術前DIC-CTにて低位合流肝管を伴う肝外胆管走向異常と診断した2例

Objective To investigate how to avoid and deal with injuries to the aberrant right posterior hepatic duct during laparoscopic cholecystectomy (LC).Method We studied 1 710 patients who underwent LC in our unit from January 2011 to November 2013.There were 5 patients with right posterior hepatic duct abnormally,and this paper analysed the cases.Results In the 5 patients,one patient had the right posterior hepatic duct draining into the gallbladder body (Ⅰ A type),two patients had the right posterior hepatic duct draining into the cystic duct (ⅢA type),and two patients had the cystic duct draining into the right posterior hepatic duct (ⅢB type).There was no damage to the right posterior hepatic duct during operation.One patient was converted from LC to open operation.The major aberrance was class Ⅲ.Conclusions Variant bile duct is an important cause of bile duct injuries during LC.The right posterior hepatic duct variation is the most common form.To raise our vigilance and fully understand the types of aberrant right posterior hepatic duct,reasonable use of preoperative MRCP and intraoperative cholangiography in selected patients are fundamental.Aberrant right posterior hepatic duct injuries can effectively be avoided. Key words: Cholecystectomy,laparoscopic; Bile duct variation; Hepatic duct injury

Anatomic variations of the biliary tree are frequent and increase complications after liver transplantation. To describe the anatomy of the bile ducts of donors and recipients of living related liver transplantation. From March 1998 to September 2002, the study was retrospective (23 transplantations). From October 2002 to August 2003, the study was prospective (17 transplantations). We studied the hepatic anatomy of 80 consecutive patients (40 donors and 40 recipients) of the living-related liver transplantation program of the "Hospital de Clínicas da Universidade Federal do Paraná" and the "Hospital Nossa Senhora das Graças", Curitiba, PR, Brazil; 51 were male (27 recipients 24 donors) and 29 female (13 recipients and 16 donors). The median age among the donors was 32.6 years and among the recipients was 36.3 years. Thirty-two recipients were adults and 8 recipients were under 15 years old. The bile duct anatomy was studied by magnetic resonance cholangiography in 33 patients, and anomalies were seen in 3 of them (9.1%). The most prevalent variation of bile ducts was the fusion of the right posterior duct with the left duct (6.06%; n=2). In the 40 harvesting operations, the right bile duct was single in 25 patients (87.5%), among the 32 right-lobe donors, double in 2 (6.25%) and triple in 2 (6.25%). All of the eight left livers procured had single bile ducts. Among the 40 recipients, the common bile duct was bifurcated in 2 of them (5%). The prevalence of biliary anomalies is high in patients subjected to living liver transplantation and some anomalies are not diagnosed with preoperative imaging exams.

Three-dimensional CT has become an essential tool for successful hepatic surgery. Up to now, efforts have been made to simultaneously visualize hepatic vasculature and bile ducts. Herein, we introduce a new one-stop shop approach to hepatic 3D-anatomy, using a standard enhanced MDCT alone. A 3D-reconstruction of hepatic vasculature was made using data from contrast enhanced MDCT and SYNAPSE VINCENT software. We identified bile ducts from axial 2D image, and then reconstructed the 3D image. Both hepatic vasculature and bile duct images were integrated into a single image and it was compared with the 3D image, utilized with MRCP or DIC-CT. The first branches of both the right and left hepatic ducts were hand-traced and visualized for all 100 cases. The second branches of these ducts were visualized in 69 cases, and only the right second branch was recognized in 52 cases. Anomalous variations of bile ducts, such as posterior branch joining into common hepatic duct, were recognized in 12 cases. These biliary tract variations were all confirmed by MRCP or DIC-CT. Our new one-stop shop approach using the 3D imaging technique might contribute to successful hepatectomy as well as reduce medical costs and radiation exposure by omission of MRCP and DIC-CT.

BackgroundRisk factors for bile duct injury in laparoscopic cholecystectomy include severe inflammation at Calot’s triangle and aberrant bile duct variations. Knowledge of the various biliary anomalies and early identification may therefore assist in decreasing the rate of bile duct injury.Case presentationA 65-year-old woman was admitted with right hypochondrial pain and high fever. A diagnosis of acute calculous cholecystitis was made by radiological imaging. Magnetic resonance cholangiopancreatography revealed that the confluence of the right and left hepatic duct was unclear. Intraoperatively, the procedure was converted from a laparoscopic cholecystectomy to laparotomy because of unclear anatomy of the cystic duct with severe inflammation at Calot’s triangle. Furthermore, intraoperative cholangiography from Hartmann’s pouch showed the main right hepatic duct entering the cystic duct. Subtotal cholecystectomy was performed to avoid injuring the right hepatic duct.ConclusionAlthough an aberrant hepatic duct entering the cystic duct is not uncommon, the main right hepatic duct infiltrating the cystic duct is extremely rare. Preoperative and intraoperative evaluation of the biliary duct and awareness of aberrant biliary duct variations is important in preventing bile duct injury.

Anatomical variations of both the vascular structures of the liver and gallbladder as well as the bile ducts, are very common. Detailed knowledge of the different courses of these vessels and ducts as well as their topographical relationships to one another, is essential in hepatobiliary procedures and surgery involving the upper gastrointestinal tract. Whenever possible, these variations should be identified preoperatively. This is best achieved through contrast-enhanced computed tomography (CT) with both portal venous and arterial phases, and for bile ducts, additionally via magnetic resonance imaging (MRI)/MRCP with liver-specific contrast agents. In smaller procedures involving the hepatic hilum (such as lymph node dissection or cholecystectomy), cross-sectional imaging is not routinely available. In these cases, both the awareness of anatomical variations and the ability to use intraoperative tools (such as ICG fluorescence or cholangiography) are crucial. Although bile duct injuries during cholecystectomy are overall rare (0.2-0.8%), they are frequently associated with vascular damage (up to 61%) and have asignificant impact on postoperative morbidity.

Cannulation of the non visualised duct: Managing biliary complications after adult-to-adult living donor liver transplantation

Ultrasonography can detect extrahepatic biliary obstructions. However, visualisation of part of the bile duct using ultrasonography can be technically difficult if there is overlying bowel gas. This study investigated the safety and value of drip infusion cholangiography with computed tomography (DIC-CT) in the visualisation of the bile duct in healthy cats and extrahepatic biliary obstruction in cats with cholelithiasis. DIC-CT was performed in three healthy cats and two cats with cholelithiasis. Meglumine iotroxate was administered by intravenous drip infusion over 30 mins. The attenuation value was measured perpendicular to the lumen by a region of interest covering about 50% of the area of the lumen. The bile ducts were visualised successfully with DIC-CT in all healthy cats without any significant adverse events. The attenuation value of the contrast medium was 271 ± 37 HU. In the two cats with cholelithiasis, the presence or absence of extrahepatic biliary obstruction was determined using DIC-CT without any significant adverse events. The attenuation value of cholelithiasis in the cat with an extrahepatic biliary obstruction was 933 ± 119 HU. In the cat with no extrahepatic biliary obstruction, the attenuation value of the contrast medium was 249 ± 53 HU and the attenuation value of cholelithiasis was 167 ± 28 HU. DIC-CT visualises bile ducts and detects obstructive biliary disease without significant adverse events. Therefore, it appears to be a safe procedure for visualisation of the bile duct in cats.

Bile duct variations in partial liver transplantations from living-related donors

Abnormalities and variations of the biliary ducts are not rare. Most aberrant bile ducts eventually drain into the descending part of duodenum through the papilla of vater. However, drainage of the left hepatic bile duct into the stomach is extremely rare. A 29-year old man was admitted to the hospital with the diagnosis of biliary reflux gastritis. Comprehensive imaging modalities were performed including electronic endoscopy, endoscopic ultrasonography, endoscopic retrograde cholangiopancreatography and magnetic resonance cholangio-pancreatography. Finally, congenital ectopic left intrahepatic bile duct draining into the stomach was found, which caused biliary reflux gastritis. The patient did not receive any surgery. Good recovery was achieved by medical treatment.

Intravenous cholangiography was carried out in 80 anicteric patients using ioglycamide (Biligram). Twenty patients were given a 30 ml ampoule of 35% ioglycamide as a slow hand injection over ten minutes; the remainder were given ioglycamide by one hour slow drip infusion at a rate of 2, 3, or 4 mg per kg body weight per minute. The radiological opacification of the bile duct was then assessed independently by two radiologists. There was a statistically significant difference between the bile duct opacification found in patients given either 3 or 4 mg/kg/min of ioglycamide for one hour compared with those given ioglycamide either by ten minute injection or by 2 mg/kg/min drip infusion.

Improved visualization of a fine intrahepatic biliary duct on drip infusion cholangiography-computed tomography: Impact of knowledge-based iterative model reconstruction.

ObjectiveTo describe the anatomical variations occurring in intrahepatic bile ducts (IHDs) and their frequencies in general adult Egyptian population using 3.0-T MR cholangiography (MRC) as well as its clinical importance to reduce the biliary complications of hepatobiliary surgery. Materials and methodsMRC was applied to a study group of 106 subjects (26 potential liver donors and 80 volunteers). Anatomical variations in IHDs were classified based on the variable insertion of right posterior hepatic bile duct (RPHD) using Huang classification. ResultsAccording to this classification, the frequencies of each type were as follows: Huang A1 (typical pattern): 63.2% (n=67), Huang A2: 10.4% (n=11), Huang A3: 17% (n=18), Huang A4, 7.5% (n=8), and Huang A5: 1.9% (n=2). Total frequency for atypical types (i.e. A2, A3, A4 and A5) was 36.8%. No significant difference was detected in the distance between RPHD insertion to the junction of right and left hepatic duct in-between these Huang types. This distance was short (<1cm) in 21 of subjects under Huang A classification. Twenty-one donors underwent intraoperative cholangiograms, of which twenty (95.2%) had similar classification in both intraoperative and MRC findings. ConclusionThe incidence of variant biliary anatomy in general Egyptian population (36.8%) as well as the presence of Huang type A with short distance (<1cm) between RPHD insertion and junction of right and left hepatic duct (19.8%) enhance the importance of MRC as a pre-operative tool before hepato-biliary surgical procedures to reduce post-operative biliary complications.

Knowledge of the configuration of the extrahepatic bile duct is indispensable to avoid bile duct injury during cholecystectomy. Various methods of examining the biliary tract have been developed; however, the most appropriate preoperative diagnostic modality at cholecystectomy for cholecystolithiasis has not yet been reported. Considering the frequency of bile duct maljunction (BDM) and operative bile duct injury, in addition to the cost and invasiveness of the various examination methods, we evaluated the usefulness of drip infusion cholecystocholangiography (DIC) as the optimal method of examination at cholecystectomy for cholecystolithiasis. Preoperative diagnostic accuracy of BDM was analyzed in relation to operative bile duct injury using 469 patients with benign biliary diseases who was diagnosed with DIC and endoscopic retrograde cholecystography and underwent cholecystectomy. BDM was classified according to Hisatsugu criteria. Out of 469 consecutive patients who underwent a cholecystectomy for biliary stones between January 1, 1995, and September 30, 1998, at Ohta Nishinouchi General Hospital, 21 (4.48%) had a cystic duct maljunction (CDM) and 12 (2.56%) had an aberrant bile duct (ABD). The most common variants were types C and D for CDM, and types II and III for ABD, according to Hisatsugu's classification. Fourteen patients (42.4%) were diagnosed before the surgery; 13 of them received preoperative endoscopic retrograde cholangiography (ERC), and the remaining patient underwent preoperative drip infusion cholecystocholangiography (DIC). Nineteen patients could not be correctly diagnosed based on their preoperative examinations, but were diagnosed during surgery. Operative bile duct injury occurred in 1 patient (0.2%) whose maljunction could not be diagnosed before the operation. Taking into account the medical cost and invasiveness, and the frequency of BDM and related bile duct injuries, we conclude that DIC is an acceptable preoperative diagnostic modality to employ at cholecystectomy for cholecystolithiasis. Knowledge of the configuration of the extrahepatic bile duct is indispensable to avoid bile duct injury during cholecystectomy. Various methods of examining the biliary tract have been developed; however, the most appropriate preoperative diagnostic modality at cholecystectomy for cholecystolithiasis has not yet been reported. Considering the frequency of bile duct maljunction (BDM) and operative bile duct injury, in addition to the cost and invasiveness of the various examination methods, we evaluated the usefulness of drip infusion cholecystocholangiography (DIC) as the optimal method of examination at cholecystectomy for cholecystolithiasis.

BackgroundHepatopancreatoduodenectomy (HPD) for diffusely spreading bile duct cancer (DSBDC) usually involves a major hepatectomy and a concomitant pancreatoduodenectomy, and is still challenging surgery because of postoperative liver failure. The present case report demonstrated two cases of DSBDC where we could achieve successful HPD with central liver resection (CHPD) as liver parenchymal sparing surgery.Case presentationIn Case 1, endoscopic retrograde cholangiography (ERC) with multiple biopsies revealed that she had DSBDC with Bismuth-Corlette type IIIA. 3D integrated images reconstructed by contrast enhanced CT and CT with drip infusion cholecystocholangiography data revealed the right antero-ventral bile duct (RAVD) confluent to the right hepatic duct and the right antero-dorsal bile duct (RADD) independently confluent to the right posterior bile duct (RPD). Tumor extended common bile duct including intrapancreatic bile duct to the left hepatic duct and RAVD, but the RADD and RPD were spared. Because the future liver remnant (FLR) was assumed not to achieve desirable volume by preoperative portal vein embolization for left or right trisegmentectomy, CHPD including resection of the segments IV and I, and the right antero-ventral segment was done and achieved R0. This procedure is tailored to the anatomical extent of disease in the context of variable biliary anatomy as a modified CHPD, and to our knowledge, this is the first reported case of modified CHPD with antero-dorsal segment preservation. In Case 2, preoperative imaging revealed DSBDC with Bismuth Corlette type IIIA. FLR volume was assumed insufficient for major hepatectomy, CHPD including resection of the segments IV and I, and the right anterior sector was done with R0. The remnant liver volumes of these cases were spared by 55.1% and 25% respectively, and postoperative course was uneventful in both.ConclusionCHPD should be considered a valid option for well-selected cases of DSBDC. This is the first case report of modified CHPD with antero-dorsal segment preservation.

Plamen Getsov, Sylvie Siminkovitch, Mila Kovacheva-Slavova, Stoyanka Dineva, Borislav Vladimirov, Anatomical Variations of Bile Ducts. Study of Their Frequency in the Bulgarian Population, Using Magnetic Resonance Cholangiopancreatography