Cystic duct entering to right hepatic duct; a case report with literature review.

INTRODUCTION AND IMPORTANCE: Surgeons may mistakenly consider the right hepatic duct as cystic duct, ligate, and divide it. CASE PRESENTATION: A 58-year-old woman presented with right upper quadrant (RUQ) abdominal pain, nausea, and RUQ tenderness, but negative Murphy's sign. Common bile duct was 10 mm based on abdominal ultrasound. Common hepatic duct and intrahepatic ducts consist of multiple common bile duct (CBD) stones with sludge and multiple small gallstones. Different diagnostic procedures (Computed tomography (CT) scan, magnetic resonance cholangiopancreatography (MRCP), and endoscopic retrograde cholangiopancreatography (ERCP)) showed the connection of the cystic duct to the right hepatic duct. Balloon sweeping for stones extraction and then laparoscopic cholecystectomy was successfully done. CLINICAL DISCUSSION: Radiologic evaluations like MRCP, CT scan, ERCP or sonography before or during the surgery/endoscopic interventions seem logical at least for selected patients. CONCLUSION: Before endoscopic/surgical interventions we need to be sure about the anatomy of biliary tree by a suitable para-clinic evaluation.

Reduction of the severity of ischemia reperfusion-induced pancreatitis by ischemic pre-conditioning of the liver.

Pre-conditioning by brief exposure to ischemia does not only protect the concerned organ against subsequent severe ischemic damage, but also has protective effect on other organs, which is called remote pre-conditioning. Our aim in this study was to evaluate the protective effect of brief liver ischemia on the pancreas against severe ischemia-reperfusion-induced pancreatitis. This study was performed on 30 male Wistar rats. Ischemic pre-conditioning of liver was performed by first clamping of the hepatic pedicle for 10 minutes. Following this, ischemia-reperfusion of the pancreas was performed by first clamping the inferior splenic artery for 30 minutes, followed by reperfusion for one hour. The rats were divided into three groups (10 rats in each group). Group one was the sham operated group, without clamping of any artery. Group two developed ischemia-reperfusion-induced pancreatitis, without ischemic pre-conditioning of the liver, while Group three underwent ischemic pre-conditioning of the liver followed by ischemia-reperfusion of the pancreas. Ischemic pre-conditioning, applied prior to induction of pancreatitis, caused a reduction in plasma lipase, plasma interleukin-1beta and histological signs of pancreatic damage, but plasma interleukin-10 levels were not significantly different between the three groups. Ischemic pre-conditioning of the liver did not cause any alteration of the liver enzymes. Our study suggests that ischemic pre-conditioning of the liver reduces the severity of ischemia-reperfusion-induced pancreatitis. These effects are partly related to the reduction of pro-inflammatory interleukin -1beta.