Anatomía quirúrgica del conducto colédoco: revisión de la clasificación topográfica / Surgical anatomy of the bile duct: revision of its topographical classification

Introducción: Se han clasificado diversas porciones del conducto colédoco, desde su origen en la unión cistohepática, hasta la segunda porción del duodeno. No se puede lograr un consenso al momento de segmentarlo, debido a que algunos autores sostienen la existencia de 3 o 4 porciones. Objetivo: El objetivo fue establecer la prevalencia de cada una de las porciones del conducto colédoco, determinar sus características morfológicas y analizar su asociación quirúrgica. Material y método: Estudio analítico de corte transversal en el que se diseccionaron 40 vías biliares. Resultados: Se evidenció 85% de porción retroduodenal, 20% retropancreática, 80% intrapancreática y 45% intramural. No se evidenció la porción supraduodenal debido a las relaciones anatómicas regionales, al tabique cistohepático o a una unión cistohepática baja. La combinación secuencial más frecuente fue la retroduodenal e intrapancreática. El conducto colédoco tuvo una longitud de 66,19 mm y un diámetro de 6,31 mm. Conclusiones: La segmentación biliar establecida tendría implicancias tanto teóricas, al justificar las teorías etiopatogénicas vigentes de la pancreatitis biliar, como prácticas, redefiniendo la coledocotomía supraduodenal y los cuadros clínicos de ictericia obstructiva.

Introduction. Several portions of the bile duct have been classified from its origin in the cystohepatic junction to its outfall in the second portion of the duodenum. An agreement could not be reached among the authors at the time of segmenting it, since some of them claim that there are three or four portions. Objective. To establish the prevalence of each of the bile duct portions, determine its morphological characteristics and to analyze its surgical associations. Material and method. A cross-sectional study. 40 biliary tracks were dissected. Results: Retroduodenal portion 85%, retropancreatic 20%, intrapancreatic 80%, intramural 45%. The supraduodenal portion was not made evident because of the regional anatomic relations, the cystohepatic septum or a cystohepatic lower junction. The bile duct had an average lenght of 66.19 mm and a diameter of 6.31 mm. Conclusions: The biliary segmentation would have a theoretical explanation to justify the etiopathogenic theories of the biliary pancreatitis, and a practical implication by redefining the choledochotomy supraduodenal and clinical pictures of obstructive jaundice.

Clinical Features and Outcomes of Endoscopic Treatment for Stones in Stemware-Shaped Common Bile Ducts: A Multicenter Data Analysis

BACKGROUND/AIMS: Various anatomical features of the biliary tree affect ability to remove difficult common bile duct (CBD) stones. In this study, we evaluated the clinical characteristics and outcomes of the endoscopic treatment of stones in stemware-shaped CBDs. METHODS: Thirty-four patients with a stone and a stemware-shaped CBD who were treated at different tertiary referral centers from January 2008 to December 2012 were studied retrospectively. When stone removal failed, percutaneous or direct peroral cholangioscopic lithotripsy, endoscopic retrograde biliary drainage, or surgery was performed as a second-line procedure. RESULTS: The overall success rate of the first-line procedure was 41.2%. Five of the 34 patients (14.7%) experienced procedure-related complications. No procedure-related mortality occurred. Mechanical lithotripsy was required to completely remove stones in 13 patients (38.2%). Conversion to a second-line procedure was required in 20 patients (58.8%). Mechanical lithotripsy was needed in 75% and 66.7% of those with a stone size of or =1 cm, respectively. Stone recurrence occurred in two patients (9.1%) after 6 months and 27 months, respectively. CONCLUSIONS: The endoscopic treatment of stones in a stemware-shaped CBD is challenging. The careful assessment of difficult CBD stones is required before endoscopic procedures.

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.

Hemobilia: diagnóstico por imágenes a propósito de dos casos / Hemobilia: imaging report of two cases

El diagnóstico de hemobilia resulta difícil en la práctica diaria; el tratamiento está destinado a detener el sangrado y resolver la causa del mismo. Los aneurismas de la arteria hepática constituyen una patología poco frecuente y una de las causas raras de hemobilia, la presentación clínica es inespecífica e incluye dolor abdominal, ictericia obstructiva y sangrado digestivo alto. Recientemente con el desarrollo de la radiología intervencionista se ha logrado reducir el número de cirugías, mediante la embolización transarterial, obteniendo tasas de éxito entre 80-100%.2 Se presentaran 2 casos de hemobilia, todos fueron estudiados con ecografía, colangiografía por resonancia magnética y angiotomografía. Se describen las características de esta patología con los distintos métodos por imágenes; se destaca la indicación de la arteriografía no sólo para el diagnóstico sino también como tratamiento (embolización). En un caso, la hemobilia fue identificada por duodenoscopia y en el otro por gastroscopia. A ambos pacientes se le realizó ultrasonido abdominal el cual mostró hepatomegalia, vesícula distendida con barro biliar, dilatación de vías biliares e imagen hipoecogénica en segmento V hepático. El doppler revela flujo activo en la vía biliar. Angiotomografía y colangiografía por resonancia magnetica revelaron aneurisma en la arteria hepática derecha en íntimo contacto con la vía biliar, correlacionado con la imágen hipoecogénica observada por ultrasonido. Ambos casos fueron resueltos por la liberación de coils intra-arteriales sin complicaciones.

The diagnosis of hemobilia is difficult in daily practice; treatment is designed to stop the bleeding and resolve its cause. Hepatic artery aneurysms are an uncommon condition and one of the rare causes of hemobilia; clinical presentation is nonspecific and includes abdominal pain, obstructive jaundice and upper gastrointestinal bleeding. Recently, due to the development of interventional radiology, the number of surgeries has successfully been reduced through transarterial embolization, achieving success rates between 80-100%.2 We present 2 cases of hemobilia that were evaluated by ultrasound, MRI cholangiography and angiotomography. We describe the characteristics of this disease with the use of different imaging methods; with emphasis on the use of arteriography not only for diagnosis but also for treatment (embolization). In one case, the hemobilia was identified by duodenoscopy, and in the other by gastroscopy. Both patients underwent abdominal ultrasound that showed hepatomegaly, distended gallbladder with biliary sludge, distended bile ducts and a hypoechoic image in liver segment V. Doppler revealed active flow into the bile duct. Angiotomography and MRI reported an aneurysm in the right hepatic artery in close contact to the bile duct, correlated to the hypoechoic image seen by ultrasound. Both cases were treated with transarterial coil placements without any complications.

The Effect of Periampullary Diverticulum on the Outcome of Bile Duct Stone Treatment with Endoscopic Papillary Large Balloon Dilation / 대한소화기학회지

BACKGROUND/AIMS: Periampullary diverticulum (PAD) causes difficulty in the extraction of common bile duct (CBD) stones with conventional endoscopic therapy. Our study was designed to evaluate the effect of PAD on endoscopic large balloon dilation (EPLBD) with/without limited endoscopic sphincterotomy (EST) for CBD stone treatment. METHODS: We retrospectively reviewed cases of 141 patients treated CBD stones by EPLBD with/without limited EST at Gachon Gil Medical Center from September 2008 to February 2010. PAD were classified into three groups according to the location of the papilla and diverticulum. Clinical parameters, endoscopic parameters, and procedure outcomes were analyzed. RESULTS: PAD were identified in 46.1% (65/141), with 23 male (35.4%) and 42 female (64.6%) and a mean age of 72.9+/-11.1 years. Mean diameter of the stones was 14.8+/-6.0 mm and mean diameter of CBD was 21.6+/-7.7 mm. PAD group was significantly older than control group (72.9 vs. 68.6, p=0.043) and the incidence of large stone (> or =15 mm) was higher in PAD group (60.0% vs. 42.1%, p=0.034). Success rate of complete removal of stones in the first session was 32/65 patients (49.2%) and overall successful complete stone removal rates was 63/65 (96.9%). There was no significant difference between the PAD and control groups in success rate. Major complications were similar between two groups. CONCLUSIONS: PAD is associated with an increased incidence of large bile duct stones and older age. PAD seems to not increase technical failure rate or complication risk on EPLBD with/without limited EST.

The Relationship of Anatomic Variation of Pancreatic Ductal System and Pancreaticobiliary Diseases

The aims of this study were to identify the morphological diversities and anatomical variations of pancreatic ductal system and to define the relationships between pancreatic ductal systems, pancreaticobiliary diseases, and procedure-related complications, including post-ERCP pancreatitis. This study included 582 patients in whom both pancreatic duct (PD) and common bile duct were clearly visible by ERCP. PD systems were categorized into four types according to the relationship between common bile duct and PD. In types A and B, Wirsung duct formed the main PD. In type C, Wirsung duct did not form the main PD. If PD system did not fall into any of these three types, it was categorized as type D. The distribution of types among pancreatic ducts examined was as follows: type A: 491 cases (84.4%), type B: 56 cases (9.6%), type C: 20 cases (3.4%), and type D: 15 cases (2.6%). The anomalous anatomic variations of PD systems were divided into migration, fusion, and duplication anomalies. PD anomalies were noted in 51 patients, of which 19 (3.3%) were fusion anomalies (12 complete pancreas divisum, 7 incomplete pancreas divisum), and 32 (5.5%) were duplication anomalies (5 number variations, 27 form variations). No significant relationships between various PD morphologies and pancreaticobiliary diseases were found. However, post- ERCP hyperamylasemia was more frequently found in types C (41.7%), D (50%) and A (19.8%) than in type B (9.4%). In summary, whether Wirsung duct forms the main PD and the presence or absence of the opening of the Santorini duct are both important factors in determining the development of pancreatitis and hyperamylasemia after ERCP.

Endoscopic ultrasound versus endoscopic retrograde cholangiography for the diagnosis of choledocholithiasis: the influence of the size of the stone and diameter of the common bile duct

RACIONAL: A colangiografia retrógrada endoscópica é método acurado porém invasivo para o diagnóstico da coledocolitíase. A ecoendoscopia também é método bastante eficaz para a detecção de cálculo coledociano e apresenta riscos semelhantes àqueles de uma endoscopia digestiva convencional.OBJETIVOS: Comparar a acurácia da ecoendoscopia e da colangiografia endoscópica para o diagnóstico do cálculo da via biliar principal antes da colecistectomia laparoscópica e analisar a influência do tamanho do cálculo e do calibre da via biliar principal na eficácia diagnóstica da ecoendoscopia. PACIENTES E MÉTODOS: Duzentos e quinze pacientes com colecistolitíase sintomática foram admitidos para colecistectomia laparoscópica. Destes, 68 (31,7%) apresentaram dilatação da via biliar extra-hepática à ecografia convencional e/ou alteração de enzimas hepáticas e canaliculares. Foram, então, submetidos a ecoendoscopia e colangiografia endoscópica, seguida de papilotomia, se qualquer um dos métodos sugerisse a presença de coledocolitíase. Após a papilotomia, o maior cálculo foi recuperado e medido. A exploração endoscópica ou cirúrgica da via biliar foi considerada o padrão-ouro para o diagnóstico de coledocolitíase. RESULTADOS: Todos os 68 pacientes foram submetidos a colecistectomia laparoscópica com colangiografia intra-operatória, comprovando-se colecistolitíase neste grupo. A ecoendoscopia foi mais sensível do que a colangiografia endoscópica para a detecção de cálculos coledocianos (97% vs. 67%). Para os cálculos maiores de 4,0 mm, os métodos apresentaram sensibilidades semelhantes (96% vs. 90%). Os resultados da ecoendoscopia não foram influenciados pelo tamanho do cálculo ou pelo calibre do colédoco. CONCLUSÕES: Para pacientes com risco intermediário para coledocolitíase, a ecoendoscopia é método mais sensível do que a colangiografia endoscópica, especialmente para cálculos pequenos.

Topography and morphometry of the common bile duct and major duodenal papilla of man and principal domesticated animals.

A comparative topography and morphometry of the common bile duct and major duodenal papilla was studied on the extrahepatic biliary apparatus of human and major domesticated animals such as horse, ox, Black Bengal (BB) goat, sheep, dog and cat of local breed. In Black Bengal goat, sheep, dog and cat, the extrahepatic biliary system seemed to be the continuation of the cystic duct, which was found to continue as the common hepatic/common bile duct into which all the hepatic/lobar ducts open. In man, the mean length and the mean diameter of the common bile duct were 7.67+/-0.58 cm. and 7.27+/-0.77 mm. respectively. In the ox, these values were 1.57+/-0.72 cm. and 11.82+/-0.79 mm. respectively; in the Black Bengal goat, 7.23+/-0.74 cm. and 4.45+/-0.72 mm. respectively; in the sheep, 5.27+/-0.66 cm. and 3.75+/-0.79 mm. respectively; in the dog, 4.72+/-0.67 cm. and 6.43+/-0.55 mm. respectively and in the cat, 3.26+/-0.87 cm. and 5.63+/-0.43 mm. respectively. In man, the mean length and the mean diameter at the base of the MDP were 4.37+/-0.56 mm. and 3.97+/-0.72 mm. respectively. In horse, these were 52.36+/-0.67 mm. and 12.47+/-0.63 mm. respectively; in ox, 12.53+/-0.73 mm. and 8.83+/-0.68 mm. respectively; in Black Bengal goat, 14.36+/-0.55 mm. and 5.23+/-0.57 mm. respectively; in sheep, 11.27+/-0.69 mm. and 4.51+/-0.74 mm. respectively; in dog, 17.43+/-0.82 mm. and 6.72+/-0.64 mm. respectively and in cat, these values were 12.36+/-0.47 mm. and 7.12+/-0.87 mm. The distance of the Major Duodenal Papilla (MDP) form the pyloric end of the stomach was proportionately shorter in the meat-eaters, i.e., the omnivorous man (9.76+/-0.88 cm), and the carnivores, dog (6.37+/-0.73 cm) and cat (2.75+/-0.87 cm.) when compared to that of the herbivores, i.e., ox (55.37+/-0.68 cm.), BB goat (23.27+/-0.89 cm.) and sheep (25.62+/-0.77 cm.). In the horse, the major duodenal papilla was perpendicular to the duodenal mucosal surface with the largest mean length and the mean diameter. In all other animals, it was obliquely placed on the duodenal surface with its opening directed aborally.

Gadobenate Dimeglumine as an Intrabiliary Contrast Agent: Comparison with Mangafodipir Trisodium with Respect to Non-dilated Biliary Tree Depiction

OBJECTIVE: To compare the efficacy of Mangafodipir trisodium (Mn-DPDP) -enhanced MR cholangiogrphy (MRC) and Gadobenate dimeglumine (Gd-BOPTA) -enhanced MRC in visualizing a non-dilated biliary system. MATERIALS AND METHODS: Eighty-eight healthy liver donor candidates underwent contrast-enhanced T1-weighted MRC. Mn-DPDP and Gd-BOPTA was used in 36 and 52 patients, respectively. Two radiologists reviewed the MR images and rated the visualization of the common duct, the right and left hepatic ducts, and the second-order branches using a 4-point scale. The contrast-to-noise ratio (CNR) of the common duct to the liver in the two groups was also compared. RESULTS: Mn-DPDP MRC and Gd-BOPTA MRC both showed similar visualization grades in the common duct (p = .380, Mann-Whitney U test). In the case of the proximal bile ducts, the median visualization grade was significantly higher with Gd-BOPTA MRC than with Mn-DPDP MRC (right hepatic duct: p = 0.016, left hepatic duct: p = 0.014, right secondary order branches: p = 0.006, left secondary order branches, p = 0.003). The common duct-to-liver CNR of the Gd-BOPTA MRC group was significantly higher (38.90+/-24.50) than that of the Mn-DPDP MRC group (24.14+/-17.98) (p = .003, Student's t test). CONCLUSION: Gd-BOPTA, as a biliary contrast agent, is a potential substitute for Mn-DPDP.

Ultrasonographic evaluation of common duct diameter in pre and post cholecystectomy patients.

Thirty four patients with gall bladder disease and normal common duct were investigated prospectively by ultrasonography just before cholecystectomy and at periodic intervals of 1 months, 2 months, 3 months and once in 4-6 months after cholecystectomy. The pre and post cholecystectomy common duct diameters were measured at each visit and compared with each other to determine the statistical significance. No significant change (p > 0.05) occurred in common duct diameter following cholecystectomy.

Histological study of extrahepatic part of human biliary tree with emphasis on peribiliary glands

Extrahepatic part of human biliary tree was lined with simple tall columnar epithelium. Supranuclear cytoplasm of the cell was darkly stained. Histochemistry of the epithelium revealed that it was mucus secreting. Below the epithelium there was a thick compact layer of connective tissue. Outside the compact layer there was a loose layer of areolar tissue in which smooth muscle, blood vessels and nerves were found. Glandular acini were present within and outside the compact layer of intrapancreatic bile duct [IPBD] and common bile duct [CBD] whereas these were present only within the compact layer of bile duct of ampulla of Vater [BDAV]. Statistical significance of quantitative difference between glandular acini of BDAV with other regions revealed that the difference was significant [P < 0.01] with IPBD and non significant [P > 0.05] with CBD. Statistical significance of quantitative difference between glandular acini of IPBD with other regions revealed that the difference was significant [P < 0.01 and P < 0.05] with BDAV and CBD respectively. Statistical significance of quantitative difference between glandular acini of CBD with other regions also revealed that difference was significant [P<0.05] with IPBD whereas it was not significant with BDAV [P>0.05]. Intramural and extramural glandular acini were present in IPBD and CBD whereas BDAV contained only intramural glands. The difference between intramural and extramural glandular acini was statistically significant [P < 0.02] in IPBD. The difference between intramural and extramural glandular acini of CBD was also statistically highly significant [P<0.001]. Glandular acini as demonstrated by different stains were 100% mucous type in BDAV and IPBD whereas it was mixed type in CBD. The acini of CBD were serous, mucous and mixed type. The difference between serous and mucous, mucous and mixed glandular acini was statistically highly significant [P<0.001]. The difference between serous and mixed glandular acini was statistically not significant [P>0.05]. Ratio of serous, mucous and mixed glandular acini was 1:22:1 respectively

Estudo da anatomia vascular sanguínea e biliar do segmento lateral esquerdo do fígado e sua aplicaçäo cirúrgica / Study of the blood and bile anatomy of the left lateral segment of the liver and its surgical application

O objetivo do presente estudo é investigar a anatomia vascular sanguínea e biliar do segmento lateral esquerdo ou segmentos II e III do fígado, assim como suas variaçöes, para se evitarem complicaçöes isquêmicas ou trombóticas do segmento lateral esquerdo, bem como o surgimento de fistulas biliares após o transplante hepático parcial ou reduzido. 25 cadáveres foram avaliados. A veia porta, artéria hepática, via bilífera e veias hepáticas foram submetidas a técnica de injeçäo de acrílico na forma líquida para posterior obtençäo dos moldes hepáticos. Näo foram encontradas variaçöes no ramo esquerdo da veia porta. A irritaçäo arterial de tal segmento se seu a partir da artéria hepática esquerdo ramo da artéria hepática comum em 24/25 casos; em um caso encontrou-se uma artéria hepática substituta, ramo da artéria gástrica esquerda, irrigando os segmentos II e III: em outro caso (1/24) foi encontrado um ramo acessório da artéria gástrica esquerda irrigando o segmento II. O ducto hepático esquerdo recebeu os ramos de drenagem dos segmentos II e III em todos os casos estudados; em 23/25 casos notou-se a presença de um ducto bilífero proveniente do segmento IV desembocando ducto hepático esquerdo. Quanto a veia hepática esquerda, responsável pela drenagem de tais segmentos, uniu-se a veia hepática intermédia formando um tronco comum antes de sua desembocadura na veia cava inferior em todos os casos estudados.

Colangio-debitomanometria por sonda en T en control posoperatorio / Cholangio-debitomanometry by a T probe in the postoperative control

Se realiza un estudio prospectivo en 30 enfermos en los hospitales Clinicoquirurgico Docente "Miguel Enriquez" y Qued-Rhiou de Argelia durante 1986 a 1990, a quienes se les realizo coledocostomia. Al no disponer de equipos de circuito cerrado de television para el estudio dinamico del esfinter de Oddi, se midieron las presiones y el debito biliar al realizarseles la colangiografia de control, lo que permitio conocer no solo la morfologia de las vias biliares, sino tambien la dinamica del esfinter, alteradas en ocasiones por edema, esclerosis o calculos pequenos que actuan como valvula. El resultado de esta prueba posibilito la extraccion de calculos residuales por papilo-esfinterotomia transdoudenal endoscopica. Los resultados fueron satisfactorios al lograrse realizar un estudio mas completo de la funcion biliar en su status posoperatorio mediato y poder solucionar complicaciones biliares en 5 pacientes

The distribution of the billiary ducts in wolves (Cerdocyon thons and Chrysocyon brachyurus)

O estudo da distribuiçäo extra e intraparenquimal dos ductos biliares dos raros "lobos brasileiros" um exemplar de "lobo guará Chrysocyon brachyurus" e 3 exemplares de "cachorro do mato" Cerdocyon thons, revelou a presença do ducto hepático, no Chrysocyon brachyurus, porém, o mesmo estava ausente nos 3 animais de outra espécie, uma vez que o ductus hepaticus dexter e o ductus hepaticus sinister convergem para o ductus cysticus (triconvergência). Um arranjo variável na distribuiçäo de outros ductos biliares foi observado nos 4 animais estudados. As semelhanças e diferenças entre estes achados com o cäo doméstico sem raça definida, Pastor Alemäo e Pequinês também estäo indicados

The excretory system of the liver in wild animals. VI. Biliary ducts of the great anteater (Myrmecophaga tridactyla)

Neste trabalho säo sistematizadas as vias bilíferas do tamanduá bandeira (Myrmecophaga tridactyla). Os resultados demonstram: o ductos choledocus, livre de afluentes, origina-se da uniäo do ramus principalis dexter e do ramus principalis sinister. O ramus principalis dexter é invariavelmente composto pelo ramus lateralis lobi dextri e pelo ramus medialis lobi dextri, enquanto o ramo pincipalis sinister está composto pelo ramus lateralis lobi sinistri, ramus medialis lobi sinistri e ramus lobi quadrati

Vesícula biliar y conductos biliares

Se detallan la anatomía y funciones de la vesícula biliar y conductos biliares. Se explican las características clínicas, diagnóstico y tratamiento de la colecistitis y colelitiasis, colecistitis aguda no calculosa, colecistitis primaria bacteriana, colecistitis aguda no calculosa en el período posoperatorio, colangitis aguda supurativa obstructiva, torsiones, lesiones traumáticas, tumores y parásitos