A New Quantitative Classification of the Extrahepatic Biliary Tract Related to Cystic Duct Implantation

Renzulli, Matteo; Brocchi, Stefano; Marasco, Giovanni; Spinelli, Daniele; Balacchi, Caterina; Barakat, Massimo; Pettinari, Irene; Golfieri, Rita

doi:10.1007/s11605-020-04852-8

Cited by 9 publications

(4 citation statements)

References 26 publications

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“…An understanding of the anatomy of the biliary tree and its main variations is essential for many reasons, such as providing precise pre‐operative information for surgeons in order to reduce the rate of procedure‐related complications (Farias et al, 2013; Naeem et al, 2020; Sureka et al, 2016). Moreover, accurate knowledge of the biliary system is also required for radiologists since its variations can be associated with biliary tract pathologies and both staging and localization of intrahepatic liver neoplasms and bile duct tumours are based on its segmental anatomy (Medisoglu et al, 2021; Mortelé & Ros, 2001; Mosconi, Solaini, et al, 2021; Renzulli, Brocchi, et al, 2021).…”

Section: Discussionmentioning

confidence: 99%

“…CHD plus CBD). Subsequently, these data were used to calculate the CDDP/EHBD ratio and to provide the extra‐hepatic bile duct classification, according to both qualitative “conventional” classification (defined as low, middle and high implants) (Fujimoto et al, 2020; Mortelé et al, 2006; Turner & Fulcher, 2001) and the new proposed quantitative classification (Renzulli, Brocchi, et al, 2021). In particular, according to the new proposed quantitative classification, the EHBD was classified as type 1 (below the 25th percentile, when the CDDP/EHBD ratio is ≤50%), type 2 (between the 25th and 75th percentile, when the CDDP/EHBD ratio is >50% but ≤75%) and type 3 (above the 75th percentile, when the CDDP/EHBD ratio is >75%) (Figure 2b).…”

Section: Methodsmentioning

confidence: 99%

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Association between anatomic variations of extrahepatic and intrahepatic bile ducts: Do look up!

et al. 2023

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Biliary anatomic variations are usually asymptomatic, but they may cause problems in diagnostic investigations and interventional and surgical procedures, increasing both their technical difficulty and their postoperative complication rates. The aim of the present study was to evaluate the prevalence of anatomic variations in the intrahepatic biliary ducts (IHBD) in relation to demographical and clinical characteristics in a large study population requiring magnetic resonance cholangiopancreatography (MRCP) for various clinical conditions. The possible association between IHBD and extrahepatic biliary ducts (EHBD) variants was then explored. From January 2017 to May 2019, 1004 patients underwent MRCP. Demographical and clinical data were collected. IHBD and EHBD anatomy were recorded and the EHBD anatomy was classified using both qualitative and quantitative classifications. The presence of a type 3 EHBD variant (an abnormal proximal cystic duct [CD] insertion) in both qualitative and quantitative classifications and an intrapancreatic CD were associated with the presence of IHBD variants at univariate analysis (p = 0.008, p = 0.019, and p = 0.001, respectively). The presence of a posterior or medial insertion of the CD into the EHBD was a strong predictive factor of the presence of IHBD variants both at uni-and multivariate analysis (p = 0.002 and p = 0.003 for posterior insertion and p = 0.002 and p = 0.002 for medial insertion, respectively). The presence of gallstones on MRCP resulted in a strong predictor of the presence of an anatomical variant of the IHBD both at uni-and multivariate analysis (p = 0.027 and p = 0.046, respectively). In conclusion, the presence of a type 3 variant of the EHBD, an intrapancreatic CD and, especially, a posterior/medial CD insertion into the EHBD represent predictive factors of the concomitant presence of IHBD variants, thus radiologists must be vigilant when encountering these EHBD configurations and always remember to "look up" at the IHBD.Finally, the presence of an IHBD variant is a strong predictive factor of gallstones.

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Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Association between anatomic variations of extrahepatic and intrahepatic bile ducts: Do look up!

et al. 2023

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“…A recent study has found an association between intrapancreatic low insertion cystic duct and choledocholithiasis [16]. However, a plausible underlying mechanism for how low insertion may trigger stone formation in the common bile duct was not provided.…”

Section: Choledocholithiasismentioning

confidence: 98%

Anatomical variations of cystic duct insertion and their relationship with choledocholithiasis: an MRCP study

Gündüz

Doğan²,

Alacagöz³

et al. 2021

Egypt J Radiol Nucl Med

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Background The frequency of insertion variations of cystic duct (CD) is inconsistent between studies caused to some extent by the way they give the relative frequency of the variations. Moreover, certain insertion variations have been reported to be associated with choledocholithiasis. This study aimed to assess the frequency of CD insertion variations with a comprehensive way of classification in an unselected population in whom MRCP was performed. Moreover, the relationship between the types of variant insertions and choledocholithiasis using MRCP was also assessed. Patients undergoing magnetic resonance cholangiopancreatography (MRCP) were reviewed retrospectively by two radiologists who were blinded to the clinical data. The normal insertion was defined as the union through middle one third of the lateral border of the extrahepatic bile duct. The transverse site (lateral, medial, anterior, and posterior) and the craniocaudal level (high, mid and low) of insertions and their intersections were assessed using axial and coronal slices, respectively. In addition, the frequencies of the CD insertion variations were compared between choledocholithiasis and control (no-choledocholithiasis) groups. Results A total of 307 patients (124 with choledocholithiasis and 183 controls) were analyzed. A true variant insertion was found in 149 (48.5%) cases. The insertion variations were less frequent in the choledocholithiasis group [50 (40.3%) vs. 99 (54.1%), respectively, p = 0.018]. The frequencies of craniocaudal level of insertion differed significantly between groups (p = 0.014) that was driven by a lower rate of low medial insertion (1.6% vs. 9.8%, respectively) in the choledocholithiasis group. The frequencies of transverse site of insertion were similar between groups (p = 0.314). The low medial insertion was 80.7% less likely associated with choledocholithiasis even after adjustment for age (Odds ratio: 0.193, 95% Confidence interval: 0.039–0.954, p = 0.044). The interreader agreement for insertion assessment was good (Cohen’s Kappa: 0.748, p < 0.001). Conclusions The prevalence of CD insertion variations in an unselected population undergoing MRCP is quite high and a mid-posterior insertion is the most common variant type. Insertion variations of CD, the low medial insertion in particular, are less common in patients with choledocholithiasis than controls.

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“…For example, a low union of the CD has previously been associated with a higher risk of pancreatitis and even periampullary cancer and this association was ascribed to an anatomy-induced pressure process leading to chemical/bilious irritation [2]; this association is probably supported also by the shorter and lesser exposure of the biliary epithelium to the protective or dilutional effect of peri-biliary mucus glands in the upper biliary tree which happens in the presence of a low union [1]. In addition, previous studies have found an association between low insertion of the CD and choledocholithiasis [10] which can be due to increased retrograde pressure in the CD leading to both bile stagnation and impaired gallbladder emptying. In the present case, however, no calculi were detected on both US and MRCP.…”

Section: Main Textmentioning

confidence: 96%

An exceedingly rare case of separated drainage of the cystic duct, the common bile duct and the main pancreatic duct documented on magnetic resonance cholangiopancreatography

Brandi

Fiscaletti²,

Renzulli

2023

Preprint

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Anatomical variations of the intra- and extra-hepatic biliary system are common, including those affecting the course and insertion point of the cystic duct. Adequate knowledge of such variations and an appropriate roadmap before any surgical, endoscopic or percutaneous procedure help in preventing associated iatrogenic complications. Magnetic resonance cholangiopancreatography (MRCP) can precisely delineate the anatomy of the biliary system preoperatively. We report the case of a 72-year-old female patient who presented with chronic right upper quadrant abdominal pain of 6 months duration, which had acutely worsened over the previous 2 weeks, and no other comorbidities. Blood tests were normal. Abdominal ultrasound revealed a slight dilatation of the common hepatic duct (10 mm) but no gallstones or sludge were demonstrated. MRCP excluded choledocholithiasis but revealed a cystic duct coursing medial to the common bile duct before anastomosing at the level of the ampulla of Vater. Trifurcation (Type 2 variant) of the intra-hepatic bile system was also observed. To the best of the Authors’ knowledge, this is the very first report of this exceptionally rare anatomic cystic duct anomaly on MRCP.

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A New Quantitative Classification of the Extrahepatic Biliary Tract Related to Cystic Duct Implantation

Cited by 9 publications

References 26 publications

Association between anatomic variations of extrahepatic and intrahepatic bile ducts: Do look up!

Association between anatomic variations of extrahepatic and intrahepatic bile ducts: Do look up!

Anatomical variations of cystic duct insertion and their relationship with choledocholithiasis: an MRCP study

An exceedingly rare case of separated drainage of the cystic duct, the common bile duct and the main pancreatic duct documented on magnetic resonance cholangiopancreatography

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