Variations in the cystic duct: frequency and the relationship among insertion sides and heights on the bile duct.

BACKGROUND: Evaluation of the cystic duct anatomy prior to bile duct or gallbladder surgery is important, to decrease the risk of bile duct injury. This study aimed to clarify the frequency of cystic duct variations and the relationship between them. METHODS: Data of 205 patients who underwent cholecystectomy after imaging at Sada Hospital, Japan, were analyzed. The Chi-square test was used to analyze the relationships among variations. RESULTS: The lateral and posterior sides of the bile duct were the two most common insertion points (92 patients, 44.9%), and the middle height was the most common insertion height (135 patients, 65.9%). Clinically important variations (spiral courses, parallel courses, low insertions, and right hepatic duct draining) relating to the risk of bile duct injury were observed in 24 patients (11.7%). Regarding the relationship between the insertion sides and heights, we noticed that the posterior insertion frequently existed in low insertions (75.0%, P < 0.001) and did not exist in high insertions. In contrast, the anterior insertion coexisted with high and never low insertions. Spiral courses have two courses: anterior and posterior, and anterior ones were only found in high insertion cases. CONCLUSIONS: The insertion point of the cystic duct and the spiral courses tended to be anterior or lateral superiorly and posterior inferiorly. Clinically significant variations in cystic duct insertions are common and surgeons should be cautious about these variations to avoid complications.

[Cystic duct carcinoma in a patient with a history of cholecystectomy: a case report].

An 83-year-old Japanese man who underwent cholecystectomy for cholecystolithiasis 17 years ago visited our hospital owing to epigastric pain. He was initially diagnosed with choledocholithiasis and acute cholangitis following white blood cell, C-reactive protein, total bilirubin, alkaline phosphatase, and γ-glutamyltranspeptidase level elevations along with common bile duct stones on computed tomography (CT). Moreover, CT, magnetic resonance imaging, endoscopic retrograde cholangiography (ERC), and endoscopic ultrasonography (EUS) also revealed a 2-cm-diameter mass arising from the remnant cystic duct. The cytology of the bile at the time of ERC was not conclusive. However, EUS-assisted fine needle aspiration (EUS-FNA) of the mass confirmed the diagnosis of adenocarcinoma of the remnant cystic duct. The patient underwent extrahepatic bile duct resection. Cystic duct carcinoma following cholecystectomy is rare. We report a case diagnosed by EUS-FNA.

Percutaneous Cystic Duct Interventions and Drain Internalization for Calculous Cholecystitis in Patients Ineligible for Surgery.

PURPOSE: To evaluate the feasibility, effectiveness, and outcomes of percutaneous cholecystostomy drain internalization in patients with calculous cholecystitis who were not surgical candidates. MATERIALS AND METHODS: Percutaneous cystic duct interventions were attempted in 17 patients (with the intent to place dual cholecystoduodenal stents) who were deemed unfit for surgery and had previously undergone percutaneous cholecystostomies for acute calculous cholecystitis. Baseline demographics, technical success, time from percutaneous cholecystostomy to internalization (dual cholecystoduodenal stent placement), stent patency duration, and adverse event rates were evaluated. RESULTS: Fifteen (88%) of 17 procedures to cross the cystic duct were technically successful. Of these 17 patients, 13 (76%) underwent successful placement of dual cholecystoduodenal stents. Two of these 13 patients (who had successful dual cholecystoduodenal stent placement) needed repeat percutaneous cholecystostomy drains (1 patient had stent migration leading to recurrent cholecystitis, and the other had a perihepatic biloma). The 1-year patency rate was 77% (95% CI, 47%-100%). CONCLUSIONS: Dual cholecystoduodenal stent placement in nonsurgical patients is a technically feasible treatment option with the goal to remove percutaneous cholecystostomy drains.

Incidence and management of cystic duct perforation during endoscopic transpapillary gallbladder drainage for acute cholecystitis.

BACKGROUND AND AIM: Evidence regarding the incidence and clinical outcome of cystic duct perforation (CDP) during endoscopic transpapillary gallbladder drainage (ETGBD) is inadequate. The present study aimed to evaluate the incidence and management of CDP during ETGBD. METHODS: Between March 2011 and December 2019, 249 patients underwent initial ETGBD for acute cholecystitis. The incidence of CDP was retrospectively examined and the outcomes between the CDP and non-CDP groups were compared. RESULTS: CDP during ETGBD occurred in 23 (9.2%) of 249 patients (caused by guidewire in 15 and cannula in 8). ETGBD was successful in 10 patients following CDP. In 13 patients who failed ETGBD, 11 underwent bile duct drainage during the same session; nine patients underwent gallbladder decompression by other methods, such as percutaneous drainage. Clinical resolution for acute cholecystitis was achieved in 20 patients, and no bile peritonitis was noted. ETGBD technical success rates (45.3% vs. 91.2%, p < 0.001), ETGBD procedure times (66.5 vs. 54.8 min, p = 0.041), and hospitalization periods (24.5 vs. 18.7 days, p = 0.028) were significantly inferior in the CDP group (n = 23) compared with the non-CDP group (n = 216). There were no differences in clinical success and adverse events other than CDP between both groups. CONCLUSIONS: Cystic duct perforation reduced the ETGBD technical success rate. However, even in patients with cystic duct perforation, an improvement of acute cholecystitis was achieved by subsequent successful ETGBD or additional procedures, such as percutaneous drainage.

The anatomy of the cystic duct and its association with cholelithiasis: MR cholangiopancreatographic study.

The aims of this article are to detail the anatomy of the cystic duct in patients with and without gallstones as it relates to maneuvering of the duct during endoscopic transpapillary gallbladder cannulation, and to elucidate its role in the dynamics of bile flow during gallbladder contraction. One hundred MRCPs were retrieved from the prospectively maintained radiology data system to assess the configuration of the cystic duct and its confluence vis-a-vis the main biliary duct. The configuration of the cystic duct was broadly classified into four types: Angular (44%), Linear (40%), Spiral (11%), and Complex (5%). The level of emergence of the cystic duct from the bile duct was proximal in 29%, middle in 49% and distal in 20%. Its direction from the bile duct was to the right and angled upward in 69%, right and angled downward in 15%, left and angled upward in 13%, and left and angled downward in 1%. Its orifice was on the lateral surface of the bile duct in 50%, posterior in 19%, anterior in 15% and medial in 14%. In two cases, the cystic duct opened directly into the duodenum. Tortuous cystic ducts and non-lateral unions with the bile duct were significantly more prevalent in gallstone cases than the non-gallstone group (p = 0.02). The present study details the spatial anatomy of the cystic duct vis a vis the main biliary duct. This has not been well investigated to date but has become increasingly relevant with the advent of recent gallbladder interventions.

Cystic duct stones in postcholecystectomy Mirizzi syndrome - A novel endoscopic treatment.

Mirizzi syndrome is a rare type of cholelithiasis, and the main treatment is still surgery. The development of endoscopic technology has made surgeons more active in the management of rare diseases of the biliary tract and pancreas. Here we report that our center applied the new endoscopic method to treat a Mirizzi patient with residual cystic neck duct stones after laparoscopic cholecystectomy.

Anaotmical variability in the position of cystic artery during laparoscopic visualization.

BACKGROUND: The laparoscopic view of extrahepatic biliary tract and cystic artery is different anatomically from open approach. Consequently iatrogenic injuries due to inadverent damage to cystic artery are not uncommon. These complications can be prevented by careful dissection in Calots triangle and better knowledge of laparoscopic anatomy of cystic artery and its variations. The aim of this study is to establish the prevalence of variation in position of cystic artery in relation to cystic duct. This will help identify the safe area for dissecting peritoneum in Calots triangle and thus help young surgeons overcome the long learning curve associated with laparoscopy. MATERIALS AND METHODS: During a 10 year period from January 2009 to January 2019, 1850 laparoscopic cholecystectomies that were performed at a tertiary care hospital were studied. Patients with history of previous abdominal surgery were excluded from the study. Cystic artery was divided into four groups based on its relative position to cystic duct. It includes superomedial, superolateral, anterior and absent cystic artery relative to the cystic duct. RESULTS: Out of 1850 cases of laparoscopic cholecystectomy 1676 (90.59%) patients had cystic artery superomedial to cystic duct and 96 (5.19%) had a cystic artery at superolateral position to cystic duct. In 48 (2.59%) patients it was found anterior to cystic duct and in 30 (1.62%) patients it was absent. CONCLUSIONS: It is concluded that the most common position of cystic artery is superomedial while the least common position was found to be anterior to cystic duct. Hence it is postulated that blind dissection from anterior side is the safest approach to avoid injury to cystic artery.

3D-printed anatomical models of the cystic duct and its variants, a low-cost solution for an in-house built simulator for laparoscopic surgery training.

OBJECTIVES: To explore a method to create affordable anatomical models of the biliary tree that are adequate for training laparoscopic cholecystectomy with an in-house built simulator. METHODS: We used a fused deposition modeling 3D printer to create molds of Acrylonitrile Butadiene Styrene (ABS) from Digital Imaging and Communication on Medicine (DICOM) images, and the molds were filled with silicone rubber. Thirteen surgeons with 4-5-year experience in the procedure evaluated the molds using a low-cost in-house built simulator utilizing a 5-point Likert-type scale. RESULTS: Molds produced through this method had a consistent anatomical appearance and overall realism that evaluators agreed or definitely agreed (4.5/5). Evaluators agreed on recommending the mold for resident surgical training. CONCLUSIONS: 3D-printed molds created through this method can be applied to create affordable high-quality educational anatomical models of the biliary tree for training laparoscopic cholecystectomy.

Cystic duct remnant syndrome in a cholecystectomized patient, confirmed by cholangiography.

Wereport the case of a 59-year-old male with cholelithiasis, choledocholithiasis, and biliary obstruction due to enolic chronic pancreatitis. He was treated 7 years previously with cholecystectomy, ERCP, and a fully-coated biliary metal stent for 6 months.

Cystic duct cyst: type VI in Todani's classification.

Regarding the article recently published by Junquera E et al. that referenced our work, we agree with the authors that the cystic duct cyst (CDC) is type VI according to Todani's classification, which describes five different types of biliary cysts.

Cystic Duct Embolization with Chemical Gallbladder Ablation for the Treatment of Acute Calculous Cholecystitis in High-Risk Patients: A Prospective Single-Center Study.

PURPOSE: To demonstrate the feasibility of cystic duct embolization and chemical gallbladder ablation as an alternative to cholecystectomy in high-risk patients with calculous cholecystitis who were not candidates for surgery. MATERIALS AND METHODS: This prospective study included 10 patients with acute cholecystitis (7 males and 3 females) aged 70-91 years (average age, 81.6 years) between 2013 and 2019. A cholecystostomy catheter was inserted during the acute phase, followed by cystic duct coil embolization performed via the existing drainage tube tract. Once asymptomatic, 3% aethoxysklerol was injected into the gallbladder, and the drain was removed upon sonographic confirmation that the gallbladder remained contracted. Each phase of the procedure was performed with an interval of 2-3 weeks. Clinical, cholangiographic, and sonographic data were collected before and after drain removal at 1-month follow-up. RESULTS: Cystic duct embolization was technically successful in all patients, with no immediate post-procedure complications. Gallbladder ablation performed in 10 patients was technically successful in all of them (median follow-up, 11 months). One patient required repeat ablation at 14 months, and the prolonged biliary excretions of 1 other patient ceased only at 8 months. CONCLUSIONS: Cystic duct embolization with gallbladder ablation is a feasible procedure for patients in whom cholecystectomy is contraindicated.

A novel classification of aberrant right hepatic ducts ensures a critical view of safety in laparoscopic cholecystectomy.

BACKGROUND: Based on the spatial relationship of an aberrant right hepatic duct (ARHD) with the cystic duct and gallbladder neck, we propose a practical classification to evaluate the specific form predisposing to injury in laparoscopic cholecystectomy (LC). METHODS: We retrospectively investigated the preoperative images (mostly magnetic resonance cholangiopancreatography) and clinical outcomes of 721 consecutive patients who underwent LC at our institute from 2015 to 2018. We defined the high-risk ARHD as follows: Type A: communicating with the cystic duct and Type B: running along the gallbladder neck or adjacent to the infundibulum (the minimal distance from the ARHD < 5 mm), regardless of the confluence pattern in the biliary tree. Other ARHDs were considered to be of low risk. RESULTS: A high-risk ARHD was identified in 16 cases (2.2%): four (0.6%) with Type A anatomy and 12 (1.7%) with Type B. The remaining ARHD cases (n = 34, 4.7%) were categorized as low risk. There were no significant differences in the operative outcomes (operative time, blood loss, hospital stay) between the high- and low- risk groups. Subtotal cholecystectomy was applied in four cases (25%) in the high-risk group, a significantly higher percentage than the low-risk group (n = 1, 2.9%). In all patients with high-risk ARHD, LC was completed safely without bile duct injury or conversion to laparotomy. CONCLUSIONS: Our simple classification of high-risk ARHD can highlight the variants located close to the dissecting site to achieve a critical view of safety and may contribute to avoiding inadvertent damage of an ARHD in LC.

Effectiveness of near-infrared fluorescent cholangiography in the identification of cystic duct-common hepatic duct anatomy in comparison to magnetic resonance cholangio-pancreatography: a preliminary study.

INTRODUCTION: Bile duct injury represents the most serious complication of LC, with an incidence of 0.3-0.7% resulting in a significant impact on quality-of-life, overall survival, and frequent medico-legal litigations. Near-infrared fluorescent cholangiography (NIRF-C) represents a novel intra-operative imaging technique that allows a real-time enhanced visualization of the extrahepatic biliary tree by fluorescence. The role of routine use of pre-operative magnetic resonance cholangio-pancreatography (MRCP) to better clarify the biliary anatomy before laparoscopic cholecystectomy is still a matter of debate. The primary aim of this study was to evaluate the effectiveness of NIRF-C in the detection of cystic duct-common hepatic duct anatomy intra-operatively in comparison with pre-operative MRCP. METHODS: Data from 26 consecutive patients with symptomatic cholelithiasis or chronic cholecystitis, who underwent elective laparoscopic cholecystectomy with intra-operative fluorescent cholangiography and pre-operative MRCP examination between January 2018 and May 2018, were analyzed. Three selected features of the cystic duct-common hepatic duct anatomy were identified and analyzed by the two different imaging methods: insertion of cystic duct, cystic duct-common hepatic duct junction, and cystic duct course. RESULTS: Fluorescent cholangiography was performed successfully in all twenty-six patients undergoing elective laparoscopic cholecystectomy. The visualization of cystic duct was reported in 23 out of 26 cases, showing an overall diagnostic accuracy of 86.9%. The level of insertion, course, and wall implantation of cystic duct were achieved by NIRF-C with diagnostic accuracy values of 65.2%, 78.3%, and 91.3%, respectively in comparison with MRCP data. No bile duct injuries were reported. CONCLUSION: Fluorescent cholangiography can be considered a useful imaging diagnostic tool comparable to MRCP for detailed intra-operative visualization of the cystic duct-common hepatic duct anatomy during elective laparoscopic cholecystectomies.

Todani type VI bile duct cyst: cystic duct malformation as an uncommon cause of abdominal pain.

We report the case of a 62-year-old woman who was admitted for epigastralgia and oral intolerance for 15 days, associating cholestasis in blood tests. A magnetic resonance cholangiography (MRC) revealed the presence of a lobulation continuous with the cystic duct that was consistent with a Todani VI bile duct cyst. The biliary cyst Todani VI is a rare entity within bile duct malformations. The first well-documented case was reported back in 1983, and its inclusion as sixth type in the classification was suggested in 1991. It is an uncommon cause of abdominal pain that we must keep in mind, and the importance of early diagnosis and treatment lies in the condition's oncogenic potential.

Selective Trans-Catheter Coil Embolization of Cystic Duct Stump in Post-Cholecystectomy Bile Leak.

BACKGROUND: Percutaneous drainage is a first-line treatment for bilomas developed post-cholecystectomy in the setting of bile leak from the cystic duct stump. Percutaneous drainage is usually followed by surgical or endoscopic treatment to address the leak. AIMS: This study aimed to evaluate outcome of selective coil embolization of the cystic duct stump via the percutaneously placed drainage catheters in patients with post-cholecystectomy bile leak. METHODS: Seven patients with persistent bile leak after laparoscopic cholecystectomy who underwent percutaneous catheter placement for biloma/abscess formation in the region of the gallbladder fossa were followed. These patients underwent selective trans-catheter cystic duct stump coil embolization from Feb 2013 to Feb 2019. Procedural management, complications, and success rates were analyzed. RESULTS: All patients underwent placement of a percutaneous catheter for drainage of biloma formation in the gallbladder fossa post-cholecystectomy. Selective coil embolization of the cystic duct was performed through the existing percutaneous tract on average 3.5 weeks after percutaneous catheter placement, resulting in resolution of the biloma. All bile leaks were immediately closed. None of the patients showed recurrent bile leak or further clinical symptoms. Coil migration to the common bile duct was diagnosed in a single case, after 2.5 years, with no bile leak reported. CONCLUSIONS: Selective trans-catheter coil embolization of the cystic stump is a feasible and safe procedure, which successfully seals leaking cystic duct stumps and can circumvent the need for repeat surgical or endoscopic intervention in selected patient populations.

Intraoperative detection of the remnant cystic duct during robot-assisted surgery using near-infrared fluorescence imaging: a case report.

BACKGROUND: Post cholecystectomy syndrome is characterized as recurrence of symptoms as experienced before cholecystectomy. In rare cases, a remnant cystic duct is causing these symptoms and occasionally surgical resection is performed. During surgery, visualization of the biliary ducts could be difficult due to inflammation and dense adhesions. CASE PRESENTATION: In this article, we presented a 36-year old woman with post-cholecystectomy syndrome in which we evaluated the feasibility of near-infrared (NIR) fluorescence imaging using indocyanine green (ICG) for visualization of the remnant cystic and common bile duct during robot-assisted surgery. Intraoperative visualization of the remnant biliary duct and other important structures was feasible, and resection of the remnant cystic duct was successfully performed under fluorescence guidance, without any complications. CONCLUSIONS: NIR fluorescence imaging of the biliary ducts using ICG does not prolong the operating time, and could potentially decrease the operation time in difficult procedures, because of easy and fast detection of the biliary tract. Furthermore, it is a non-hazardous and non-invasive technique, as it does not require use of radiation and cannot cause bile duct injury. This case illustrated that ICG NIR fluorescence imaging during difficult robot-assisted surgical procedures of the bile ducts is effective and therefore highly recommended.

Near-infrared cholecystocholangiography with direct intragallbladder indocyanine green injection: preliminary clinical results.

BACKGROUND: Near-infrared (NIR) fluorescence cholangiography by systemic administration of indocyanine green (ICG) enhances the visualization of the biliary tree anatomy. However, the simultaneous enhancement of liver parenchyma can disturb the visualization of critical details. We herein proposed a new technique of NIR cholecystocholangiography by intragallbladder ICG injection to increase the safety during laparoscopic cholecystectomy. METHODS: A total of 46 patients scheduled for laparoscopic cholecystectomy for symptomatic lithiasis (n = 21) or cholecystitis (n = 25) were enrolled. A fluorescence cholangiography by direct gallbladder injection of ICG was performed in all cases. Of them, the ICG was injected through a previously placed percutaneous transhepatic gallbladder drainage catheter (n = 18) or by intraoperative, percutaneous needle puncture of the gallbladder (n = 28). Visualization of biliary structures, including the cystic duct (CD), the common bile and hepatic ducts (CBD and CHD), the gallbladder neck, and the Hartmann's pouch (HP), was performed using White Light (served as control modality) and by NIR enhancement. RESULTS: Cholecystocholangiography provided a significantly higher rate of visualization of the CD in case of cholecystitis with mild adhesions, and an improved visualization of the HP, CBD, and CHD in case of severe inflammation, when compared to White Light observation. There were no benefits of NIR in case of non-inflamed lithiasis. CONCLUSIONS: Clinical translation of NIR cholecystocholangiography has been successful with a noise-free visualization of biliary anatomy. It can be considered in difficult cases to increase the safety of laparoscopic cholecystectomy.