Bile leak from duct of Luschka after liver transplantation

Duct of Luschka Bile Leak Following Deceased Donor Liver Transplant

BACKGROUND Biliary leak is a relatively uncommon but potentially severe complication of liver transplantation. Duct of Luschka (also known as subvesical bile ducts) is a term that refers to a number of accessory biliary ducts. While leaks from Ducts of Luschka are well-described in the field of hepatobiliary surgery, only 2 case reports of such leaks exist in the setting of liver transplant. CASE REPORT We report the first case of a Duct of Luschka biliary leak seen after DCD liver transplant in a 41-year-old woman with cirrhosis secondary to primary sclerosing cholangitis. The patient underwent surgical re-exploration in the immediate postoperative period due to bilious output from a surgical drain. A Duct of Luschka was found intraoperatively at the gallbladder fossa and was oversewn. Apart from immunosuppression-related neutropenia, the patient recovered uneventfully. CONCLUSIONS Given the variability in preoperative detection of subvesical bile ducts, accessory bile duct leak remains an important consideration in the liver transplant perioperative period. The prevalence of Ducts of Luschka and the relative risk of leakage from such subvesical bile ducts in liver transplants compared to cholecystectomies are unclear. Further research into anatomical accessory bile duct variants and preoperative techniques for detecting such ducts is warranted.

Treatment of postoperative accessory bile duct injury by fibrin glue and balloon tamponade: a case report

Laparoscopic cholecystectomy has become the gold standard for the treatment of symptomatic cholelithiasis. Iatrogenic bile duct injuries are still a diagnostic and therapeutic problem and their incidence increased with the introduction of laparoscopic technique. This case report documents a patient with a biliary fistula from an accessory bile duct - Lushka's duct - after routine laparoscopic cholecystectomy, unresponsive to relaparoscopy, ERCP with papillosphincterotomy, biliary stent and nosobiliary tube placement and finally treated with injection of fibrin glue and balloon tamponade through the external drain. Iatrogenic bile duct injuries remain a challenging problem, in particular when they do not communicate with central biliary tree. The detection of this fistulas is more difficult and their management should be multidisciplinary. This case presentation is to emphasize importance of correct diagnostic evaluation and timely and adequate non-surgical methods of treatment of biliary fistulas. (www.actabiomedica.it).

Ducts of Luschka as a rare cause of postoperative biloma. MRCP findings

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.

Luschka Duct Leak: An Unexpected Cause of Choleperitoneum After Liver Transplant

The anatomic variabilities in ducts of Luschka put patients at risk during hepatobiliary surgery. Clinically relevant bile leakage is the cause of 0.4% to 1.2% of complications of cholecystectomies, with almost one-third of complications caused by an inadvertent injury to the duct of Luschka. However, bile leakage from a duct of Luschka after liver transplant is rare, and only one previously published report has been found. Here, we report a case of a 67-year-old male patient who underwent liver transplant for cirrhosis due to hepatitis C virus infection. After transplant, the patient had a choleperitoneum caused by bile leakage from a duct of Luschka. The donor surgery had been performed by surgeons from another institution, and they had also performed the previous cholecystectomy. Fifteen days after surgery, a cholangiography showed bile leakage near the anastomosis. A new intervention was decided. After confirmation of the integrity of the anastomosis, methylene blue was injected through the Kehr's tube, which escaped from a duct of Luschka. The duct was closed, and an intraoperative cholangiography confirmed that the biliary tree was intact. After this intervention, a new bile leakage was observed, resulting in an endoscopic retrograde cholangiopancreatography scan and sphincterotomy. The Kehr's tube was kept open until leak resolution. Although unusual after liver transplant, this complication should be considered in cases of bile leakage. The ducts of Luschka are difficult to see during cholecystectomy in the graft due to perivesicular edema.

Intraoperative Treatment of Duct of Luschka during Laparoscopic Cholecystectomy: A Case Report and Revision of Literature

Background

Bile leakage still remains a serious complication during cholecystectomies. In limited cases, this complication may occur from injury of the so-called ducts of Luschka. These rare ducts are usually discovered intraoperatively, and their presence poses the risk of bile injury and clinically significant bile leak.

Presentation Case

We present a unique case of a 59-year-old male patient with acute cholecystitis. After removal of the gallbladder, thorough inspection of the hepatic bed was made and a little bile leak was identified from a duct of Luschka 1 cm away from the gallbladder hilum. We report on the use of endoscopic QuickClip Pro® clips (Olympus Medical Systems Corp., Tokyo, Japan) to avoid further more invasive treatment.

Discussion

Endoscopic retrograde cholangiopancreatography with sphincterotomy played a crucial role for diagnosis and treatment of bile leaks with success rate near 94%. Many authors have argued the role of relaparoscopy, Diagnosis may be intraoperatively but this option does not seem to occur very often; in fact, there is a lack of data in literature.

Conclusion

This is the first case report of bile leak from duct of Luschka treated during the cholecystectomies with endoscopic clip.

Aberrant subvesical bile ducts identified during laparoscopic cholecystectomy: A rare case report and review of the literature

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Aberrant subvesical bile ducts are a rare anatomical variation defined as a network of bile ducts located in the peri-hepatic tissue of the gallbladder fossa.

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Their injury is almost inevitable and it leads to bile leakage, which is a life-threatening complication of laparoscopic cholecystectomy.

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Meticulous operative technique and detailed exposure of the operative field is the cornerstone of a safe laparoscopic cholecystectomy, when surgeons encounter this rare anatomical variation.

Introduction

Aberrant subvesical bile ducts are a scarce anatomical variation, consisted by a network of bile ducts located in the peri-hepatic capsule of the gallbladder fossa. These rare ducts are usually discovered intraoperatively and their presence poses the risk of bile injury and clinically significant bile leak.

Presentation of case

Aberrant subvesical bile ducts were unexpectedly identified in a young woman during laparoscopic cholecystectomy. These three ducts were clipped carefully for avoidance of bile duct injury and subsequent bile leak. The operation was uneventful. A meticulous review of the recent literature was conducted as well.

Discussion

This unusual anatomical variation of the biliary tract is mainly discovered during the operation. Thus, surgical injury of these ducts is nearly inevitable and it provokes the severe complication of bile leak. Bile injury represents the most crucial and life-threatening postoperative complication of cholecystectomies. Surgeons in the right upper quadrant of the abdomen should be constantly aware of this rare anatomical variation.

Conclusion

Aberrant subvesical bile ducts are associated with a high risk of surgical bile duct injury. Nevertheless, meticulous operative technique combined with surgeons’ perpetual awareness concerning this peculiar anatomical aberration leads to a safe laparoscopic cholecystectomy.

Endoscopic management of bile leakage after liver transplantation

BACKGROUND/AIMS

Endoscopic retrograde cholangiopancreatography (ERCP) can be an effective treatment for bile leakage after liver transplantation. We evaluated the efficacy of endoscopic treatment in liver transplantation in patients who developed bile leaks.

METHODS

Forty-two patients who developed bile leaks after liver transplantation were included in the study. If a bile leak was observed on ERCP, a sphincterotomy was performed, and a nasobiliary catheter was then inserted. If a bile leak was accompanied by a bile duct stricture, either the stricture was dilated with balloons, followed by nasobiliary catheter insertion across the bile duct stricture, or endoscopic retrograde biliary drainage was performed.

RESULTS

In the bile leakage alone group (22 patients), endoscopic treatment was technically successful in 19 (86.4%) and clinically successful in 17 (77.3%) cases. Among the 20 patients with bile leaks with bile duct strictures, endoscopic treatment was technically successful in 13 (65.0%) and clinically successful in 10 (50.0%) cases. Among the 42 patients who underwent ERCP, technical success was achieved in 32 (76.2%) cases and clinical success was achieved in 27 (64.3%) cases.

CONCLUSIONS

ERCP is an effective and safe therapeutic modality for bile leaks after liver transplantation. ERCP should be considered as an initial therapeutic modality in post-liver transplantation patients.

What is the duct of Luschka?--A systematic review

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.

A study of the subvesical bile duct (duct of Luschka) in resected liver specimens

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.

Bile leaks from the duct of Luschka (subvesical duct): a review

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.

Heterogeneity of subvesical ducts or the ducts of Luschka: a study using drip-infusion cholangiography-computed tomography in patients and cadaver specimens

The objective of this study was to examine the heterogeneity of the subvesical duct or the ducts of Luschka as well as the reliability of drip-infusion cholangiography with computed tomography (DIC-CT) for their identification. DIC-CT was used in 277 consecutive patients (135 men, 142 women) and for the dissection and histologic study of 10 cadaver livers. We found 32 subvesical ducts in 28 (10.1%) of 277 patients. Irrespective of whether the terminals were extra- or intraparenchymal, the subvesical ducts often (17/32 ducts, 15/28 patients) drained into a subsegmental duct of S5 or S4. Notably, some displayed an "intermediate" course along the gallbladder fossa with an intraparenchymal origin and terminated at S5. Such ducts tended to be seen in the elderly. Another 15 ducts drained into a thick, centrally located duct, such as the right sectorial or hepatic duct. The anatomic study demonstrated that the subvesical duct likely included the cystic vein-concomitant duct. A major type of subvesical duct, characterized by an intermediate course along its bed, appeared to result from degenerative exposure of a peripheral duct with aging. The subvesical duct draining into the thick duct included both a "daughter branch," such as seen in the lung, and the so-called anomaly. Such ducts can be demonstrated with DIC-CT, but the incidence might be limited. However, the cystic vein/concomitant duct was difficult to identify radiologically. Consequently, although presurgical radiology is useful for avoiding bile leakage after laparoscopic cholecystectomy, surgeons should be aware of its limitations.