Cystic Duct

The so-called "Postcholecystectomy Syndrome" may be due to various pathological biliary causes. The aim of this study was to evaluate the significance of the cystic duct stump syndrome and if so, how often a long (greater than 1.5 cm) cystic duct stump was an indication for reoperation on the bile ducts after cholecystectomy in our patients. Three hundred and twenty two patients underwent a second operation on the bile ducts after cholecystectomy in the last ten years. In 35 patients (10.8%) a striking findings was a long cystic duct stump (greater than 1.5 cm). In 24 of these patients, a pathological finding, in addition to the long cystic duct stump, was found on exploration. Out of these 24 patients there were 14 with common bile duct stones; 6 with stenosis of the sphincter of Oddi; 3 with chronic pancreatitis and in one patient hepatitis was the cause of the symptoms. From the remaining 11 patients 8 had a stone in a partial gall bladder or cystic duct stump. One patient had a fistula between the cystic duct stump and duodenum and one a suture granuloma. There was only one patient where a 1.5 cm long cystic duct stump remnant was the only pathological finding. Four years after reoperation this patient is still suffering from the same intermittent gastrointestinal symptoms. We conclude that the cystic duct stump is hardly ever a cause for recurrent symptoms in itself. Total excision of the cystic duct does not eliminate the existence of postcholecystectomy symptoms.

BackgroundIt is not clear whether laparoscopic transcystic exploration (LTCE) laparoscopic choledochotomy (LCD) is superior in the management of choledocholithiasis. In this meta-analysis, the success of LTCE versus LCD was evaluated.MethodsCochrane Central Register of Controlled Trials, Web of Science, Trip, PubMed, Ovid and Embase databases were searched systematically for relevant literature up to May 2017. Studies that compared the success rate of LTCE and LCD in patients with choledocholithiasis were included. PRISMA guidelines were followed. Multiple independent reviewers contributed on a cloud-based platform. Random-effects model was used to calculate odds ratios (ORs) or standardized mean differences (MDs) with 95 per cent confidence intervals. An a priori hypothesis was generated based on clinical experience that LTCE is as successful as LCD.ResultsOf 3533 screened articles, 25 studies comprising 4224 patients were included. LTCE achieved a lower duct clearance rate than LCD (OR 0.38, 95 per cent c.i. 0·24 to 0·59). It was associated with a shorter duration of surgery (MD -0·86, 95 per cent c.i. -0·97 to -0·77), lower bile leak (OR 0·46, 0·23 to 0·93) and shorter hospital stay (MD -0·78, -1·14 to -0·42) than LCD. There was no statistically significant difference in conversion, stricture formation or reintervention rate.ConclusionLCD has a higher rate of successful duct clearance, but is associated with a longer duration of surgery and hospital stay, and a higher bile leak rate.

BackgroundEndoscopic transpapillary cannulation of the gallbladder is useful but challenging. This study aimed to investigate cystic duct anatomy patterns, which may guide cystic duct cannulation.MethodsA total of 226 patients who underwent endoscopic transpapillary cannulation of the gallbladder were analyzed retrospectively.ResultsAccording to the cystic duct take-off, 226 cystic duct patterns were divided into 3 patterns: Type I (193, 85.4%), located on the right and angled up; Type II (7, 3.1%), located on the right and angled down; and Type III (26, 11.5%), located on the left and angled up. Type I was further divided into three subtypes: Line type, S type (S1, not surrounding the common bile duct; S2, surrounding the common bile duct), and α type (α1, forward α; α2, reverse α). Types I and III cystic ducts were easier to be cannulated with a higher success rate (85.1 and 86.4%, respectively) compared with Type II cystic duct (75%) despite no statistically significant difference. The reasons for the failure of gallbladder cannulation included invisible cyst duct take-off, severe cyst duct stenosis, impacted stones in cyst duct or neck of the gallbladder, sharply angled cyst duct, and markedly dilated cyst duct with the tortuous valves of Heister.ConclusionClassification of cystic duct patterns was helpful in guiding endoscopic transpapillary gallbladder cannulation.

BackgroundLaparoscopic cholecystectomy (LC) is the gold-standard treatment for benign gallbladder disease but carries a higher risk of bile duct injury than the open approach, largely due to misidentification of critical hepatobiliary structures. This systematic review and meta-analysis synthesizes intraoperative evidence on the prevalence and surgical relevance of anatomical variations and evaluates their implications for safe LC.MethodsFollowing Evidence-based Anatomy and PRISMA 2020 guidelines, four databases were investigated. Random-effects meta-analyses estimated pooled prevalences and small-study effects were assessed.ResultsTwenty-seven studies (n = 9618) were included. Conventional cystic artery and duct (CA and CD) anatomy was observed in 86.15% and 89.02% of cases, respectively. Among arterial variants, duplicate CA (7.18%) and caterpillar hump of the right hepatic artery (6.26%) were the most common "third elements" entering the hepatocystic triangle. CA positional deviations included courses posterior (14.95%), anterior (10.75%), and inferior (6.23%) to the CD. Aberrant right hepatic duct entering the hepatocystic triangle was recorded in 1.03%.ConclusionsMost CA and CD variations relevant to LC occur within the hepatocystic triangle, where they can interfere with identification of the vascular-biliary pedicle and increase the risk of vasculo-biliary injury. Integrating these findings into the cognitive framework of the Critical View of Safety (CVS) highlights the importance of anticipating "third elements" and heterotopic courses when dissecting.