Protective strategy for the caudate lobe bile duct during left hemihepatectomy based on imaging data analysis

Mo1455 Extended Left Hepatic Trisectionectomy as a Feasible Surgical Procedure for Advanced Perihilar Cholangiocarcinoma

Bile duct adenomas are rare tumours that arise more frequently in the distal extrahepatic biliary tree. We report the case of a papillary adenoma arising at the junction of the common and left hepatic ducts and review the available literature on this rare entity. A 73-year-old lady presented with a history of mild weight loss and vague upper abdominal pain. Routine blood tests revealed an elevated c-glutaryl transferase, and an ultrasound scan showed gross dilatation of the intrahepatic and extrahepatic biliary tree. Subsequent radiological imaging confirmed biliary dilatation and identified tumour within the left and common hepatic ducts with the provisional diagnosis of cholangiocarcinoma. At laparotomy, there was no evidence of extraductal tumour, and choledochoscopy showed a papillary lesion within the common hepatic and proximal left hepatic ducts. The tumour was excised and the biliary tree was reconstructed. Histological evaluation of the resected specimen confirmed a papillary adenoma with mild dysplasia. This case illustrates that not all biliary tumours are cholangiocarcinomas and referral to a hepatopancreaticobiliary unit for investigation and treatment is mandatory for all cases of obstructive jaundice.

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.

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

A 74-year-old woman underwent endoscopic retrograde cholangiopancreatography because of obstructive jaundice, caused by pancreatic cancer. The patient received a plastic biliary stent (half-pigtail type) placement into the left hepatic bile duct for biliary drainage. After 28days, the patient presented to our hospital with fever and jaundice. Emergent endoscopic retrograde cholangiopancreatography revealed bleeding from the papilla and blood clots filling the entire bile duct. To treat the hemobilia, endoscopic nasobiliary drainage was performed after placement of a self-expandable metallic stent in the common bile duct. Frequent irrigation of the bile duct failed to remove the clots. Although endoscopic retrograde cholangiopancreatography was repeated to remove the clots, fresh blood flowed from the bile duct. Enhanced computed tomography revealed a left hepatic artery pseudoaneurysm that had likely ruptured into the bile duct. Following successful transcatheter arterial embolization, there was no recurrent bleeding. Since the tip of the stent was located at the site of the pseudoaneurysm, it was suspected that stent insertion caused the complication. This report describes a rare case of hemobilia of a hepatic artery pseudoaneurysm caused by insertion of a half-pigtail type biliary stent into the left hepatic duct. The case was successfully treated with embolization.

Changing Perspectives in the Assessment of Resectability of Hilar Cholangiocarcinoma

Background and Objective: Precise identification of biliary structures is fundamental to preventing bile duct injury during laparoscopic cholecystectomy. Conventional intraoperative cholangiography provides valuable information but requires radiation and ductal manipulation. The present study aimed to access the efficacy of Indocyanine green (ICG)-based near-infrared (NIRF) fluorescence in visualizing biliary anatomy intraoperatively. Methods: In Cuttack, Odisha, at SCB Medical College and Hospital, a prospective observational study was conducted, between October 2022 and March 2024. Two hours prior to surgery, 40 patients who were scheduled for elective LC received intravenous ICG at a dose of 0.25 mg/kg. An illustration of the common bile, common hepatic, and cystic ducts was documented using a NIF laparoscopic system. Operative parameters, including operative time, blood loss, and complications, were analyzed. Results: The cystic duct was identified in 95% of patients, the common hepatic duct in 85%, and the common bile duct in 80%. The mean operative duration was 72 ± 12.6 minutes, and the average time to obtain the critical view of safety was 17.9 ± 2.9 minutes. Mean intraoperative blood loss was 14.9 mL. No conversions, allergic reactions, or bile duct injuries were recorded. Conclusion: Real-time biliary anatomy visualization is improved by NIF imaging with ICG without radiation or added operative risk. It is a safe, efficient, and cost-effective adjunct for LC, particularly beneficial in teaching and high-volume centers.

To qualitatively and quantitatively compare gadoxate-enhanced T 1-weighted MR cholangiography at magnetic field strengths of 1.5 T and 3.0 T. A total of 40 patients with a non-dilated biliary system were retrospectively included in the study. T 1-weighted MR cholangiography 20 min after IV administration of 0.025 mmol/kg gadoxate (Primovist) was performed in 20 patients at 1.5 T and in another 20 patients at 3.0 T. Contrast-to-noise ratios (CNR) of the biliary system (common bile duct - CBD, right hepatic duct - RHD, left hepatic duct - LHD) compared to the periductal tissue were measured. Two radiologists also qualitatively assessed the visibility of the intrahepatic and extrahepatic biliary system using a six-point rating scale. The Mann-Whitney U-test and Pearson's correlation coefficient were used for statistical analysis. The CNRs of the intrahepatic and extrahepatic hepatic bile ducts were significantly higher at 3.0 T. Qualitative analysis showed a significant superiority for 3.0 T in the delineation of the intrahepatic biliary system (RHD, LHD, segmental ducts). Gadoxate-enhanced T 1-w MR cholangiography at 3.0 T offers better delineation of the intrahepatic biliary system in comparison to imaging at 1.5 T.

Postoperative stricture of the bile duct commonly occurs following operation of the bile duct, mainly for cholelithiasis. In a recent one decade was operated on 232 patients for cholelithiasis, and no patients developed postoperative stricture. In the same period, we treated 5 patients with this disease who were referred to our department for obstructive jaundice following biliary tract surgery. The initial surgical procedures at outside hospital were cholecystectomy alone in four and cholecystectomy with T-drainage to repair the injured common hepatic duct in one case. All of the cases developed jaundice on various times during the postoperation period. Cholangiographic examinations revealed complete obstruction of the common hepatic duct in two and strictures of left, right and common hepatic bile duct in three cases. Left and right cholangiojejunostomy in one, common hepatic duct-jejunostomy in three and dissection of periductal scar tissue in one case were performed respectively.After reoperation, one patient died from hepatic failure, but the remaining patients showed almost good results. It is very important for prophylaxis of the disease to make the biliary structure clear and to avoid the injury of the biliary duct.

Ischemic cholangiopathy

Obesity has been associated with onset and progression of chronic kidney disease (CKD) but causal relationship remains uncertain. This study investigated how obesity causally affects estimated glomerular filtration rate. Cross-sectional and magnetic resonance imaging (MRI) data analyses were performed within the Prospective Investigation of Obesity, Energy, and Metabolism (POEM) study (502 participants, all aged 50 years). Additionally Mendelian randomization was performed using published summary data. Outcomes were creatinine- and cystatin C-based eGFR. Body mass index (BMI) and waist circumference (WC) were used as exposure variables in the cross-sectional and Mendelian randomization analyses. In the imaging data analyses, eGFR was regressed non-parametrically on tissue volume for each 3D voxel and visualized as a correlation "Imiomics" map. Negative correlations were shown between cystatin C-based eGFR and BMI [beta = -0.190 (95% CI: -0.280 to -0.100)] and WC [beta = -0.160 (95% CI: -0.250 to -0.060)] in an adjusted model. In contrast, a positive association was found for creatinine-based eGFR [BMI beta=1.20 (95% CI: 0.030 to 0.210) and WC beta=0.160 (95% CI: 0.070 to 0.260)]. Similar patterns were found using MRI analysis (Imiomics map). Mendelian randomization implied a negative causal effect of obesity-related measures on cystatin C-based eGFR [BMI beta = -0.031 (95% CI: -0.037 to -0.026) and WC beta = -0.038 (95% CI: -0.045 to -0.031)], but no statistically significant effect was found for creatinine-based eGFR. This study suggests a causal negative effect of obesity on cystatin C-based, but not creatinine-based eGFR. These findings warrant further research regarding estimations of kidney function when assessing obesity and CKD.

Management of an epidermoid cyst of the intrahepatic ducts

Robotic choledocoduodenostomy

Objective To study the characteristics and changes of bile duct injury induced by lapa- roscopic cholecystectomy （LC） in recent years. Methods The clinical data of patients who underwent LC between October 1992 and June 1998 （ early group） were compared with those between June 2003 and March 2009 （recent group）. Results Of 18,613 cases in recent group, the bile duct injury occurred in 11 cases （0.06%） , which included 2 cases of bile duct transection （ occurred during open cholecystectomy in 1 case）, 3 cases of dissociation impairment,-2 eases of electric coagulation injury （1 in common hepatic duct, the other accessory hepatic duct）, 2 cases of partial shearing in common bile duct, 1 case of accessory he- patic duct transection, 1 case of suture injury in common hepatic duct during open eholecystectomy. In 11, 796 cases of early group, bile duct injury occurred in 15 cases （0.13%） , including 6 cases of bile duct transection, 6 cases of electric coagulation injury to lateral extrahepatic bile duct and 3 cases of dissociation impairment of bile duct. Injury-rate.of bile duct in recent group was significantly lower than that of the early group （χ2 = 3.92, P = 0. 04784）. Conclusion The incidence of bile duct injury induced by LC in recent years is significantly lower than that in years before, so is the severity of injury, while the types of bile duct injury are increasing. Individualized management can prevent further injury to the bile duct, as well as post- operative complications. Key words: Cholecystectomy,laparoscopic ; Bile duct injury

Intrahepatic and extrahepatic anatomical knowledge is essential for pre procedural planning of liver transplantation, liver resection, complex biliary reconstruction and radiological biliary tree intervention. Indian data of biliary anatomy and its variation is scant in literature. The aim of our study is to find out the prevalence of common and uncommon pattern of biliary tree anatomy in magnetic resonance cholangiopancreatography (MRCP) in our population. A total of 1,038 cases of MRCP of population of Odisha were obtained from Picture Archiving and Communication System of the department and were reviewed by two senior radiologists for anatomical pattern and variations. The typical and most common pattern of right hepatic duct (RHD) branching was seen in 72.8% cases. The most common variant of RHD was trifurcation pattern of insertion of right anterior sectoral duct (RASD), right posterior sectoral duct and left hepatic duct (LHD) forming common hepatic duct (CHD) in 11.3% of cases. The common trunk of segment (SEG) II and III ducts joining the SEG IV duct was the most common LHD branching pattern in 90.3% of cases. The most common pattern of cystic duct was posterior insertion to middle third of CHD (42.8%). MRCP is the non-invasive imaging modality for demonstration of biliary duct morphology to prevent iatrogenic injury during hepatobiliary intervention and surgery.