AJR 2003; 180:694-696
© American Roentgen Ray Society
Bile Duct of Luschka Connecting with the Cystohepatic Duct: The Importance of Cholangiography During Surgery
Taku Aoki1,
Hiroshi Imamura1,
Yoshihiro Sakamoto1,
Kiyoshi Hasegawa1,
Yasuji Seyama1,
Keiichi Kubota2 and
Masatoshi Makuuchi1
1 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.
2 Second Department of Surgery, Dokkyo University School of Medicine, 880 Mibu,
Tochigi 321-0293, Japan.
Received July 15, 2002;
accepted after revision August 20, 2002.
Address correspondence to T. Aoki.
Introduction
The anatomy of the biliary system is highly variable, and some of these
variations and anomalies can be problematic for surgeons. Surgery carried out
in ignorance of such anomalies can result in accidental injury to the patient
or to inadequate ligation of these ducts. As a result, persistent bile leakage
or segmental biliary obstruction may occur. Operative cholangiography has been
used to help avoid these complications. The clear characterization of an
individual's biliary anatomy offered by operative cholangiography provides
important information regarding anomalous bile ducts. Among various biliary
anomalies, the bile duct of Luschka and the cystohepatic duct have received
attention because of their vulnerable position during cholecystectomy
[1,
2,
3]. Using operative
cholangiography, cadaver livers, or casts, several investigators have reported
in detail the prevalence and patterns of draining of the bile duct of Luschka
and the cystohepatic duct [1,
2,
4]. However, the significance
of these aberrant bile ducts has recently been reevaluated in the present
laparoscopic era [3].
In general, the bile duct of Luschka is a thin, short, vestigial bile duct
lying in the gallbladder bed
[1]. In contrast, the
cystohepatic duct is a thick aberrant hepatic duct that frequently travels in
the triangle of Calot [2,
3]. We present the case of an
elderly woman in whom the bile duct of Luschka acted as an intrahepatic
communicating duct between the cystohepatic duct and the hepatic duct of the
right paramedian sector of the liver (liver segments V and VIII according to
Couinaud's nomenclature). We focus particularly on the findings of operative
cholangiography.
Case Report
A 79-year-old woman was admitted to our hospital for investigation of
severe anemia. Gastroendoscopy revealed a large tumor with a deep ulcer, later
shown at biopsy to be adenocarcinoma, at the ampulla of Vater. She was
diagnosed with carcinoma of the ampulla of Vater, and pancreaticoduodenectomy
was performed for radical resection.
At surgery, unexpected bile leakage occurred when the gallbladder was
dissected from the gallbladder fossa. Pinhole bile leakage in the gallbladder
fossa was halted by suture closure. The cystic duct was found to be joined to
an aberrant hepatic duct that was separate from the common hepatic duct, so
the cystic duct was ligated and divided proximal to its junction with the
aberrant hepatic duct. After cholecystectomy, the common hepatic duct and the
aberrant hepatic duct were transected separately proximal to their confluence
(Fig. 1A).
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Fig. 1A. —79-year-old woman with rare combination of biliary anomalies.
Photograph taken during pancreaticoduodenectomy shows biliary anomalies.
Gallbladder was removed, and cystic duct was ligated and divided proximal to
its junction with aberrant hepatic duct (white arrowhead). Common
hepatic duct (black arrow) and aberrant hepatic duct (white
arrow) were transected separately. Probe is inserted through stump of
aberrant hepatic duct. Pinhole bile leakage in gallbladder bed was sutured
(black arrowhead). CHA = common hepatic artery, RHA = replaced right
hepatic artery, P = body of pancreas, SMV = superior mesenteric vein.
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Operative cholangiography performed through the stump of the aberrant
hepatic duct showed that this duct ran into the gallbladder fossa and drained
a portion of the right lateral sector of the liver, that is, the cystohepatic
duct. Successively, a meshwork of bile ducts was visualized (the bile duct of
Luschka). In addition, the contrast medium flowed into the hepatic duct of the
right paramedian sector via the ductules, known as the bile duct of Luschka.
The pinhole bile leakage in the gallbladder bed, which was previously sutured,
was revealed to be caused by a branch of the bile duct of Luschka
(Fig. 1B). In contrast,
cholangiography performed through the stump of the common hepatic duct
revealed the hepatic duct of the right lateral sector first, followed by the
hepatic duct of the right paramedian sector and the left hepatic duct
(Fig. 1C). The bile duct of
Luschka was not visualized on cholangiography performed through the common
hepatic duct. These findings led us to conclude that the bile duct of Luschka
was an intrahepatic communicating bile duct between the cystohepatic duct and
the hepatic duct of the right paramedian sector
(Fig. 1D). Because it was
thought that the region drained by the cystohepatic duct could be drained from
the hepatic duct of the right paramedian sector via the bile duct of Luschka,
the stump of the cystohepatic duct was closed by transfixion sutures.
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Fig. 1B. —79-year-old woman with rare combination of biliary anomalies.
Operative cholangiogram obtained through stump of aberrant hepatic duct shows
that aberrant duct is cystohepatic duct. Thereafter, bile duct of Luschka
(asterisk) is visualized, followed by hepatic duct of right
paramedian sector and left hepatic duct. Sutured bile duct in gallbladder
fossa is branch of bile duct of Luschka (arrowhead). Arrows indicate
order of opacification. LHD = left hepatic duct, Para = hepatic duct of right
paramedian sector.
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Fig. 1C. —79-year-old woman with rare combination of biliary anomalies.
Operative cholangiogram obtained through common hepatic duct shows hepatic
duct of right lateral sector, hepatic duct of right paramedian sector, and
left hepatic duct, in that order. Bile duct of Luschka is not visualized. Para
= hepatic duct of right paramedian sector, LHD = left hepatic duct, Lat =
hepatic duct of right lateral sector.
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Fig. 1D. —79-year-old woman with rare combination of biliary anomalies.
Schema of biliary system shows bile duct of Luschka (asterisk) acting
as intrahepatic communicating branch between cystohepatic duct and hepatic
duct of right paramedian sector. Para = hepatic duct of right paramedian
sector, Lat = hepatic duct of right lateral sector, LHD = left hepatic duct,
CHD = common hepatic duct, GB = gallbladder.
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The postoperative course was uneventful, and there was no complication
during the follow-up period. The patient died 29 months after the operation
because of tumor recurrence.
Discussion
Anomalous bile ducts in the gallbladder fossa have conventionally been
classified into two types: the bile duct of Luschka and the cystohepatic duct.
The bile duct of Luschka has been described as a slender bile duct, 1-2 mm in
diameter, that drains a variably sized portion of the right lateral sector of
the liver to empty into the right hepatic duct or the common hepatic duct
[1,
2,
3]. Previous reports have shown
that the bile duct of Luschka reaches the adventitial layer of the gallbladder
bed but does not enter the gallbladder lumen (a subvesical duct)
[1,
3]. Histologic examination
reveals that the bile duct of Luschka is a meshwork of tiny ductules rather
than a single duct [1]. The
prevalence of the bile duct of Luschka has been estimated at one third of the
population according to an autopsy study
[1,
4]. Meanwhile, the cystohepatic
duct has been described as a thick bile duct that drains a variable amount of
the parenchyma of the right liver
[2,
3]. It has been reported that
this duct frequently courses through the gallbladder fossa and that it
typically empties into the cystic duct or the right hepatic duct
[3]. The prevalence of the
cystohepatic duct has been estimated at 1-2% of the surgical cases
[2].
The liver, hepatic ducts, gallbladder, and extrahepatic biliary system
arise from the hepatic diverticulum, which develops by the beginning of the
fourth embryonic week as an endodermal outgrowth from the ventral aspect of
the caudalmost foregut [5]. The
ventral part of the diverticulum develops into the gallbladder and the cystic
duct. The cranial part of the diverticulum invades the septum transversum as
the liver primordium. The liver primordium proliferates to form the liver
cells and the epithelial lining of the intrahepatic biliary ducts. The hepatic
ducts are also formed by these proliferating cells, initially as a plexus.
Later (in the 4- to 5-week embryo), many of these ducts involute to form the
definitive hepatic duct pattern, but one or more may persist as ducts draining
a small portion of the liver. The bile duct of Luschka and the cystohepatic
duct are left as a result of atypical resorption of the initially plexiform
arrangement of the hepatic ducts
[2,
5].
Our case is unique in that both the bile duct of Luschka and the
cystohepatic duct were present and that the bile duct of Luschka, which is
generally vestigial, acted as an intrahepatic communicating duct between the
cystohepatic duct and the hepatic duct of the right paramedian sector. To the
best of our knowledge, this is the first report of the bile duct of Luschka
acting as an intrahepatic communicating branch between an aberrant hepatic
duct and the main biliary branch of the liver. In this case, the bile duct of
Luschka was found to be a meshwork of tiny ductules, whereas the cystohepatic
duct was shown to be a thick bile duct, about 3 mm in diameter. These
observations are consistent with previous reports
[1,
2]. The anatomic relationship
among the bile ducts, including the connection between the bile duct of
Luschka and the cystohepatic duct, was revealed clearly by operative
cholangiography. In general, an aberrant hepatic duct is the only route of
drainage of the related hepatic region
[2], so careful preservation of
the aberrant duct is required to avoid postoperative bile leakage,
cholangitis, or atrophy of the associated territory, especially in a patient
with poor hepatic functional reserve. However, in this particular patient,
suture closure of the cystohepatic duct was justified on the basis of the
observation that the related hepatic region could be drained via the bile duct
of Luschka. It is recommended that all the branches of the biliary system are
examined intraoperatively when a biliary tract anomaly is suspected.
In conclusion, we presented a rare combination of the bile duct of Luschka
and the cystohepatic duct. The importance of operative cholangiography is
emphasized.
References
- McQuillan T, Manolas SG, Hayman JA, Kune GA. Surgical significance
of the bile duct of Luschka. Br J Surg
1989;76:696
-698[Medline]
- Champetier J, Létoublon C, Alnaasan I, Charvin B. The
cystohepatic ducts: surgical implications. Surg Radiol
Anat 1991;13:203
-211[Medline]
- 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
-196[Medline]
- Healey JE, Schroy PC. Anatomy of the biliary ducts within the human
liver. Arch Surg
1953;66:599
-616
- Schneck CD. Embryology, histology, gross anatomy, and normal
imaging anatomy of the gallbladder and biliary tract. In: Friedman AC, Dachman
AH, eds. Radiology of the liver, biliary tract, and
pancreas. St. Louis: Mosby-Year Book, 1994:355
-376
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Introduction
Case Report
