GB agenesis - Forum

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Re: GB agenesis - Ärzteforum

Post#31 »

It did stimulate me to look into my "old" Maingot's Abdominal Operations
(8th edition, 1985) and I think I found the figure(s) you were referring
to (both quoted Gross: Congenital anomalies of the gallbladder. Arch
Surg 32:131, 1936 (!)). Just a few pages before those figures (p1754 in
my edition, Figure 70-2) in the section on the normal anatomy of the
gallbladder "variations of the cystic duct" are shown (and by
coincidence the source is Schwartz, 4th ed. which I had quoted..). In
Fig. 70-2 G and H the cystic duct crosses the CHD and joins it
anteriorly or posteriorly (I agree that this is not the same as "left").
Yet in the 2nd source I had quoted to you (a standard book for operative
techniques in German speaking countries) the cystic duct does join from
the left side.

I think, the "crossing cystic duct" can often be missed
because it is kind of hidden in the fat of the hepatoduodenal ligament.
At least in the cases I remember I am not sure whether I would have seen
it correctly intraoperatively if I would not have had a preoperative
cholangiogram! I am sure that it has no clinical significance if the
"crossing cystic duct" is ligated and severed to the right of the CBD
unless a stone remains in the remaining cystic duct. But again I want
to thank you for this stimulus to refresh my "gallbladder anatomy"!


Re: GB agenesis - Ärzteforum

Post#32 »

As opposed to congenital anomalies, the anatomical variations,
are issued from a normal morphological development. The variations of
division of extra-hepatic biliary ducts are very frequent. They are clearly
explained by the sequence of embryological development.

The anatomical variation you are describing above is called " low
junction of the cystic duct" or "low insertion of cystic duct", it is not
uncommon and constitutes about 10% of the anatomical variations of the
extra-hepatic biliary ducts, I am sure all of us have seen it quite often.
In this anatomical variation the lower part of the cystic duct is always
included in the head of pancreas, joining the CHD from the left side just
above the pancreatic duct.

If we go back to the 7 mm embryo at 35 days of development, at
the junction of foregut and midgut, the future duodenum, two buds
originates from its endodermal lining, the dorsal pancreatic bud is located
to the left in the dorsal mesentery, and the ventral pancreatic bud to the
RIGHT which is closely related to the lower most part of bile duct, at this
stage the bile duct open anteriorly in the duodenum. The cystic duct joins
the bile duct from its RIGHT SIDE, if the junction was very low it will be
inside the ventral pancreatic bud just above the future pancreatic duct
(Wirsung) which also join the bile duct from the RIGHT side to form the
ampulla of Vater.

When the duodenum rotates to the right and becomes C-shaped, the
ventral pancreatic bud migrates dourly, 180 degree, to lie immediately
below and behind the dorsal pancreatic bud. The entrance of the bile duct
shifts from its initial anterior position to a posterior one, and
consequently the bile duct is found passing behind the duodenum. Any
structures joining THE LOWER MOST PART of bile duct from the right side
before rotation will be on the left side after rotation. These changes
occurs during the 6th week of development.

By the statement " I personally have never seen a cystic duct
opening on the left side of CBD" I mean the supraduodenal portion and not
the intrapancreatic part, as the later is explained, embryologically to
arise from the right side.

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Re: GB agenesis - Ärzteforum

Post#33 »

Doctor Green wrote:Here's a story: I failed that day to get pre-approval for colonoscopy for a 57 y/o F who had a 3-4 week history of change in bowel habits, being more constipated (never had a colon study in the past, heme negative!). They will approve sigmoidoscopy &/or barium enema (quite insulting).

I must agree that a tumor which causes changes in bowel habits should
be large enough to be reliably detected by Barium Enema and sigmoidoscopy.
Therefore I am quite happy with these two when these are the presenting

The colonoscopy is more sensitive, but the missed BE lesions are the small
cancers or polyps that present with anemia and occult or overt bleeding.
Or do you have contradictory data? I would be happy to see the reference,
perhaps we ought to change our practice.

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