[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.

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.

High-grade dysplasia of the cystic duct margin: how should this be managed?

High-grade dysplasia (HGD) in the cystic duct is a rare epithelial lesion that may lead to biliary tract malignancy. Due to its association with aggressive multifocal cholangiocarcinoma, it is important to investigate for concurrent malignancy, remove all areas of HGD and monitor for recurrence or metastasis.We present a case of a woman in her 60s with cholecystitis who underwent a laparoscopic cholecystectomy. On histopathology, the patient was found to have incidental HGD involving the cystic duct margin. After ensuring the absence of concurrent malignancy on cross-sectional imaging, she underwent further resection until the margins were clear of dysplasia. In the absence of clear follow-up guidelines, the patient was closely monitored with outpatient scans for up to 5 years.

Length of the Remnant Cystic Duct and Bile Duct Stone Recurrence: a Case‒Control Study.

BACKGROUND: Since the introduction of the Critical View of Safety approach in laparoscopic cholecystectomy, exposure of the common bile duct, and common hepatic duct is not recommended, therefore, the length of the cystic duct remnant is no longer controlled. The aim of this case‒control study is to evaluate the relationship between the length of the cystic duct remnant and the risk for bile duct stone recurrence after cholecystectomy. METHODS: All MRIs with dedicated sequences of the biliary tract taken between 2010 and 2020 from patients who underwent prior cholecystectomy were reviewed. The length of the cystic duct remnant was measured and compared between the patients with and without bile duct stones using multivariate logistic regression analysis. RESULTS: A total of 362 patients were included in this study, 23.5% of whom had bile duct stones on MRI. The cystic duct remnant was significantly longer in the patients with stones than in the control group (median 31 mm versus 18 mm, P < 0.001). In the MRIs performed > 2 years after cholecystectomy, the cystic duct remnant was also significantly longer in the patients with bile duct stones (median 32 mm versus 21 mm, P < 0.001). A cystic duct remnant ≥ 15 mm in length increased the odds of stones (OR = 2.3, P = 0.001). Overall, the odds of bile duct stones increased with an increasing cystic duct remnant length (≥ 45 mm, OR = 5.0, P < 0.001). CONCLUSIONS: An excessive cystic duct remnant length increases the odds of recurrent bile duct stones after cholecystectomy.

Cystic duct straightening using a fine-gauge balloon dilator for successful endoscopic transpapillary gallbladder stenting.

Endoscopic transpapillary gallbladder stenting is sometimes inhibited by a cystic duct loop, necessitating cystic duct straightening. Mandai and colleagues report a novel technique for straightening the looped cystic duct using a fine-gauge balloon dilator, which is useful during endoscopic gallbladder stenting when the double-guidewire technique fails.

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.

A Preoperative Diagnosis of Advanced Cystic Duct Carcinoma Using SpyGlass DS Cholangioscopy: A Report of Two Cases.

Primary cystic duct carcinoma is a rare tumor. The curative treatment of cystic duct carcinoma is complete surgical resection, for which the evaluation of local extension is important. We herein report two cases of cystic duct carcinoma in which a preoperative examination was performed using per-oral cholangioscopy (POCS). Both patients underwent POCS due to suspicion of cystic duct carcinoma based on imaging findings. A visual analysis and biopsy were performed to evaluate local extension, which led to surgery. These cases suggest that POCS is useful for the preoperative assessment of local extension in advanced cystic duct carcinoma.

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.

Extrahepatic Biliary Tract Variations is an Effect for Acute Calculous Cholecystitis.

OBJECTIVE: To evaluate the anatomy of the extrahepatic bile duct and to reveal its importance in the formation of acute calculous cholecystitis (ACC). STUDY DESIGN: Case-control study. PLACE AND DURATION OF STUDY: Department of General Surgery and Radiology, Kanuni Sultan Suleyman Training and Research Hospital of the University of Health Sciences, Turkey, between January 2016 and December 2021. METHODOLOGY: The data of the patients treated with ACC were analysed on MRCP by an experienced radiologist. The patients were divided into two groups; asymptomatic gallstones (AsGS, control group) and ACC. The cystic duct, common hepatic duct, and common bile duct lengths and variations in cystic duct opening were measured. Receiver operating characteristics (ROC) analysis was conducted to define a cut-off value and compared categorical results of the two groups by Mann-Whitney U test. RESULTS: One-hundred and seventy-three patients were analysed, one-hundred and seven were females, and 66 were males. The median age was 46 years in the AsGS group and 53 years in the ACC group. It was statistically significant that ACC had a higher median age value than AsGS (p=0.014). In the analysis of extrahepatic variations, cystic duct, common hepatic duct, and common bile duct length, were statistically longer in the calculous cholecystitis group (p<0.001, p=0.022, and p=0.019 respectively). ROC analysis was performed for cystic, common hepatic, and common bile duct length, respectively. Cut-off values ​​were 30.5 mm, 36.5 mm, and 42.5 mm. CONCLUSION: Extrahepatic bile duct variations are of critical importance in ACC surgery. In the data, as the cystic duct and common bile duct lengthens, the possibility of ACC increases. There is need for studies with larger samples. KEY WORDS: Acute calculous cholecystitis, Extrahepatic biliary tract, Anatomical variations, Cholelithiasis.

Presence of cystic duct stone is a risk for postoperative retained stones in patients with acute cholecystitis.

PURPOSE: Retained stones (RS) in the common bile duct (CBD) are one of the major problems after laparoscopic cholecystectomy and usually require endoscopic treatment. However, few reports have investigated risk factors for the development of RS in the CBD. METHODS: A total of 325 patients with acute cholecystitis underwent laparoscopic cholecystectomy at our hospital between January 2013 and Jury 2021. Patient characteristics, including radiographic factors and perioperative outcomes, were reviewed, and perioperative factors predicting RS in the CBD were investigated. RESULTS: RS in the CBD were developed in 34 patients. All 34 patients were treated endoscopically. ASA-PS class 3 or more (p = 0.029, odds ratio = 2.601), subtotal cholecystectomy performance (p = 0.004, odds ratio = 3.783) and the presence of cystic duct stones (p < 0.001, odds ratio = 11.759) were found by logistic regression analysis to be independent risk factors for developing RS in the CBD. Cystic duct stones were preoperatively detected in 60 patients. Of these, 21 cases were not detected on magnetic resonance cholangiopancreatography (MRCP) but on CT, while 15 cases were not detected on CT but on MRCP. CONCLUSIONS: The presence of cystic duct stones on preoperative CT or MRCP is a crucial risk factor for developing RS in the CBD. Both CT and MRCP are useful to avoid overlooking cystic duct stones.

Dual Cystic Duct Found and Confirmed by Intraoperative Cholangiography.

This report presents a case of aberrant gallbladder anatomy. A 75-year-old female presented to the hospital with choledocholithiasis was admitted and underwent an endoscopic retrograde cholangiopancreatography (ERCP) to clear the common bile duct stones; no aberrant anatomy was noted at this time. The following day she was taken to the operating room for cholecystectomy prior to discharge. During the surgical procedure, the patient was found to have aberrant anatomy and an intraoperative cholangiogram was performed. This identified a dual cystic duct, a rare anomaly.

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.

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.