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Gupta R, Kumar A, Hariprasad CP, Kumar M. Anatomical variations of cystic artery, cystic duct, and gall bladder and their associated intraoperative and postoperative complications: an observational study. Ann Med Surg (Lond) 2023; 85:3880-3886. [PMID: 37554913 PMCID: PMC10406088 DOI: 10.1097/ms9.0000000000001079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 07/04/2023] [Indexed: 08/10/2023] Open
Abstract
UNLABELLED Anatomical variations in the calots triangle encountered during laparoscopic cholecystectomy are not uncommon. Misidentification and misperception of these structures are the major cause of vasculobiliary injuries. This study was conducted to estimate the prevalence of anatomical variations of the cystic artery, cystic duct (CD), and gall bladder. This is the first study in India to access the rate of intraoperative and postoperative complications in anatomical variants compared to normal individuals. PATIENTS AND METHODS It was a prospective observational study on patients undergoing laparoscopic cholecystectomy in the department of General Surgery at the tertiary center of India. The calculated sample size was 298. Variations of the cystic artery, CD, and gall bladder along with intraoperative and postoperative complications were noted. The comparative analysis of intraoperative and postoperative complications and a subgroup analysis between anatomical variants and normal patients were performed. RESULTS The most common variations were found in cystic arteries (16.8%). CD anomalies were present in 11.4% of patients, and gall bladder anomalies were the least common of all (5.4%). Intraoperative and postoperative complications were compared between patients with anatomical variations and normal anatomy. Intraoperative complications in patients with anatomical variations were significantly higher. Bile leak (15.7% vs. 6.4%) (P=0.01), haemorrhage (16.8% vs. 1.9%) (P-value <0.001), conversion to open (3 vs. 0 patients) (P-value =0.03). Subgroup analysis revealed a strong association between intraoperative haemorrhage and bile leak with cystic artery and CD anomalies, respectively. CONCLUSION Cystic artery anomalies are the most common variations. Patients with anatomical variations had significant intraoperative and postoperative complications compared to patients with normal anatomy.
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Affiliation(s)
| | - Anil Kumar
- Department of Trauma Surgery and Critical Care, All India Institute of Medical Sciences, Patna, India
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Garg S, Dutta U, Chaluvashetty SB, Kumar KH, Kalra N, Sahni D, Aggarwal A. The anatomy of the cystic duct and its association with cholelithiasis: MR Cholangiopancreatographic study. Clin Anat 2022; 35:847-854. [PMID: 35316537 DOI: 10.1002/ca.23856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 02/17/2022] [Accepted: 03/11/2022] [Indexed: 11/12/2022]
Abstract
INTRODUCTION The aims of this article are to detail the anatomy of the cystic duct in patients with and without gallstones as it relates to maneuvering of the duct during endoscopic transpapillary gallbladder cannulation, and to elucidate its role in the dynamics of bile flow during gallbladder contraction. MATERIAL AND METHODS One hundred MRCPs were retrieved from the prospectively maintained radiology data system to assess the configuration of the cystic duct and its confluence vis-a-vis the main biliary duct. RESULTS The configuration of the cystic duct was broadly classified into four types: Angular (44%), Linear (40%), Spiral (11%) and Complex (5%). The level of emergence of the cystic duct from the bile duct was proximal in 29%, middle in 49% and distal in 20%. Its direction from the bile duct was to the right and angled upward in 69%, right and angled downward in 15%, left and angled upward in 13%, and left and angled downward in 1%. Its orifice was on the lateral surface of the bile duct in 50%, posterior in 19%, anterior in 15% and medial in 14%. In two cases, the cystic duct opened directly into the duodenum. Tortuous cystic ducts and non-lateral unions with the bile duct were significantly more prevalent in gallstone cases than the non-gallstone group (p=0.02). CONCLUSIONS The present study details the spatial anatomy of the cystic duct vis a vis the main biliary duct. This has not been well investigated to date but has become increasingly relevant with the advent of recent gallbladder interventions.
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Affiliation(s)
- Shallu Garg
- Department of Anatomy, St. John's Medical College affiliated to RGUHS, Bengaluru, India
| | - Usha Dutta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sreedhara B Chaluvashetty
- Department of Radio diagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - K Hemanth Kumar
- Department of Gastrointestinal Surgery, Manipal hospital, Bengaluru, India
| | - Naveen Kalra
- Department of Radio diagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Daisy Sahni
- Department of Anatomy, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anjali Aggarwal
- Department of Anatomy, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Muraki T, Reid MD, Pehlivanoglu B, Gonzalez RS, Sekhar A, Memis B, Xue Y, Cheng J, Jang KT, Mittal P, Cardona K, Kooby DA, Maithel S, Sarmiento JM, El-Rayes B, Lomberk G, Urrutia RA, Christians K, Tsai S, Evans DB, Adsay V. Variant anatomy of the biliary system as a cause of pancreatic and peri-ampullary cancers. HPB (Oxford) 2020; 22:1675-1685. [PMID: 32336556 DOI: 10.1016/j.hpb.2020.03.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 03/01/2020] [Accepted: 03/16/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The cause of most pancreatic and periampullary cancers (PAC) is unknown. Recently, anatomic variations such as pancreatobiliary maljunction have been recognized as risk factors, similar to Barrett-related gastro-esophageal cancers. METHODS Pre-operative MRI from 860 pancreatic/biliary resections, including 322 PACs, were evaluated for low-union (cystic duct joining the common hepatic duct inside of the pancreas or within 5 mm of the pancreatic border) RESULTS: Low-union, seen <10% of the population, was present in 44% of PACs (73% distal bile duct/cholangiocarcinoma, 42% pancreatic head, and 34% ampullary). It was significantly lower(11%) in conditions without connection to the ductal system (thus not exposed to the ductal/biliary tract contents), namely mucinous cystic neoplasms and intrahepatic cholangiocarcinomas(p < 0.0001). Intra-pancreatic type low-union was seen in 16% of PACs versus 2% of controls(p < 0.0001). DISCUSSION This study establishes an association between low-union and PACs, and points to an anatomy-induced chemical/bilious carcinogenesis. This may explain why most pancreas cancers are in the head. It is possible that the same chemical milieu, caused by conditions other than low-union/insertion, may also play a role in the remaining half of PACs. This opens various treatment opportunities including milieu modifications (chemoprevention), focused screening of at-risk patients, and early detection with possible corrective actions.
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Affiliation(s)
- Takashi Muraki
- Department of Pathology, Emory University School of Medicine, GA, USA
| | - Michelle D Reid
- Department of Pathology, Emory University School of Medicine, GA, USA
| | | | - Raul S Gonzalez
- Department of Pathology, Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Aarti Sekhar
- Department of Radiology, Emory University School of Medicine, GA, USA
| | - Bahar Memis
- Department of Pathology, Emory University School of Medicine, GA, USA
| | - Yue Xue
- Department of Pathology, Emory University School of Medicine, GA, USA
| | - Jeanette Cheng
- Department of Pathology, Piedmont Hospital, Atlanta, GA, USA
| | - Kee-Taek Jang
- Department of Pathology, Samsung Medical Center, Seoul, South Korea
| | - Pardeep Mittal
- Department of Radiology, Emory University School of Medicine, GA, USA
| | - Kenneth Cardona
- Department of Surgery, Emory University School of Medicine, GA, USA
| | - David A Kooby
- Department of Surgery, Emory University School of Medicine, GA, USA
| | - Shishir Maithel
- Department of Surgery, Emory University School of Medicine, GA, USA
| | - Juan M Sarmiento
- Department of Surgery, Emory University School of Medicine, GA, USA
| | - Bassel El-Rayes
- Department of Medical Oncology, Emory University School of Medicine, GA, USA
| | - Gwen Lomberk
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Raul A Urrutia
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Susan Tsai
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Douglas B Evans
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Volkan Adsay
- Department of Pathology, Koç University Hospital, Istanbul, Turkey; Koç University Research Center for Translational Medicine (KUTTAM), Istanbul, Turkey.
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Ojo AS, Pollard A. Risk of Gallstone Formation in Aberrant Extrahepatic Biliary Tract Anatomy: A Review of Literature. Cureus 2020; 12:e10009. [PMID: 32864277 PMCID: PMC7449616 DOI: 10.7759/cureus.10009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The age-long mnemonic of '5Fs' (fat, female, fertile, forty, and fair) has traditionally been used in medical school instructions to describe the risk factors for gallstone disease. However, evidence suggests that aberrant extrahepatic biliary tract (EHBT) anatomy may contribute significantly to the risk of gallstone disease. This review explores the anatomy and embryological bases of EHBT variations as well as the prevalence of these variations. Also, we discuss the risk factors for gallstone formation in the relationship between gallstone disease and aberrant EHBT anatomy.
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Kin T, Wasel BA, Shapiro AMJ. Isolated cystic duct atresia. Dig Liver Dis 2014; 46:385-6. [PMID: 24405782 DOI: 10.1016/j.dld.2013.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 11/07/2013] [Accepted: 11/27/2013] [Indexed: 02/07/2023]
Affiliation(s)
- Tatsuya Kin
- Clinical Islet Transplant Program, University of Alberta, Edmonton, Alberta, Canada.
| | - Bassam Abu Wasel
- Multi-Organ Transplant Program, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
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Double cancer of the cystic duct and gallbladder associated with low junction of the cystic duct. ACTA ACUST UNITED AC 2008; 15:338-43. [PMID: 18535776 DOI: 10.1007/s00534-007-1245-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2007] [Accepted: 03/01/2007] [Indexed: 10/22/2022]
Abstract
We report a case of double cancer of the cystic duct and gallbladder associated with low junction of the cystic duct. A 73-year-old woman was admitted to the hospital complaining of upper abdominal pain. Endoscopic retrograde cholangiography showed a stenotic lesion in the lower common bile duct and no visualization of the cystic duct or gallbladder. Enhanced computed tomography revealed a heterogeneously enhanced tumorous lesion around the lower bile duct in the pancreatic head. A diagnosis of cancer arising from the cystic duct that entered the lower part of the common hepatic duct was made by intraductal ultrasonography, which showed an intraluminal protruding lesion in the cystic duct. Isolated gallbladder cancer was also diagnosed, by abdominal computed tomography. She underwent pancreaticoduodenectomy with dissection of regional lymph nodes. Histological examination revealed moderately differentiated adenocarcinoma of the cystic duct and well-differentiated adenocarcinoma of the gallbladder. Double cancer of the cystic duct and gallbladder is extremely rare, and this case also suggests a relationship between a low junction of the cystic duct and neoplasm in the biliary tract.
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Santiago MS, Santiago TS, Melo VAD, Mendonça JC. Estudo anatômico das variações de posição da junção dos ductos cístico e hepático comum em fetos. Acta Cir Bras 2003. [DOI: 10.1590/s0102-86502003000100004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Definir e classificar as variações anatômicas da junção dos ductos cístico e hepático comum em fetos, analisando a freqüência, trajeto e relação entre eles. MÉTODOS: Dissecaram-se 33 fetos , no período de setembro de 1999 a julho de 2000, utilizando-se fotografias para registrar as junções cístico-hepáticas. As uniões foram classificadas como alta, média e baixa e, quanto ao curso, paralelo ou angular. Constatado o tipo de união, aferiu-se o comprimento dos ductos. RESULTADOS: Visualizou-se a junção cístico-hepática em 93,9% dos fetos, sendo encontrada a inserção média em 45,2% delas, a inserção alta em 29% e a inserção baixa em 25,8%. Quanto ao curso ductal, a união aguda foi observada em 71% dos fetos, enquanto a paralela, em 29%. Quanto ao comprimento ductal, o ducto cístico variou de 4 - 6 mm, o ducto hepático comum de 9 - 13 mm, e o ducto colédoco de 5 - 10 mm. CONCLUSÃO: Dentre as variações anatômicas, a inserção média foi a prevalente, seguida do curso angular, com comprimentos dos ductos cístico e hepático comum variando entre 6mm e 7 mm, respectivamente. Foi demonstrada uma freqüência significativa de inserção baixa cístico-hepático comum.
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Cavalcanti JS, Oliveira EDL, Santos LPF, Godoi ETA, Oliveira CLA, Lins APES, Duarte SM. Estudo anatomotopográfico das vias biliares extra hepáticas e do trígono cistohepático. Acta Cir Bras 2002. [DOI: 10.1590/s0102-86502002000100005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Estudar a morfologia do sistema biliar extra-hepático e do trígono cistohepático (triângulo de Calot) analisando a sua disposição, variações ou malformações MÉTODOS: foram investigados 50 cadáveres adultos. RESULTADOS: em 47 casos (94%) a junção hepato-cística se dava próxima ao hilo hepático. Em 3 casos (6%), a junção entre esses ductos se dava distalmente, ao nível da ampola hepato-pancreática (ampola de Vater). O ângulo formado pela junção hepato-cística foi menor que 30º em 72,3% dos casos; em 23,4% , ficou entre 30 e 45º; em 2,1% variou entre 45 e 60º e em 2,1% foi maior do que 60º. A junção hepato-cística se fez, na maior parte dos casos, pela direita (59,6%), seguida pela anterior (17%), posterior (12,8%) e esquerda (10,6%). Em relação aos componentes do trígono cistohepático, a artéria cística esteve presente em 56% dos casos; a veia porta em 36%; a artéria hepática direita em 34%; a artéria hepática esquerda em 2% e a artéria hepática própria em 2% dos casos. O comprimento e o diâmetro do ducto cístico foi 2,53± 1,19cm e 0,29± 0,12cm, respectivamente. A prega espiral do ducto cístico ( válvula de Heister) foi observada em 80% dos casos. O infundíbulo da vesícula biliar (bolsa de Hartmann) esteve presente em 74% dos casos. Esses conhecimentos são importantes, principalmente para os cirurgiões que atuam nesta região, através de videolaparoscopia. CONCLUSÃO: No trígono cistohepático a artéria cística foi encontrada com mais freqüência.
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Lamah M, Karanjia ND, Dickson GH. Anatomical variations of the extrahepatic biliary tree: review of the world literature. Clin Anat 2001; 14:167-72. [PMID: 11301462 DOI: 10.1002/ca.1028] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The anatomy facing a surgeon during cholecystectomy involves complex relationships between the hepatic artery, extrahepatic biliary tree, and gallbladder. A sound knowledge of the normal anatomy of the extrahepatic biliary tract is thus essential in the prevention of operative injury to it. Equally important, however, is an understanding of congenital variation of biliary and vascular anatomy, as the literature abounds with reports of specific anatomical variations, and their operative implications. This article reviews the world literature on congenital variation of extrahepatic biliary anatomy.
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Affiliation(s)
- M Lamah
- St. George's Hospital Medical School, London, United Kingdom.
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Contractor QQ. Endoscopic sphincterotomy could have been a better alternative. Gastrointest Endosc 1999; 49:273-4. [PMID: 9925720 DOI: 10.1016/s0016-5107(99)70507-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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11
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Dodda G, Brown RD, O'Neil HK, Venu RP. Cystic duct insertion at ampulla as a cause for acute recurrent pancreatitis. Gastrointest Endosc 1998; 47:181-3. [PMID: 9512286 DOI: 10.1016/s0016-5107(98)70354-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- G Dodda
- University of Illinois at Chicago, Section of Digestive and Liver Diseases, 60612-7323, USA
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