Anatomical Variations Of The Cystic Duct And Their Surgical Implications In Sudanese Population: A Cadaveric Study

Background: Anatomic variations of cystic ducts are common and continuously encountered during Surgical andradiological interventions. Failure to identify these clinically important variations may result in complicationsduring surgical or endoscopic procedures.Patients and methods: This is an observational descriptive cross-sectional study. 65 cadavers in the dissectingrooms of the medical colleges, in which the length and mode of insertion of cystic duct (CD) into common bileduct (CBD) were observed.Results: The mean length of the CD in the cadavers examined was (2.06 ± 1.03) with a minimum length of d” 0.5 cmand a maximum of 5 cm. Regarding the mode of insertion of CD into the CBD; 53.8% were found to have a lowjunction between the CD and common hepatic duct (CHD) which is considered the normal insertion. 46.2% foundto be abnormal variations of insertion; short CD (d”0.5 cm) observed in 10.8%; whereas in 13.8% of cadavers wefound that the CD is adherent to the CHD and runs in parallel to it. In 7.8% there was a high junction between theCD and CBD and in 9.2% we found that CD courses anterior or posterior to CBD and joins it medially.Conclusion: CD variations are not uncommon and it is important to identify these anatomical variations. Adetailed knowledge of the extra hepatic biliary tract, as well as of its variations, is important for the diagnosticand therapeutic success in many clinical situations since they allow the surgeon prompt identification ofcertain pathologies, making surgical procedures more accurate and affective.

Radiological and pulmonary function test assessment in clinically stable bronchiectasis patients

Background: Bronchiectasis is a disease in which patients spends morbid life having dyspnoea and productive, often foul-smelling sputum which produces social isolation and depressive states. The mortality rate in bronchiectasis patients 2, states the mortality rate of bronchiectasis in 12 years follow up period is 29.7% in the age group at 52 in 1years. 70% cause of death in bronchiectasis is due to respiratory tract infection leading to respiratory failure. Aim of the study: To evaluate the Bronchial inflammatory response and its relationship to bacterial colonization through radiological evaluation. Materials and methods: This study was done for a period of 7 months from February 2016 to August 2016 in the Department of Thoracic Medicine, Government Villupuram Medical College, Villupuram. The Bacterial flora from Lower Respiratory tract of Bronchiectasis patients who attended Thoracic Medicine Outpatient Department with diagnosis confirmed by a radiologist was studied. Bronchoalveolar lavage was done as an invasive procedure in 90 patients with bronchiectasis and from 6 patients admitted with chronic upper respiratory symptoms as laboratory control in Interleukin-8 estimation for all the patients radiological and pulmonary function test assessment done. Results: Among the 90 patients in this study Cylindrical types were 53%, Cystic types were 35%, Varicose types were 4.4 %, Traction bronchiectasis were 3% and 3% were mixed types i.e. Cystic A. Sundrarajaperumal, R. Nedunchezhian, D. Ranganathan, V Sundar. Radiological and pulmonary function test assessment in clinically stable bronchiectasis patients. IAIM, 2019; 6(6): 87-91. Page 88 plus cylindrical and Traction plus cylindrical. Spirometry pattern distribution showing Normal spirometer in 14% of patients, Obstructive pattern observed in 64% of patients, Restrictive pattern observed in 15% of patients and the mixed pattern was observed in 7% of patients. Conclusion: Increased incidence of bronchiectasis in females (58%). Cylindrical bronchiectasis was the commonest type followed by Cystic bronchiectasis. Regarding etiology of Bronchiectasis, 42% of bronchiectasis was Idiopathic followed by post infectious 21%. The pulmonary function FEV1< 70% was associated with microorganisms colonization of bronchiectasis airways.

Cystic duct drainage into hepatic ducts: a primary study using three dimensional magnetic resonance cholangiopancreatography / 中华肝胆外科杂志

Objective To study the pattern of cystic duct (CD) drainage into hepatic ducts (CDIHD) by using three dimensional magnetic resonance cholangiopancreatography (3D M RCP) combined with conventional MRI sequences.Methods Thirty-eight patients with CDIHD were studied retrospectively and they served as the observation group.Another 38 patients who had no CDIHD were selected randomly and they served as the control group.The hepatic bile duct where the CD drained in the observation group,the site where the common hepatic duct (CCHD) started,and the types of the intrahepatic bile duct (IHBD) in the two groups were analyzed.The types of the IHBD were classified according to the modified Couinaud's criteria.Results There were 26 patients who had their CD draining into the right liver bile ducts,9 into the incomplete common hepatic duct,and 3 into the left hepatic duct in the observation group.For the types of IHBD in the observation/control groups,type A was observed in 15/19 patients,type B in 0/6,type C in 22/1,type D in 0/9,type E in 0/2,and type F in 1/1,respectively.The differences were significant (P ＜ 0.05).The number of patients who had their CCHD starting in the porta hepatis,superior duodenal bulb,posterior duodenal bulb,and pancreatic head in the observation/control groups,were 1/36,19/2,17/0,1/0,respectively.The differences were also significant (P ＜ 0.05).Conclusion In patients with CDIHD,CD most commonly drained into the right hepatic duct.Patients with CDIHD had a different IHBD type,and the IHBD confluence was lower.

Cystic duct drainage into hepatic ducts: a primary study using three dimensional magnetic resonance cholangiopancreatography / 中华肝胆外科杂志

Objective To study the pattern of cystic duct (CD) drainage into hepatic ducts (CDIHD) by using three dimensional magnetic resonance cholangiopancreatography (3D M RCP) combined with conventional MRI sequences.Methods Thirty-eight patients with CDIHD were studied retrospectively and they served as the observation group.Another 38 patients who had no CDIHD were selected randomly and they served as the control group.The hepatic bile duct where the CD drained in the observation group,the site where the common hepatic duct (CCHD) started,and the types of the intrahepatic bile duct (IHBD) in the two groups were analyzed.The types of the IHBD were classified according to the modified Couinaud's criteria.Results There were 26 patients who had their CD draining into the right liver bile ducts,9 into the incomplete common hepatic duct,and 3 into the left hepatic duct in the observation group.For the types of IHBD in the observation/control groups,type A was observed in 15/19 patients,type B in 0/6,type C in 22/1,type D in 0/9,type E in 0/2,and type F in 1/1,respectively.The differences were significant (P ＜ 0.05).The number of patients who had their CCHD starting in the porta hepatis,superior duodenal bulb,posterior duodenal bulb,and pancreatic head in the observation/control groups,were 1/36,19/2,17/0,1/0,respectively.The differences were also significant (P ＜ 0.05).Conclusion In patients with CDIHD,CD most commonly drained into the right hepatic duct.Patients with CDIHD had a different IHBD type,and the IHBD confluence was lower.

Mirizzi Syndrome: A Case Report.

Mirizzi syndrome is a seldom-observed complication of gallstone disease, which if not diagnosed hitherto, may cause major biliary problems. It has a prevalence ranging from 0.05% to 2.7% among patients with cholelithiasis and is characterized by mechanical obstruction of the common hepatic duct caused by impaction of stones in the neck of the gallbladder (most frequently in the Hartmann pouch) or cystic duct and presents clinically as intermittent or persistent jaundice. Th is syndrome was described, in 1948, by an Argentinean surgeon Mirizzi. Here, we report the case of a 50-year-old female patient, who presented with acute right upper abdominal pain, predominantly in the epigastria and right subcostal region, which was colicky in nature, nausea, and high-grade fever since 1 day with clinically unremarkable abdominal fi ndings. Abdominal ultrasonography revealed a partially distended gallbladder showing the presence of an intraluminal calculus measuring 1.6 cm × 1.3 cm, impacted at the neck region. Further investigations resulted in the diagnosis of Mirizzi syndrome.

A Case of Biliary Fascioliasis Mimicking Neoplasia of the Common Hepatic Duct / 대한내과학회지

Fascioliasis is a rare zoonotic disease caused by Fasciola hepatica, the liver fluke. Humans can become accidental hosts of this parasite by ingesting contaminated drinking water or plants containing viable metacercariae. There are two disease stages: the hepatic (acute) and biliary (chronic) stages. The biliary stage of this zoonotic infection is often misdiagnosed because the symptoms are subclinical, with intermittent cholangitis as the only sign. Endoscopic retrograde cholangiopancreatography (ERCP) has been described in the diagnosis of a few cases of fascioliasis. We used this modality to diagnose biliary fascioliasis in a 39-year-old woman with chronic hepatitis B who had intermittent abdominal pain for three years with irregular wall thickening and luminal narrowing of the common hepatic duct (CHD), which resembled neoplasia of the CHD. Following the correct diagnosis, the adult worm was removed using endoluminal forceps via endoscopic sphincterotomy. This case report confirms the diagnostic and therapeutic value of ERCP in patients with biliary fascioliasis that may mimic neoplasia of the CHD.

Anatomic variations of extrahepatic bile ducts and evaluation of the length of ducts composing the cystohepatic triangle / Variaciones anatómicas de los ductos biliares extrahepáticos y longitud de los ductos del trígono hepato-cístico

It is of paramount importance for surgeons to have a thorough knowledge of the normal anatomy of the extrahepatic bile ducts and its variations due to the high frequency with which they perform in this anatomic site. The cystohepatic triangle, or Calot's Triangle, is bound by the cystic duct, common hepatic duct, and the hepatic border; therefore, its surface area depends on the conformation of these ducts and is closely linked to surgical procedures performed in this region. It has been reported that the length and the position of these ducts may be related to the formation of bile duct stones, Mirizzi's syndrome, and bile duct cancer. Thus, the present work aims to analyze the configuration of the extrahepatic biliary tree and its possible variations, as well as measure the components that make up the cystohepatic triangle. For this task 41 samples from fixated human cadavers were analyzed, with 25 consisting of anatomic parts (liver and biliary tree) and 16 in situ samples. The extrahepatic biliary trees were dissected in order to measure the length of the common hepatic and cystic ducts with a digital caliper, and all anatomic variations were registered. The length of the common hepatic duct varied between 4.18 mm and 50.64 mm, with an average of 21.76 +/- 9.51 mm. The length of the cystic duct varied between 7.28 and 38.88 mm, with an average of 19.11 +/- 6.77 mm. Anatomic variations were found in 3 samples (7.3 percent): in one of them the cystic duct connected to the left hepatic duct; in another, the cystic duct connected to the right hepatic duct; in the third, there was a triple confluence of hepatic ducts (two right ducts and one left duct). The results are a contribution to the clinical and surgical anatomy of this region.

El conocimiento de la anatomía normal de las vías biliares extrahepáticas y sus variaciones es fundamental para los cirujanos digestivos debido a la frecuencia con que se actúa en esa región. El trígono hepato-cístico o de Calot es delimitado por el ducto cístico, ducto hepático común y el margen del hígado. De este modo, su área depende de la conformación de esos ductos y está íntimamente relacionada a procedimientos quirúrgicos efectuados en esa zona. Se ha señalado que la longitud y la disposición de esos ductos estarían involucradas en la formación de cálculos biliares, síndrome de Mirizzi y neoplasias de vías biliares. Así, el presente estudio tuvo como objetivo analizar la configuración de las vías biliares extrahepáticas y sus posibles variaciones, además de registrar parámetros métricos de los componentes del sistema biliar que integran el trígono hepato-cístico. Para el estudio se utilizaron 41 muestras de cadáveres formolizados de individuos adultos, siendo 25 piezas anatómicas (de hígado y vías biliares) y 16 in situ. Las vías biliares fueron disecadas, esquematizadas y fotografiadas, se registró la longitud del ducto hepático común y cístico con un caliper digital. La longitud promedio del ducto hepático común fue de 21,76 +/- 9,51 mm, variando de 4,18 mm a 50,64 mm; la longitud promedio del ducto cístico fue de 19,11 +/- 6,77 mm, variando de 7,28 a 38,88 mm. Se observaron variaciones en 3 muestras (7,3 por ciento), en una de ellas, el ducto cístico se unió al ducto hepático izquierdo, en otra, el ducto cístico se unió al ducto hepático derecho y en la otra muestra, se presentó una confluencia triple de ductos hepáticos, dos derechos y uno izquierdo. Los resultados obtenidos son un aporte a la anatomía clínica y quirúrgica de la región.

A Case of Tubular Adenoma of the Common Hepatic Duct Accompanied with Gallbladder Carcinoma / 대한소화기내시경학회지

Biliary adenoma is rarely found in the biliary tract, and there are currently few reported cases of tubular adenoma. Biliary adenoma most often occurs on the duodenal ampulla and the next most common site is on the common bile duct. Because the clinical signs, symptoms and the laboratory findings of these lesions may be similar to malignant biliary diseases, it is difficult to differentiate benign biliary adenoma from malignancy. Therefore, the diagnosis of these tumors tends to be delayed and physicians usually make the pathologic confirmation after a surgical operation. We experienced a case of the simultaneous occurrence of tubular adenoma of the common hepatic duct and gallbladder carcinoma, and all this was diagnosed and treated with common hepatic duct resection and a Roux-en-Y hepaticojejunostomy operation. To the best of our knowledge, this is the first report of biliary tubular adenoma accompanied with gallbladder carcinoma arising from tubulovillous adenoma.

A common hepatic duct web in association with choledocholithiasis / 대한내과학회지

Biliary web is a very rare disease and it can be diagnosed by its characteristic findings on endoscopic retrograde cholangiogram. The etiology of biliary web is variable. We were able to diagnose a common hepatic duct web in association with choledocholithiasis by performing endoscopic retrograde cholangiogram and operation. A 31-year-old woman visited our emergency room because of colicky right upper abdominal pain she had experienced for several hours. The endoscopic retrograde cholangiogram showed web-like stricture and stone at the common hepatic duct. She was treated by cholecystectomy with Roux-en-Y hepaticojejunostomy. We report here on this rare case along with a review of the literature.

Treatment of Common Bile Duct or Common Hepatic Duct Transverse Injures in Cholecystectomy:Report of 5 Cases / 中国微创外科杂志

Objective To investigate the treatment of common bile duct or common hepatic duct transverse injures(CBDTI) in cholecystectomy.Methods From January 1993 to March 2008,3362 patients received cholecystectomy in our hospital,among them 5 developed CBDTI.We reviewed the clinic feature,management,and outcomes of these patients. Results Of the 5 patients,2 had common hepatic duct transverse injuries and 3 showed common bile transverse injuries.One of the five received postenterobiliary drainage and the other four underwent choledoch end-to-end anastomosis.No biliary leakage was found after the operation.One patient developed biliary stenosis and cholangitis after the end-to-end anastomosis and thus received postenterobiliary drainage.This case was followed up for 15 years,during which no abdominal pain,fever or jaundice occurred.The patient who underwent postenterobiliary drainage showed symptoms of cholangitis for 3 times whithin 2 months after the treatment;therefore,conservative therapy was carried out.Afterwards,the patient was cured and showed no abdominal pain,fever or jaundice during a 5-year follow-up.The other 3 patients who received end-to-end anastomosis were followed up for 1,2,or 4 years,no complications were noticed during the period.Conclusions Based on personal experience and the type of injury,surgeons may chose choledoch end-to-end anastomosis or postenterobiliary drainage to treat CBDTI.

Four Cases of Hepatic Fascioliasis Mimicking Cholangiocarcinoma / 대한간학회지

Human fascioliasis is a zoonosis caused by Fasciola hepatica, and this is a trematode that infests cattle and sheep. Humans are accidental hosts in the life cycle of this parasite. People are infected by ingestion of the water or the raw aquatic vegetables that are contaminated with the metacercaria. This fluke's worldwide distribution occurs in areas where sheep, cattle and goats are raised, and there is a life-cycle niche for this fluke in lymnaeid snails. However, it is a rare disease in Korea. We experienced four human fascioliasis which were difficult to differentiate from hepatic malignancy in three patients, and this was misdiagnosed as common hepatic duct tumor in one patient. The patients manifested only vague abdominal symptoms. Intrahepatic fascioliasis showed multiple ill-defined hypoattenuating lesions and filling defects of the lesion lumens on radiologic study. A striking eosinophilia from the patients' blood was identified and a positive finding of a serum enzyme linked immunosorbent assay for the Fasciola hepatica was also noted in three of four patients. The therapeutic trial with triclabendazole and praziquantel was not successful.

Hepatocellular Carcinoma Presenting as Klatskin's Tumor

Hepatocellular carcinoma has a great tendency to invade blood vessels, particularly the portal vein. Invasion into the biliary lumen has been considered to be a rather rare event. Ultrasonogram and endoscopic retrograde cholangiopancreatography of the patient, a 65-year-old man presenting with obstructive jaundice, revealed an obstructing mass at the common hepatic duct and dilatation of the intrahepatic bile ducts. Abdominal computed tomography and hepatic angiogram showed no abnormal mass and abnormal staining in the liver. Obstructive jaundice due to Klatskin's tumor was suspected preoperatively. During operation, although no tumor was palpable in the liver, an intraductal tumor measuring 3.5X3.0 cm was found in the common hepatic duct. Bile duct resection was performed in a patient. Histologically, the tumor, a hepatocellular carcinoma showing abundant eosinophilic cytoplasm, was structurally arranged in a solid and trabecular pattern. We report a case of hepatocellular carcinoma mainly presenting as Klatskin tumor.

Obstructive jaundice due to compression of the common hepatic duct by right hepatic artery: a case associated with the absence of the lateral segment of the left hepatic lobe

Various benign and malignant conditions can cause biliary obstruction. We present a rare case of obstructive jaundice due to the compression of the common hepatic duct by the anteriorly overriding right hepatic artery. This case was also associated with the absence of the lateral segment of the left hepatic lobe. The patient was a 39 year-old housewife with a 4-day history of jaundice and occasional febrile sensation. An abdominal computed tomography showed absence of the lateral segment of the left hepatic lobe and a percutaneous transhepatic cholangiography showed a band-like filling defect of 2 mm width at the level of the upper common hepatic duct. The anteriorly overriding right hepatic artery compressing the common hepatic duct and the absence of the lateral segment of the left hepatic lobe were confirmed by operation.

A Case of Papillary Adenocarcinoma of the Common Hepatic Duct Diagnosed by Peroral Choledochoscopy / 대한소화기내시경학회지

A 56-year-old man who had suffered from intermittent right upper quadrant abdominal pain for 6 months and jaundice for 2 months was admitted for evaluation. Endoscopic retrograde cholangio-pancreatography showed filling defect which suggested tumor. Peroral choledo-choscopy was performed which showed polypoid tumor of the common hepatic duct and biopsy reported as papiilary adenocarcinoma. So segmental resection of the bile duct including removal of tumor with Roux-en Y hepaticojejunostomy was performed successfully.

A Case of Papillary Adenocarcinoma of the Common Hepatic Duct Diagnosed by Peroral Choledochoscopy / 대한소화기내시경학회지

A 56-year-old man who had suffered from intermittent right upper quadrant abdominal pain for 6 months and jaundice for 2 months was admitted for evaluation. Endoscopic retrograde cholangio-pancreatography showed filling defect which suggested tumor. Peroral choledo-choscopy was performed which showed polypoid tumor of the common hepatic duct and biopsy reported as papiilary adenocarcinoma. So segmental resection of the bile duct including removal of tumor with Roux-en Y hepaticojejunostomy was performed successfully.