J Korean Soc Radiol.  2010 Jan;62(1):41-46. 10.3348/jksr.2010.62.1.41.

Distribution of the Insertion Site of the Cystic Duct: CT Analysis

• Kim SY
• Shin HC
• Kim IY
• Kim SW
• Lee HK
• Choi GC
• Kim HC

• KMID: 2208993
• DOI: http://doi.org/10.3348/jksr.2010.62.1.41

Abstract

PURPOSE
To provide immediate information on the anatomic position of the cystic duct for surgical candidates with biliary disease, we evaluate the insertion site of the cystic duct into the common bile duct by using computed tomography (CT).
MATERIALS AND METHODS
Axial CT images of 126 patients with biliary disease were reviewed by measuring the insertion angle between the dilated cystic duct and common bile duct. The insertion site of the cystic duct was located posterior to the horizontal line crossing the center of the common bile duct, i.e., the posterior insertion, in 115 patients (91.3%). Considering the negligible frequency of the anterior insertion (8.7%), we finally analyzed the patients with posterior insertion by subdividing the insertion angle at an interval of 20degrees.
RESULTS
In total, 11 and 115 patients show the anterior and posterior insertion, respectively. The patient distribution with the posterior insertion was 1 (0degrees-20degrees), 7 (20degrees-40degrees), 26 (40degrees-60degrees), 43 (60degrees-80degrees), 15 (80degrees-100degrees), 7 (100degrees-120degrees), 8 (120degrees-140degrees), 5 (140degrees-160degrees), and 3 (160degrees-180degrees). The mean insertion angle was 77.4degrees.
CONCLUSION
We designed the method to readily evaluate the insertion site of the cystic duct at CT. Accordingly, the cystic duct sites were predominantly located posterior to the common bile duct, and most of them ranged from 40degrees to 100degrees.

MeSH Terms

Common Bile Duct
Cystic Duct
Humans
Tomography, X-Ray Computed

Figure

• 

  Fig. 1 Diagram of the measurement method of the insertion angle between the cystic duct and common bile duct. The insertion angle indicates the angle between the horizontal line crossing the center of the common bile duct and the line perpendicular to the tangent line crossing the point where the cystic duct and the common bile duct most closely attached. In cases of the posterior insertion, the insertion angle increases from 0°to 180°counter-clockwise. A. This diagram shows the posterior insertion case with right posterolateral insertion site of the cystic duct and the insertion angle of 60°. B. This diagram shows the posterior insertion case with left posterolateral insertion site of the cystic duct and the insertion angle of 120°.

• 

  Fig. 2 CT images which show various insertion site of cystic duct. A. Axial CT scan shows the right anterolateral insertion site of cystic duct (straight arrow) with the insertion angle of -71.5° (curved arrow) in 67-year-old man with pancreatic cancer. B. Axial CT scan shows the right posterolateral insertion site of cystic duct (straight arrow) with the insertion angle of 53.8°(curved arrow) in 50-year-old woman with intrahepatic stone disease. C. Axial CT scan shows the left posterolateral insertion site of cystic duct (straight arrow) with the insertion angle of 115.1° (curved arrow) in 47-year-old woman with gallstone.

• 

  Fig. 3 A pie chart shows the percentage and number of persons (parenthesis) according to insertion angle of patients with posterior insertion.

Reference

1. Turner MA, Fulcher AS. The cystic duct: normal anatomy and disease processes. Radiographics. 2001; 21:3–22.

2. Friedman AC, Sachs L. Embryology, anatomy, histology and radiologic anatomy. In : Friedman AC, editor. Radiology of the liver, biliary tract, pancreas and spleen. Baltimore, Md: Williams & Wilkins;1987. p. 305–332.

3. Shaw MJ, Dorsher PJ, Vennes JA. Cystic duct anatomy: an endoscopic perspective. Am J Gastroenterol. 1993; 88:2102–2106.

4. Zeman PK, Burrell MI. Gallbladder and bile duct imaging. New York, NY: Churchill-Livingstone;1987. p. 36–46.

5. Hopkins SF, Bivins BA, Griffen WO Jr. The problem of the cystic duct remnant. Surg Gynecol Obstet. 1979; 148:531–533.

6. Puente SG, Bannura GC. Radiological anatomy of the biliary tract: variations and congenital abnormalities. World J Surg. 1983; 7:271–276.

7. Baron RL. Computed tomography of the bile ducts. Semin Roentgenol. 1997; 32:172–187.

8. Barish MA, Soto JA. MR cholangiopancreatography: techniques and clinical applications. AJR Am J Roentgenol. 1997; 169:1295–1303.

9. Fulcher AS, Turner MA, Capps GW, Zfass AM, Baker KM. Half-Fourier RARE MR cholangiopancreatography: experience in 300 subjects. Radiology. 1998; 207:21–32.

10. Fulcher AS, Turner MA. Pitfalls of MR cholangiopancreatography (MRCP). J Comput Assist Tomogr. 1998; 22:845–850.

11. Taourel P, Bret PM, Reinhold C, Borkun AN, Atri M. Anatomic variants of the biliary tree: diagnosis with MR cholangiopancreatography. Radiology. 1996; 199:521–527.

12. Hayes MA, Goldenberg IS, Bishop CC. The developmental basis for bile duct anomalies. Surg Gynecol Obstet. 1958; 107:447–456.

13. Ghahremani GG. Post-surgical biliary tract complications. Gastroenterologist. 1997; 5:46–57.

14. Ghahremani GG, Crampton AR, Bernstein JR, Caprini JA. Iatrogenic biliary tract complications: radiologic features and clinical significance. Radiographics. 1991; 11:441–456.

15. Toyota N, Takada T, Amano H, Yoshida M, Miura F, Wada K. Endoscopic naso-gallbladder drainage in the treatment of acute cholecystitis: alleviates inflammation and fixes operator's aim during early laparoscopic cholecystectomy. J Hepatobiliary Pancreat Surg. 2006; 13:80–85.

16. Sugiyama M, Tokuhara M, Atomi Y. Is percutaneous cholecystostomy the optimal treatment for acute cholecystitis in the very elderly? World J Surg. 1998; 22:459–463.

17. Akhan O, Akinci D, Ozmen MN. Percutaneous cholecystostomy. Eur J Radiol. 2002; 43:229–236.

18. Ito K, Fujita N, Noda Y, Kobayashi G, Kimura K, Sugawara T. Percutaneous cholecystostomy versus gallbladder aspiration for acute cholecystitis: a prospective randomized controlled trial. AJR Am J Roentgenol. 2004; 183:193–196.

19. Zhou PH, Liu FL, Yao LO, Oin XY. Endoscopic diagnosis and treatment of post-cholecystectomy syndrome. Hepatobiliary Pancreat Dis Int. 2003; 2:117–120.

20. Zhou PH, Yao LO, Zhang YO, Gao WD, He GJ, Xu MD, et al. Endoscopic biliary drainage for biliary obstruction. Hepatobiliary Pancreat Dis Int. 2003; 2:598–601.

21. Kozarek RA. Selective cannulation of the cystic duct at time of ERCP. J Clin Gastroenterol. 1984; 6:37–40.

22. Foerster EC, Auth J, Runge U, Ell C, Kerzel W, Domschke W. ERCG: endoscopic retrograde catheterization of the gallbladder. Endoscopy. 1988; 20:30–32.

23. Tamada K, Seki H, Sato K, Kano T, Suqivanma S, Ichivama M, et al. Efficacy of endoscopic retrograde cholecystoendoprosthesis (ERCCE) for cholecystitis. Endoscopy. 1991; 23:2–3.

24. Johlin FC Jr, Neil GA. Drainage of the gallbladder in patients with acute acalculous cholecystitis by transpapillary endoscopic cholecystotomy. Gastrointest Endosc. 1993; 39:645–651.

25. Lai EC. Current status of therapeutic endoscopy in hepatobiliary and pancreatic surgery. Chin Med J (Engl). 1997; 110:438–443.

26. Brodish RJ, Fink AS. ERCP, cholangiography and laparoscopic cholecystectomy. The society of American Gastrointestinal Endoscopic Surgeons(SAGES) opinion survey. Surg Endosc. 1993; 7:3–8.