Spontaneous biliary perforation: biloma resembling a small bowel duplication cyst.

Complex spontaneous bile duct perforation: An alternative approach to standard porta hepatis drainage therapy

Common bile duct exploration via the cystic duct with the septum orifice at the confluence: anatomical basis and surgical outcomes

Introduction: Mirizzi syndrome is an uncommon presentation of gallstone disease and refers to an obstruction of the common hepatic duct secondary to a stone wedged into the cystic duct. Many cases are not diagnosed prior to cholecystectomy, and the incidence in the developed world is approximately 1-2%.1 Case Description/Methods: An active 70-year-old male with a medical history significant for hypertension, hyperlipidemia, and well-controlled type 2 diabetes presented to his primary care physician for postprandial right upper quadrant (RUQ) abdominal pain and nausea. Outpatient RUQ ultrasound was concerning for choledocholithiasis with common bile duct dilation (8 mm) and cholelithiasis. He was referred to surgery for a cholecystectomy. However, prior to this consult, he presented to the Emergency Department for worsening RUQ pain and jaundice. At this time, he was afebrile and hemodynamically stable. Overall, he was well-appearing with scleral icterus and jaundice. Abdominal exam was non-revealing, with a soft, non-distended, non-tender abdomen and a negative Murphy’s sign. Labs showed no leukocytosis, total bilirubin 10.2, alkaline phosphatase 1450, AST 743, ALT 848, and normal lipase. CT scan showed cholelithiasis, a thickened gallbladder neck suggesting cholecystitis, and high-grade obstruction of the cystic duct and common hepatic duct consistent with Mirizzi syndrome (Figure 1, A-B). Patient underwent EUS and ERCP, which showed an 8.4x11.6mm ill-defined mass in the mid common bile duct (Figure 1, C). Biopsies were obtained and a plastic biliary stent was placed. Total bilirubin trended down while in the hospital, and pathology revealed adenocarcinoma. Discussion: Those with Mirizzi syndrome have a 5.3% to 28% incidence of developing gallbladder cancer.1 Therefore, providers should have a high suspicion for cancer in patients with signs of Mirizzi syndrome, especially in the elderly population. Further testing, including CA 19-9 and more definitive imaging, should be obtained prior to cholecystectomy in those with suspected malignancy, as subsequent surgery is associated with a worse prognosis.1Figure 1.: (A) Axial view shows abnormal enhancement at the cystic duct as it empties into the common hepatic duct. (B) Coronal view shows abrupt luminal transition in the mid common bile duct. (C) EUS shows mass in the mid common bile duct.

During a cholecystectomy, cystic duct anatomical variation mostly transpires might experience. Understanding the complex anatomy of the cystic duct and cholecystitis junction is crucial before undergoing biliary surgery to prevent severe ductal damage. This article highlights two unusual cases of irregular cystic duct, i.e., cystic duct narrow-wide and low lateral insertion. The first case was of a 66-year-old male patient having chronic cholecystitis and cholelithiasis. The aberrant cystic duct entry was thought to be rapid and heading into the correct hepatic duct during surgery. Multiple calculi were discovered after more investigation of the common and proper hepatic ducts. Following the completion of the cholecystectomy, the standard and right hepatic ducts were drained using T-tubes. The two T-tubes were found in the cystic and common hepatic ducts, respectively, according to postoperative T-tube cholangiography. The distal choledochus residual stones were removed six weeks later by cholangioscopy through the T-tube's sinus tract. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) in the second case of a 44-year-old woman exposed to a lengthy cystic duct with a small and bent-in lumen. The cholecystectomy was done openly on the patient. Both of the patients recovered. The approach described by the authors for identifying structural changes in the cystic duct is preoperative or MRCP or ERCP, as well as intraoperative cholangiography or cholangioscopy.

Laparoscopic cholecystectomy has become the procedure of choice for surgical removal of the gallbladder. The most significant complication of this new technique is injury to the bile duct. Twelve cases of bile duct injury during laparoscopic cholecystectomy were reviewed. Eight injuries were of a classic type: misidentification of the common duct for the cystic duct, resection of part of the common and hepatic ducts, and associated right hepatic arterial injury. Another injury was similar: clip ligation of the distal common duct with proximal ligation and division of the cystic duct, resulting in biliary obstruction and leakage. Three complications arose from excessive use of cautery or laser in the region of the common duct, resulting in biliary strictures. Evaluation of persistent diffuse abdominal pain led to the recognition of ductal injury in most patients. Ultimately, 10 patients required a Roux-en-Y hepaticojejunostomy to provide adequate biliary drainage. One patient had a successful direct common duct repair, and the remaining patient underwent endoscopic dilatation.

Ectopic thyroid is a rare disease, with ectopic thyroid in the porta hepatis being extremely rare. We present a rare case involving an infant with biliary atresia (BA) wherein ectopic thyroid tissue was incidentally discovered in the porta hepatis after the Kasai operation. A 2-month-old boy initially presented with jaundice, manifesting as yellow skin and sclera, on the first day following birth. After receiving treatment at a local healthcare facility, jaundice partially subsided, but the color of his stool became lighter 15 days before admission to Tianjin Children's Hospital. Upon B-ultrasound examination at our outpatient clinic, the patient showed bilateral oblique hernia, bilateral testicular hydrocele, and umbilical hernia, and he was admitted to the Department of Gastroenterology at Tianjin Children's Hospital for further treatment of unexplained jaundice. Laparotomy was performed after a comprehensive evaluation, during which we observed the gallbladder to be small and poorly developed. Cholangiography was then performed, revealing visualization of the gallbladder and common bile duct but not the common hepatic duct or right and left hepatic ducts. Intraoperative frozen section examination of wedge-shaped liver tissue indicated findings consistent with extrahepatic biliary obstruction. The Kasai operation was subsequently performed, and an examination of the gallbladder and a fibrous plaque from the porta hepatis after the operation revealed the presence of ectopic thyroid tissues. Ectopic thyroid in the porta hepatis is extremely rare. We reviewed literature from 1960 to 2022 and identified six relevant case reports of ectopic thyroid in the porta hepatis. To our knowledge, this report constitutes the first report of BA complicated by ectopic thyroid in the porta hepatis.

Introduction. Cystic duct anatomical variations are encountered frequently during surgical procedures. In this report, a female patient underwent laparoscopic cholecystectomy for acute cholecystitis and developed symptoms of obstructive jaundice subsequently, which was diagnosed as low insertion of the cystic duct and an impacted stone that was causing common hepatic duct obstruction. Case report. A 42-year-old female presented to the emergency room complaining of persistent right upper quadrant pain that was radiating to the back. White blood count (WBC) was slightly elevated with normal liver function tests (LFTs). An abdominal ultrasound was performed and confirmed cholelithiasis with no signs of acute cholecystitis or biliary dilatation. The patient underwent laparoscopic cholecystectomy as an emergency procedure for persistent biliary colic. Eight days later, the patient returned to the emergency room with obstructive jaundice and continued right upper quadrant pain with elevated WBC and LFTs. Further tests were conducted, and the patient was found to have a long cystic duct with a low insertion variant to the common hepatic duct. An impacted stone was identified in the cystic duct, referred to as Mirizzi syndrome Type I. The patient underwent endoscopic retrograde cholangiopancreatography (ERCP) several times, but the common bile duct could not be cannulated. In the last ERCP session, SpyGlass and electrohydraulic lithotripsy were performed with a balloon sweep. Conclusion. This case demonstrates the importance of understanding Mirizzi syndrome and cystic duct variation to achieve optimal treatment, and careful assessment and investigation are essential for proper diagnosis. In experienced hands, Mirizzi syndrome secondary to an impacted cystic duct stone can be managed successfully with ERCP, electrohydraulic lithotripsy, and SpyGlass.

This is a peculiar condition which seems limited to the first few weeks of life whereby perforation occurs in the extrahepatic bile duct typically leading to bile in the peritoneal cavity, abdominal distension and jaundice. It should be distinguished from spontaneous perforation in a pre-existing choledochal malformation, said to occur in about 5–10% of all large series.

Mirizzi's syndrome is a rare complication of gallstone disease, that gallbladder lumen can lie alongside the common hepatic duct, resulting in inflammation and resultant bile duct stricture. Most cases are not identified preoperatively. Variations of the cystic duct and its point of union with the common hepatic duct are surgically important. Here, we present an unusual case of type I Mirizzi's syndrome with an uncommon anomalous cystic duct that long cystic duct joins common hepatic duct behind the duodenum. Also, there is a high bilirubin level due to gallstone and bile duct stone.

Introduction: Bile leaks following cadaveric orthotropic liver transplantation (OLT) have a reported incidence of 2.7%. Leaks most commonly occur at the choledochocholedochostomy and cholangiojejunostomy sites. Bile leaks from an accessory cystic duct (duct of Luschka) represent the second most common etiology of post-cholecystectomy leaks but a rare etiology following OLT with an incidence of 0.74%. Only 2 cases of bile leaks following OLT from duct of Luschka are reported. Case Description/Methods: We report a case of an infected biloma secondary to a biliary leak from an accessory cystic duct following cadaveric OLT in a 35-year-old male transplanted for alcoholic cirrhosis. Intra-operatively, standard cavo-cavostomy, portal vein, and arterial anastomoses were performed. A donor cholecystectomy was performed by sharp dissection and standard cystic artery and duct ligation. A combined cyst and hepatic donor duct to recipient common bile duct anastomosis eliminated a pre-existing size mismatch. Immunosuppression consisted of a methylprednisolone, tacrolimus, and mycophenolate mofetil. On post-operative day 15, persistent alkaline phosphatase elevation to 185 U/L and hyperbilirubinemia to 5.1 mg/dL prompted evaluation with a magnetic resonance cholangiopancreatogram. This demonstrated fluid collections in the gallbladder fossa (7.3x7.6 cm) and within the porta hepatis (6.2x4.9 cm), no biliary duct dilatation and patent vasculature. He developed a low-grade fever and blood cultures eventually yielded Vancomycin-sensitive E. Faecium (VSE). An endoscopic retrograde cholangiopancreatogram (ERCP) was performed demonstrating no biliary duct stricture but an active leak from an accessory cystic duct (duct of Luschka) (Figure 1). A 5-mm biliary sphincterotomy was followed by a 10 Fr stent placement 9 cm into the common hepatic duct. Ultrasound-guided aspiration of the porta hepatis and gallbladder fossa collections confirmed the biloma diagnosis and fluid cultures of the latter demonstrated VSE. Percutaneous drains were inserted, and intravenous Vancomycin was continued. Four days following ERCP, alkaline phosphatase improved to 155 U/L, aspartate aminotransferase to 19 U/L, alanine aminotransferase to 28 U/L and bilirubin to 3.0 mg/dL. Discussion: An accessory cystic duct occurs in 5-30% of the population and is a critical anatomic variation to consider during cadaveric OLT. We also illustrate the feasibility of a combined endoscopic and radiologic therapeutic approach in case such a leak arises.Figure 1.: Fluoroscopic image demonstrating active extravasation from an accessory cystic duct (duct of Luschka) during the endoscopic retrograde cholangiopancreatogram (ERCP).

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.

BackgroundMirizzi syndrome is a rare complication of chronic cholecystitis, usually caused by gallstones impacted in the cystic duct or the neck of the gallbladder. Mirizzi syndrome results in compression of the hepatic duct or fistula formation between the gallbladder and common bile duct (or hepatic duct, right hepatic duct, or even mutative right posterior hepatic duct). Clinical features include abdominal pain, fever, and obstructive jaundice. Severe inflammation and adhesion at Calot’s triangle are potentially very dangerous for patients with Mirizzi syndrome undergoing cholecystectomy.Case presentation: We report the case of a 68-year-old Asian woman who presented with abdominal pain and jaundice. She had a medical history of gallstones, but no fever. Magnetic resonance cholangiopancreatography revealed cholecystitis, cholelithiasis, common hepatic duct stones, and ascites. Findings at surgery included a porcelainized, atrophic gallbladder that was full of gallstones, fistula formation between the gallbladder and common hepatic duct, and left hepatic atrophy. The prominent feature was the left hepatic atrophy, but stones were not visible pre-operatively in the left liver by radiologic examination.ConclusionsThis patient exhibited what can be considered a special type II of Mirizzi syndrome with a fistula of the common hepatic duct as well as left hepatic atrophy.

Anatomy of the gallbladder and bile ducts

The point of the junction of the cystic duct with the common hepatic duct was studied by means of various preoperative and intraoperative cholangiographic procedures and by gross intraoperative examinations in 468 surgical patients with biliary diseases. The cystic duct entered the hepatic duct at a very low position and was consequently long in 39 patients. The clinical significance of this abnormally low junction of the cystic duct was studied in comparison with 358 patients with gallstones with a normal cystic duct-hepatic duct junction. In the low-junction group with a short common bile duct several complications, including gallstone pancreatitis (7 patients), the Mirizzi syndrome (7), confluence stones (2), gallbladder cancer (3), and congenital dilation of the cystic duct (1), were demonstrated preoperatively. The anomalous junction of the cystic duct with the common bile duct may cause stagnation of bile and/or reflux of pancreatic juice into the bile duct, producing a choledochopancreatic ductal junction and posing difficulties at surgery.

Introduction: Percutaneous liver biopsies are considered quite safe with a rate of fatal complications <1/1000. Biliary leak with biliary peritonitis is a rare (0.03-0.22%) but known complication of percutaneous liver biopsy. Larger extra hepatic duct injury with this procedure is extremely rare. It may present as frank peritonitis with systemic response, hence the likely hood of it responding to conservative management is less. HIDA scan is diagnostic. ERCP along with sphinctrotomy and stent placement in common bile duct is the procedure of choice. We report a case of common hepatic duct injury after CT guided liver biopsy which to the best of our knowledge has not been reported in literature. Case: A 46-year-old lady with a history of autoimmune hepatitis presented with epigastric pain radiating to right flank, associate with nausea and vomiting. A CT guided liver biopsy was done 5 days before presentation. On examination she had pulse of 100/min, BP 94/53 & temperature 99.2 F. Abdomen was tender all over with guarding in the right upper quadrant and hypoactive bowel sounds. Initial labs showed total WBC of 10.6, total bilirubin 2.4 mg/dl and direct bilirubin 1.0 mg/dl. CT scan abdomen revealed fluid surrounding the liver and HIDA scan showed extra hepatic biliary leak. She was initially managed conservatively with nothing by mouth, intravenous fluids, pain medications and antibiotics; however her condition did not improve in 48 hours. ERCP (endoscopic retrograde cholangio pancreatography) was done which showed high-grade biliary leak at the common hepatic duct. A CBD stent was placed. Patient's clinical condition improved significantly after the therapeutic ERCP and was subsequently discharged home. One week follow-up HIDA scan revealed no extra hepatic biliary leak. Six weeks later, stent was removed via ERCP and repeat cholangiogram did not demonstrate any contrast extravasation. Conclusion: In conclusion, extra hepatic biliary duct injury is an extremely rare but potentially life threatening complication of liver biopsy. One should consider it in the differential diagnosis of abdominal pain after liver biopsy as prompt endoscopic treatment can be lifesaving.Figure A: Endoscopic Cholangiogram showing high grade biliary leak at the level of common hepatic (arrow). Figure B. Endoscopic Cholangiogram 6 weeks later showing no leak.