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Vasiliadis K, Moschou E, Papaioannou S, Tzitzis P, Totsi A, Dimou S, Lazaridou E, Kapetanos D, Papavasiliou C. Isolated aberrant right cysticohepatic duct injury during laparoscopic cholecystectomy: Evaluation and treatment challenges of a severe postoperative complication associated with an extremely rare anatomical variant. Ann Hepatobiliary Pancreat Surg 2020; 24:221-227. [PMID: 32457271 PMCID: PMC7271109 DOI: 10.14701/ahbps.2020.24.2.221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 01/15/2020] [Accepted: 01/20/2020] [Indexed: 11/17/2022] Open
Abstract
A typical bile duct branching patterns represent one of the major causes of bile duct injury (BDI) during laparoscopic cholecystectomy (LC). The most common classified variations of bile duct branching, involve the right posterior sectoral duct (RPSD) and its joining with the right anterior or left hepatic duct. Variant bile duct anatomy can rarely be extremely complex and unclassified. This report describes an extremely rare case of an isolated injury to an aberrant right hepatic duct formed by the joining of ducts from segments V, VII, and VIII draining into the cystic duct (cysticohepatic duct) during LC, associated with an inferior RPSD opening to left hepatic duct. Detailed evaluation of both endoscopic and magnetic cholangiograms established the diagnosis. Bile duct injury was subsequently managed surgically by a demanding Roux-en-Y hepaticojejunostomy. This extremely rare case aims to serve as a useful reminder of the consistent inconsistency of biliary anatomy, alerting surgeons to beware of variant bile duct branching patterns during open or LC that constitute a dreadful pitfall for severe and life-threatening bile duct injuries.
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Affiliation(s)
| | | | - Sofia Papaioannou
- Department of Radiology, General Hospital Papageorgiou, Thessaloniki, Greece
| | | | | | | | - Eleni Lazaridou
- School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios Kapetanos
- Department of Gastroenterology, General Hospital Papanikolaou, Thessaloniki, Greece
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Maeda K, Tabata M, Sakamoto T, Fujimura Y, Takeuchi T, Desaki R, Kobayashi M, Ohsawa I, Kato K, Iwata M, Sanda T. Cholecystohepatic duct detected during laparoscopic cholecystectomy: a case report. Surg Case Rep 2020; 6:19. [PMID: 31932993 PMCID: PMC6957650 DOI: 10.1186/s40792-020-0786-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 01/06/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The cholecystohepatic duct is a rare form of an aberrant hepatic duct that connects to the gallbladder. Although cholecystohepatic duct is reported to be a very rare anomaly, injury of cholecystohepatic duct during cholecystectomy may result in serious complications. Herein, we present a case of cholecystohepatic duct in the ventral branch of the right posterior inferior segmental bile duct detected during laparoscopic cholecystectomy. CASE PRESENTATION A 77-year-old woman with cholecystolithiasis had been referred to our hospital for surgery. Drip infusion cholecystocholangiography-computed tomography revealed a bile duct branch without communication between the intra- and extrabiliary systems, although the existence of this aberrant hepatic duct was not suspected preoperatively. A 4-port laparoscopic cholecystectomy was performed. After critical view of safety was confirmed, the cystic artery and duct were divided after double clipping. During antegrade mobilization of the gallbladder from the gallbladder bed, a thin, white cord-like material connecting the gallbladder neck and bed was detected. After clipping and dividing it, a cholecystohepatic duct injury was recognized through rechecking the results of the preoperative examinations. Biliary reconstruction was considered unnecessary because of the lesion's small drainage area. The postoperative course was uneventful, and an enhanced computed tomography performed 6 months after the surgery revealed a dilation in the ventral branch of the right posterior inferior segmental bile duct. The patient's liver function remained normal, and she had no symptoms of cholangitis 42 months after the surgery. CONCLUSIONS Although cholecystohepatic duct is a rare anomaly compared to other aberrant hepatic ducts, surgeons performing cholecystectomy should always keep its existence in mind to avoid serious postoperative complications. Ideally, preoperative detection of cholecystohepatic duct is preferable, but even if it is detected during surgery, the appropriate management according to the drainage area is also important.
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Affiliation(s)
- Koki Maeda
- Department of Hepatobiliary-Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-0001, Japan.
| | - Masami Tabata
- Department of Surgery, Matsusaka Central General Hospital, 102 Kobo, Kawaimachi, Matsusaka, Mie, 515-8566, Japan
| | - Tatsuya Sakamoto
- Department of Surgery, Matsusaka Central General Hospital, 102 Kobo, Kawaimachi, Matsusaka, Mie, 515-8566, Japan
| | - Yu Fujimura
- Department of Surgery, Matsusaka Central General Hospital, 102 Kobo, Kawaimachi, Matsusaka, Mie, 515-8566, Japan
| | - Taijiro Takeuchi
- Department of Surgery, Matsusaka Central General Hospital, 102 Kobo, Kawaimachi, Matsusaka, Mie, 515-8566, Japan
| | - Ryosuke Desaki
- Department of Surgery, Matsusaka Central General Hospital, 102 Kobo, Kawaimachi, Matsusaka, Mie, 515-8566, Japan
| | - Motoyuki Kobayashi
- Department of Surgery, Matsusaka Central General Hospital, 102 Kobo, Kawaimachi, Matsusaka, Mie, 515-8566, Japan
| | - Ichiro Ohsawa
- Department of Surgery, Matsusaka Central General Hospital, 102 Kobo, Kawaimachi, Matsusaka, Mie, 515-8566, Japan
| | - Kenji Kato
- Department of Surgery, Matsusaka Central General Hospital, 102 Kobo, Kawaimachi, Matsusaka, Mie, 515-8566, Japan
| | - Makoto Iwata
- Department of Surgery, Matsusaka Central General Hospital, 102 Kobo, Kawaimachi, Matsusaka, Mie, 515-8566, Japan
| | - Takayuki Sanda
- Department of Surgery, Matsusaka Central General Hospital, 102 Kobo, Kawaimachi, Matsusaka, Mie, 515-8566, Japan
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El Hariri M, Riad MM. Intrahepatic bile duct variation: MR cholangiography and implication in hepatobiliary surgery. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2019. [DOI: 10.1186/s43055-019-0092-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Abstract
Background
The aim of this study was to assess the prevalence of biliary anatomical variants using 3-T MR cholangiography (MRC) with its impact in reduction of the complication of hepatobiliary surgical techniques.
Results
MRC was applied to 120 subjects (24 potential liver donors and 96 volunteers) and the right posterior hepatic duct insertion was documented, and accordingly, the biliary variants were classified based on Huang classification (Huang et al, Transplant Proc 28: 1669–1670, 1996).
Biliary anatomic variants were divided based on Huang classification: Huang A1, 65.83% (n = 79); Huang A2, 11.67% (n = 14); Huang A3, 13.3% (n = 16); Huang A4, 7.5% (n = 9); and Huang A5, 1.67% (n = 2). The total frequency for A2, A3, A4, and A5 was 34.17% (n = 41). The distance between RPHD insertion and the junction of right and left hepatic ducts (L) was measured, and Huang A1 cases were then subtyped into S1 subtype (L > 1 cm) and S2 subtype (L ≤ 1 cm). We had 52 subjects with subtype S1 (43.33%) and 27 subjects with subtype S2 (22.5%).
Twenty-three subjects had bile duct exploration or intraoperative cholangiograms and showed Huang type A1 in 14 (60.87%), type A2 in 3 (13.05%), and type A3 in 6 (26.08%). Twenty-two (95.65%) had the same classification in MRC and intraoperative while only one case (4.35%) was considered as A2 at MRC but the intraoperative classification was Huang A3, which was attributed to the insertion of the RPHD insertion at the distal end of the left hepatic duct.
Conclusion
MRC is an accurate tool for biliary tract mapping before hepatobiliary surgery to provide excellent identification of biliary variants which can reduce the incidence of biliary complications.
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Paramythiotis D, Moysidis M, Rafailidis V, Bangeas P, Karakatsanis A, Kalogera A, Michalopoulos A. Ducts of Luschka as a rare cause of postoperative biloma. MRCP findings. Radiol Case Rep 2019; 14:1237-1240. [PMID: 31440322 PMCID: PMC6699188 DOI: 10.1016/j.radcr.2019.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 07/17/2019] [Accepted: 07/18/2019] [Indexed: 11/23/2022] Open
Abstract
Laparoscopic cholecystectomy can be complicated by a post- operative biloma. Bile leak from the duct of Luschka is reported to be the second most frequent cause, reported in 0.15%-2% of the patients. This case report aims to underline the significance of this anatomic variation and how the management of the aforementioned complication can be facilitated by MRI- MRCP. A 78 year old male patient underwent an elective laparoscopic cholecystectomy and was found to have a post-operative biloma. An MRCP was carried out to visualize the bile tree and bile leak was identified to be originated from a duct of Luschka. The patient was referred for an ERCP, sphingterotomy and placement of biliary stent to release the pressure in the bile ducts. In the next few days the bile leak was controlled and eventually ceased. The patient was discharged free of symptoms and no sign of bile leak was to be found on his follow up imaging. In comparison with other imaging modalities picturing the bile tree, MRCP fits the ideal profile to be used as a first line choice for clinicians, as it offers detailed anatomical images with high contrast between bile and adjacent tissues, without using any contrast agent or radiation.
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Affiliation(s)
- Daniel Paramythiotis
- 1st Propaedeutic Surgery Department, AHEPA University Hospital of Thessaloniki, St. Kiriakidi 1, Thessaloniki 54636, Greece
| | - Moysis Moysidis
- 1st Propaedeutic Surgery Department, AHEPA University Hospital of Thessaloniki, St. Kiriakidi 1, Thessaloniki 54636, Greece
| | - Vasileios Rafailidis
- Radiology Department, AHEPA University Hospital of Thessaloniki, Thessaloniki, Greece
| | - Petros Bangeas
- 1st University Surgery Department, Papageorgiou Hospital of Thessaloniki, Thessaloniki, Greece
| | - Anestis Karakatsanis
- 1st Propaedeutic Surgery Department, AHEPA University Hospital of Thessaloniki, St. Kiriakidi 1, Thessaloniki 54636, Greece
| | - Anna Kalogera
- Radiology Department, AHEPA University Hospital of Thessaloniki, Thessaloniki, Greece
| | - Antonios Michalopoulos
- 1st Propaedeutic Surgery Department, AHEPA University Hospital of Thessaloniki, St. Kiriakidi 1, Thessaloniki 54636, Greece
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Cholecystohepatic Duct: A Biliary Duct Variant Resulting in Postcholecystectomy Bile Leak-Case Report and Review of Normal and Common Variant Biliary Anatomy. Case Rep Radiol 2019; 2019:6812793. [PMID: 31316855 PMCID: PMC6601483 DOI: 10.1155/2019/6812793] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 05/06/2019] [Accepted: 05/26/2019] [Indexed: 11/18/2022] Open
Abstract
Although relatively infrequent, bile duct leaks are among the primary complications of hepatobiliary surgery and cholecystectomy given the large number of these operations performed annually around the world. Variant biliary anatomy increases the risk of surgical complications, especially if unrecognized on preoperative imaging or intraoperatively. Presented here is a case of a patient with an unrecognized cholecystohepatic duct at the time of surgery leading to bile leak after cholecystectomy. Numerous factors made for a technically difficult surgery with obscuration of the true anatomy, ultimately resulting in transection of the cholecystohepatic duct. Understanding normal and variant biliary anatomy will help prevent avoidable complications of hepatobiliary surgery.
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Magnetic resonance and retrograde endoscopic cholangiopancreatography-based identification of biliary tree variants: are there type-related variabilities among the Saudi population? Surg Radiol Anat 2019; 41:869-877. [DOI: 10.1007/s00276-019-02249-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Accepted: 04/25/2019] [Indexed: 12/17/2022]
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Abe T, Ito S, Kaneda Y, Suto R, Noshima S. Main right hepatic duct entering the cystic duct: a case report. Surg Case Rep 2019; 5:46. [PMID: 30911867 PMCID: PMC6434006 DOI: 10.1186/s40792-019-0604-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 03/12/2019] [Indexed: 12/24/2022] Open
Abstract
Background Risk factors for bile duct injury in laparoscopic cholecystectomy include severe inflammation at Calot’s triangle and aberrant bile duct variations. Knowledge of the various biliary anomalies and early identification may therefore assist in decreasing the rate of bile duct injury. Case presentation A 65-year-old woman was admitted with right hypochondrial pain and high fever. A diagnosis of acute calculous cholecystitis was made by radiological imaging. Magnetic resonance cholangiopancreatography revealed that the confluence of the right and left hepatic duct was unclear. Intraoperatively, the procedure was converted from a laparoscopic cholecystectomy to laparotomy because of unclear anatomy of the cystic duct with severe inflammation at Calot’s triangle. Furthermore, intraoperative cholangiography from Hartmann’s pouch showed the main right hepatic duct entering the cystic duct. Subtotal cholecystectomy was performed to avoid injuring the right hepatic duct. Conclusion Although an aberrant hepatic duct entering the cystic duct is not uncommon, the main right hepatic duct infiltrating the cystic duct is extremely rare. Preoperative and intraoperative evaluation of the biliary duct and awareness of aberrant biliary duct variations is important in preventing bile duct injury.
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Affiliation(s)
- Toshiya Abe
- Department of Surgery, Yamaguchi Prefectural Grand Medical Center, Yamaguchi, Japan.
| | - Shinichiro Ito
- Department of Surgery, Yamaguchi Prefectural Grand Medical Center, Yamaguchi, Japan
| | - Yoshikazu Kaneda
- Department of Surgery, Yamaguchi Prefectural Grand Medical Center, Yamaguchi, Japan
| | - Ryuichiro Suto
- Department of Surgery, Yamaguchi Prefectural Grand Medical Center, Yamaguchi, Japan
| | - Shinji Noshima
- Department of Surgery, Yamaguchi Prefectural Grand Medical Center, Yamaguchi, Japan
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Uemura S, Namikawa T, Kitagawa H, Iwabu J, Fujisawa K, Tsuda S, Maeda H, Kobayashi M, Hanazaki K. Bile leakage after cholecystectomy in a patient with cholecystohepatic duct : a case report. ANNALS OF CANCER RESEARCH AND THERAPY 2018. [DOI: 10.4993/acrt.26.07] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
| | | | | | - Jun Iwabu
- Department of Surgery, Kochi Medical School
| | | | | | | | - Michiya Kobayashi
- Cancer Treatment Center, Kochi Medical School Hospital
- Department of Human Health and Medical Sciences, Kochi Medical School
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Bonatti HJR, Corey MR, Taylor JT, Geevarghese SK. Bile leak from the gallbladder fossa after liver transplantation. Eur Surg 2017. [DOI: 10.1007/s10353-017-0505-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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10
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The Prevalence of Hjortsjo Crook Sign of Right Posterior Sectional Bile Duct and Bile Duct Anatomy in ERCP. Can J Gastroenterol Hepatol 2017; 2017:2532610. [PMID: 28785551 PMCID: PMC5529631 DOI: 10.1155/2017/2532610] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 05/04/2017] [Accepted: 06/12/2017] [Indexed: 11/18/2022] Open
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.
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Doumenc B, Boutros M, Dégremont R, Bouras AF. Biliary leakage from gallbladder bed after cholecystectomy: Luschka duct or hepaticocholecystic duct? Morphologie 2016; 100:36-40. [PMID: 26404734 DOI: 10.1016/j.morpho.2015.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 08/04/2015] [Accepted: 08/20/2015] [Indexed: 06/05/2023]
Abstract
Anatomic variations in the biliary tract are common and can cause difficulties when a cholecystectomy is performed. One of the most common ones are hepaticocholecystic ducts and Luschka ducts, connecting the gallbladder or its bed to the bile ducts but distinction between these two types of ducts can be difficult. We do discuss here the differences between these anatomical variations, their origin and their clinical implications. These aberrant ducts may go unnoticed and may require further complementary procedures in case of postoperative biliary leakage. In addition to a careful surgical procedure and an examination of the cystic bed in the end of the intervention, an intraoperative cholangiography should be performed as often as possible.
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Affiliation(s)
- B Doumenc
- Chirurgie générale et digestive, service de chirurgie générale et digestive, centre hospitalier Germon-et-Gauthier, rue Delbecque, BP 10809, 62408 Béthune cedex, France
| | - M Boutros
- Chirurgie générale et digestive, service de chirurgie générale et digestive, centre hospitalier Germon-et-Gauthier, rue Delbecque, BP 10809, 62408 Béthune cedex, France
| | - R Dégremont
- Chirurgie générale et digestive, service de chirurgie générale et digestive, centre hospitalier Germon-et-Gauthier, rue Delbecque, BP 10809, 62408 Béthune cedex, France
| | - A F Bouras
- Chirurgie générale et digestive, service de chirurgie générale et digestive, centre hospitalier Germon-et-Gauthier, rue Delbecque, BP 10809, 62408 Béthune cedex, France.
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Lee SE, Park KW, Choi YS, Lee ES. Rare bile duct anomaly: B3 duct draining to gallbladder. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2016. [DOI: 10.1016/j.epsc.2015.11.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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The use of laparoscopic subtotal cholecystectomy in a case with a cholecystohepatic duct. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2015. [DOI: 10.1016/j.epsc.2014.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Minutoli F, Naso S, Visalli C, Iannelli D, Silipigni S, Pitrone A, Bottari A. A new variant of cholecystohepatic duct: MR cholangiography demonstration. Surg Radiol Anat 2014; 37:539-41. [PMID: 25086964 DOI: 10.1007/s00276-014-1356-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 07/28/2014] [Indexed: 11/29/2022]
Abstract
Magnetic resonance cholangiography used before laparoscopic cholecystectomy may reduce the incidence of post-operative complications related to the high anatomic variability of the biliary system. A number of anatomic variants of the biliary tree have been reported. We present a rare case in which magnetic resonance cholangiography demonstrated a new variant of the cholecystohepatic bile duct acting as a communication between the gallbladder fundus and an intrahepatic biliary duct.
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Affiliation(s)
- Fabio Minutoli
- Department of Biomedical Sciences and of Morphologic and Functional Images, University of Messina, via Consolare Valeria, 1, 98125, Messina, Italy,
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Tawab MA, Taha Ali TF. Anatomic variations of intrahepatic bile ducts in the general adult Egyptian population: 3.0-T MR cholangiography and clinical importance. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2012. [DOI: 10.1016/j.ejrnm.2012.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Schnelldorfer T, Sarr MG, Adams DB. What is the duct of Luschka?--A systematic review. J Gastrointest Surg 2012; 16:656-62. [PMID: 22215244 DOI: 10.1007/s11605-011-1802-5] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2011] [Accepted: 12/14/2011] [Indexed: 01/31/2023]
Abstract
BACKGROUND Subvesical bile ducts (frequently termed incorrectly "ducts of Luschka") have gained increased clinical recognition in the era of laparoscopic cholecystectomy. Though cited frequently and discussed in the literature, the original description by Hubert von Luschka and many anatomic details of these subvesical bile ducts remain ill-defined. STUDY DESIGN A systematic literature search was conducted including publications that described either radiographic features or gross anatomy of bile ducts in close contact with the gallbladder fossa. Of 2,545 publications identified from electronic databases, 116 met inclusion criteria. RESULTS Of 116 articles, 13 incorporated a prevalence study design. These 13 articles investigated 3,996 patients, of whom 156 were diagnosed with a subvesical duct for a prevalence of 4%. The prevalence in articles focusing on subvesical bile ducts was greater than in articles studying biliary anatomy in general (10% versus 3%; p<0.0001). Furthermore, of 116 articles, 54 provided detailed anatomic information identifying 238 subvesical ducts, most of which represented accessory ducts. The origin and drainage of these ducts were limited primarily to the right lobe of the liver, but great variation was seen. The mean diameter of the subvesical ducts was 2 mm (range 1-18 mm). CONCLUSIONS The term "ducts of Luschka" should be abandoned and should be replaced by the correct term of "subvesical bile duct". The variability in anatomic location of subvesical bile ducts puts them at risk during hepato-biliary operations. A better understanding of ductal anatomy is elemental in preventing and managing operative injury to the subvesical ducts. This review debunks common myths about the so-called "duct of Luschka" and offers a systematic overview of the anatomy of the subvesical bile duct.
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Affiliation(s)
- Thomas Schnelldorfer
- Department of Surgery, University of Pennsylvania School of Medicine, 4 Silverstein, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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Dubale N, Anupama NK, Tandon M, Pradeep R, Reddy D, Rao G. Anomalous biliary duct mistaken as hilar stricture. A case report. JOURNAL OF INTERVENTIONAL GASTROENTEROLOGY 2011; 1:34-36. [PMID: 21686112 DOI: 10.4161/jig.1.1.14600] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2010] [Revised: 07/11/2010] [Accepted: 07/16/2010] [Indexed: 11/19/2022]
Abstract
Anomalous biliary anatomy is frequently encountered by surgeons during cholecystectomy. Importance of its recognition lies in avoiding serious biliary injuries. One such anomaly is cholecystohepatic duct. We describe rare clinical situation wherein agenesis of CHD along with cholecystohepatic duct was mistaken for hilar stricture.
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18
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Ishiguro Y, Hyodo M, Fujiwara T, Sakuma Y, Hojo N, Mizuta K, Kawarasaki H, Lefor AT, Yasuda Y. Right anterior segmental hepatic duct emptying directly into the cystic duct in a living donor. World J Gastroenterol 2010; 16:3723-6. [PMID: 20677347 PMCID: PMC2915435 DOI: 10.3748/wjg.v16.i29.3723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
A 35-year-old mother was scheduled to be the living donor for liver transplantation to her second son, who suffered from biliary atresia complicated with biliary cirrhosis at the age of 2 years. The operative plan was to recover the left lateral segment of the mother’s liver for living donor transplantation. With the use of cholangiography at the time of surgery, we found the right anterior segmental duct (RASD) emptying directly into the cystic duct, and the catheter passed into the RASD. After repairing the incision in the cystic duct, transplantation was successfully performed. Her postoperative course was uneventful. Biliary anatomical variations were frequently encountered, however, this variation has very rarely been reported. If the RASD was divided, the repair would be very difficult because the duct will not dilate sufficiently in an otherwise healthy donor. Meticulous preoperative evaluation of the living donor’s biliary anatomy, especially using magnetic resonance cholangiography and careful intraoperative techniques, is important to prevent bile duct injury and avoid the risk to the healthy donor.
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Affiliation(s)
- Robert C Gandy
- Department of Surgery, St Vincent's Hospital, Sydney, Australia
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20
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Kocabiyik N, Yalcin B, Kilbas Z, Karadeniz SR, Kurt B, Comert A, Ozan H. Anatomical assessment of bile ducts of Luschka in human fetuses. Surg Radiol Anat 2009; 31:517-21. [DOI: 10.1007/s00276-009-0473-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2008] [Accepted: 01/22/2009] [Indexed: 11/29/2022]
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Jahan M, Xiao P, Go A, Cheema M, Hameed A. Intraductal and invasive adenocarcinoma of duct of Luschka, mimicking chronic cholecystitis and cholelithiasis. World J Surg Oncol 2009; 7:4. [PMID: 19128463 PMCID: PMC2631453 DOI: 10.1186/1477-7819-7-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2008] [Accepted: 01/07/2009] [Indexed: 11/22/2022] Open
Abstract
Background Intraductal and invasive adenocarcinoma of duct of Luschka is rare. To the best of our knowledge, this is the second case report of intraductal and invasive carcinoma arising from ducts of Luschka. Case presentation Patient presented to hospital with signs and symptoms of chronic cholecystitis and cholelithiasis. Ultrasound examination revealed thickening of gallbladder wall with abnormal septation around liver bed. Patient underwent laparoscopic cholecystectomy and resection of the adjacent liver bed. Histologic examination confirmed an intraductal and invasive adenocarcinoma arising from Luschka ducts. Conclusion Adenocarcinoma of ducts of Luschka should be considered among differential diagnoses for the patients with typical clinical presentations of chronic cholecystitis and cholelithiasis.
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Affiliation(s)
- Mumtaz Jahan
- Department of Family Practice, The Brooklyn Hospital Center, Brooklyn, NY 11201, USA.
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Sharma V, Saraswat VA, Baijal SS, Choudhuri G. Anatomic variations in intrahepatic bile ducts in a north Indian population. J Gastroenterol Hepatol 2008; 23:e58-62. [PMID: 18700937 DOI: 10.1111/j.1440-1746.2008.05418.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIM In the present study, we described the anatomical variations in the branching patterns of intrahepatic bile ducts (IHD) and determined the frequency of each variation in north Indian patients. There are no data from India. METHODS The study group consisted of 253 consecutive patients (131 women) undergoing endoscopic retrograde cholangiograms for different indications. Anatomical variations in IHD were classified according to the branching pattern of the right anterior segmental duct (RASD) and the right posterior segmental duct (RPSD), presence or absence of first-order branch of left hepatic duct (LHD) and of an accessory hepatic duct. RESULTS Anatomy of the IHD was typical in 52.9% of cases (n = 134), showing triple confluence in 11.46% (n = 29), anomalous drainage of the RPSD into the LHD in 18.2% (n = 46), anomalous drainage of the RPSD into the common hepatic duct (CHD) in 7.1% (n = 18), drainage of the right hepatic duct (RHD) into the cystic duct 0.4% (n = 1), presence of an accessory duct leading to the CHD or RHD in 4.7% (n = 12), individual drainage of the LHD into the RHD or CHD in 2.4% (n = 6), and unclassified or complex variations in 2.7% (n = 7). None had anomalous drainage of RPSD into the cystic duct. CONCLUSION The branching pattern of IHD was atypical in 47% patients. The two most common variations were drainage of the RPSD into the LHD (18.2%) and triple confluence of the RASD, RPSD, and LHD (11.5%).
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Affiliation(s)
- Vijay Sharma
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Ko K, Kamiya J, Nagino M, Oda K, Yuasa N, Arai T, Nishio H, Nimura Y. A study of the subvesical bile duct (duct of Luschka) in resected liver specimens. World J Surg 2006; 30:1316-20. [PMID: 16830216 DOI: 10.1007/s00268-005-0469-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Injury to the duct of Luschka is associated with biliary fistula from the gallbladder bed after cholecystectomy. However, few studies have reported on the detailed anatomy. We elucidated the anatomy and frequency of the duct of Luschka METHODS A total of 128 specimens from patients who underwent right hepatectomy or more extensive right-sided liver resection between February 1992 and December 2003 were examined. Specimens were fixed in formalin, and serial sections were prepared to trace the course of the bile ducts from the subsegmental branch level. RESULTS The duct of Luschka was observed in 6 (4.6%) specimens. The sites of confluence were as follows: right anterior inferior dorsal branch (2 patients), right anterior branch (2 patients), right hepatic duct (1 patient), and common hepatic duct (1 patient). The upstream end was located in the liver parenchyma of the right anterior inferior dorsal subsegment (5b) and connective tissue of the gallbladder bed in 4 and 2 specimens, respectively. CONCLUSIONS The duct of Luschka never crosses the segmental (5b) border. Therefore, its upstream region may not be injured by segmentectomy or more extensive liver resection. However, it is possible to injure the duct of Luschka at the common hepatic duct, even if right-sided hepatectomy is performed, as the sites of confluence included the common hepatic duct.
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Affiliation(s)
- Kenju Ko
- Department of Surgery, Division of Surgical Oncology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho Showa-ku, Nagoya, 466-8550, Japan.
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24
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Spanos CP, Syrakos T. Bile leaks from the duct of Luschka (subvesical duct): a review. Langenbecks Arch Surg 2006; 391:441-7. [PMID: 16927110 DOI: 10.1007/s00423-006-0078-9] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2006] [Accepted: 05/17/2006] [Indexed: 12/17/2022]
Abstract
BACKGROUND Gallstone disease remains the most common disease of the digestive system in Western societies and laparoscopic cholecystectomy one of the most common surgical procedures performed. Bile leaks remain a significant cause of morbidity for patients undergoing this procedure. These occur in 0.2-2% of cases. The bile ducts of Luschka, or subvesical ducts, are small ducts which originate from the right hepatic lobe, course along the gallbladder fossa, and usually drain in the extrahepatic bile ducts. Injuries to these ducts are the second most frequent cause of postcholecystectomy bile leaks. METHODS A literature search using MEDLINE's Medical Subject Heading terms was used to identify recent articles. Cross-references from these articles were also used. RESULTS Subvesical bile duct leaks can be detected by drip-infusion cholangiography using computed tomography preoperatively, direct visualization or cholangiography intraoperatively, and fistulography, endoscopic retrograde cholangiopancreatography (ERCP), and magnetic resonance cholangiopancreatography with intravenous contrast postoperatively. ERCP is the most common diagnostic method used. Most patients with subvesical duct leaks are symptomatic, and most leaks will be detected postoperatively during the first postoperative week. Drainage of extravasated bile is mandatory in all cases. Reduction of intrabiliary pressure with endoscopic sphincterotomy and stent placement will lead to preferential flow of bile through the papilla, thus permitting subvesical duct injuries to heal. This is the most common treatment modality used. In a minority of patients, relaparoscopy is performed. In such cases, the leaking subvesical duct is visualized directly, and ligation usually is sufficient treatment. Simple drainage is adequate treatment for a small number of asymptomatic patients with low-volume leaks. CONCLUSIONS Subvesical duct leaks occur after cholecystectomy regardless of gallbladder pathology or urgency of operation. They have been encountered more frequently in the era of laparoscopic cholecystectomy. Intraoperative cholangiography does not detect all such leaks. Staying close to the gallbladder wall during its removal from the fossa is the only known prophylactic measure. ERCP and stent placement are the most common effective diagnostic and therapeutic methods used. Intraoperative and perioperative adjunctive measures, such as fibrin glue instillation and pharmacologic relaxation of the sphincter of Oddi, can potentially be used in lowering the incidence of subvesical bile leaks.
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Aoki T, Imamura H, Sakamoto Y, Hasegawa K, Seyama Y, Kubota K, Makuuchi M. Bile duct of Luschka connecting with the cystohepatic duct: the importance of cholangiography during surgery. AJR Am J Roentgenol 2003; 180:694-6. [PMID: 12591676 DOI: 10.2214/ajr.180.3.1800694] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Taku Aoki
- Department of Surgery, Division of Hepato-Biliary-Pancreatic and Transplantation Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
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26
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Abstract
BACKGROUND Cholecystohepatic ducts are rare congenital variants of the biliary tree. CASE OUTLINE An 81-year-old woman presented with biliary colic and elevated liver function tests. An ERCP demonstrated a common bile duct stone and stricture of the common hepatic duct. An operative cholangiogram demonstrated an atrophic common hepatic duct and retrograde filling of the gallbladder through a large cholecystoheptic duct. The patient had a cholecystectomy and reconstructive cholecystohepatic duct jejunostomy. DISCUSSION This case demonstrates a rare congenital anomaly where the gallbladder fills retrograde during an intraoperative cholangiogram despite clipping of the cystic duct. The major path of biliary drainage was through a large cholecystoheptic duct similar to a gallbladder interposition; however, the common hepatic duct was still present but atrophic. This anomaly has not been described previously.
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Affiliation(s)
- A Schofield
- Department of Surgery, University of CalgaryCalgary AlbertaCanada
| | - J Hankins
- Department of Surgery, University of CalgaryCalgary AlbertaCanada
| | - F Sutherland
- Department of Surgery, University of CalgaryCalgary AlbertaCanada
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Choi JW, Kim TK, Kim KW, Kim AY, Kim PN, Ha HK, Lee MG. Anatomic variation in intrahepatic bile ducts: an analysis of intraoperative cholangiograms in 300 consecutive donors for living donor liver transplantation. Korean J Radiol 2003; 4:85-90. [PMID: 12845303 PMCID: PMC2698075 DOI: 10.3348/kjr.2003.4.2.85] [Citation(s) in RCA: 99] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE To describe the anatomical variation occurring in intrahepatic bile ducts (IHDs) in terms of their branching patterns, and to determine the frequency of each variation. MATERIALS AND METHODS The study group consisted of 300 consecutive donors for liver transplantation who underwent intraoperative cholangiography. Anatomical variation in IHDs was classified according to the branching pattern of the right anterior and right posterior segmental duct (RASD and RPSD, respectively), and the presence or absence of the first-order branch of the left hepatic duct (LHD), and of an accessory hepatic duct. RESULTS The anatomy of the intrahepatic bile ducts was typical in 63% of cases (n=188), showed triple confluence in 10% (n=29), anomalous drainage of the RPSD into the LHD in 11% (n=34), anomalous drainage of the RPSD into the common hepatic duct (CHD) in 6% (n=19), anomalous drainage of the RPSD into the cystic duct in 2% (n=6), drainage of the right hepatic duct (RHD) into the cystic duct (n=1), the presence of an accessory duct leading to the CHD or RHD in 5% (n=16), individual drainage of the LHD into the RHD or CHD in 1% (n=4), and unclassified or complex variation in 1% (n=3). CONCLUSION The branching pattern of IHDs was atypical in 37% of cases. The two most common variations were drainage of the RPSD into the LHD (11%) and triple confluence of the RASD, RPSD and LHD (10%).
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Affiliation(s)
- Jin Woo Choi
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae Kyoung Kim
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyoung Won Kim
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ah Young Kim
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Pyo Nyun Kim
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyun Kwon Ha
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Moon-Gyu Lee
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Conrad GR, Sinha P. Delayed postoperative stenosis of a right hepatic choledochojejunostomy. Clin Nucl Med 2002; 27:597-8. [PMID: 12170010 DOI: 10.1097/00003072-200208000-00013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Gary R Conrad
- Department of Radiology, The University of Kentucky Chandler Medical Center, Lexington, Kentucky, USA.
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Abstract
The cystic duct can be depicted with a variety of imaging modalities but is optimally visualized with direct cholangiography or magnetic resonance cholangiopancreatography. Nevertheless, unrecognized anatomic variants of the cystic duct may cause confusion on imaging studies and complicate subsequent surgical, endoscopic, and percutaneous procedures. Primary entities involving the cystic duct include calculous disease, Mirizzi syndrome, cystic duct-duodenal fistula, biliary obstruction, neoplasia, and primary sclerosing cholangitis. The cystic duct may also be secondarily involved by adjacent malignant or inflammatory processes. Postoperative alterations are seen after liver transplantation or cholecystectomy when a portion of the cystic duct is left behind as a remnant. Recognized postoperative complications include retained cystic duct stones, cystic duct leakage, and malposition of T tubes in the remnant. Pitfalls encountered in cystic duct imaging include pseudocalculous defects from overlap of the cystic duct and common bile duct, underfilling of the cystic duct during direct cholangiography, and admixture defects at the cystic duct orifice. Pseudomass or pseudotumor defects may result from an impacted cystic duct stone or from a tortuous, redundant cystic duct. Familiarity with the imaging appearance of the normal cystic duct, its anatomic variants, and related disease processes facilitates accurate diagnosis and helps avoid misinterpretation.
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Affiliation(s)
- M A Turner
- Department of Radiology, Medical College of Virginia, 401 N 12th St, Box 980615-MCV Station, Richmond, VA 23298, USA.
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30
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Lamah M, Dickson GH. Congenital anatomical abnormalities of the extrahepatic biliary duct: a personal audit. Surg Radiol Anat 2000; 21:325-7. [PMID: 10635096 DOI: 10.1007/bf01631333] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Awareness of variations in the anatomy of extrahepatic bile ducts may be important in preventing iatrogenic injury to the duct system during cholecystectomy. Their delineation, before or during surgery is therefore considered mandatory in this surgical unit, and a policy of always performing a per-operative cholangiogram has allowed us to evaluate the duct system in a retrospective review of 2080 cases. Twelve surgically significant anatomical variations were found, consisting of absent cystic duct (three cases), abnormal termination of cystic duct (two into the right hepatic duct, and one into the left hepatic duct), one case of double cystic duct, and five cases of significant accessory bile ducts.
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Mergener K, Strobel JC, Suhocki P, Jowell PS, Enns RA, Branch MS, Baillie J. The role of ERCP in diagnosis and management of accessory bile duct leaks after cholecystectomy. Gastrointest Endosc 1999; 50:527-31. [PMID: 10502175 DOI: 10.1016/s0016-5107(99)70077-5] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) plays an important role in the management of bile leaks after cholecystectomy. Although most leaks occur from the cystic duct stump, clinically significant leakage from accessory bile ducts is less common and has not been investigated systematically. We report our experience with endoscopic diagnosis and treatment of accessory bile duct leaks after cholecystectomy. METHODS Patients with accessory bile duct leaks were identified from a computerized database. Hospital charts and cholangiograms were reviewed to determine the outcome of diagnostic and therapeutic interventions. RESULTS Of 86 patients with postcholecystectomy leaks, 15 (17%) were diagnosed with accessory bile duct leaks. ERCP established the diagnosis of accessory bile duct leaks in 11 of 15 patients (73%); percutaneous fistulography (2) and percutaneous transhepatic cholangiography (2) were diagnostic in 4 patients. Endoscopic therapy led to resolution of the leak in 12 patients. One patient underwent successful percutaneous biliary drainage, and two patients required surgical repair. CONCLUSIONS Accessory bile ducts are rare sites of significant bile leakage after cholecystectomy. ERCP identifies the leak in the majority of patients; percutaneous fistulography or percutaneous transhepatic cholangiography may help clarify the diagnosis if ERCP is nondiagnostic. Most patients can be successfully treated with endoscopic stenting. If endoscopic therapy fails, percutaneous drainage or surgical repair needs to be considered.
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Affiliation(s)
- K Mergener
- Division of Gastroenterology, Department of Medicine, and Department of Radiology, Duke University Medical Center, Durham, North Carolina 27710, USA
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Anomalous Insertion of the Right Hepatic Duct into the Cystic Duct: Report of a Case Diagnosed Before Laparoscopic Cholecystectomy. Surg Laparosc Endosc Percutan Tech 1999. [DOI: 10.1097/00129689-199906000-00012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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33
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Nomura T, Shirai Y, Sasagawa M, Wakai T, Hatakeyama K. Surg Laparosc Endosc Percutan Tech 1999; 9:211-212. [DOI: 10.1097/00019509-199906000-00012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Jenkins MA, Ponsky JL, Lehman GA, Fanelli R, Bianchi T. Treatment of bile leaks from the cystohepatic ducts after laparoscopic cholecystectomy. Surg Endosc 1994; 8:193-6. [PMID: 8191357 DOI: 10.1007/bf00591828] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The cystohepatic ducts represent accessory bile ducts of variable size which frequently travel within the gallbladder fossa or in the posterior wall of the gallbladder. These ducts can be injured during laparoscopic cholecystectomy and can result in bile collections if transected. Successful treatment by operative means or radiologically guided percutaneous drainage is possible, but endoscopic management has several advantages. We describe cases managed by endoscopic retrograde cholangiopancreatography (ERCP) with stent placement and discuss the advantages of this method. Also discussed is the anatomy of these accessory bile ducts, additional management options, and techniques for avoiding this injury during open or closed cholecystectomy.
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Affiliation(s)
- M A Jenkins
- Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, OH 44106
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Wittgen CM, Andrus JP, Andrus CH, Kaminski DL. Cholecystectomy. Which procedure is best for the high-risk patient? Surg Endosc 1993; 7:395-9. [PMID: 8211615 DOI: 10.1007/bf00311728] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Laparoscopic cholecystectomy (LC), which results in less postoperative pain, disability, and scarring, has become an attractive alternative method of surgical management of the ambulatory patient with gallbladder disease. The best procedure for severely ill patients who are poor operative risks but require cholecystectomy, however, is unknown since the operative morbidity and mortality of LC in this group of patients had not been studied. All patients (177) undergoing cholecystectomy at one institution were evaluated. Based on their preoperative state of health as defined by a modified acute physiologic score (APS), patients were divided into two groups; one group was defined by an APS of less than 10, indicating they were in good health, and the other had an APS greater than or equal to 10, indicating that the group had multiple risk factors, predicting an increased postoperative morbidity and mortality. Selection for either procedure, LC or open cholecystectomy (OC), was made independently of the patient's preoperative status. Patients' past medical histories; demographic, physiologic, and laboratory data; and postoperative complications were evaluated. When all cholecystectomy patients were arranged into the respective risk groups, the age and severity of illness scores (APS) between LC and OC were not statistically different. Intraoperative and postoperative complications were not significantly different when patients undergoing LC were compared to patients undergoing OC. Laparoscopic cholecystectomy was associated with decreased hospitalization when compared to patients undergoing OC. The overall mortality of the patients undergoing OC was significantly greater than those undergoing LC. LC is an acceptable surgical alternative for high-risk patients requiring cholecystectomy.
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Affiliation(s)
- C M Wittgen
- Department of Surgery, St. Louis University School of Medicine, MO 63110-0250
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36
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Berci G. Biliary ductal anatomy and anomalies. The role of intraoperative cholangiography during laparoscopic cholecystectomy. Surg Clin North Am 1992; 72:1069-75. [PMID: 1388297 DOI: 10.1016/s0039-6109(16)45832-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Biliary ductal anomalies of surgical importance can occur in 10% of patients. The short cystic duct draining into the common bile or right hepatic duct and the extreme proximity of the common bile duct in case of spiral or posterior entry of the cystic duct--if not recognized in time--can result in ductal injuries. The new mobile, digitized fluoroscopic units provide a vastly improved image within minutes. In case of an inadvertent ductal injury (extravasation, no contrast material visible in the proximal ductal system) the surgeon can immediately repair the injury. Routine intraoperative cholangiography is strongly recommended during laparoscopic cholecystectomies.
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Affiliation(s)
- G Berci
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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