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Trifurcation anomaly with ansa pancreatica: Coronal MRCP image showing trifurcation of biliary confluence (arrow) with ansa pancreatica variation as the duct of Santorini (arrowhead) forms a sigmoid curve as it courses to the duct of Wirsung
Source publication
Biliary anatomy and its common and uncommon variations are of considerable clinical significance when performing living donor transplantation, radiological interventions in hepatobiliary system, laparoscopic cholecystectomy, and liver resection (hepatectomy, segmentectomy). Because of increasing trend found in the number of liver transplant surgeri...
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The purpose of this article was to review the literature on hepatobiliary anatomy evaluation using different imaging modalities and opt for the best suitable imaging technique to show a specified part of the hepatobiliary system. For this article, the best suitable literature was searched using PubMed database and reviewed. This article describes m...
Objective
The celiac trunk normally has three branches; i.e. the left gastric, splenic, and common hepatic artery. It is known that the right hepatic artery occasionally branches from the superior mesenteric artery, while the cystic artery arising from the superior mesenteric artery is extremely rare. A deeper understanding of cystic arterial varia...
This report describes the concurrent vascular and ductal variations of the hepatobiliary system. The right hepatic artery arose directly from the common hepatic artery, passed through the Calot’s triangle and entered the right lobe of the liver through the gall bladder fossa. The left hepatic artery arose from a common gastrohepatic trunk and enter...
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Citations
... Isolated segmental branches draining to the cystic or right hepatic ducts, isolated segmental ducts draining to the left or right hepatic duct, and complex biliary variations were a few examples [5]. Furthermore, it was crucial to evaluate variant biliary tree systems that are frequently associated with variations in the portal vein in order to lower the risk of iatrogenic insults [16]. ...
Background
For patients with end-stage liver disease, liver transplantation is considered the chief curative option. Radiological imaging has a pivotal role in evaluating both donors and recipients before and after transplantation. So the purpose of our study is to assess anatomical variant of intra-hepatic bile duct variation among liver transplant donors by MRCP and its implication in liver transplantation. Retrospective study was carried out in Mansoura University Hospitals over period from January 2019 till June 2022. Study included 64 liver transplant donors aged from 21 to 46 years old. All subjects underwent MRCP. Analysis of data obtained from images as well as reconstruction was performed to get images of bile ducts with a maximum intensity projection and volume rendering.
Results
Our study included 64 liver transplant donors. Donor mean age was 29.8 ± 2.57 years with range between 20 and 38 years. There were 40 males (62.5%) and 24 females (37.5%). Regarding right posterior hepatic duct drainage based on Huang classification, the type of bile duct variant was classified as follows: The most common variant was type A1 in 50% of the donors followed by type A4 in 20.3% then type A2 and type A3 in 14.1% each. The distance between RPHD insertion and junction between the right and left hepatic ducts (L) owns a surgical importance as it may need modification of surgical technique if L was more than 1 cm. So according to karakas classification, we had to subtype Huang A1 cases into K1 subtype (L > 1 cm) and K2a subtype (L ≤ 1 cm). Our subjects were 20 with K1 subtype (31.25%) and 12 with K2a subtype (18.75%).
Conclusions
Assessment of anatomical variation of right hepatic duct in liver transplant donor by non-invasive method as MRCP had a fundamental role to obtain successful surgical outcome and also to reduce hepatobiliary surgical complications.
... In some cases, a trifurcation branching pattern is observed, with right posterior sectoral duct (RPSD) directly emptying into the confluence. 13 Maintain clockwise torque and follow the CHD. On maintaining clockwise torque and pushing down echoendoscope large hypoechoic lesion was seen in HOP in this case. ...
... 9A-C). 13 Low insertion of cystic duct is considered when it joins with the CBD in the HOP, which is observed in 10% of the population. 13 Knowledge of the cystic duct insertion location is vital for choosing self-expandable metallic stents and the route of EUS-guided biliary drainage. ...
... 13 Low insertion of cystic duct is considered when it joins with the CBD in the HOP, which is observed in 10% of the population. 13 Knowledge of the cystic duct insertion location is vital for choosing self-expandable metallic stents and the route of EUS-guided biliary drainage. ...
Endoscopic ultrasound (EUS) examination of the biliary system plays pivotal role in pancreatobiliary studies. EUS offers a safe and noninvasive method of the biliary tract disorder evaluation. Although radial EUS provides a straightforward orientation, practicing biliary system examination with a curvilinear echoendoscope is advisable because of its added therapeutic benefits. Linear EUS may pose challenge in understanding the orientation and tracing nondilated bile duct in the beginning. However, adopting a systematic station-wise approach can help in comprehending the orientation and effectively tracing the entire bile duct. In this review, we have discussed linear EUS examination of the bile duct and gallbladder from various stations and its clinical applications.
... 9 Identification of accessory ducts is essential for liver resections and biliary drainage. [20][21][22][23] Unmentioned accessory ducts may be a source of biliary leakage or cholangitis. The basis for our proposed classification is the number of ducts joining the CHD. ...
Purpose:
To propose a novel, inclusive classification that facilitates the selection of the appropriate donor and surgical technique in living-donor liver transplantation (LDLT).
Methods:
The magnetic resonance cholangiography examinations of 201 healthy liver donors were retrospectively evaluated. The study group was classified according to the proposed classification. The findings were compared with the surgical technique used in 93 patients who underwent transplantation. The Couinaud, Huang, Karakas, Choi, and Ohkubo classifications were also applied to all cases.
Results:
There were 118 right-lobe donors (58.7%) and 83 left-lateral-segment donors (41.3%). Fifty-six (28.8%) of the cases were classified as type 1, 136 (67.7%) as type 2, and 7 (3.5%) as type 3 in the proposed classification; all cases could be classified. The number of individuals able to become liver donors was 93. A total of 36 cases were type 1, 56 were type 2, and 1 was type 3. Of the type 1 donors, 83% required single anastomosis during transplantation, whereas six patients classified as type 1 required two anastomoses, all of which were caused by technical challenges during resection. Moreover, 51.8% of the cases classified as type 2 required additional anastomosis during transplantation. The type 3 patient required three anastomoses. The type 1 and type 2 donors required a different number of anastomoses (P < 0.001).
Conclusion:
The proposed classification in this study includes all anatomical variations. This inclusive classification accurately predicts the surgical technique for LDLT.
... The variations that occur in cystic duct could represent its number, length, course and point of insertion to the extra hepatic biliary tree. 2,6,10 MRCP is the best noninvasive imaging modality in detecting the anatomy of the non-dilated cystic duct compared to USS and CT without IV cholangiographic contrast media. 1,2,4 MRCP can provide coronal images with higher resolution, and angle of image acquisition oriented along the long axis of cystic duct provides best demonstration of the cystic duct. ...
Background and objectives- Anatomical variants of the cystic duct (CD) are important be identified and described in the radiological report. This facilitates proper interpretation of the pathological process related to the biliary tree. Also, prior information is important before surgical, percutaneous and endoscopic interventional procedures related to the biliary tree, to avoid inadvertent complications and for successful outcomes. Magnetic Resonance Cholangiopancreatography (MRCP)is the best non-invasive imaging modality in detecting anatomy of the non-dilated cystic duct. This study was carried out to demonstrate imaging appearance of the cystic duct and its anatomical variants detected on MRCP and to document their prevalence in the study group. Methods- This is a single centre retrospective cross-sectional study including all consecutive patients who underwent MRCP form May 2020 to May 2021 at the neurosurgical MRI unit at National Hospital of Sri Lanka. Patients who had undergone cholecystectomies and images with poor quality were excluded.Results- Total 180 MRCP studies were analysed. Normally inserting CD to the lateral aspect of the Common Hepatic Duct (CHD) was observed in 127cases out of 180 (70.5%). 10(5.5%) demonstrated high inserting CD.12(6.6%) cases demonstrated low inserting CD.3(1.6%) had short CD. Parallel course of CD was noted in 12(6.6%). Low and medially inserting CD was present in 4(2.2%) cases. Anterior insertion was demonstrated in 5(2.7%) cases, and posterior insertion was demonstrated in 7(3.8%). Conclusion- Anatomical variants of the CD observed in our study group were comparable to reported frequencies, however posterior insertion was lesser than that found in literature.
... Many studies have examined the anatomy of the biliary tract using MRCP, and these studies mainly included preoperative and postoperative evaluations and were mostly based on preoperative planning and postoperative complications. Studies advocate the necessity of MRCP for preoperative planning (13)(14)(15) Therefore, it is important to examine the anatomic type and variations in the biliary tract as a cause of stone and/or cholecystitis. One of the most important studies on this subject was that by Sipahi et al. ...
Aim: The development of gallstones and stone-induced inflammatory processes depends on several biological factors. Knowledge of the predisposing factors for both the development of stones and their inflammation is important in predicting, monitoring, and treating the disease and subsequent complications. This study aimed to determine whether the length of the cystic duct (CD) and the level and direction of its junction with the common hepatic duct (CHD) are associated with cholecystitis and cholelithiasis. Material-Method : This retrospective study included 172 patients who underwent MRCP between January 2017 and December 2020. A 1.5 Tesla MR device (Signa HDI, General Electric, Milwaukee, WI, USA) was used with an HD 8-channel body array coil. The findings were analyzed using SPSS version 23 software. Results: The level at which the cystic duct (CD) joined the common hepatic duct (CHD) was not significantly correlated with the development of calculi or cholecystitis (p >0.05). The side of the CD joining the CHD was not significantly correlated with the development of calculi or cholecystitis (p>0.05). Of the 27(15.7%) patients with CD length less than 2 cm, 3(1.7%) had only stones, 8(4.7%) had cholecystitis, and 16(9.3%) were normal. Of the 88(51.2%) cases with a length between 2 and 4 cm, 43(25%) had only calculi, 19(11%) had cholecystitis with calculi, and 26(115.1%) were normal. Of the 57(33.1%) patients with cystic ducts longer than 4 cm, 31(18%) had only stones, 16(9.3%) had cholecystitis, and 10(5.8%) were normal, and the frequency of stones and cholestasis increased with increasing CD length (p
... Unconventional biliary anatomy is encountered in less than half of patients. It is mostly related to the intrahepatic biliary system [1]. However, duplication of the extrahepatic bile duct (EBD) is one of the rare biliary variations reported uncommonly. ...
Congenital duplication of the extrahepatic bile duct (DEBD) is an unusual anomaly of the biliary system. It occurs due to inability of the embryological duplex biliary system to regress. DEBD has various subtypes depending on the morphology and opening of the aberrant common bile duct. It can have distinct complications. We encountered a 38-year-old lady who experienced pain in the right upper abdomen along with a low-grade fever. Magnetic resonance cholangiopancreatography revealed DEBD with multiple calculi in the right hepatic duct (ductolithiasis) and joining of the right hepatic duct with the left hepatic duct in the intrapancreatic region. Endoscopic retrograde cholangiography failed to clear the calculi from the right duct. They were then managed by common bile duct exploration and roux-en-Y right hepaticojejunostomy for biliary drainage. Her postoperative period was uneventful. She is currently doing well after three months of follow-up. Hence, a proper preoperative delineation of such rare anomalies is essential. It could avoid inadvertent injury to the bile duct and operative complications.
... Biliary complications are one of the major causes of morbidity in these living donor liver transplantations. Preoperative evaluation of prospective liver donors for variants in the biliary anatomy is the key to minimizing major biliary complications following surgery [1][2][3][4]. Magnetic resonance cholangiopancreatography (MRCP) is the non-invasive imaging modality of choice to evaluate the biliary system and pancreatic duct. In recent days, MRCP has gained wide acceptance as the most reliable alternate modality to intraoperative cholangiography for clearly demonstrating the biliary system [5][6][7]. ...
Objective
Biliary anatomy is of paramount importance for hepatobiliary pancreatic surgeons for operative planning. Preoperative assessment with magnetic resonance cholangiopancreatography (MRCP) to evaluate the biliary anatomy plays a vital role, especially for prospective liver donors in living donor liver transplantation (LDLT). Our objective was to evaluate the diagnostic accuracy of MRCP in assessing the anatomical variations of the biliary system and the frequency of biliary variation in the donors of LDLT.
Materials and Methods
Sixty-five donors of living donor liver transplantation in the age range of 20 to 51 years were studied retrospectively to evaluate the anatomical variations of the biliary tree. As a part of the pre-transplantation donor workup, MRI with MRCP was performed in a 1.5T machine for all these candidates. MRCP source data sets were processed with maximum intensity projections, surface shading, and multi-planar reconstructions. Images were reviewed by two radiologists, and the classification system of Huang et al. was utilized to evaluate the biliary anatomy. The results were compared with the intraoperative cholangiogram, considered the gold standard.
Results
We identified standard biliary anatomy in 34 candidates (52.3%), and variant biliary anatomy was observed in 31 candidates (47.7%) on MRCP. An intraoperative cholangiogram showed standard anatomy in 36 candidates (55.4%) and biliary variation in 29 candidates (44.6%). Our study showed a sensitivity of 100% and a specificity of 94.5% for identifying biliary variant anatomy on MRCP in comparison with the gold standard intraoperative cholangiogram. The accuracy of MRCP in detecting the variant biliary anatomy in our study was 96.9%. The most common biliary variation was the right posterior sectoral duct draining into the left hepatic duct, Huang type A3.
Conclusion
The frequency of biliary variations is high in potential liver donors. MRCP is sensitive and highly accurate in identifying the biliary variations of surgical significance.
... It was reported that there were about 10% of humans with anomalous biliary tracts (1-3). The biliary ducts that communicating between the liver and the gallbladder was one kind of anomalous biliary tract, which was firstly reported by Luschka, and was named as cystohepatic duct subsequently (4)(5)(6)(7). ...
Cholestasis and obstructive jaundice can be extrahepatic or intrahepatic. Here we present one case with calculous cholecystitis who presenting with repeated obstructive jaundice and without bile duct dilation. The patient received laparoscopic cholecystectomy, and cystohepatic duct was identified intraoperatively, there was no cholestasis or obstructive jaundice postoperatively. Cystohepatic duct is a rare biliary anomaly observed in 0.7% of all surgical cases and in 1.5% of all cadaveric dissections. The cystohepatic duct can be the bridge of calculous cholecystitis complicating cholangitis and obstructive jaundice, here we for the first time presented this entity.
... Further, the lower end of cystic duct joins the right margin of common hepatic duct at an acute angle to form common bile duct (also known as Choledochal duct). The cystic duct usually measures 20 to 40 mm in length and the diameter of the cystic duct ranging from 1 to 5 mm [47,52,55]. Likewise, the length and diameter of CBD is generally varying between, 60 to 80 mm. ...
... The union can be right lateral, anterior spiral, posterior spiral, proximal, distal medial, distal lateral, or into the right hepatic duct. Based on this view, it has been classified [52]. This article attempts to review the existing literature on the variations of extrahepatic part of biliary tree to comprehend the possible cause and risk of post-operative complications of this region. ...
... This pattern has been classified in different ways by various authors [6,9,23,47,52]. Cao et al., 2019 gave a slightly unique classification in which the cystic duct represented three types of patterns (Type I-right and angled up, Type II-right and angled down, Type III-angled up and left) [9]. Type I pattern was found to have great variation and could be further divided into three subtypes based on their mode of insertion: linear type, s type (s1, not surrounding common bile duct; s2, surrounding common bile duct), and α type (α1, forward α; α2, reverse α) by doing retrospective analysis of endoscopic trans papillary cannulation of the gallbladder. ...
The morphometry and morphology of the components of extrahepatic biliary tree show extensive variations. A beforehand recognition of these variations is very crucial to prevent unintended complications while performing surgeries in this region. This study was conducted to analyze the configuration of the extrahepatic biliary tree and its possible variations, as well as measure the components that limit the cystohepatic triangle. Articles were searched in major online indexed databases (Medline and PubMed, Scopus, Embase, CINAHL Plus, Web of Science and Google Scholar) using relevant key words. A total of 73 articles matched the search criteria of which 55 articles were identified for data extraction. The length of left and right hepatic duct in majority of studies was found to be >10 mm. A wide range of diameters of hepatic ducts were observed between 5-43 mm. The average length of cystic duct is around 20 mm. The length and diameter of the common bile duct are 50-150 mm and 3-9 mm respectively. The most frequently observed pattern of insertion of cystic duct into common hepatic duct is right lateral, rarely anterior, or posterior spiral insertion can present. The results of this study will provide a standard reference range which instead will help to differentiate the normal and pathological conditions.
... There was a low entry (distal 1/3rd of the BD) in 20% and an abnormally high fusion with the hepatic duct (proximal 1/3rd of the BD) in 29% of our cases, a higher incidence than reported in the literature F I G U R E 6 Schematic representation showing: (a) horizontal section of the bile duct depicting the site of the cystic duct/ bile duct union (cystic duct orifice); (b) extrahepatic biliary apparatus depicting the level of emergence of the cystic duct from the bile duct (5.4%-14% and 2.2%-5.5%, respectively) (Flint, 1923;Onder et al., 2013;Shaw et al., 1993;Sureka et al., 2016;Taourel et al., 1996;Tsitouridis et al., 2007;Uetsuji et al., 1993). Very rarely, the cystic duct inserts directly into the duodenum. ...
... In our cohort it was between 0.3 and 4.7 cm in length (average 2.97 cm), within the range reported by other authors (Turner & Fulcher, 2001); ≥2 cm in 41% of our cases. Long ducts have been associated with a predisposition to stone formation, Mirizzi's syndrome, and pancreatitis (Flint, 1923;Sureka et al., 2016). Deenitchin et al. (1998) found that a longer and narrower cystic duct was strongly correlated with the presence of gallstones. ...
The aims of this article are to detail the anatomy of the cystic duct in patients with and without gallstones as it relates to maneuvering of the duct during endoscopic transpapillary gallbladder cannulation, and to elucidate its role in the dynamics of bile flow during gallbladder contraction. One hundred MRCPs were retrieved from the prospectively maintained radiology data system to assess the configuration of the cystic duct and its confluence vis‐a‐vis the main biliary duct. The configuration of the cystic duct was broadly classified into four types: Angular (44%), Linear (40%), Spiral (11%), and Complex (5%). The level of emergence of the cystic duct from the bile duct was proximal in 29%, middle in 49% and distal in 20%. Its direction from the bile duct was to the right and angled upward in 69%, right and angled downward in 15%, left and angled upward in 13%, and left and angled downward in 1%. Its orifice was on the lateral surface of the bile duct in 50%, posterior in 19%, anterior in 15% and medial in 14%. In two cases, the cystic duct opened directly into the duodenum. Tortuous cystic ducts and non‐lateral unions with the bile duct were significantly more prevalent in gallstone cases than the non‐gallstone group (p = 0.02). The present study details the spatial anatomy of the cystic duct vis a vis the main biliary duct. This has not been well investigated to date but has become increasingly relevant with the advent of recent gallbladder interventions.
