Endoscopic Stenting as First-Line Treatment in Duct of Lushka Leaks after Choledochocystic Anastomosis in Two Cases of Liver Transplantation

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.

Rapid-sequence endoscopic management of posttransplant anastomotic biliary strictures

BACKGROUND

Post-liver-transplant anastomotic biliary strictures generally have been managed through ERCP with gradual balloon dilation and placement of multiple stents over an extended period of time.

OBJECTIVE

Our purpose was to evaluate the long-term outcome of rapid sequence dilation and to shorten the duration of stenting as a therapy for anastomotic biliary strictures.

DESIGN

Prospective case series.

SETTING

Academic tertiary referral center.

INTERVENTIONS

ERCP with rapid-sequence balloon dilation of post-liver-transplant anastomotic biliary strictures followed by stenting with multiple stents over a short time period.

MAIN OUTCOME MEASUREMENT

Long-term anastomotic stricture resolution.

RESULTS

Thirty-eight patients were prospectively enrolled into a standardized ERCP treatment protocol. The mean number of ERCPs per patient was 3.4 (range 2-6), the mean number of maximum stents inserted was 2.5 (range 1-6), and the mean total stenting period was 107 days (range 20-198 days); the mean follow-up time from completion of the endoscopic therapy was 360 days (range 140-1347 days). Long-term stricture resolution was achieved in 33 of the 38 (87%) patients.

LIMITATIONS

Lack of control group, relatively small patient population.

CONCLUSIONS

Accelerated dilation and shorter total length of stenting leads to long-term success in the majority of patients with post-liver-transplant anastomotic biliary strictures.