodenal ligament for hepatobiliary or pancreatic tumour were enrolled. Retrospective review of preoperative MDCT images and surgical records was performed. RESULTS: Preoperative MDCT detected 8 (3.6%) unenhanced ducts between Rouviere's sulcus and CD. Surgical records identified 7 (3.1%) cases of aberrant PHD communicating with CD, and all 7 cases showed an unenhanced duct between Rouviere's sulcus and CD on preoperative MDCT imaging. Among the 7 patients, 5 (71%) were without bile duct dilatation. CONCLUSION: MDCT could detect troublesome aberrant PHD communicating with CD, regardless of the presence or absence of bile duct dilatation. Advances in knowledge: MDCT could detect most troublesome PHD communicating with CD, regardless of the presence or absence of bile duct dilatation.

Preoperative evaluation of accessory hepatic ducts by drip infusion cholangiography with CT.

BACKGROUND: This retrospective study aimed to investigate the incidence of each type of accessory hepatic duct by drip infusion cholangiography with CT (DIC-CT). METHODS: Five hundred sixty nine patients who underwent preoperative DIC-CT and laparoscopic cholecystectomy were reviewed. Accessory hepatic ducts were classified as follows: type I (accessory hepatic ducts that merged with the common hepatic duct between the confluence of the right and left hepatic ducts and the cystic duct confluence), type II (those that merged with the common hepatic duct at the same site as the cystic duct), type III (those that merged with the common bile duct distal to the cystic duct confluence), type IV (the cystic duct merged with the accessory hepatic duct), and type V (accessory hepatic ducts that merged with the common hepatic or bile duct on the left side). RESULTS: Accessory hepatic ducts were observed in 50 patients. Type I, II, III, IV, and V accessory hepatic ducts were detected in 32, 3, 1, 11, and 3 patients, respectively. Based on their drainage areas, the accessory hepatic ducts were also classified as follows: a posterior branch in 22 patients, an anterior branch in 9 patients, a combination of posterior and anterior branches in 16 patients, a left-sided branch in 2 patients, and a caudate branch in 1 patient. None of the patients with accessory hepatic ducts suffered bile duct injuries. CONCLUSION: There are a number of variants of the accessory hepatic duct. DIC-CT is useful to detect the accessory hepatic duct.

Magnetic Resonance (MR) Cholangiopancreatography Demonstration of the Cystic Duct Entering the Right Hepatic Duct.

BACKGROUND MR cholangiopancreatography is widely performed before laparoscopic cholecystectomy to rule out choledocholithiasis and to avoid iatrogenic injuries that may be related to the high frequency of anatomical variations of the biliary tree. Although most of these variants have already been demonstrated surgically and by endoscopic retrograde cholangiopancreatography and CT cholangiography, there are no references in which MR cholangiopancreatography has shown a cystic duct draining into the right hepatic biliary duct. CASE REPORT A 51-year-old woman with a history of recurrent abdominal pain underwent an abdominal ultrasound in an outside center, which revealed gallbladder cholelithiasis. In this patient, an MR cholangiopancreatography was performed and the laboratory data were obtained. Laboratory findings showed only a mild increase of cholestasis. MRCP did not reveal significant dilatation of intra- or extrahepatic biliary ducts, while the cystic duct showed an atypical insertion, draining directly into the right hepatic duct. CONCLUSIONS To avoid unintentional bile duct injuries, MRCP evaluation of the biliary anatomy is particularly important for pre-operative evaluation of patients undergoing laparoscopic cholecystectomy. In particular, in the case we describe, the right hepatic duct might have been mistaken for the cystic duct, with potentially severe surgical complications and clinical consequences.

An unusual type of biliar cyst: A case report.

 We present the case of a 56-yr-old woman with vague abdominal pain of approximately 5 months duration. An ultrasound study showed moderate dilation of the common bile duct. Magnetic resonance cholangiopancreatography confirmed a cystic dilatation of the right hepatic duct with intra and extra hepatic component. The patient underwent right hepatectomy and complete excision of the cyst. Microscopically, the cyst wall was formed by fibrous tissue with mild acute and chronic inflammatory infiltrate, the inner surface showed a single layer of columnar epithelium and extensive squamous metaplasia without atypia, wich expressed p63 and high molecular weight cytoqueratin (34BE12).

Preoperative detection and handling of aberrant right posterior sectoral hepatic duct during laparoscopic cholecystectomy.

BACKGROUND: An aberrant right posterior sectoral hepatic duct (PHD) draining into extrahepatic bile duct, gallbladder or cystic duct directly is a common and critical anomaly during cholecystectomy. This study aimed to investigate the frequency of aberrant PHD and describe why PHD is critical. METHODS: In 753 consecutive patients who underwent laparoscopic cholecystectomy (LC) using our standardized procedure over 9 years, we reinvestigated whether an aberrant PHD was present using preoperative images. A PHD joining the common bile duct through the cranial side of the hilar plate was defined as the supraportal type, and one passing through the caudal side of the right portal vein was defined as the infraportal type. RESULTS: Fifty-one (6.8%) patients had aberrant PHD. All of them had the infraportal type, and the cystic duct drained into aberrant PHD in 10 (1.3%) and aberrant PHD drained into the cystic duct in six (0.8%). These 16 most dangerous anomalies were diagnosed before surgery. In all patients with aberrant PHD, LC was completed without any complications. CONCLUSIONS: It seems possible to identify most aberrant PHD by attention to the infraportal-type PHD, and injury to them can be avoided by exposing a critical view using an appropriate procedure.

Management of bile duct injuries combined with accessory hepatic duct during laparoscopic cholecystectomy.

Bile duct injuries (BDIs) are difficult to avoid absolutely when the biliary tract has a malformation, such as accessory hepatic duct. Here, we investigated the management strategies for BDI combined with accessory hepatic duct during laparoscopic cholecystectomy.

One-stop shop for 3-dimensional anatomy of hepatic vasculature and bile duct with special reference to biliary image reconstruction.

BACKGROUND/AIMS: Three-dimensional CT has become an essential tool for successful hepatic surgery. Up to now, efforts have been made to simultaneously visualize hepatic vasculature and bile ducts. Herein, we introduce a new one-stop shop approach to hepatic 3D-anatomy, using a standard enhanced MDCT alone. METHODOLOGY: A 3D-reconstruction of hepatic vasculature was made using data from contrast enhanced MDCT and SYNAPSE VINCENT software. We identified bile ducts from axial 2D image, and then reconstructed the 3D image. Both hepatic vasculature and bile duct images were integrated into a single image and it was compared with the 3D image, utilized with MRCP or DIC-CT. RESULTS: The first branches of both the right and left hepatic ducts were hand-traced and visualized for all 100 cases. The second branches of these ducts were visualized in 69 cases, and only the right second branch was recognized in 52 cases. Anomalous variations of bile ducts, such as posterior branch joining into common hepatic duct, were recognized in 12 cases. These biliary tract variations were all confirmed by MRCP or DIC-CT. CONCLUSIONS: Our new one-stop shop approach using the 3D imaging technique might contribute to successful hepatectomy as well as reduce medical costs and radiation exposure by omission of MRCP and DIC-CT.