[THE PLACE OF PANCREATICODUODENAL RESECTION IN SURGICAL TREATMENT OF COMPLICATED FORMS OF CHRONIC PANCREATITIS]

Results of surgical treatment of 120 patients, suffering complicated forms of chronic pancreatitis, were analyzed. In 5 patients pancreaticoduodenal resection in accordance to Whipple method have constituted the operation of choice. The indications for operation were: impossibility to exclude completely the malignant process inside pancreatic head; enhancement of the pancreatic head, causing duodenal, common biliary duct and the pancreatoduodenal zone vessels compression; cystic changes of pancreatic head with several episodes of hemorrhage inside the cyst and duodenum. The immediate, short-term and intermediate results of the operation were estimated as good and satisfactory.

[Modern classification of the lymph nodes groups in hepatopancreatobiliary zone, multifactorial criterion "T" and the lymphadenectomy extent in malignant diseases of pancreatic head]

Modern classifications of lymph nodes of the hepatopancreatobiliary zone organs, applied by domestic and leading foreign surgeons were analyzed. A modified classification of lymph nodes was proposed, basing on recommendations of Japanese society of pancreatologists (V edition). Basing on own experience, the results of studying of the lymph nodes groups and extent of lymphadenectomy in patients while presence of malignant tumors of pancreas and distal portion of common biliary duct were analyzed.

Portal biliopathy diagnosed using color Doppler and contrast-enhanced ultrasound

Portal biliopathy is a morphological abnormality of the biliary ductal and gallbladder wall associated with portal hypertension. A patient with essential thrombocythemia was initially diagnosed with extrahepatic portal vein obstruction (EHPVO). The contrast-enhanced computed tomography (CT) findings were similar to those of cholangiocarcinoma or sclerosing cholangitis. However, color Doppler and contrast-enhanced ultrasound (US) were more specific. The paracholedocheal veins around the bile ducts appeared as beads soon after the injection of contrast medium, followed by linear enhancement of the epicholedochal veins and the gradual enhancement of the whole bile ducts. These findings led to a diagnosis of portal biliopathy, which prevented the patient from having to endure hazardous procedures such as bile duct biopsies. Color Doppler and contrast-enhanced US findings are useful for diagnosing or ruling out portal biliopathy in patients who present with EHPVO.

The common bile duct: size, course, relations

The common bile duct may present a number of anatomical peculiarities regarding its size, course and relations, which should be taken into consideration by the anatomists and by the surgeons as well, during the surgery of the gallbladder, pancreas and duodenum. In the present study, we have analyzed the anatomical peculiarities of the common bile duct in 150 adult corpses of both sexes from the Anatomy Department and 22 human fetuses from the Pathology Department, University of Medicine and Pharmacy Cluj-Napoca.

[Obstructive jaundice due to compression of the common bile duct by right hepatic artery originated from gastroduodenal artery]

Obstructive jaundice by vascular compression is rare. The causative arteries were identified as the right hepatic artery, gastroduodenal artery, cystic artery, proper hepatic artery, and an unspecified branch of the common hepatic artery. Also the venous system, such as enlarging collateral veins in cases of portal hypertension was a causative vessel. Herein, we describe a case of a proximal choledocholithiasis due to compression of the common bile duct by right hepatic artery originated from gastroduodenal artery. Final diagnosis and treatment were achieved through an operation.

Small arteriovenous malformation of the common bile duct causing hemobilia in a patient with hereditary hemorrhagic telangiectasia

We report a 54-year-old male patient with arteriovenous malformation located at the common bile duct and hereditary hemorrhagic telangiectasia. The patient was treated as gallstone pancreatitis at first. Three days after endoscopic nasobiliary drainage (ENBD) for biliary drainage to subside gallstone pancreatitis, hemobilia was drained from the ENBD tube and the serum hemoglobin level gradually decreased. Cholangioscopy and angiography revealed that hemobilia was due to a small arteriovenous malformation located at the common bile duct. Subsequently, the patient was successfully treated by endovascular intervention.

Common bile duct wall thickening due to intramural varices diagnosed by colour Doppler ultrasound

Cases of common bile duct (CBD) wall thickening due to varicose dilation of intramural veins consequential to portal vein thrombosis (PVT) are rare and present a considerable differential diagnostic problem, as they can mimic cholangiocarcinoma. In such cases, colour Doppler ultrasound (CD US) is a very valuable diagnostic method. There are only a few reports in literature on CD US findings of collateral circulation in a thickened CBD wall following PVT. A patient with obstructive jaundice, a tumour of the pancreatic head, CBD wall thickening, and pre-existing PVT is presented. CD US demonstrated collateral circulation of the thrombosed portal vein in the thickened wall of the common bile duct, thus ruling out a mass in the CBD. Obstructive jaundice seldom occurs with choledocal varices. In this patient, the bile duct obstruction was due to the carcinoma of the pancreatic head.

[Influence of method of cholecystectomy performance on the central hemodynamics indices in patients with an acute cholecystitis]

There were examined 120 patients, using the method of the integral rheography of the body (according to method of M. I. Tyshchenko), and than operated on for the acute cholecystitis. In 60 patients, constituting the main group, cholecystectomy using minimal approach (CHMA) was done and in 60 (control group)--open cholecystectomy (OCH) using wide laparotomy. After performance of OCH the significant reduction of volumetric indices of blood flow was established. Extremely significant changes of the hemodynamics indices was observed on 1-3 days and than they had slowly improved and on 7-9 day restored, but not completely up to primary data in majority of cases. After performance of CHMA the indices changes were less significant and had restored earlier.

A new technique for reconstruction of the common bile duct by an autologous vein graft and a biodegradable endoluminal stent

The incidence of severe bile duct injuries has significantly increased since the introduction of laparoscopic cholecystectomy. The ideal reconstruction procedure for traumatic defects of the bile duct should be technically simple and should preserve both the physiological passage of bile and the sphincter of Oddi. In this article we describe a new technique for bile duct reconstruction in a pig model by means of an autologous vein graft that is splinted by a endoluminal biodegradable polylactate acid stent. In 12 pigs the external jugular vein was removed and used as an autologous vein graft. After performing a median laparotomy a 2-cm segment was resected from the bile duct. The common bile duct was reconstructed by a venous interponate that had been endoluminally stented by a biodegradable polylactate acid stent. For the examination of stent degradation, 2 pigs were sacrificed at 3, 4, and 5 months (stent degradation group) and the remaining 6 pigs at 6 months (survival group). All the pigs in the survival group survived for 6 months before being sacrificed. After 4 months the stent material had been completely broken down and the vein graft had been relined with bile duct epithelium. Thus, this new technique for bile duct reconstruction using an autologous vein graft with an endoluminal stent is simple to perform and reliable, and constitutes an interesting alternative to bilodigestive anastomosis due to the preservation of the papilla of Vateri.

Unusual mass in the hepatic portal of an 86-year-old woman

Varicose veins in the hepatoduodenal ligament and hepatic portal are normally due to cavernous transformation of the portal vein. We present an unusual case of varices of the common bile duct in an asymptomatic 86-year-old woman who was referred to our hospital for evaluation of a suspected cholangiocarcinoma. A cholangiocarcinoma could be excluded, however, and the diagnosis of intramural varicosis of the common bile duct was made with transabdominal colour Doppler sonography. Sonography showed multiple dilated vessels in the wall of the common bile duct. Most patients with choledochal varices are asymptomatic. Choledochal varices may, however, result in dilatation of the biliary system, causing raised levels of serum alkaline phosphatase and even jaundice.

Perivascular epithelioid clear cell tumor of the common bile duct

The perivascular epithelioid clear cell tumor (PEComa) has been described in a number of locations, including the pancreas, uterus, bladder, prostate, and gastrointestinal tract. We report the existence of a similar tumor occurring in the distal common bile duct of a 51-year-old man admitted for obstructive jaundice. The tumor had characteristic histologic features of a PEComa, including a richly vascular organoid architecture, tumor cells with clear to lightly eosinophilic cytoplasm, and variably prominent nucleoli. Immunohistochemically, the tumor cells were positive for HMB-45 and neuron specific enolase but negative for epithelial markers, smooth muscle markers, other neuroendocrine markers, vimentin, melan-A, and S-100 protein. PEComas appear to be ubiquitous tumors with characteristic histology and immunophenotype. Although most of these tumors have behaved in a benign fashion, they should be considered tumors of uncertain malignant potential given previous reports of recurrence and metastases. During a short follow-up period following a conservative local excision, our patient remains free of disease.

[Experimental study on repair of bile duct defects with expanded polytetrafluoroethylene]

OBJECTIVE

To explore the possibility of repair of the extensive bile duct injuries with expanded polytetrafluoroethylene (ePTFE).

METHODS

A total of 36 local healthy hybrid dogs were employed to establish bile duct injury models by means of partial removal of bile duct (group A, 14 dogs), excision of a segmental duct (group B, 10 dogs), and ligation of the lower part of common bile duct(group C, 5 dogs; group D, 7 dogs). Group A were patched with ePTFE mesh, group B replaced by ePTFE tube. Interposition of the grafts between gallbladder and duedenum or jejunum was performed on group C and group D. The animals' postoperative performance status were evaluated. Cholangiography was used to define the patency of bile ducts. Tissues of bile ducts and liver were taken at 3 days, 2, 4, 8, 12 and 52 weeks for microscopic and ultrastructural examination to observe the healing process of bile duct and morphological changes in the liver.

RESULTS

Group A with ePTFE patch covered by epithelium had a high patency rate of 75%(9/12) and pathological damages were not found in the liver. The patency rate of group B was merely 40%(4/10), to some extent, accompanying damages in the liver. The grafts of group C and group D were fully expelled, ultimately leading to cystic-duodenal or cystic-jejunal fistulas formation.

CONCLUSION

The study suggests that application of ePTFE patch to repair bile duct defects is feasible.

Pancreaticobiliary arteriovenous malformation with common bile duct dilation in a patient with hemobilia

Arteriovenous malformation of the pancreas is a very rare entity. We describe a case involving the head of the pancreas associated with progressive hemobilia bleeding from the lower part of the common bile duct. The patient was a 50-year-old man with acute epigastralgia. Endoscopic retrograde cholangiopancreatography revealed hemobilia and cystic dilation of the common bile duct. Angiography demonstrated increased blood volume in the head of the pancreas and early filling of the superior mesenteric and portal veins. Abdominal pain and progressive anemia caused by hemobilia required surgical treatment. Histologic examination of the resected specimen revealed marked proliferation of the blood vessels in the pericholedochal area and the exact point of bleeding from the pancreaticobiliary arteriovenous malformation.

Anatomy of the cystic artery arising from the gastroduodenal artery and its choledochal branch--a case report

Variations in the branching pattern of the common hepatic artery often occur and may be encountered during cholecystectomy. Variants of the cystic artery, its branches and relations with the biliary structures and blood vessels emphasise the importance of arterial dissection in biliary surgery. In this study, a rare variant of the cystic artery and its choledochal branch is described. The cystic artery arose from the gastroduodenal artery, passed anterior to structures in the free margin of lesser omentum and travelled a long distance before supplying the gall bladder. A long choledochal branch was noted accompanying the common bile duct. Surgical implications of this variation of the cystic and choledochal arteries are discussed.

Biliary varices on endoscopic ultrasonography: clinical presentation and outcome

BACKGROUND AND STUDY AIMS

Bile duct varices are not a well-recognized feature of portal venous obstruction. The aim of the present study was to describe the clinical and endosonographic features of biliary involvement in patients with extrahepatic portal venous obstruction (EPVO).

PATIENTS AND METHODS

A retrospective study was conducted of the clinical features, outcome, and endosonographic findings (using Olympus EUM-3 or EUM-20 probes) in 21 patients with EPVO and endosonographic features of biliary varices. Biliary varices were defined as multiple, large, serpiginous, anechoic vascular channels in and/or surrounding the extrahepatic biliary tracts.

RESULTS

Biliary varices have not previously been visible using conventional imaging methods (computed tomography and ultrasonography). They were identified using EUS in the wall of the common bile duct in 16 patients (76%), surrounding the common bile duct (CBD) in 11 patients (52%), and in the gallbladder in nine (43%). The varices were the cause of obstructive jaundice in three of the 21 patients (14%), but only when they were in the wall of the CBD. Two of these patients were treated using portosystemic shunting, and the other received a biliary endoprosthesis. The EUS examination also provided evidence of unrecognized pancreatic or biliary tumors in three other patients with EPVO of undetermined origin.

CONCLUSIONS

EUS can serve to diagnose biliary varices in patients with EPVO and jaundice. Although biliary varices are mainly asymptomatic, they may cause obstructive jaundice when they are located in the wall of the CBD. EUS can also detect unrecognized malignant tumors in patients with EPVO of undetermined origin.

Infarction of the choledochus, liver, gallbladder, and pancreas: a unique complication of the hemolytic uremic syndrome

Hemolytic uremic syndrome (HUS) is associated with multiple nonrenal manifestations. A unique case is described of a 3-year-old boy who presented with a classic diarrheal prodrome followed by massive necrosis of the biliary tree and common bile duct, pancreas, and the left lobe of his liver. This complication of HUS has not been reported in the English-language literature.

The blood supply of the biliary ductal system and its relevance to vasculobiliary injuries following cholecystectomy

BACKGROUND

Cholecystectomy remains the only satisfactory treatment for symptomatic gall bladder stones. Unfortunately, in some cases the operation is complicated by vasculobiliary injury. The present study was undertaken to investigate the blood supply of the normal biliary system, to simulate vasculobiliary injuries described after cholecystectomy, and to determine the possible effects of the vascular injury on biliary reconstruction.

METHODS

The blood supply of the biliary system in nine normal livers was investigated by injection of the coeliac axis and superior mesenteric arteries with coloured gelatin. The specimens were dissected under magnification and drawings prepared. Injection dissection studies were also carried out in eight specimens in which various vasculobiliary injuries encountered after cholecystectomy were simulated.

RESULTS

The bile ducts possess an arterial plexus on their surface which is supplied from below by ascending marginal vessels derived from the postero-superior pancreaticoduodenal artery. These marginal vessels end above in the right hepatic artery or its branches. The right and left hepatic ductal systems are supplied by the right and left hepatic arteries and their sectoral or segmental branches. The right and left hepatic arteries communicate freely via the hilar plate arterial plexus. This collateral system allows the blood supply to the right hepatic duct to be maintained after ligation of the right hepatic artery and interruption of the common hepatic duct or excision of the confluence.

CONCLUSION

A knowledge of the blood supply of the normal biliary system and the collateral hilar plate arterial plexus forms the anatomical foundation for successful reconstructive surgery, not only in vasculobiliary injuries following cholecystectomy, but also for a wide range of hepatobiliary procedures.

Diameter of the common bile duct in the elderly patient: measurement by ultrasound

We wanted to assess the width of the common bile duct (CBD) in an asymptomatic elderly (> 75 years) population, since no previous report has particularly considered the important age-related increase in CBD diameter for this patient group. CBD width of 92 asymptomatic people over 75 years of age (mean 84.7 years, range 75-96 years) without clinical or laboratory evidence for biliary, hepatocellular or pancreatic disease was measured by real-time high-resolution ultrasound of the upper abdomen. All examinations were performed by one experienced radiologist. Mean values were calculated for three groups: patients with and without cholecystolithiasis and after cholecystectomy. Statistical analysis was carried out by analysis of variance. Considering the measurements of all patients, the mean width (+/- SD) of the CBD was calculated as 6.5 +/- 2.5 mm. The difference between patients without cholecystolithiasis (6.2 +/- 2.3 mm) and patients after cholecystectomy (8.7 +/- 2.9 mm) was statistically significant (P < 0.0001). Cholecystolithiasis (6.0 +/- 1.6 mm) proves not to be an additional factor for CBD widening in comparison with patients without stone disease. The CBD of these very elderly subjects shows a considerable increase in comparison with the recommended borderline values in the ultrasound literature. An upper limit of 10 mm seems reasonable for patients with and without cholecystolithiasis. A significant increase in CBD width after cholecystectomy was found and measurements up to 14 mm may occur. Measurements have to be correlated with clinical and laboratory findings.

Limitations of percutaneous transhepatic cholangioscopy for the diagnosis of the intramural extension of bile duct carcinoma

BACKGROUND AND STUDY AIMS

Vascular dilatation seen on percutaneous transhepatic cholangioscopy (PTCS) is diagnostic of intramural invasive carcinoma of the bile duct, but the limitations of the technique, including biopsy, for the diagnosis of intramural extension of bile duct carcinoma have not to our knowledge been investigated before. The aims of the present study were to estimate the thickness of the specimens of bile duct wall taken by biopsy, to assess the sensitivity of PTCS for detecting intramural invasive carcinoma, and to identify the characteristics of the intramural extension of bile duct carcinoma associated with vascular dilatation.

PATIENTS AND METHODS

A total of 135 biopsy, and 16 surgical specimens obtained from 25 bile duct carcinomas were examined for: the thickness of the biopsy specimens and of the mucosa and combined mucosal-fibromuscular layers in the resected common bile ducts and common hepatic ducts; the presence of muscular and neural bundles in the biopsy specimens; the number of invasive carcinomas in the biopsy specimens that had been taken from stenosed regions; and the relation between intramural extension of invasive carcinoma and vascular dilatation.

RESULTS

The mean thickness of the biopsy specimens did not differ from the mean thickness of the mucosa in the resected specimens, but was significantly lower than that of the combined mucosa and fibromuscular layer. Muscular bundles were included in only 13 (14%) of the biopsy specimens, and there were no neural bundles. Carcinomas and invasive carcinomas were diagnosed histologically from the biopsy specimen in 96% and 91% of the cases, respectively. The sensitivity of a single biopsy for diagnosis for invasive carcinoma in stenosed regions was 62%, almost the same as the sensitivity in non-stenosed regions with vascular dilatation (68%). On histologic examination of 16 resected specimens, the sensitivity and specificity of vascular dilatation as a marker of the intramural extension of an invasive carcinoma were 39% and 100%, respectively, and this was significantly more common in invasive carcinomas that were invading the mucosa beyond the adventitia than in those limited to the adventitia.

CONCLUSION

Histologic examinations of specimens obtained by PTCS-guided biopsy can detect invasive carcinoma in only the superficial layers of the bile duct, such as the mucosa and the shallowest fibromuscular layer. Multiple specimens are needed for the diagnosis of invasive carcinoma because the sensitivity of examination of a single specimen for detecting invasive carcinoma is low. Vascular dilatation is characteristic of carcinoma that is invading the mucosa beyond the adventitia, so the diagnosis of intramural extension of bile duct carcinoma limited to the adventitia, particularly if it has spread to the deeper fibromuscular layer and the adventitia, is difficult to make by PTCS.

[Portal thrombosis, common bile duct varices and cholestasis]

A case of cholestasis in a young patient with portal cavernomatosis is reported. This clinical picture is very infrequent and appears as a consequence of extrinsic compression on the common bile duct due to which the derivative venous collaterals. There does not appear to be any relationship between the intensity of the morphologic alteration of the biliary tract and the level of portal hypertension and the degree of extrahepatic obstruction. Diagnosis was fundamentally achieved by arteriography and retrograde cholangiography with differential diagnosis with the previously mentioned diseases being required. Chronic cholestasis advises derivative surgery in which difficulties may be found due to the presence of thick collaterals in the hepatic pedicle as occurred in this patient.

Microangioarchitecture of the guinea pig common bile duct and duodenal papilla: a scanning electron and light microscopic study

BACKGROUND

The microvascular pattern of the duodenal papilla is unknown. Since the duodenal papilla is located in the transition zone between the stomach and duodenum, and because it regulates bile transfer into the duodenum, a particular microangioarchitecture can be expected. Therefore, we examined the microvasculature of the papilla using guinea pigs as a model.

METHODS

The microvascularization of the duodenal papilla and common bile duct was studied in 26 adult guinea pigs (Cavia porcellus), using scanning electron microscopy of microvascular corrosion casts and critical point dried specimens, and light microscopy of tissue sections.

RESULTS

The duodenal papilla is located in the cranial portion of the duodenum, approximately 5 mm beyond the pyloric valve. At the most luminal aspect of the cast papilla, ring-shaped capillaries, resembling those of the cast gastric mucosa, are present. Deeper parts of the papilla are provided with villi. Subepithelial capillaries of the papilla are 15 microns thick in average. These capillaries have a dual blood supply either via the straight long arterioles arising from the submucosa or by the pericryptal capillaries. The common bile duct comprises numerous mucoid glands with their pits surrounded by ring-shaped capillaries in corresponding casts.

CONCLUSIONS

The special arrangement of different capillary patterns, together with their luminal size and the dual blood supply, favor their protective role from the gastric chyme.

Circumferential choledochoplasties with autologous venous and arterial grafts

Circumferential choledochoplasties with vascular grafts have rarely been attempted either experimentally or in clinical practice. In this study, choledochoplasties using autologous venous and arterial grafts were performed in rats. Sixty-four rats were randomly selected into five treatment groups: A) venous interpositional graft replacement of a choledochus gap without a stent; B) venous graft with prolene stent; C) venous graft with polyethylene stent; D) arterial graft; E) a control group with simple resection between ligatures in the choledochus. The operative mortality in treatment groups B, C, D, and E, was 0, and 13% in group A. At 12 weeks follow-up, all the rats in group E had died, whereas, 52.2% (P < .05) of the rats in group A, 30% of the rats in group B, 57% of the rats in group C, and 92.8% of the rats in group D survived treatment. Surviving animals were sacrificed at 3 months for further examination. The morphology and caliber of the common bile duct of these rats were normal in 25% of the rats in group A, 33% of the rats in group B, 25% of the rats in group C, and 84.6% of the rats in group D. Proximal dilations were found in the rats presenting with abnormal morphology. The dilations were less marked in the group treated by arterial choledochoplasties. Laboratory and clinical cholestatic parameters were within normal ranges in the presence of common bile duct dilations less than four times the normal duct caliber.(ABSTRACT TRUNCATED AT 250 WORDS)

Pancreaticoduodenectomy. The importance of preserving hepatic blood flow to prevent biliary fistula

The arterial blood supply to the common bile duct must be preserved during pancreaticoduodenectomy to avoid ischemic breakdown of the biliary-enteric anastomosis. Interruption of this blood supply can occur during operation because of inadvertent division of the common hepatic artery or a hepatic artery variation. Approximately 17 per cent of patients have a hepatic artery variation that could contribute to devascularization of the common bile duct during surgical resection of the pancreatic head. This report discusses these hepatic artery variations and the value of angiography in defining hepatic arterial anatomy prior to surgery. Two cases are presented in which biliary-enteric anastomoses became ischemic and dehisced secondary to interruption of hepatic arterial blood flow.

[Peri-choledochal varices. (Report of a case)]

A case presentation of choledochal varices is published. Operative findings show extrahepatic portal hypertension, secondary to postoperative fibrosis and adhesions following cholecystectomy and choledochal stone extraction 15 and 3 years before this hospitalization.

Bile duct varices

The diagnosis of biliary duct varices and portal vein occlusion should be considered when nodular or notched defects in the wall of the biliary duct system are shown by cholangiography or when pedunculated vascular structures in the bile ducts are seen at surgery. We present two cases of common hepatic and common bile duct varices due to portal vein occlusion.

Post-traumatic ischemic necrosis of the common bile duct

A case of blunt injury to the extrahepatic bile ducts is reported. The injury was more likely caused by ischemia than by forces acting directly on the ducts. When disruption occurs at the time of injury, its recognition may be delayed considerably, because the leaked bile is encapsulated or remains sterile and is therefore well tolerated. When there is ischemia without disruption, as in the case presented, perforation due to necrosis may also take some time (days to weeks) to occur. In the interval, loss of appetite, nausea, vomiting, abdominal distension and jaundice may develop. Bile-stained ascitic fluid is present.

[Arterial circulation of the extrahepatic bile ducts]

The blood supply of the extrahepatic bile ducts was investigated in 15 human specimens. Human embryology explains the origin of the main blood supply in this area by the a. pancreaticoduodenalis posterior superior, the a. cystica and the a. hepatic propria. Other arteries are inconsistent and functionally unimportant. 2 or 3 marginal arteries are predominant in the arterial system surrounding the common bile duct. Surgery of the extrahepatic bile ducts should be performed with respect to this particular arterial network.

[Morphological aspect of the development of stenosis and suture insufficiency in the common bile duct after choledochotomy and biliary anastomoses]

The formation of stenosis following choledochotomy, common duct injury and repair can be observed frequently. A severe complication following a common duct repair, which can almost span a defect of about 3 cm, is the insufficient suture. An insufficient blood supply of the suture margins and a seam which is standing under tension are quoted as reasons for insufficient suture. The extra- and intramural distribution of arterial blood supply of the superior part of common bile duct is described. The results are based on preparations of 25 dissections and further 6 dissections following to another special arterial injection method. The "main-streets" of arterial blood supply of the common bile duct are described and hints are given to the surgeon, how to avoid stenosis or ischemic margins following anastomosis of the common duct.

Preduodenal portal vein: Two cases with differing presentation

Preduodenal or precholedochal veins are rare developmental anomalies of considerable surgical importance. Injury to these structures because of failure to recognize them during operations for unrelated diseases may result in thrombosis or hemorrhage. We recently encountered this anomaly twice, once in a newborn infant with duodenal obstruction and once in a 54-year-old woman undergoing cholecystectomy. The preduodenal vein was not the primary cause of obstruction in the infant, but injury to the previously unrecognized percholedochal vein in the woman resulted in a considerable loss of blood. Besides describing and illustrating these two cases, we also discuss the anatomy and the embryology of these structures and briefly review the patterns of 44 previously reported cases that we found.

Varices of the common bile duct as a surgical hazard

In the case of a 78-year-old woman with three common duct stones is reported. The most striking finding at operation, was extensive varices of the common duct. There was no evidence of varices elsewhere nor of an arteriovenous fistula. The varices are assumed to be idiopathic or a unique manifestation of a chronic cholangitic venous disorder. The situation, although unique, is readily recognized. Methods of management directed at avoiding intraoperative bleeding are suggested.

Infarction of the common bile duct in an infant after surfical exploration for jaundice: a possible cause of extrahepatic biliary atresia

An infant explored for obstructive jaundice died 6 days postoperatively and was found to have extensive infarction of the common duct. This would have gone undetected had the patient survived and without careful sampling at autopsy. The incidence of this unsuspected complication is unknown. Surgical infarction may be one cause of fibrosis and secondary atresia of the extra-hepatic bile ducts.