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Bile duct of luschka leading to bile leak after cholecystectomy—revisiting the biliary anatomy
Bile Duct of Luschka Leading to Bile Leak After Cholecystectomy— Revisiting the Biliary Anatomy By K. Sharif and J. de Ville de Goyet Birmingham, England
Bile ducts of Luschka (also called supravesicular ducts) are small bile ducts in the gallbladder bed. Although they do not drain any liver parenchyma, they can be a source of bile leak or biliary peritonitis after cholecystectomy in both adults and children, as shown in this case report. As a reminder, variations of biliary anatomy in the gallbladder bed and cholecysto-hepatic triangle of Calot, are reviewed.
S
UPRAVESICULAR DUCTS (ducts of Luschka) are small bile ducts located in the cystic fossa; they branch from right hepatic or common hepatic duct but are not accompanied by arteries and veins as other bile ducts draining liver segments. In fact, they have blind distal ends and do not drain any liver parenchyma.1-4 Surgical significance of these ducts lies in the fact that they can be injured during cholecystectomy and are a well-recognized cause of bile leak and secondary peritonitis in adults.3,5,6 The following observation is the first report of a similar complication in a child. Variations of biliary anatomy in the gallbladder bed and around the so-called cholecysto-hepatic triangle of Calot that may lead to bile leak after cholecystectomy are reviewed. CASE REPORT A 12-year-old boy with a primary diagnosis of hereditary spherocytosis and jaundice was referred after repeated episodes of pain in the right upper quadrant. In the medical history, he had undergone a laparotomy for splenectomy 5 years before and a thoracotomy for removal of a thrombus from the superior vena cava 3 years before. At ultrasonographic examination, stones in the gallbladder and the dilated common bile duct were seen. At operation, a hugely distended gallbladder was found, and the operative cholangiogram result was normal (Fig 1A). On the first postoperative day, he complained of pain in his right shoulder and in the lower abdomen. The abdominal drain was noticed to drain a large volume of bile. Hence, he was taken back to the operating room; at exploration there was a considerable amount of bile in the peritoneal cavity. The ligature on the cystic duct duct was in place, but, interestingly, a small duct opening (2 mm diameter), leaking bile, was noticed in the empty gallbladder fossa at the level of the triangle of “Calot” and around 1 cm from the cystic duct; no adjacent vessel was found, and no other duct lumen was seen more distally. A 5F tube was inserted into that opening, and a cholangiogram was performed (Fig 1B). The cholangiogram showed that this was a small bile duct branching from the right hepatic duct. This duct was ligated simply, the child recovered quickly, and he was discharged home on day 5 after the initial operation. Journal of Pediatric Surgery, Vol 38, No 11 (November), 2003: E60
J Pediatr Surg 38:E60. © 2003 Elsevier Inc. All rights reserved.
INDEX WORDS: Anatomy of liver and bile ducts, bile duct of Luschka, cholecystectomy, surgical techniques, complication of surgery.
DISCUSSION
Luschka described aberrant biliary ductules in the gallbladder fossa in 1863.1 These often are small, less than 1 mm diameter, bile ducts running along the gallbladder fossa between the gallbladder and the liver parenchyma. They also have been described as “subvesicular” or “supravesicular ducts” by other anatomists (Champetier et al2 and Couinaud3, respectively). Interestingly, they are not accompanied by artery or vein as are normal bile ducts entering the liver parenchyma and also do not drain any liver parenchyma. They do not open into the gallbladder as do the so-called “cystohepatic ducts.”2,8,10 As highlighted by Couinaud3 Luschka ducts are anatomic variations of the biliary system, different from other variations that can be seen around the same area, such as ectopic drainage of a liver segment (typically a right posterior bile duct draining into the hepatic duct), cystohepatic ducts (true bile ducts that drain a portion of liver parenchyma and open into the gallbladder or the cystic duct2,8,10), vaginali ductuli (very small communications between 2 bile ducts or 1 bile duct and the cystic duct3), and duplication of the cystic duct or gallbladder (Fig 2). The very particular anatomy of the duct of Luschka has not been understood clearly in the past, and many reports have wrongly described or discussed cystohepatic ducts under the name of duct of Luschka.8 AttenFrom the Liver Unit, Birmingham Children’s Hospital, Birmingham, England. Address reprint requests to Jean de Ville de Goyet, Paediatric Surgery, Clinique St Luc—UCL, Av. Hippocrate 10, B1200 Brussels, Belgium. © 2003 Elsevier Inc. All rights reserved. 1531-5037/03/3811-0040$30.00/0 doi:10.1016/S0022-3468(03)00598-0 21
22
SHARIF AND DE VILLE DE GOYET
Fig 1. Operative cholangiograms performed at cholecystectomy (A) and at reoperation for bile leak (B), show the duct of Luschka (arrow). DoL, Duct of Luschka; CD, cystic duct.
tion should be given in future reports to use the appropriate terminology according to the original anatomic description. Variations of the biliary system anatomy increase the risk of trauma to the biliary system and of bile leak after cholecystectomy.5,6,8 The surgical significance of the duct of Luschka resides in that it is relatively common (around 30% of cases2,3,7), it is quite small in diameter and running deep in the gallbladder bed, and intraoperative cholangiogram may be strictly normal.8 It can be left injured or transsected and unnoticed by the surgeon until secondary bile fistula and biliary peritonitis occur. This has been well analyzed by Mcquillan et al6 in a series of postmortem dissections; these investigators also
Fig 2. Schematic view of main variations of the biliary system anatomy in the triangle of Calot and the gallbladder fossa. (A) Duct of Luschka, (B) cystohepatic duct, (C) vaginali ductuli, (D) variant drainage of right posterior sector, (E) duplication of cystic duct, (F) duplication of gallbladder. CD, cystic duct; DL, duct of Luschka; CHD, cystohepatic duct; CBD, common bile duct; RBD, right bile duct; GB, gallbladder; VD, vaginali ductuli.
reported a 9% incidence of bile leak after open cholecystectomy and 4 cases of injury to the duct of Luschka during cholecystectomy. In all 4 cases, the duct of Luschka was identified and ligated without any further problem.6 Not surprisingly, laparoscopic cholecystectomy that has become the gold standard for cholecystectomy carries a similar risk (0.2% to 2% incidence according Jamshidi et al9). Injury to a bile duct of Luschka can be avoided by careful dissection of the gallbladder close to its wall,6 tying structures that are divided in the triangle of Calot rather than simply using diathermy and carefully examining the gallbladder fossa at the end of the operation. The cholangiogram may be normal at operation (before
BILE DUCT OF LUSCHKA AND BILIARY LEAK
23
removing the gallbladder),8 but, according to previous reports and in this case, it is positive when the bile leak is established.6,10 Awareness of the surgeon for this particular anatomic variation may be the most important factor for preventing injury. In cases in which a duct of Luschka is divided, simply tying off the open end is enough. In cases of postoperative bile leak, these ducts often stop draining bile spontaneously with time if the leak is limited and draining well through an external drain. In case of a major leak and biliary peritonitis, reoperation or endoscopic placement of a bile duct stent may be indicated.9 On the contrary, cystohepatic ducts drain liver parenchyma; thus, in case of injury or division, draining these ducts must be considered (depending of the amount of parenchyma that is drained) either by biliary reconstruction or diversion to the jejunum. This confirms the relevance of differentiating and diagnosing correctly cystohepatic duct and duct of Luschka, respectively.
In cases of duplication of the gallbladder or cystic duct and those with variant drainage of right sectorial bile ducts, identifying the variant anatomy is facilitated at surgery by the larger diameter of these structures and by operative cholangiography. In case of trauma, these may be associated with major bile leaks that often require interventions. Injury to a duct of Luschka may lead to bile leak after cholecystectomy, and surgeons should be aware of this particular anatomic detail when performing cholecystectomies. Keeping close to the gallbladder wall when resecting the gallbladder might be helpful. In case of established bile leak from a duct running in the gallbladder fossa, a cholangiogram may help define the bile duct anatomy and choose the right procedure to avoid further problems. We believe it is useful to remind surgeons of this anatomic variation because awareness of it is likely to be the most important factor for preventing related problems.
REFERENCES 1. Luschka H: Die Anatomie des Menschlichen.BdII: Tu¨ bigen Laupp und Siebeckle, 1863, 248-255 2. Champetier J, Davin JL, Letoublon C, et al: Abberant Biliary ducts (vasa aberrantia): Surgical implications. Anat Clin 4:137-145, 1982 3. Couinaud C: Intrahepatic biliary ducts, in Couinaud C (ed): Surgical Anatomy of the Liver Revisited. 15, rue spontins, F75116, Paris. 1989, 60-74 4. Blumgart LH, Hann LE: Surgical and Radiological Anatomy in Surgery of the Liver and Biliary tract, Vol 1. ed 3. Philadelphia, PA, Saunders, 2000, 3-33 5. Thompson RW, Schuler JG: Bile peritonitis from a cholecystohepatic bile ductule: An unusual complication of cholecystectomy. Surgery 99:511-513, 1986
6. Mcquillan T, Manolas SG, Hayman JA, et al: Surgical significance of the bile duct of Luschka. Br J Surg 76:696-698, 1989 7. Healy JE, Schroy PC: Anatomy of biliary duct within the human liver. Arch Surg 66:599-616, 1953 8. Javors BR, Simmons MZ, Wachsberg RH: Cholangiographic demonstration of the cholecystohepatic duct of Luschka. Abdom Imag 23:620-621, 1998 9. Suhocki PV, Meyers WC: Injury to aberrant bile ducts during cholecystectomy: A common cause of diagnostic error and treatment delay. AJR 172:955-959, 1999 10. Jamshidi M, Obermeyer RJ, Garcia G, et al: Post-laparoscopic cholecystectomy bile leak secondary to an accessory duct of Luschka. Int Surg 84:86-88, 1999
Bile ducts of Luschka (also called supravesicular ducts) are small bile ducts in the gallbladder bed. Although they do not drain any liver parenchyma, they can be a source of bile leak or biliary peritonitis after cholecystectomy in both adults and children, as shown in this case report. As a reminder, variations of biliary anatomy in the gallbladder bed and cholecysto-hepatic triangle of Calot, are reviewed.
S
UPRAVESICULAR DUCTS (ducts of Luschka) are small bile ducts located in the cystic fossa; they branch from right hepatic or common hepatic duct but are not accompanied by arteries and veins as other bile ducts draining liver segments. In fact, they have blind distal ends and do not drain any liver parenchyma.1-4 Surgical significance of these ducts lies in the fact that they can be injured during cholecystectomy and are a well-recognized cause of bile leak and secondary peritonitis in adults.3,5,6 The following observation is the first report of a similar complication in a child. Variations of biliary anatomy in the gallbladder bed and around the so-called cholecysto-hepatic triangle of Calot that may lead to bile leak after cholecystectomy are reviewed. CASE REPORT A 12-year-old boy with a primary diagnosis of hereditary spherocytosis and jaundice was referred after repeated episodes of pain in the right upper quadrant. In the medical history, he had undergone a laparotomy for splenectomy 5 years before and a thoracotomy for removal of a thrombus from the superior vena cava 3 years before. At ultrasonographic examination, stones in the gallbladder and the dilated common bile duct were seen. At operation, a hugely distended gallbladder was found, and the operative cholangiogram result was normal (Fig 1A). On the first postoperative day, he complained of pain in his right shoulder and in the lower abdomen. The abdominal drain was noticed to drain a large volume of bile. Hence, he was taken back to the operating room; at exploration there was a considerable amount of bile in the peritoneal cavity. The ligature on the cystic duct duct was in place, but, interestingly, a small duct opening (2 mm diameter), leaking bile, was noticed in the empty gallbladder fossa at the level of the triangle of “Calot” and around 1 cm from the cystic duct; no adjacent vessel was found, and no other duct lumen was seen more distally. A 5F tube was inserted into that opening, and a cholangiogram was performed (Fig 1B). The cholangiogram showed that this was a small bile duct branching from the right hepatic duct. This duct was ligated simply, the child recovered quickly, and he was discharged home on day 5 after the initial operation. Journal of Pediatric Surgery, Vol 38, No 11 (November), 2003: E60
J Pediatr Surg 38:E60. © 2003 Elsevier Inc. All rights reserved.
INDEX WORDS: Anatomy of liver and bile ducts, bile duct of Luschka, cholecystectomy, surgical techniques, complication of surgery.
DISCUSSION
Luschka described aberrant biliary ductules in the gallbladder fossa in 1863.1 These often are small, less than 1 mm diameter, bile ducts running along the gallbladder fossa between the gallbladder and the liver parenchyma. They also have been described as “subvesicular” or “supravesicular ducts” by other anatomists (Champetier et al2 and Couinaud3, respectively). Interestingly, they are not accompanied by artery or vein as are normal bile ducts entering the liver parenchyma and also do not drain any liver parenchyma. They do not open into the gallbladder as do the so-called “cystohepatic ducts.”2,8,10 As highlighted by Couinaud3 Luschka ducts are anatomic variations of the biliary system, different from other variations that can be seen around the same area, such as ectopic drainage of a liver segment (typically a right posterior bile duct draining into the hepatic duct), cystohepatic ducts (true bile ducts that drain a portion of liver parenchyma and open into the gallbladder or the cystic duct2,8,10), vaginali ductuli (very small communications between 2 bile ducts or 1 bile duct and the cystic duct3), and duplication of the cystic duct or gallbladder (Fig 2). The very particular anatomy of the duct of Luschka has not been understood clearly in the past, and many reports have wrongly described or discussed cystohepatic ducts under the name of duct of Luschka.8 AttenFrom the Liver Unit, Birmingham Children’s Hospital, Birmingham, England. Address reprint requests to Jean de Ville de Goyet, Paediatric Surgery, Clinique St Luc—UCL, Av. Hippocrate 10, B1200 Brussels, Belgium. © 2003 Elsevier Inc. All rights reserved. 1531-5037/03/3811-0040$30.00/0 doi:10.1016/S0022-3468(03)00598-0 21
22
SHARIF AND DE VILLE DE GOYET
Fig 1. Operative cholangiograms performed at cholecystectomy (A) and at reoperation for bile leak (B), show the duct of Luschka (arrow). DoL, Duct of Luschka; CD, cystic duct.
tion should be given in future reports to use the appropriate terminology according to the original anatomic description. Variations of the biliary system anatomy increase the risk of trauma to the biliary system and of bile leak after cholecystectomy.5,6,8 The surgical significance of the duct of Luschka resides in that it is relatively common (around 30% of cases2,3,7), it is quite small in diameter and running deep in the gallbladder bed, and intraoperative cholangiogram may be strictly normal.8 It can be left injured or transsected and unnoticed by the surgeon until secondary bile fistula and biliary peritonitis occur. This has been well analyzed by Mcquillan et al6 in a series of postmortem dissections; these investigators also
Fig 2. Schematic view of main variations of the biliary system anatomy in the triangle of Calot and the gallbladder fossa. (A) Duct of Luschka, (B) cystohepatic duct, (C) vaginali ductuli, (D) variant drainage of right posterior sector, (E) duplication of cystic duct, (F) duplication of gallbladder. CD, cystic duct; DL, duct of Luschka; CHD, cystohepatic duct; CBD, common bile duct; RBD, right bile duct; GB, gallbladder; VD, vaginali ductuli.
reported a 9% incidence of bile leak after open cholecystectomy and 4 cases of injury to the duct of Luschka during cholecystectomy. In all 4 cases, the duct of Luschka was identified and ligated without any further problem.6 Not surprisingly, laparoscopic cholecystectomy that has become the gold standard for cholecystectomy carries a similar risk (0.2% to 2% incidence according Jamshidi et al9). Injury to a bile duct of Luschka can be avoided by careful dissection of the gallbladder close to its wall,6 tying structures that are divided in the triangle of Calot rather than simply using diathermy and carefully examining the gallbladder fossa at the end of the operation. The cholangiogram may be normal at operation (before
BILE DUCT OF LUSCHKA AND BILIARY LEAK
23
removing the gallbladder),8 but, according to previous reports and in this case, it is positive when the bile leak is established.6,10 Awareness of the surgeon for this particular anatomic variation may be the most important factor for preventing injury. In cases in which a duct of Luschka is divided, simply tying off the open end is enough. In cases of postoperative bile leak, these ducts often stop draining bile spontaneously with time if the leak is limited and draining well through an external drain. In case of a major leak and biliary peritonitis, reoperation or endoscopic placement of a bile duct stent may be indicated.9 On the contrary, cystohepatic ducts drain liver parenchyma; thus, in case of injury or division, draining these ducts must be considered (depending of the amount of parenchyma that is drained) either by biliary reconstruction or diversion to the jejunum. This confirms the relevance of differentiating and diagnosing correctly cystohepatic duct and duct of Luschka, respectively.
In cases of duplication of the gallbladder or cystic duct and those with variant drainage of right sectorial bile ducts, identifying the variant anatomy is facilitated at surgery by the larger diameter of these structures and by operative cholangiography. In case of trauma, these may be associated with major bile leaks that often require interventions. Injury to a duct of Luschka may lead to bile leak after cholecystectomy, and surgeons should be aware of this particular anatomic detail when performing cholecystectomies. Keeping close to the gallbladder wall when resecting the gallbladder might be helpful. In case of established bile leak from a duct running in the gallbladder fossa, a cholangiogram may help define the bile duct anatomy and choose the right procedure to avoid further problems. We believe it is useful to remind surgeons of this anatomic variation because awareness of it is likely to be the most important factor for preventing related problems.
REFERENCES 1. Luschka H: Die Anatomie des Menschlichen.BdII: Tu¨ bigen Laupp und Siebeckle, 1863, 248-255 2. Champetier J, Davin JL, Letoublon C, et al: Abberant Biliary ducts (vasa aberrantia): Surgical implications. Anat Clin 4:137-145, 1982 3. Couinaud C: Intrahepatic biliary ducts, in Couinaud C (ed): Surgical Anatomy of the Liver Revisited. 15, rue spontins, F75116, Paris. 1989, 60-74 4. Blumgart LH, Hann LE: Surgical and Radiological Anatomy in Surgery of the Liver and Biliary tract, Vol 1. ed 3. Philadelphia, PA, Saunders, 2000, 3-33 5. Thompson RW, Schuler JG: Bile peritonitis from a cholecystohepatic bile ductule: An unusual complication of cholecystectomy. Surgery 99:511-513, 1986
6. Mcquillan T, Manolas SG, Hayman JA, et al: Surgical significance of the bile duct of Luschka. Br J Surg 76:696-698, 1989 7. Healy JE, Schroy PC: Anatomy of biliary duct within the human liver. Arch Surg 66:599-616, 1953 8. Javors BR, Simmons MZ, Wachsberg RH: Cholangiographic demonstration of the cholecystohepatic duct of Luschka. Abdom Imag 23:620-621, 1998 9. Suhocki PV, Meyers WC: Injury to aberrant bile ducts during cholecystectomy: A common cause of diagnostic error and treatment delay. AJR 172:955-959, 1999 10. Jamshidi M, Obermeyer RJ, Garcia G, et al: Post-laparoscopic cholecystectomy bile leak secondary to an accessory duct of Luschka. Int Surg 84:86-88, 1999