Anatomical and Morphological Features of the Fetal Human Pancreaticobiliary Ductal Union.

To investigate pancreaticobiliary ductal anatomy during developmental stages, gallbladders, common bile ducts, pancreatic ducts and their interface with the duodenum were studied in 36 human fetuses between 4-6 weeks postconceptual age were studied. For histological examination, sections were cut continuously from the paraffin-embedded tissue block and stained with hematoxylin and eosin. The expression of proliferating cell nuclear antigen in the gallbladder was examined with immunohistochemistry. Among 36 cases, three shapes of the greater duodenal papilla were found: hemispheroid (58.1%), circular cylinder (25%), and flat shape (16.9%). For the location of the greater duodenal papillas, more than half (69.4%) of the cases were in the middle descendant duodenum. Seven cases (19.4%) were in the lower descendant duodenum. Three cases (8.3%) were in the upper descendant duodenum, and one (2.9%) was in the distal descending part of duodenum. There were four types of the pancreaticobiliary ductal union: "Y" in 24 cases(66.7%), "U" in 4 cases (11.1%),"V" in 7 cases (19.4%), and pancreaticobiliary maljunction in 1 case (2.8%). For patients with congenital bile duct dilation and Biliary cancer, the positive cells of proliferating cell nuclear antigen were increased significantly (P < 0.05). Different types in pancreaticobiliary ductal union investigated in this study may provide clues for pathogenesis and clinical treatment of pancreaticobiliary maljunction.

The common bile duct: size, course, relations.

The common bile duct may present a number of anatomical peculiarities regarding its size, course and relations, which should be taken into consideration by the anatomists and by the surgeons as well, during the surgery of the gallbladder, pancreas and duodenum. In the present study, we have analyzed the anatomical peculiarities of the common bile duct in 150 adult corpses of both sexes from the Anatomy Department and 22 human fetuses from the Pathology Department, University of Medicine and Pharmacy Cluj-Napoca.

Ten strategies to improve the efficacy of laparoscopic biliary surgery. / Diez estrategias para mejorar la eficacia de la cirugía biliar laparoscópica.

Laparoscopic surgery is the gold standard treatment of symptomatic gallstones. For some, it is also the treatment of choice for choledocholithiasis. Certain special and rare circumstances regarding the number, size and location of bile duct stones or altered bile duct anatomy (embryonic or acquired), can be challenging to resolve with usual laparoscopic techniques. For these situations, we describe 10 surgical strategies that are relatively simple and inexpensive to apply, making them appropriate to be used in most surgical centers.

Sinistroposition of the gallbladder and common bile duct.

BACKGROUND: Despite its rare incidence, few cases of left-side gallbladder have been already published. METHODS: We reported herein the case of a 29-year-old man with a left liver tumor in whom left lateral bisegmentectomy was mandatory. It represents the first description of a sinistroposition of both gallbladder and common bile duct. RESULTS: Surgical exploration revealed a left-side gallbladder, located under the left lobe of the liver. During hepatic parenchyma dissection at the left side of the round ligament and the Rex recessus, the common bile duct was injured. Complete separation of hepatic pedicle structures showed that the upper biliary convergence passed on the left side of the Rex recessus before reaching the hepatoduodenal ligament. CONCLUSION: Only careful dissection of the hepatoduodenal ligament up to Rex recessus level prior to liver parenchyma resection could avoid biliary tract injury during left lobectomy.

Embryologic and anatomic basis of duodenal surgery.

The following points should be remembered by surgeons (Table 1). In writing about the head of the pancreas, the common bile duct, and the duodenum in 1979, the authors stated that Embryologically, anatomically and surgically these three entities form an inseparable unit. Their relations and blood supply make it impossible for the surgeon to remove completely the head of the pancreas without removing the duodenum and the distal part of the common bile duct. Here embryology and anatomy conspire to produce some of the most difficult surgery of the abdominal cavity. The only alternative procedure, the so-called 95% pancreatectomy, leaves a rim of pancreas along the medial border of the duodenum to preserve the duodenal blood supply. The authors had several conversations with Child, one of the pioneers of this procedure, whose constant message was to always be careful with the blood supply of the duodenum (personal communication, 1970). Beger et al popularized duodenum-preserving resection of the pancreatic head, emphasizing preservation of endocrine pancreatic function. They reported that ampullectomy (removal of the papilla and ampulla of Vater) carries a mortality rate of less than 0.4% and a morbidity rate of less than 10.0%. Surgeons should not ligate the superior and inferior pancreaticoduodenal arteries because such ligation may cause necrosis of the head of the pancreas and of much of the duodenum. The accessory pancreatic duct of Santorini passes under the gastrointestinal artery. For safety, surgeons should ligate the artery away from the anterior medial duodenal wall, where the papilla is located, thereby avoiding injury to or ligation of the duct. "Water under the bridge" applies not only to the relationship of the uterine artery and ureter but also to the gastroduodenal artery and the accessory pancreatic duct. In 10% of cases, the duct of Santorini is the only duct draining the pancreas, so ligation of the gastroduodenal artery with accidental inclusion of the duct is catastrophic. With the Kocher maneuver, surgeons reconstruct the primitive mesoduodenum and achieve mobilization of the duodenum, which is useful for some surgical procedures. Surgeons should not skeletonize more than 2 cm of the first part of the duodenum. If more than 2 cm of skeletonization is done, a duodenostomy using a Foley catheter may be necessary to avoid blow-up of the stump secondary to poor blood supply. Proximal duodenojejunostomy is advised for the safe management of patients with difficult duodenal stumps. Roux-en-Y choledochojejunostomy and duodenojejunostomy divert bile and food in the treatment of the complicated duodenal diverticulum. The suspensory ligament may be transected with impunity. It should be ligated before being sectioned so that bleeding from small vessels contained within can be avoided. Failure to sever the suspensory muscle completely, which is possible if the insertion is multiple, fails to relieve the symptoms of vascular compression of the duodenum (Fig. 18). Mobilization, resection, and end-to-end anastomosis of the duodenal flexure have been performed as a uniform surgical procedure, avoiding the conventional gastrojejunostomy. With a large, penetrating posterior duodenal or pyloric ulcer, surgeons should remember that The proximal duodenum shortens because of the inflammatory process (duodenal shortening) The anatomic topography of the distal common bile duct and the opening of the duct of Santorini and the ampulla of Vater is distorted Leaving the ulcer in situ is wise Careful palpation for or visualization of the location of the ampulla of Vater or common bile duct exploration with a catheter insertion into the common bile duct and the duodenum are useful procedures In most cases, the common bile duct is located to the right of the gastroduodenal artery at the posterior wall of the first part of the duodenum. (ABSTRACT TRUNCATED)

Ampulla of Vater. Anatomic, embryologic, and surgical aspects.

The region of the ampulla of Vater constitutes a complex anatomic and functional entity, the biliopancreaticoduodenal confluence, of which the essentials of this rapid review are the: Variation in site of implantation of the greater duodenal papilla, whereas the relations between the common bile duct and the main pancreatic duct are relatively constant Presence at this site of a weak point in the duodenal wall, commonly the site of mucosal diverticula Interdependence of the parietal duodenal mucosa and the sphincteric system of Oddi Existence of an extramural zone of this sphincter, which should be the only one involved in sphincterotomy Danger of wide excisions of the papilla, which, apart from the risk for hemorrhage, cause a breach of the digestive barrier The ampulla of Vater corresponds to the dilated junction of the common bile duct and main pancreatic duct, if present. The ampulla is an extensive anatomic and functional region that includes not only the choledochopancreatic junction but also the sphincter of Oddi, the whole traversing the duodenal wall to open at the greater duodenal papilla. The chief anatomic features of this biliopancreaticoduodenal junction have been reviewed, forming the basis of techniques of surgical or endoscopic sphincterotomies and localized excisions of vaterian tumors.

Sinistroposition of the gallbladder and the common bile duct.

A left lateral bisegmentectomy was performed in a 29-year-old man presenting a primary lymphoma of the liver. Surgical exploration revealed a left-side gallbladder, located under the left lobe of the liver. During hepatic parenchyma dissection, performed strictly at the left of the round ligament and the umbilical portion of the left portal vein, common bile duct was injured. Complete separation of hepatic pedicle structures showed that the upper biliary convergence passed on the left side of the umbilical portion of the left portal vein before reaching the hepatoduodenal ligament. This case report discusses the embryological mechanism that could explain this uncommon bile duct abnormality, focusing on its consequences during left ruled lobectomy.

[Congenital cystic dilatation of the common bile duct, anomaly of the biliopancreatic junction and cancer of the bile ducts]. / Dilatation kystique congénitale du cholédoque, anomalie de la jonction bilio-pancréatique et cancer des voies biliaires.

The choledochus and pancreatic duct ordinarily enter the duodenum either separately or via a common channel located in the duodenal wall. The usual maximal length of the common channel is approximately 0.5 cm. An anomalous junction of the pancreaticobiliary tract is defined by the presence of an unusually long common channel whose length is 1 cm or longer. During the last 8 years, we studied 9 cases of congenital dilatation of the bile duct. Besides the choledochal cyst, all patients had a common channel which measured 1.5 cm or longer. The mean age of patients (6 females, 3 males) was 36.5 years. Three patients had extrahepatic bile tract carcinoma. One patient, a 51-year old man, had gallbladder carcinoma without stones while the two other patients, a 43-year old woman and a 32-year old man, had carcinoma arising from the wall of the cystic dilatation. These two patients had undergone a simple internal drainage procedure 16 and 8 years before, respectively. Our study suggests that the anomalous junction of the pancreaticobiliary tract, an embryonic anomaly which allows the reflux of pancreatic juice into the bile duct and gallbladder, may be responsible for congenital bile duct dilatation and biliary tract carcinoma. Total excision of the cystic dilatation and the gallbladder with hepaticojejunostomy is the appropriate surgical treatment.

[Hypothesis on the embryologic moment in arising of the cystic dilatation of the choledodochus]. / Ipotesi sul momento embriologico d'insorgenza della dilatazione cistica del coledoco

It is felt that congenital cystic dilatation of the common bile duct and duodenal stenosis with annular pancreas begin at the same moment during embryonal life in the light of an observation of these deformities in a sibship.

[Congenital dilatation of the common bile duct in an adult]. / Dilatazione congenita della via biliare principale nell'adulto.

The Authors present a case of congenital dilatation of the common bile duct in adult life, selecting this lesion from the cystic dilatations of biliary tract group. The type I of biliary tract cystic dilatations is, in fact, considered a clinical-pathological situation apart, that, because of his frequence and his peculiar characteristics especially present in the adult, puts particular problems regarding his arrangement an treatment. The most recent aspects of etiophatogenetic and therapeutic problems of this lesion are treated. The increased risk of neoplastic degeneration in the adult, the recognition of an anomalous pancreaticobiliary duct junction as etiophatogenetic fondamental cause and the necessity of a radical exeretic treatment in in opposition to the old therapheutic orientations are especi-5ally considered.

[A new case of cyst of the common bile duct with an anomaly of the bilio-pancreatic convergence]. / Une nouvelle observation de kyste du cholédoque avec anomalie de la convergence bilio-pancréatique.

A case of common bile duct cyst operated upon in a 2 1/2 year old girl is used as a basic for discussing the forms associated with anomaly of convergence of common bile and wirsung's ducts. The latter, of dysembryoplastic origin, appears to be the cause of this type of cyst. These forms are atypical in that no mass is palpable and they are frequently complicated by a pancreatitis. They constitute the majority of Japanese cases when the anomaly is investigated. Its detection is possible by retrograde catheterization or more rarely during perioperative cholangiography, the only possibility in the very young infant. Different operative technics are outlined, taking into account principally the risk of secondary malignant changes and the possible performance of a hepatico-duodenal anastomosis without increasing the risk of an ascending angiocholitis.

Expression of Β-catenin and c-myc during human common bile duct development: a possible role in the morphogenesis of the common bile duct.

ß-catenin and c-myc play important roles in the development of tissues and organs. However, little is known about their expression patterns during the development of the human common bile duct. Immunohistochemistry was used to detect ß-catenin and c-myc expression in common bile duct samples from postmortem tissues of 14 premature infants and 6 spontaneously aborted fetuses. The expression of ß-catenin and c-myc was also analyzed by Western blot. The samples were divided into four groups based on the stage of human fetal development: 12, 13-27, 28-37, and >37 weeks. The Image-Pro Plus v. 6.0 image analysis software was used to calculate the mean qualifying score (MQS). At fetal stages 12, 13-27, 28-37, and >37 weeks, MQS of ß-catenin were 612.52 ± 262.13, 818.38 ± 311.73, 706.33 ± 157.19, and 350.69 ± 110.19, respectively. There was a significant difference in MQS among the four groups (ANOVA, P=0.0155) and between the scores at >37 and 13-27 weeks (Student-Newman-Keuls, P<0.05). At fetal stages 12, 13-27, 28-37, and >37 weeks, the MQS of c-myc were 1376.64 ± 330.04, 1224.18 ± 171.66, 1270.24 ± 320.75, and 741.04 ± 219.19, respectively. There was a significant difference in MQS among the four groups (ANOVA, P=0.0087) and between the scores at >37 and 12 weeks, >37 and 13-27 weeks, and >37 and 28-37 weeks (all P<0.05, Student-Newman-Keuls). Western blots showed that ß-catenin and c-myc expression were significantly higher in fetal than in postnatal control duct tissue (P<0.05). c-myc and ß-catenin are involved in the normal development of the human common bile duct.

Preduodenal portal vein with preduodenal common bile duct: an extremely rare anomaly.

Preduodenal portal vein (PDPV) may occur as an isolated event and result in no symptoms, or it may found at autopsy as an incidental finding; associated preduodenal common bile duct (PDCBD) is an extremely rare event. To the 8 reported cases of PDPV with PDCBD, we add this rare case. Such a discovery is often incidental and of little import; however, it takes on major importance for hepatobiliary surgeons because the accidental damage of PDPV with PDCBD can lead to serious consequences. In addition to describing and illustrating this case, we discuss its relevant anatomy, embryology and associated malformations.

Expression of ?-catenin and c-myc during human common bile duct development: a possible role in the morphogenesis of the common bile duct

β-catenin and c-myc play important roles in the development of tissues and organs. However, little is known about their expression patterns during the development of the human common bile duct. Immunohistochemistry was used to detect β-catenin and c-myc expression in common bile duct samples from postmortem tissues of 14 premature infants and 6 spontaneously aborted fetuses. The expression of β-catenin and c-myc was also analyzed by Western blot. The samples were divided into four groups based on the stage of human fetal development: 12, 13-27, 28-37, and >37 weeks. The Image-Pro Plus v. 6.0 image analysis software was used to calculate the mean qualifying score (MQS). At fetal stages 12, 13-27, 28-37, and >37 weeks, MQS of β-catenin were 612.52±262.13, 818.38±311.73, 706.33±157.19, and 350.69±110.19, respectively. There was a significant difference in MQS among the four groups (ANOVA, P=0.0155) and between the scores at >37 and 13-27 weeks (Student-Newman-Keuls, P<0.05). At fetal stages 12, 13-27, 28-37, and >37 weeks, the MQS of c-myc were 1376.64±330.04, 1224.18±171.66, 1270.24±320.75, and 741.04±219.19, respectively. There was a significant difference in MQS among the four groups (ANOVA, P=0.0087) and between the scores at >37 and 12 weeks, >37 and 13-27 weeks, and >37 and 28-37 weeks (all P<0.05, Student-Newman-Keuls). Western blots showed that β-catenin and c-myc expression were significantly higher in fetal than in postnatal control duct tissue (P<0.05). c-myc and β-catenin are involved in the normal development of the human common bile duct.

Loss of the major duodenal papilla results in brown pigment biliary stone formation in pdx1 null mice.

BACKGROUND & AIMS: Pdx1 plays a pivotal role in pancreas organogenesis and specification of some types of cells in the duodenum and antral stomach. However, its expression is not restricted to pancreas, duodenum, and antral stomach but is also found in the common bile duct during embryogenesis. This study aimed to elucidate the role of Pdx1 in the development of the common bile duct, major duodenal papilla, and duodenum. METHODS: Expression pattern of pdx1 during embryogenesis and the morphology of the common bile duct, major duodenal papilla, and duodenum in pdx1 null mice were analyzed. RESULTS: The major duodenal papilla, peribiliary glands, and mucin-producing cells in the common bile duct were not formed in pdx1 null mice. Pdx1 null mice had shorter periampullary duodenal villi than wild-type mice at postnatal stages associated with reduced cell proliferation and increased apoptosis of the duodenal epithelial cells. Loss of the major duodenal papilla allowed duodeno-biliary reflux and bile infection, resulting in the formation of brown pigment biliary stones in pdx1 null mice, and antibiotics treatment significantly reduced the incidence of biliary stone formation. CONCLUSIONS: Pdx1 is required for proper development of the major duodenal papilla, peribiliary glands, and mucin-producing cells in the common bile duct and for maintenance of the periampullary duodenal epithelial cells during perinatal period. Bile infection because of loss of the major duodenal papilla plays a significant role in the formation of brown pigment biliary stones in pdx1 null mice.

[Accessory bile duct (author's transl)]. / Akzessorischer Ductus choledochus.

A case report is given of a patient with an accessory choledochus duct opening into the gastric antrum. This is the fifth case reported in the literature. A short review is given about incidence of malformations of extrahepatic bile ducts, ontogenetic background and clinical relevance.

Ligation of the common bile duct in the fetal lamb: an experimental model for the study of biliary atresia.

Intrauterine ligation of the common bile duct was carried out in ten fetal lambs at approximately 80 days gestational age. Six of the fetal lambs survived until term and were sacrificed at varying periods until the 36th day of life. The lesion which developed resembled a "correctable" type of extrahepatic biliary atresia [Kasai type I (b)]. The lining epithelium was either totally or incompletely denuded in the blind end of the common duct proximal to the obstruction.

A pair of monozygotic twins with anomalous pancreaticobiliary junction and pancreatitis.

The authors describe a pair of white 7-year-old monozygotic twin girls with the same anomaly of the pancreaticobiliary junction (APBJ), in whom the clinical presentation and disease evolution are slightly divergent. The pathogenesis and genetic control of the disease are discussed.

The development of the glands of the common bile duct.

The number of glands at a constant level within the wall of the common bile duct was measured in the foetus, infant, child and adult. The number of glandular acini increases from foetal life to reach a maximum within the 1st year of life. Thereafter it remains remarkably constant. This is in contrast to the lumen and wall of the common bile duct which only reaches adult proportions in adult life. Conversely, the density of acini within the wall of the common bile duct is at a peak in early foetal life and decreases progressively throughout infancy and childhood.