Association between common bile duct diameter and abdominal aorta calcium score

BACKGROUND AND OBJECTIVE

There is evidence of association between aging and increase in the normal upper limit of the common bile duct (CBD) diameter. As aging is a documented risk factor for atherosclerosis, and the possible effect that atherosclerosis can have on the CBD diameter via affecting its smooth muscle contractility and blood flow, we decided to determine the association between CBD diameter and atherosclerosis in the abdominal aorta (AA).

METHODS

A total of 99 asymptomatic patients (53 males and 46 females; age range of 18-88 years) without history of cholecystectomy who underwent abdominal contrast-enhanced CT scan were included. The CBD diameter was measured. The atherosclerosis of AA was quantified by Agatston score.

RESULTS

Mean (± SD) CBD diameter was 6.14 (± 1.95) mm; range = 2.4-12.7 mm. Agatston score was 0 in 59 patients. In the remaining 40 patients, median (interquartile range, IQR) Agatston score was 497.5 (2026.3). Mean (± SD) CBD diameter in patients with Agatston score > 0 was 7.39 (± 2.07) mm compared to 5.29 (± 1.32) mm in patients without calcification plaque (P < 0.001). A moderate correlation was seen between CBD diameter and Agatston score (ρ = 0.43; P = 0.005).

CONCLUSION

Although the exact cause of increased CBD diameter with advancing age is not understood, a general atherosclerotic process which occurs with aging may affect smooth muscle of the CBD. Whether an upper limit for normal CBD should be defined or not when evaluating dilated CBD for patients with subclinical or clinical atherosclerosis needs further studies.

A case of double common bile duct in a deceased donor for transplantation

A double common bile duct is extremely rare among the anatomical variations in the biliary tract system. We report an incidentally encountered case of the double common bile duct and discuss the novel anatomical findings of the accessory common bile duct from the viewpoint of embryology. A unique point of our case is that the accessory common bile duct bifurcated at the level of the intrapancreatic bile duct. There is no similar case in the previous literature among type II double common bile duct in the viewpoint of anatomical findings of the accessory common bile duct. We assume that this asymptomatic anatomical variation may be present more commonly, but not diagnosed.

A Technique to Define Extrahepatic Biliary Anatomy Using Robotic Near-Infrared Fluorescent Cholangiography

BACKGROUND

Bile duct injury is a rare but serious complication of minimally invasive cholecystectomy. Traditionally, intraoperative cholangiogram has been used in difficult cases to help delineate anatomical structures, however, new imaging modalities are currently available to aid in the identification of extrahepatic biliary anatomy, including near-infrared fluorescent cholangiography (NIFC) using indocyanine green (ICG).1-5 The objective of the study was to evaluate if this technique may aid in safe dissection to obtain the critical view.

METHODS

Thirty-five consecutive multiport robotic cholecystectomies using NIFC with ICG were performed using the da Vinci Firefly Fluorescence Imaging System. All patients received 2.5 mg ICG intravenously at the time of intubation, followed by patient positioning, draping, and establishment of pneumoperitoneum. No structures were divided until the critical view of safety was achieved. Real-time toggling between NIFC and bright-light illumination was utilized throughout the case to define the extrahepatic biliary anatomy.

RESULTS

ICG was successfully administered to all patients without complication, and in all cases the extrahepatic biliary anatomy was able to be identified in real-time 3D. All procedures were completed without biliary injury, conversion to an open procedure, or need for traditional cholangiography to obtain the critical view. Specific examples of cases where x-ray cholangiography or conversion to open was avoided and NIFC aided in safe dissection leading to the critical view are demonstrated, including (1) evaluation for aberrant biliary anatomy, (2) confirmation of non-biliary structures, and (3) use in cases where the infundibulum is fused to the common bile duct.

CONCLUSION

NIFC using ICG is demonstrated as a useful technique to rapidly identify and aid in the visualization of extrahepatic biliary anatomy. Techniques that selectively utilize this technology specifically in difficult cases where the anatomy is unclear are demonstrated in order to obtain the critical view of safety.

Development of a novel and simple ex vivo biologic ERCP training model

BACKGROUND

Training and teaching of ERCP in biologic models has gained importance over the past decade. However, many existing models are expensive, are not widely available, or rely on live animals.

OBJECTIVE

We describe a novel and simple ex vivo, biologic model for hands-on teaching.

DESIGN

Ex vivo porcine study.

SETTING

Experimental endoscopy unit.

METHODS

Experimental study using a custom-made ex vivo biologic ERCP simulation model. This model contains 2 new key concepts: (1) formation of a duodenal sweep by using the porcine stomach and (2) use of multiple neo-papillae for endoscopic sphincterotomy and biliary stent placement. The papilla was re-created with chicken heart, and the bile ducts were built from chicken trachea. Endoscopic sphincterotomy was performed by using a pull-type sphincterotome. Stenting was performed with Amsterdam-type plastic stents and guidewires.

MAIN OUTCOME MEASUREMENTS

The following definitions were used to evaluate the model: successful implantation of the neo-papilla, stability of the neo-papilla to the neo-duodenum, successful removal of the neo-papilla, and damage to the model. The following endoscopic endpoints were evaluated: successful cannulation, cannulation time, difficulties in positioning the papilla, quality of the biliary sphincterotomy, and prosthesis placement. Procedure-related adverse events such as perforation were also assessed.

RESULTS

Ten neo-papillae were consecutively used in 1 duodenalized stomach. The implantation and removal of the neo-papillae were easily and successfully accomplished in all 10 cases without any damage to the duodenalized stomach. The stability of the neo-papilla on the duodenal sweep was excellent in all cases. Cannulation, biliary sphincterotomy, and stent placement could be successfully performed in 100% of cases. There was no damage and were no technical problems with the model. There were no adverse events during endoscopy (ie, perforations, stent misplacement).

LIMITATIONS

Pilot study.

CONCLUSION

Although further studies are necessary, this simple, novel ex vivo model appears useful for training in sphincterotomy and bile duct cannulation. Because the neo-papillae are interchangeable, repetitive sphincterotomies and other interventions can be performed using a single porcine model.

The diameter of the common bile duct in an asymptomatic Taiwanese population: measurement by magnetic resonance cholangiopancreatography

BACKGROUND

Magnetic resonance cholangiopancreatography (MRCP) is a popular modality for evaluation of the biliary tract, yet there is no data on the normal common bile duct (CBD) size of the average Taiwanese adult. This study attempts to establish a reference range for CBD diameter for the Taiwanese population.

METHODS

Over a 2-year period, all adults who underwent abdominal magnetic resonance imaging for health screening were recruited into the study. Patients with a prior history of hepatobiliary surgery and other significant morbidity were not included. Patients who were found to have abnormal liver function test results or abnormal imaging findings were also excluded from the study. After the patients fasted for a minimum of 8 hours, MR imaging was performed with a 1.5 T MR imager using a phased-array coil. Breath-hold thick slab single-shot turbo spin echo (ssTSE BH) projections were obtained, and these were used for CBD and portal vein diameter (PVD) measurement by workstation software. Initial recruitment included 265 patients, of which 66 were excluded due to abnormal liver function tests, seven more were excluded due to excess imaging artifacts or incomplete CBD visualization, and five were excluded due to other abnormal blood tests. This yielded a final study group of 187 patients between the ages of 21 and 78 years, which comprised 69 women and 118 men.

RESULTS

The mean CBD diameter is 4.6 mm, with a range from 1.76 to 10.49 mm. CBD diameters are significantly different in patients both younger and older than 65 years of age (p < 0.05), and are not significantly related to gender, serum glucose level, cholesterol level, hepatitis status and PVD.

CONCLUSION

Our study showed that the average CBD diameter for an asymptomatic Taiwanese adult is 4.6 mm, with an upper limit of 10.49 mm. CBD diameter is only significantly correlated with age. This is a useful reference in today's clinical setting where MRCP are commonly performed for evaluation of suspected biliary tract disease.

Relative capacities of time-gated versus continuous-wave imaging to localize tissue embedded vessels with increasing depth

Surgeons often cannot see major vessels embedded in adipose tissue and inadvertently injure them. One such example occurs during surgical removal of the gallbladder, where injury of the nearby common bile duct leads to life-threatening complications. Near-infrared imaging of the intraoperative field may help surgeons localize such critical tissue-embedded vessels. We have investigated how continuous-wave (CW) imaging performs relative to time-gated wide-field imaging, presently a rather costly technology, under broad Gaussian beam-illumination conditions. We have studied the simplified case of an isolated cylinder having bile-duct optical properties, embedded at different depths within a 2-cm slab of adipose tissue. Monte Carlo simulations were preformed for both reflectance and transillumination geometries. The relative performance of CW versus time-gated imaging was compared in terms of spatial resolution and contrast-to-background ratio in the resulting simulated images. It was found that time-gated imaging offers superior spatial resolution and vessel-detection sensitivity in most cases, though CW transillumination measurements may also offer satisfactory performance for this tissue geometry at lower cost. Experiments were performed in reflectance geometry to validate simulation results, and potential challenges in the translation of this technology to the clinic are discussed.

[The relationship between age and biomechanical properties in porcine common bile duct]

The aim of this study was to detect the relationship between age and biomechanical properties in porcine common bile duct (CBD). The CBDs of 50 Hubei white pigs aged 3-12 months were obtained. The experiment of pressure-diameter was conducted on the biomechanical experiment stand for soft tissues, and then the elastic modulus and compliance were calculated. The materials were transversely extracted, refrigerated, and sliced up before HE staining. The diameter and wall thickness of the CBD were measured by a computer image analysis system. The results showed that there was statistically significant difference in regard to the compliance of the porcine CBDs of different months (F = 59.69, P = 0.00). The compliance of the porcine CBD increased gradually with monthly age. However, after the pigs being aged 10 months, the compliance decreased gradually with monthly age. The compliance of the CBD of pigs aged 7-10 months was not significantly different (P > 0.05), but the compliance of the CBDs of pigs' aged 3-6 months and 11-12 months was significantly lower than that of pigs aged 7-10 months (P < 0.01). The changes in elastic modulus of porcine CBD with age were opposed to the changes in compliance. The results of the present study suggests that the in biomechanical properties of pigs' CBDs change with their ages, and the CBDs of pigs aged 7-10 months have good compliance. Thus, for the pig-to-human liver xenotransplantation, the livers of pigs aged 7-10 months, being chosen as donators, may be more conducive to matching.

Ultrasound assessment of common bile duct diameter in Tikur Anbessa Hospital, Addis Ababa, Ethiopia

BACKGROUND

The diameter of common bile duct is one of the critical issues that has to be addressed in diagnosing and treating hepatobilary diseases. Thus measurement of common bile duct diameter is an important component of the evaluation of biliary system as the size of common bile duct is a predictor of biliary obstruction. As a dilated common bile duct distinguishes obstructive from non obstructive causes of jaundice, accurate standards for normal measurements must be available. There is no study addressing the diameter of common bile duct diameter among Ethiopians.

OBJECTIVE

To assess the normal common bile duct diameter among Ethiopians and to identify factors associated with common bile duct diameter.

MATERIALS AND METHODS

A cross-sectional descriptive study. Tikur Anbessa Teaching Hospital, Addis Ababa, Ethiopia from April, 2001 to September, 2002. A total of 293 adult patients of which 160 females and 133 males who were to undergo abdominal ultrasound were put under the study. All patients had fasted for longer than six hours. Patients with known biliary, pancreatic disease or surgery were not included in the study. The transverse and anteroposterior diameter of the common bite duct were measured just caudal to the level of portahepatis.

RESULT

The mean diameter of the common bile duct diameter was found to be 3.9 mm; measured diameter ranged from 2.1 to 6mm. There was also a positive correlation between the common bile duct diameter with age and weight. No significant difference was noted between the two sexes and common bile duct diameter. No association was observed with height and common bile duct diameter.

CONCLUSION

The study showed the mean common bile duct diameter to be 3.9 mm and the diameter of the common bile duct was observed to increase with increasing of age and weight. The normal common bile duct diameter in Ethiopia is not previously studied, so this study can be a base line for future widespread and extended studies.

Optimizing the critical view of safety in laparoscopic cholecystectomy by clipping and transecting the cystic artery before the cystic duct

Might prevent bile duct injury

Magnetic resonance cholangiopancreatography of biliary system abnormalities in children

OBJECTIVE

The aim of this study was to assess the usefulness of magnetic resonance cholangiopancreatography (MRCP) with a single-shot fast spin-echo sequence as a noninvasive method to evaluate the biliary system in children.

METHODS

Twenty-five MRCP examinations of 23 patients were evaluated. On the basis of surgical (n=5), endoscopic retrograde cholangiopancreatography (n=4), liver biopsy (n=4), clinical data, and follow-up observation, 6 children were considered to have no significant abnormality. The other 17 children were found to have pancreaticobiliary disease, including choledochal cyst, biliary system dilatation, choledocholithiasis, biliary atresia, multiseptated gallbladder, anomalous pancreaticobiliary union, ruptured hydatic cyst, and biloma. The findings were correlated with the ultrasonography, computed tomography, surgical, and endoscopic retrograde cholangiopancreatography results.

RESULTS

Magnetic resonance cholangiopancreatography showed the first branch of the intrahepatic duct, the common hepatic duct, the gallbladder, and the common bile duct in 14 children. Cystic duct was not seen in infants, but was partially visible in younger children. Although the main pancreatic duct was visible in head and body portions in 65% of the patients, it was visible in 17% of the patients in the tail. The diagnostic accuracy of MRCP was 100% in patients with choledochal cysts and stenoses. In a patient with hydatic cyst, cystobiliary communication was successfully demonstrated.

CONCLUSION

Magnetic resonance cholangiopancreatography can be used effectively for the evaluation of the biliary system in children.

Surgical anatomy of innervation of the gallbladder in humans and Suncus murinus with special reference to morphological understanding of gallstone formation after gastrectomy

AIM: To clarify the innervation of human gallbladder, with special reference to morphological understanding of gallstone formation after gastrectomy.

METHODS: The liver, gallbladder and surrounding structures were immersed in a 10 mg/L solution of alizarin red S in ethanol to stain the peripheral nerves in cadavers (n = 10). Innervation in the areas was completely dissected under a binocular microscope. Similarly, innervation in the same areas of 10 Suncus murinus (S. murinus) was examined employing whole mount immunohistochemistry.

RESULTS: Innervation of the gallbladder occurred predominantly through two routes. One was from the anterior hepatic plexus, the innervation occurred along the cystic arteries and duct. Invariably this route passed through the hepatoduodenal ligament. The other route was from the posterior hepatic plexus, the innervation occurred along the cystic duct ventrally. This route also passed through the hepatoduodenal ligament dorsally. Similar results were obtained in S. murinus.

CONCLUSION: The route from the anterior hepatic plexus via the cystic artery and/or duct is crucial for preserving gallbladder innervation. Lymph node dissection specifically in the hepatoduodenal ligament may affect the incidence of gallstones after gastrectomy. Furthermore, the route from the posterior hepatic plexus via the common bile duct and the cystic duct to the gallbladder should not be disregarded. Preservation of the plexus may attenuate the incidence of gallstone formation after gastrectomy.

Establishing a true assessment of endoscopic competence in ERCP during training and beyond: a single-operator learning curve for deep biliary cannulation in patients with native papillary anatomy

BACKGROUND

Deep cannulation of the common bile duct (CBD) in patients with native papillary anatomy can be used as a marker of competence at ERCP.

OBJECTIVE

The primary aim of this study was to analyze a single-operator learning curve for supervised ERCPs in patients with native papillary anatomy and to assess the development of endoscopic competence, defined as the ability to deeply cannulate the CBD in the setting > or =80% of the time. Posttraining outcomes were evaluated as proof of training.

DESIGN

A retrospective review: 1097 ERCP procedures were analyzed, 697 were performed during ERCP training (July 2002-July 2003), 400 were performed after training as an independent operator, 499 and 303 procedures for training and posttraining periods, respectively, were performed with the intent of deep cannulation of CBD in patients with native papillary anatomy. Procedures were chronologically grouped into subsets. Success rates were plotted against time.

SETTING

Single center.

MAIN OUTCOME MEASUREMENTS

Rate of successful deep biliary cannulation.

RESULTS

The successful cannulation rate increased from 43% at the beginning of training to > or =80% after 350 to 400 supervised procedures. The success rate continued to improve posttraining with an aggregated success rate of >96% for the next 300 procedures performed as an independent operator.

LIMITATIONS

Single operator.

CONCLUSIONS

Achievement of a satisfactory success rate for deep biliary cannulation in patients with native papillary anatomy should be tracked by ERCP trainers and trainees. The consistent achievement of > or =80% success at deep biliary cannulation in such patients should become a standard for ERCP training programs to produce skilled and competent therapeutic biliary endoscopists.

Single dose oral ranitidine improves MRCP image quality: a double-blind study

AIM

To investigate the possibility of whether a single 300 mg dose of ranitidine given orally 2-3h before magnetic resonance cholangiopancreatography (MRCP) could reduce the signal from the stomach and duodenum, and thus increase the conspicuousness of the biliary tree.

MATERIALS AND METHODS

Thirty-five volunteers (22 female, 13 male), (age range 21-50) were underwent MRCP in a double-blind, placebo-controlled, randomized, crossover trial on a Philips Intera 1.5 T machine using a phased array surface coil. Imaging was carried out in the coronal oblique plane. Six 40 mm sections were acquired at varying angles to delineate the biliary tree and pancreatic duct. The 70 examinations were blindly scored by three consultants experienced in cholangiography.

RESULTS

After ranitidine administration there was a significant decrease in signal from the stomach (mean=17.7, p=0.0005, CI 10, 25.3) and duodenum (mean=18.4, p=0.0005, 95%CI 9.6, 27.1) with a significant increase in conspicuousness of the distal common duct (mean=7.7, p=0.033, 95%CI 0.7, 14.7) and proximal common duct (mean=8.7, p=0.010 CI 2.2, 15.2). There were no adverse effects.

CONCLUSION

Oral ranitidine is a cheap and effective agent to decrease signal from the upper gastrointestinal tract and to improve visibility of the biliary tree.

Difference of CBD width on US vs. ERCP

PURPOSE

To investigate the relationship between US and ERCP in the measurement of common bile duct (CBD) width after application of Compound and Harmonic imaging on ultrasound.

METHODS

We prospectively evaluated the CBD width as measured on endoscopic retrograde cholangiopancreatography (ERCP) and ultrasonography (US), applying Compound and Harmonic US techniques, on 100 patients. Furthermore, we retrospectively re-examined US and ERCP images of 48 patients who underwent ERCP and US during the same hospitalization period.

RESULTS

The average difference in measurements by US compared to ERCP was 2.3 mm (P < 0.01) in the retrospective and 1.9 mm in the prospective study (P < 0.001). The average difference in measurements between US and ERCP in post-cholecystectomy patients was 4.0 mm in the retrospective study (10 patients), and 3.8 in the prospective study (25 patients). The difference between the measurements on both examinations decreased with increasing CBD width. There was a good correlation between ERCP and US measurements of CBD width (r = 0.73 for all patients and r = 0.88 for patients with intact gallbladder, P < 0.001).

CONCLUSIONS

There is a gap between measurement of CBD width on US and ERCP of about 2 mm. The application of Compound and Harmonic techniques in the prospective study probably enabled a more accurate sonographic measurement.

Three dimensional reconstruction of the pancreas based on the virtual Chinese human--female number 1

OBJECTIVE

To study the three dimensional (3D) reconstruction and 3D visualisation of the pancreas and create anatomy of the digitalised visual pancreas so as to construct a concrete basis for virtual operation and surgical operation on pancreas.

METHODS

The digital imaging data of pancreas, duodenum, common bile duct, arteries, and veins were obtained from the virtual Chinese human--female 1 (VCH-F1). The image data were investigated and 380 images ascertained of pancreas picked up from images numbers 2617 to 2996. Finally, the images from number 2574 to 3017 were adopted to segment and processed using ACDSee and Photoshop so as to reconstruct 3D pancreas digitally. The data of pancreatic surfaces were transformed into Visualization Toolkit (VTK). The GUI program written with VC+ was used to display this VTK file and realise 3D visualisation of the pancreas.

RESULTS

3D reconstruction and visualisation of the pancreas and the peri-pancreatic structures (the duodenum, the common bile duct,the inferior vena cava, the portal vein vessels, the aorta, the coeliac trunk vessels) was successful. The 3D and visualised pancreas manifested itself with its complete structure as well as its adjacency to other tissues.

CONCLUSION

The 3D reconstruction and 3D visualisation of the pancreas based on the digital data of VCH-F1 produces a digitally visualised pancreas, which promises a novel method for virtual operation on the pancreas, clinical operation on the pancreas, and anatomy of 3D visualised pancreas.

The Neo-Papilla: a new modification of porcine ex vivo simulators for ERCP training (with videos)

BACKGROUND

Computer simulators, live pigs, and ex vivo porcine simulators are used for training in ERCP. The location of the porcine biliary orifice in the proximal duodenum is dissimilar to human anatomy, making the endoscopy experience less realistic. In addition, in native porcine anatomy, the pancreatic duct enters the duodenum distal to the biliary orifice, limiting the teaching of pancreatic techniques and selective duct cannulation.

OBJECTIVE

To overcome these limitations, we aimed to construct a Neo-Papilla that could be incorporated into an ex vivo model.

DESIGN

We attached chicken heart tissue to the porcine duodenum, with integrated porcine arteries that resembled an artificial common bile duct and a pancreatic duct.

SETTING

The simulator was presented and evaluated at 2 major GI endoscopy conferences.

MAIN OUTCOME MEASUREMENTS

The feasibility and the realism of this prototype was tested by 9 recognized ERCP experts who rated this model in comparison to other teaching models for ERCP by recollection of prior experience.

RESULTS

The Neo-Papilla was more prominent and more distally located than the native porcine papilla. The experts rated this modification superior to existing models in its usefulness as an educational tool.

LIMITATIONS

Pilot study.

CONCLUSIONS

We demonstrated the technical feasibility of a real-tissue Neo-Papilla modification of porcine ex vivo simulators, more closely approximating the natural anatomy. This new model should facilitate ERCP training. Formal validation studies are warranted.

Gadobenate dimeglumine as an intrabiliary contrast agent: comparison with mangafodipir trisodium with respect to non-dilated biliary tree depiction

OBJECTIVE

To compare the efficacy of Mangafodipir trisodium (Mn-DPDP)-enhanced MR cholangiogrphy (MRC) and Gadobenate dimeglumine (Gd-BOPTA)-enhanced MRC in visualizing a non-dilated biliary system.

MATERIALS AND METHODS

Eighty-eight healthy liver donor candidates underwent contrast-enhanced T1-weighted MRC. Mn-DPDP and Gd-BOPTA was used in 36 and 52 patients, respectively. Two radiologists reviewed the MR images and rated the visualization of the common duct, the right and left hepatic ducts, and the second-order branches using a 4-point scale. The contrast-to-noise ratio (CNR) of the common duct to the liver in the two groups was also compared.

RESULTS

Mn-DPDP MRC and Gd-BOPTA MRC both showed similar visualization grades in the common duct (p=.380, Mann-Whitney U test). In the case of the proximal bile ducts, the median visualization grade was significantly higher with Gd-BOPTA MRC than with Mn-DPDP MRC (right hepatic duct: p=0.016, left hepatic duct: p=0.014, right secondary order branches: p=0.006, left secondary order branches, p=0.003). The common duct-to-liver CNR of the Gd-BOPTA MRC group was significantly higher (38.90+/-24.50) than that of the Mn-DPDP MRC group (24.14+/-17.98) (p=.003, Student's t test).

CONCLUSION

Gd-BOPTA, as a biliary contrast agent, is a potential substitute for Mn-DPDP.

The relationship of anatomic variation of pancreatic ductal system and pancreaticobiliary diseases

The aims of this study were to identify the morphological diversities and anatomical variations of pancreatic ductal system and to define the relationships between pancreatic ductal systems, pancreaticobiliary diseases, and procedure- related complications, including post-ERCP pancreatitis. This study included 582 patients in whom both pancreatic duct (PD) and common bile duct were clearly visible by ERCP. PD systems were categorized into four types according to the relationship between common bile duct and PD. In types A and B, Wirsung duct formed the main PD. In type C, Wirsung duct did not form the main PD. If PD system did not fall into any of these three types, it was categorized as type D. The distribution of types among pancreatic ducts examined was as follows: type A: 491 cases (84.4%), type B: 56 cases (9.6%), type C: 20 cases (3.4%), and type D: 15 cases (2.6%). The anomalous anatomic variations of PD systems were divided into migration, fusion, and duplication anomalies. PD anomalies were noted in 51 patients, of which 19 (3.3%) were fusion anomalies (12 complete pancreas divisum, 7 incomplete pancreas divisum), and 32 (5.5%) were duplication anomalies (5 number variations, 27 form variations). No significant relationships between various PD morphologies and pancreaticobiliary diseases were found. However, post- ERCP hyperamylasemia was more frequently found in types C (41.7%), D (50%) and A (19.8%) than in type B (9.4%). In summary, whether Wirsung duct forms the main PD and the presence or absence of the opening of the Santorini duct are both important factors in determining the development of pancreatitis and hyperamylasemia after ERCP.

Echo-endoscopy versus endoscopic retrograde cholangiography for the diagnosis of choledocholithiasis: the influence of the size of the stone and diameter of the common bile duct

BACKGROUND

Endoscopic retrograde cholangiography is highly accurate in diagnosing choledocholithiasis, but it is the most invasive of the available methods. Endoscopic ultrasonography is a very accurate test for the diagnosis of choledocholithiasis with a risk of complications similar to that of upper gastrointestinal endoscopy.

AIM

To compare the accuracy of endoscopic ultrasonography and endoscopic retrograde cholangiography in the diagnosis of common bile duct stones before laparoscopic cholecystectomy and to analyze endoscopic ultrasound results according to stone size and common bile duct diameter.

PATIENTS AND METHODS

Two hundred and fifteen patients with symptomatic gallstones were admitted for laparoscopic cholecystectomy. Sixty-eight of them (31.7%) had a dilated common bile duct and/or hepatic biochemical parameter abnormalities. They were submitted to endoscopic ultrasonography and endoscopic retrograde cholangiography. Sphincterotomy and sweeping of the common bile duct were performed if endoscopic ultrasonography or endoscopic retrograde cholangiography were considered positive for choledocholithiasis. After sphincterotomy and common bile duct clearance the largest stone was retrieved for measurement. Endoscopic or surgical explorations of the common bile duct were considered the gold-standard methods for the diagnosis of choledocholithiasis.

RESULTS

All 68 patients were submitted to laparoscopic cholecystectomy with intraoperative cholangiography with confirmation of the presence of gallstones. Endoscopic ultrasonography was a more sensitivity test than endoscopic retrograde cholangiography (97% vs. 67%) for the detection of choledocholithiasis. When stones >4.0 mm were analyzed, endoscopic ultrasonography and endoscopic retrograde cholangiography presented similar results (96% vs. 90%). Neither the size of the stone nor the common bile duct diameter had influence on endoscopic ultrasonographic performance.

CONCLUSIONS

For a group of patients with an intermediate or moderate risk with respect to the likelihood of having common bile duct stones, endoscopic ultrasonography is a better test for the diagnosis of choledocholithiasis when compared to endoscopic retrograde cholangiography mainly for small-sized calculi.

Three-dimensional vasculature of the bovine liver

To clarify anatomical distribution of Fasciola infection, the vascular and ductal architectures of the liver were studied by means of corrosion cast technique using synthetic resin. The arteria hepatica propria (AP) passes as the arteria gastroduodenalis (AG); AP becomes the left trunk after the porta hepatis; AP passes on the right side of vena porta communis (VPC) and projects AG while curving in a U-shape below the portal vein. Hepatic veins located between the vena hepatica media (HM) and vena hepatica dextra (HD) varied widely among specimens and were irregular, including the vena hepatica dorso-lateralis sinistra (Hds), vena hepatica dorso-lateralis dextra (Hdd), vena hepatica lobi caudati (Hlc), venae hepaticae processus caudati (Hpc), venae hepaticae processus papillaris (Hpp), and the hepatic vein to the dorsal intermediate part, which directly or indirectly drained into the vena cava caudalis. The courses of the bovine hepatic veins were markedly diverse, and anastomoses between vena hepatica sinistra (HS) and Hds were observed in about a half of the livers. The portal vein entered the liver as VPC slightly above the centre of the right lobe on the visceral surface. The intermediate or transverse part [pars transversa trunci sinistri (PTS)] of truncus sinister (TS), which extends from the entry of the portal vein into the left lobe of the liver, was slightly arched downward [pars umbilicalis trunci sinistri (PUS)]. The portal vein further arched from the distal end of TS to the umbilical vein and ran towards the inter-lobar incision between the left lobe and quadrate lobe. Based on these branches, hepatic segments were determined as 13 or 14 areas. A total of 15 bile ducts were derived from various lobes. The hepatic duct was about 2.6-6 cm long from the confluence of the right and left hepatic ducts to the division of the cystic duct and the common hepatic duct.

Cystic duct and Heister's "valves"

The anatomy and physiology of the cystic duct have been relatively neglected by anatomists and the function of the spiral mucosal folds or "valves" of Heister, first described in 1732, remains obscure. The gross and microscopic anatomy of the cystic duct is reviewed together with results from laboratory investigations into the function of the cystic duct and its spirally arranged folds. The duct and spiral folds contain muscle fibers responsive to pharmacologic, hormonal, and neural stimuli. There is, however, no convincing evidence of a discrete muscular sphincter within the duct. Although the cystic duct is unlikely to play a major role in gallbladder filling and emptying, it appears to function as more than a passive conduit. Coordinated, graded muscular activity in the cystic duct in response to hormonal and neural stimuli may facilitate gallbladder emptying. The principal function of the internal spiral folds that are found in man and other animals may be to preserve patency of this narrow, tortuous tube rather than to regulate bile flow.

EXTRAHEPATIC BILIARY ANATOMY AT LAPAROSCOPIC CHOLECYSTECTOMY: IS ABERRANT ANATOMY IMPORTANT?

BACKGROUND

The prevention of major duct injury at cholecystectomy relies on the accurate dissection of the cystic duct and artery, and avoidance of major adjacent biliary and vascular structures. Innumerable variations in the anatomy of the extrahepatic biliary tree and associated vasculature have been reported from radiographical and anatomical studies, and are cited as a potential cause of bile duct injury at cholecystectomy.

METHODS

A photographic study of the dissected anatomy of 186 consecutive cholecystectomies was undertaken and each photo analysed to assess the position of the cystic duct and artery, the common bile duct and any anomalous structures.

RESULTS

The anatomy in the region of the gallbladder neck was relatively constant. Anatomical variations were uncommon and anomalous ducts were not seen. Vascular variations were the only significant abnormalities found in the present series.

CONCLUSION

Anatomy in the region of the gallbladder neck varies mostly in vascular patterns. Aberrant ducts or duct abnormalities are rarely seen during cholecystectomy hightlighting the principle that careful dissection and identification is the key to safe cholecystectomy.

ENDOSCOPIC RETROGRADE CHOLANGIO-PANCREATOGRAPHY IN HEALTHY BEAGLES

Endoscopic retrograde cholangiography and pancreatography was performed in seven healthy Beagles to assess the common bile duct and the accessory pancreatic duct after retrograde filling with an iodine contrast medium. All dogs had a major and a minor duodenal papilla. One Beagle had additionally an accessory papilla. The diameter of the contrast filled ducts was measured at three defined measure points (MP1-3) in ventrodorsal radiographs and left lateral radiographs. In ventrodorsal radiographs of endoscopic retrograde cholangiography the common bile duct had a straight craniomedial course. The mean duct diameter was from proximal to distal 3.04 +/- 1.89mm at MP1, 2.38 +/- 1.23 mm at MP2, and 2.11 +/- 0.84 mm at MP3. In ventrodorsal radiographs of endoscopic retrograde pancreatography, the left and right branch of the accessory pancreatic duct united in the pancreatic body. The mean diameter of the right branch was 0.88 +/- 0.14 mm at MP1, 0.72 +/- 0.2 mm at MP2 and 0.61 +/- 0.11 mm at MP3. The left branch had a diameter of 0.93 +/- 0.28 mm at MP1, 0.86 +/- 0.21 at MP2, and 0.6 +/- 0.07 mm at MP3. The mean length was 81.6 +/- 14.3 mm for the right and 107.0 +/- 24.9mm for the left branch. In left lateral radiographs of endoscopic retrograde pancreatography, it was not possible to differentiate the left from the right branch. Both branches ran nearly parallel and showed similar diameters but slight differences in length. The study proves that endosopic retrograde cholangio-pancreatography is possible in dogs. Radiographs taken from dogs in dorsal recumbency allow an objective assessment of the common bile duct and the accessory pancreatic duct.

Topography and morphometry of the common bile duct and major duodenal papilla of man and principal domesticated animals

A comparative topography and morphometry of the common bile duct and major duodenal papilla was studied on the extrahepatic biliary apparatus of human and major domesticated animals such as horse, ox, Black Bengal (BB) goat, sheep, dog and cat of local breed. In Black Bengal goat, sheep, dog and cat, the extrahepatic biliary system seemed to be the continuation of the cystic duct, which was found to continue as the common hepatic/common bile duct into which all the hepatic/lobar ducts open. In man, the mean length and the mean diameter of the common bile duct were 7.67+/-0.58 cm. and 7.27+/-0.77 mm. respectively. In the ox, these values were 1.57+/-0.72 cm. and 11.82+/-0.79 mm. respectively; in the Black Bengal goat, 7.23+/-0.74 cm. and 4.45+/-0.72 mm. respectively; in the sheep, 5.27+/-0.66 cm. and 3.75+/-0.79 mm. respectively; in the dog, 4.72+/-0.67 cm. and 6.43+/-0.55 mm. respectively and in the cat, 3.26+/-0.87 cm. and 5.63+/-0.43 mm. respectively. In man, the mean length and the mean diameter at the base of the MDP were 4.37+/-0.56 mm. and 3.97+/-0.72 mm. respectively. In horse, these were 52.36+/-0.67 mm. and 12.47+/-0.63 mm. respectively; in ox, 12.53+/-0.73 mm. and 8.83+/-0.68 mm. respectively; in Black Bengal goat, 14.36+/-0.55 mm. and 5.23+/-0.57 mm. respectively; in sheep, 11.27+/-0.69 mm. and 4.51+/-0.74 mm. respectively; in dog, 17.43+/-0.82 mm. and 6.72+/-0.64 mm. respectively and in cat, these values were 12.36+/-0.47 mm. and 7.12+/-0.87 mm. The distance of the Major Duodenal Papilla (MDP) form the pyloric end of the stomach was proportionately shorter in the meat-eaters, i.e., the omnivorous man (9.76+/-0.88 cm), and the carnivores, dog (6.37+/-0.73 cm) and cat (2.75+/-0.87 cm.) when compared to that of the herbivores, i.e., ox (55.37+/-0.68 cm.), BB goat (23.27+/-0.89 cm.) and sheep (25.62+/-0.77 cm.). In the horse, the major duodenal papilla was perpendicular to the duodenal mucosal surface with the largest mean length and the mean diameter. In all other animals, it was obliquely placed on the duodenal surface with its opening directed aborally.

Mechanical properties of the porcine bile duct wall

Background and Aim

The function of the common bile duct is to transport bile from the liver and the gall bladder to the duodenum. Since the bile duct is a distensible tube consisting mainly of connective tissue, it is important to obtain data on the passive mechanical wall properties. The aims of this study were to study morphometric and biomechanical wall properties during distension of the bile duct.

Methods

Ten normal porcine common bile ducts were examined in vitro. A computer-controlled volume ramp infusion system with concomitant pressure recordings was constructed. A video camera provided simultaneous measurement of outer dimensions of the common bile duct. Wall stresses and strains were computed.

Results

The common bile duct length increased by 25% from 24.4 ± 1.8 mm at zero pressure to 30.5 ± 2.0 mm at 5 kPa (p < 0.01). The diameter increased less than 10% in the same pressure range from 8.6 ± 0.4 mm to 9.3 ± 0.4 mm (p < 0.01). The stress-strain relations showed an exponential behavior with a good fit to the equation: σ = α . (exp^(βε) - 1). The circumferential stress-strain curve was shifted to the left when compared to the longitudinal stress-strain curve, i.e. the linear constants (α values) were different (p < 0.01) whereas the exponential constants (β values) did not differ (p > 0.5).

Conclusion

The porcine bile duct exhibited nonlinear anisotropic mechanical properties.

Three-dimensional sonographic evaluation of the common bile duct

OBJECTIVE

To assess the accuracy of three-dimensional sonographic measurements of the common bile duct compared with standard two-dimensional anteroposterior measurement of the common duct.

METHODS

Fifty-five consecutive patients referred for abdominal sonography underwent standard two-dimensional abdominal sonography followed by three-dimensional sonographic data acquisition of the right upper quadrant. A radiologist blinded to the results of the two-dimensional examination later measured the three-dimensional long axis anteroposterior common duct diameter and three-dimensional short axis anteroposterior and transverse common duct diameters.

RESULTS

The mean average common duct diameter as measured by two-dimensional sonography (long axis anteroposterior) was 3.6 mm. The mean average common duct diameter as measured by long axis anteroposterior three-dimensional sonography was 4.1 mm. The mean average common duct diameter as measured by anteroposterior short axis three-dimensional sonography was 4.1 mm, and by transverse short axis three-dimensional sonography, it was 4.4 mm. The two-dimensional common duct measurement correlated with the long axis anteroposterior three-dimensional measurement (P < .001), the short axis anteroposterior three-dimensional measurement (P < .001), and the short axis transverse three-dimensional measurement (P < .005) by the Spearman rank order correlation coefficient test.

CONCLUSIONS

Three-dimensional sonographic measurements of the common bile duct correlate highly with two-dimensional measurements, validating the use of three-dimensional sonography as a reliable method for evaluation of common bile duct size.

Three-dimensional identification of the cystic infundibulum-cystic duct junction: a technique for identification of the cystic duct in laparoscopic cholecystectomy

OBJECTIVE

The main cause of bile duct injury (BDI) at laparoscopic cholecystectomy is misidentification of the common bile duct as the cystic duct (CD). The aim of this article is to introduce a modified technique, i.e., three-dimensional identification of the cystic infundibulum (CI)-CD junction, to prevent misidentification-induced BDI during laparoscopic cholecystectomy.

METHODS

The CI was extensively dissected to expose its anterior, interior-superior and inferior-dorsal aspects. With the CI nearly circularly dissected out, the CI and the appearance-indicated CI-CD junction might be three-dimensionally identified and the reality of the CI-CD junction as well as the reality of the CD could be precisely judged.

RESULTS

Overall 10 BDIs were documented in this group. Since BDI occurred in 8 of 4382 patients receiving laparoscopic cholecystectomy, the technique for prevention of misidentification-induced BDI was established. Among the late batch of 7618 patients, only two BDIs were noted.

CONCLUSIONS

Three-dimensional identification of the CI-CD junction is a reliable, feasible and relatively low experience-dependent technique to prevent most of misidentification-induced BDI.

What's right when the gallbladder's left? A case report

During laparoscopic cholecystectomy for cholelithiasis in a 40-year-old woman, we came upon a case of incidentally discovered left-sided gallbladder (LSG). Two anatomic variants of LSG are known: (a) "true LSG," in which, according to Gross, an accessory gallbladder originates from the left hepatic duct (LHD), the right embryonic bud is readsorbed, and the cystic duct joins either the CBD from the left or the LHD directly. Otherwise, a normal right-sided gallbladder adheres to the inferior left hepatic lobe, and the cystic duct joins the CBD from the right side (as in our case); (b) gallbladder under the fourth hepatic segment, medial to a right-sided round ligament, probably resulting from a prenatal obliteration of the right umbilical vein. Left-sided gallbladder is a paraphysiologic condition that when identified before surgery, must be studied by CT or MRI, when incidentally discovered during surgery must be promptly recognized by the surgeon, who must be aware of the unpredictable confluence of the cystic duct into the CBD. The following operative precautions are useful for avoiding a lesion of the CBD: The surgeon should start dissection of Calot's triangle as close as possible to the gallbladder margin, prepare and clip the cystic duct as close as possible to the infundibulum, and a 30 degrees angled telescope. If in doubt, the surgeon should perform an intraoperative cholangiography.

Effect of the diameter of the common bile duct on the incidence of bile duct stones in patients with recurrent attacks of right epigastric pain after cholecystectomy

OBJECTIVE

To study the relationship between the diameter of the common bile duct and the incidence of bile duct stones in non-jaundiced patients with recurrent attacks of right epigastric pain after cholecystectomy.

DESIGN

Retrospective study.

SETTING

University hospital, Finland.

SUBJECTS

57 consecutive, non-jaundiced patients admitted for elective endoscopic retrograde cholangiopancreatography (ERCP) because of attacks of right epigastric pain after cholecystectomy.

INTERVENTIONS

Measurement of maximum diameter of the common bile duct and presence or absence of bile duct stones.

MAIN OUTCOME MEASURES

Diameter of bile duct (10 mm or less was regarded as normal) and presence or absence of stones.

RESULTS

33 patients had normal-sized bile ducts and in 24 they were widened. Only 2/33 patients with normal-sized ducts (6%) had stones, compared with 11/24 (46%) with wide ducts (p = 0.0008). However, the degree of ductal dilatation did not seem to have any influence on the presence or absence of stones.

CONCLUSION

Bile duct stones are unlikely after cholecystectomy in patients who are not jaundiced and have a normal-sized common bile duct. However, nearly half of the patients with a wide common bile duct had stones, but the degree of dilatation was not important.

Ultrasonographic evaluation of common duct diameter in pre and post cholecystectomy patients

Thirty four patients with gall bladder disease and normal common duct were investigated prospectively by ultrasonography just before cholecystectomy and at periodic intervals of 1 months, 2 months, 3 months and once in 4-6 months after cholecystectomy. The pre and post cholecystectomy common duct diameters were measured at each visit and compared with each other to determine the statistical significance. No significant change (p > 0.05) occurred in common duct diameter following cholecystectomy.

Common bile duct measurements in an elderly population

We prospectively evaluated the diameter of the common bile duct in 1,018 patients between the ages of 60 to 96 over a 4 year period to determine if there is a significant change in its size with aging. All of the patients included in the study were being evaluated primarily for carotid or peripheral vascular disease. Any patients with a history of biliary disease (i.e., bilirubin level greater than 1.5 mg/ml, cholecystectomy, or cholelithiasis) were excluded. Ultrasonography of the common bile duct was performed only in those patients with no subjective abdominal pain or icterus. Our results demonstrated a small although statistically significant increase in the caliber of the common bile duct with increasing age (60 years old or less, mean diameter 3.6 mm +/- 0.2mm, versus over 85 years old, mean diameter 4 mm +/- 0.2 mm, P = 0.009). Although the common bile duct did increase in size with aging, 98% of all ducts remained below 6 to 7 mm, the commonly accepted upper range of normal.

Gallstones, the choledochoduodenal junction and initiation of acute pancreatitis: are two stones the culprits rather than one stone?

Reflux of biliary secretions into the pancreatic duct following gallstone obstruction of the common biliary pancreatic ampulla has been implicated as a cause of acute pancreatitis. However, the pancreatic duct pressure is higher than the biliary pressure and, therefore, the simple obstruction of the choledochoduodenal junction by one gallstone does not result in biliary pancreatic reflux. We propose a mechanism whereby simultaneous migration and sequential impaction above and below the common biliary pancreatic ampulla of two gallstones allows for the creation of a toxic bile-pancreatic juice mixture in the common bile duct, subsequent reversal of the pressure gradient and reflux of the toxic secretions into the pancreatic duct.

Oddi sphincter and common channel: evaluation with pharmacodynamic MR cholangiopancreatography using fatty meal and secretin stimulation

PURPOSE

This study was performed to assess the usefulness of pharmacodynamic MR cholangiopancreatography (MRCP) in depicting the segment covered by the Oddi sphincter.

MATERIALS AND METHODS

Twelve volunteers were studied by pharmacodynamic MRCP. After stimulation by the oral intake of a fatty meal and an intravenous injection of secretin, a single-shot rapid acquisition relaxation enhancement (RARE) sequence was used to obtain consecutive images of the segment covered by the Oddi sphincter. The contraction range of the Oddi sphincter and the lengths of the common channel were measured on the MR console by comparing the most contracted image of the sphincter with the most relaxed image.

RESULTS

Pharmacodynamic MRCP showed periodic contraction of the Oddi sphincter in all cases. The range of sphincteric contraction over the biliary duct was 8-19 mm (11.8+/-3.2 mm, mean +/- standard deviation) and over the pancreatic duct 8-23 mm (10.0+/-1.5 mm). In 11 of the 12 cases, the common channel was depicted and its length ranged from 3-8 mm (5.2+/-1.3 mm).

CONCLUSION

Pharmacodynamic MRCP clearly depicted the range of contraction of the Oddi sphincter and the common channel, which are not usually revealed by conventional MRCP.

Ultrasonographic study on the growth and dimensions of healthy children and adults organs

We measured by ultrasound the spleen, the kidneys, the pancreas in 323 children (age 0-12), the thyroid in 60 children of same age range, and all these organs in 180 adults (in adults we measured additionally the testis, the gallbladder and the choledochus). Children and adults were all healthy, without evidence of pathologies potentially involving these organs. The children have been selected looking at clinical and hematological parameters, while the adults have been selected among a military population, that is the most significant sample of healthy young adults. We measured the length, the transversal diameter and the thickness of the spleen, kidneys, pancreas, testis and thyroid, the diameter of the choledochus and the maximum length of the gallbladder (pre and post stimulus). We found a good correlation between age and dimensions for pancreas, kidneys and spleen in children, representing the progressive growth of these organs. Our data represent an assessment of the normal dimensions of these organs in vivo by means of ultrasound, and therefore they are an useful tool to discriminate pathologically enlarged or reduced organs, both in children and in adults.

Visual identification of the cystic duct-CBD junction during laparoscopic cholecystectomy (visual cholangiography): an additional step for prevention of CBD injuries

Despite advances in technical skills, common bile duct (CBD) injury during laparoscopic cholecystectomy is not an uncommon major complication. We describe a technical step that can be taken during the dissection of the triangle of Calot to allow the junction between the cystic duct and CBD to be clearly visualized. This is a safe and simple maneuver that mimics the one done in open surgery. Its routine application serves as an additional safety measure to prevent injury to the common bile duct.

Pancreaticobiliary ductal anatomy in Thai people

The complex anatomy of the pancreaticobiliary duct was studied to demonstrate basic data in Thai people. Fresh specimens of the pancreas, common bile duct, and duodenum were obtained en bloc from the autopsies of 103 patients who had died of causes not related to trauma or disease of these organs. The length of the pancreas, the location of the pancreatic ducts in relation to the surface of the pancreas, the length and types of the common channels, as well as the anatomy of the ampulla, were studied, using methylene blue infusion via the pancreatic duct cannulation and careful dissection. Ninety-three male and 10 female patients were included. Their ages ranged from 15 to 76 years (mean 31.38 +/- 12.98 years). The length of the pancreas ranged from 10.9-19 cm (mean, 15.60 +/- 1.80 cm). The intrapancreatic portion of the common bile duct showed patterns of three types; most common (90/103; 87.38%) was type A, in which the anterior surface of the common bile duct was totally covered, while its posterior surface was partially covered, by the pancreatic parenchyma. On dissection of the accessory duct of Santorini in the pancreatic substance, the accessory duct was traceable to the duodenal wall in 59 specimens (57.26%). The anatomy of the Wirsung-choledochus confluence was grouped into five different types. The common channel (junction of the common bile duct and pancreatic duct) was found in 76.70% of specimens and its length varied from just a common junction (so-called "V-type" anatomy) to 15 mm (Y-type-b). Separate papillae (so-called "II-type") were found in 12. 62% of specimens. Separate openings in the same papilla (so-called "U-type") were found in 10.68% of specimens. The Wirsung duct at the pancreatic neck was most often located posterior and superior in relation to the surface of pancreas. This study demonstrated several important points regarding the anatomy of the pancreaticobiliary junction and pancreatic ductal system in a Thai population. Some of these data were different from those reported in the literature for other population groups.

Luminal cross-sectional area and tension-strain relation of the porcine bile duct

The bile duct is a distensible tube serving to transport bile from the liver and gallbladder to the duodenum. The purpose of this study was to characterize the luminal cross-sectional area (CSA) and tension-strain properties during distension of the normal isolated porcine common bile duct in vitro. An impedance planimetric system located inside a balloon was used. Eleven porcine bile ducts were examined in two locations, in the hepatic duct and in the common bile duct. The CSAs obtained in the common bile duct were significantly higher than those in the hepatic duct in the pressure range 0-8 kPa (P < 0.001). The circumferential wall tension (T)-strain (epsilon) relations for both locations fitted to the exponential equation T = a.eb. epsilon with determination coefficients of 0.97 +/- 0.01. The a and b constants were not statistically different between the two locations indicating that the elastic properties did not differ. In conclusion, the luminal CSAs were larger in the common bile duct when compared to the hepatic duct and the tension-strain relations did not differ between the two segments of the bile duct.

The normal retrograde cholangiogram: a definition of normal caliber

PURPOSE

To evaluate normal retrograde cholangiograms to determine a normal range of ductal calibers and identify its variation with age.

MATERIALS AND METHODS

The retrograde cholangiograms of 136 patients (age range: 17-84 years; mean age 49.8 years +/- 17.3 [standard deviation]) with clinical follow-up and subsequent studies suggesting normal biliary trees were evaluated. Patients with previous cholecystectomy, choledocholithiasis, or pancreatitis were excluded. Common bile duct (CBD) and common hepatic duct (CHD) sizes were measured.

RESULTS

Measurements uncorrected for radiographic magnification of CBD revealed a mean of 8.5 mm +/- 2.7 mm [standard deviation] and CHD had a mean of 8.1 mm +/- 2.6 mm. There was an increase in CBD caliber by 0.5 mm per decade of increasing age (p < 0.001) and an increase in CHD caliber by 0.35 mm per decade of age (p < 0.01).

CONCLUSION

The range of normal cholangiographic bile duct caliber is wide and a CBD caliber of 13.9 mm occurs at the top of this range (mean plus two standard deviations). There is a small but statistically significant trend of ductal dilatation with advancing age.

Variations of the intrahepatic bile ducts: application in living related liver transplantation and splitting liver transplantation

The variations in the anatomy of intrahepatic bile ducts complicate operations in living related liver transplantation (LRLT) and therefore preoperative delineation of the biliary system is important to achieve a successful outcome. The aim of this study was to establish a standard relationship between the biliary variations and the methods of the graft splitting and anastomosis. Of 958 endoscopic retrograde cholangiographies with good visualization of bile duct branches were selected and were available for evaluation of their ramifications and variants. According to drainage of right hepatic duct and left hepatic duct, we classified the bile ducts into two major groups. Unusual routes of the intrahepatic ducts were present in 105 cases (11% in group A) the right sectoral duct drained into the left hepatic duct directly; in 200 cases (21% in groups B) the duct of segment IV drained into right side or common hepatic duct; and in 29 cases (3% in groups B) the duct of segment: II and III drained into the CBD and right hepatic duct separately. There is no specific bile duct variation that forbids someone from LRLT and SLT, but unusual intrahepatic ducts routes may require a change both in the cutting plane during graft retrieval and pattern of ductoenteral anastomosis to avoid potential complications to both donors and recipients. Cholangiography for screening intrahepatic duct variations is therefore important for safe bile drainage for both donors and recipients.

Sonographic evaluation of the common bile duct in cats

Ultrasound is an excellent imaging tool in the evaluation of the biliary tract in cats. Extrahepatic obstruction could be diagnosed by the presence of dilated common bile duct (CBD), which was measured ventral to the portal vein in the porta hepatis. At this level, the diameter of the CBD in 6 healthy cats and in 22 cats with nonsurgical jaundice was < or = 4 mm. Six of 7 cats with a CBD > 5 mm had extrahepatic biliary obstruction.

Rat common bile duct: structure, pharmacological responsiveness, CGRP innervation, and binding sites

The wall of the rat common bile duct (CBD) consists of several epithelial ducts embedded in connective tissue which contains some regions with cells weakly stained by an antibody against alpha smooth muscle actin. The hepatic side (HS) is more vascularized than the duodenal side (DS). Calcitonin gene-related peptide (CGRP)-like immunoreactivity is present in nerve fibres penetrating deeply into the CBD wall. On whole-mount preparations, CGRP innervation is mainly associated with blood vessels in the HS, whereas it forms a wide meshed network independent of vasculature in the DS. Abundance of CGRP innervation was compared between both sexes and at different ages. No differences were found in the total number of fibres between males and females except at 4 months of age, when males had statistically more abundant innervation than females. However, during aging, while the abundance of innervation (fibers/mm) remained stable in both HS and DS in females, it significantly decreased in males. Autoradiography demonstrated the presence of 125I-CGRP binding sites in the rat CBD. In vitro, 30% of HS strips showed spontaneous rhythmic contractions but all the strips (autocontractile or not) contracted dose dependently in response to acetylcholine (Ach) or substance P (SP). However, DS strips were neither autocontractile nor responsive to Ach or SP. Perfusion of all strips with 10(-7) M CGRP produced no effects nor influenced Ach- or SP-induced contractions.

Common bile duct in children: sonographic dimensions

PURPOSE

To determine the normal caliber and rate of growth of the extrahepatic biliary ducts in the pediatric population.

MATERIALS AND METHODS

The diameter of the common bile duct was measured with sonography in 173 children aged 1 day to 13 years (mean, 6.0 years; median, 5.0 years) who were examined for reasons other than hepatic or biliary tract disease. Results were subjected to regression analysis and compared with similar measurements of the extrahepatic portal vein and hepatic artery. The size of the gallbladder was subjectively estimated as distended, moderately full, and contracted. Differences in the diameter of the common bile duct in these three groups were evaluated with the Mann-Whitney U test.

RESULTS

The average diameter of the common bile duct in this population was 1.27 mm +/- 0.67 (< 3.3 mm in all patients and < 1.2 mm in children aged 3 months or less). The slope of the curve describing the growth of the common bile duct was relatively flat, similar to that of the hepatic artery and half that of the portal vein. There was a significant difference in the diameter of the common bile duct between patients with distended gallbladders and those with contracted gallbladder (P = .02).

CONCLUSION

The pediatric common bile duct is significantly smaller than adult norms; it is a distensible structure responsive to fluctuations in prandial bile flow.

[Influence of age and biliary lithiasis on the diameter of the common bile duct]

OBJECTIVE

To determine the influence of age and biliary lithiasis in the dilatation of the biliary ducts, a retrospective analysis was performed of the cholangiograms obtained by endoscopic retrograde cholangiopancreatography in patients presenting or with a past-history of biliary lithiasis and in controls.

METHODS

Among 165 patients, 113 had choledocolithiasis (53 had gallstones, 50 had been cholecystectomized and 10 had no gallstones), 35 had gallstones and 17 had been cholecystectomized for gallstones.

RESULTS

The diameter of the main biliary duct was significantly increased in the presence of common bile duct stones (14.0 +/- 4.9 mm), in cholecystectomized patients (11.7 +/- 4.3 mm), in presence of gallstones (9.2 +/- 2.4 mm). The diameter of the biliary ducts was significantly correlated with age in patients (r = 0.27; P = 0.001) and in controls (r = 0.31; P = 0.02). The different factors related to the dilatation of the main biliary duct were classified using a stepwise discriminant analysis: 1: choledocolithiasis, 2: age, 3: cholecystectomy, 4: gallstones.

CONCLUSION

There is a moderate but significant statistical correlation between age and the dilatation of the common bile duct, independent of the presence of biliary lithiasis.

An experimental model for laparoscopic common bile duct exploration

The development of an effective and reliable technique for laparoscopic common bile duct exploration has been limited by the technical difficulty of the procedure and the lack of a suitable animal model with a bile duct diameter large enough to accommodate the fiberoptic choledochoscope and other instruments used for stone extraction. Short-term bile duct ligation in the dog provides a simple and reproducible animal model that enables the surgeon to gain experience with laparoscopic common bile duct exploration in a laboratory setting. This model will enable the surgeon to develop the technical skills necessary to perform laparoscopic common bile duct exploration. In addition, the model may facilitate the development and refinement of new techniques and instruments that will facilitate laparoscopic common bile duct exploration in the clinical setting.

Respiratory variation of extrahepatic bile duct diameter during ultrasonography

The attachments and adjacent structures of the extrahepatic bile duct may not move uniformly throughout the respiratory cycle, potentially affecting the diameter of the common bile duct. This study was performed to evaluate possible respiratory variation in extrahepatic bile duct diameter. Thirty consecutive subjects with maximal anteroposterior common bile duct diameter of 5 mm or greater were studied. Inspiratory increase in ductal diameter exceeding 1 mm was noted in 11 subjects (37%), eight without biliary obstruction. Awareness of this normal phenomenon may avert sonographic misdiagnosis of common bile duct obstruction, particularly during fatty-meal sonography.