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The Prevalence of Hjortsjo Crook Sign of Right Posterior Sectional Bile Duct and Bile Duct Anatomy in 时间:2017-07-17 13:37 来源:未知作者:admin 点击: 次 Abstract:Aim. The frequency of the Right Posterior Sectional Bile Duct (RPSBD) hump sign in cholangiogram when it crosses over the right portal vein known as Hjortsjo Crook Sign and the bile duct anatomy are studied. Knowledge of the implication of positive sign can facilitate safe resection for both bile duct and portal vein. Methods. Prospectively, we included 237 patients with indicated ERCP during a period from March 2010 to January 2015. Results. The mean age (±SD) and male to female ratio were 38.8 (±19.20) and 1 : 1.28, respectively. All patients are Arab from Middle Eastern origin, had biliary stone disease, and underwent diagnostic and therapeutic ERCP. Positive Hjortsjo Crook Sign was found in 17.7% (42) of patients. The sign was found to be equally more frequent in Nakamura’s RPSBD anatomical variant types I, II, and IV in 8.4% (20), 6.8% (16), and 2.1% (5), respectively, while rare anatomical variant type III showed no positive sign. Conclusion. Hjortsjo Crook Sign frequently presents in RPSBD variation types I, II, and IV in our patients.
1. Introduction
The anatomy of the bile duct (BD) is resembling that of the portal system and liver segments. Based on the literature, the proportion of biliary anatomical variations varies between 28% and 43%. Most of hilar bile ducts anatomical variations stem from different Right Posterior Sectional Bile Duct (RPSBD) origin [1, 2].
Shimizu’s operative series showed that the RPSBD is most commonly supraportal in 84%, infraportal in 13%, and rarely a combination of both in 3% (the segment VII duct being supraportal and segment VI being infraportal) [3]. Furthermore, Nakamura’s operative series report the supraportal RPSBD to be most common in BD variant type I (65%, the classic form where the RPSBD and the anterior sectional BD join to form a single right hepatic duct), type II (9.2%, the RPSBD joins the confluence, forming trifurcation), and type IV (15.8%, the RPSBD joins the left hepatic duct), whereas the infraportal RPSBD is reported to be most common in type III (8.3%) and that of the combination in type V (1.7%) [4].
The recognition of the hump appearance in animal cholangiogram being due to supraportal upward course of the RPSBD was first reported by Hjortsjo Crooks in 1951 [5]. The sign can be positive for the supraportal type BD in the classic Nakamura type I, II, or IV. Recognition of Hjortsjo Crook Sign (HCS) in ERCP can enrich our preoperative knowledge of biliary anatomical variation; their precise delineation and anticipation for technical modifications are vital to achieving safe curative liver resection [3] and liver transplantation [4, 6–8] and to avoiding biliary injury in common general surgical procedure like cholecystectomy [9–11].
Our study describes the characteristics of HCS of the RPSBD anatomy in relation to the right portal vein (RPV) among Middle Eastern population using ERCP cholangiogram. To date, the relation of the different anatomical variation of the RPSBD to the RPV based on HCS has never been examined before in humans.
2. Materials and Methods
2.1. Patients and Methods
This prospective study was carried out during the period from March 2010 to January 2015. We prospectively included 237 consecutive patients who have undergone ERCPs fulfilling the inclusion criteria of being from adult age group (above 18 years old), being from Middle Eastern origin, and having the underlying condition of biliary disease only. Furthermore, patients with complete imaging study and without any prior history of liver resection or biliary instrumentation were considered also as inclusion criteria, while criteria like incomplete study, previous liver surgery, and previous liver transplantation were considered as exclusion criteria. Relevant demographic and laboratory data are obtained and depicted in Tables 1 and 2. The ERCP cholangiogram was reviewed by two radiologists separately. Further filling and focused image in ERCP were done if needed during the procedure (with standard ERCP technique using semiprone position); then the biliary anatomy and the HCS are interpreted by two different radiologists.