A 70 year old man with many co-morbidities (ischaemic heart disease, cardiomyopathy, atrial fibrillation, pacemaker / implantable cardioverter defibrillator (ICD) in situ, on Apixaban) had a laparoscopic cholecystectomy 7 days ago. There was a thick walled gallbladder and adhesions present. The operation was apparently straightforward. An on table cholangiogram was not performed and a sub-hepatic drain was not inserted. A couple of days post-op he became unwell with abdominal pain, collapse and hypotension (?septic). He then developed jaundice and blood tests were as follows:
– Bilirubin 114 umol/L , ALT 24, Alk Phosp 190 (NR less than130)
– Hb 9.4 g/dL, WBC 7, platelets 170
– CRP 270
An MRCP could not be done because of his pacemaker/ICD. The surgeons assumed there was a retained bile duct stone and referred him directly for an ERCP (ultrasound not performed either).
On arrival to the endoscopy unit, the patient looked unwell. A cautious ERCP without sedation was performed. The patient could only manage to get into a sub-optimal left lateral position and not the standard ERCP position. To make matters worse, biliary cannulation proved difficult requiring PD stenting and needle knife pre-cut/ fistulotomy. However, the effort was worth it as cholangiography revealed an unusual type of biliary leak (see video)…
Bile leaks occur in 0.2-2% of laparoscopic cholecystectomy (1). The commonest site of a leak is the cystic stump. The subvesical bile ducts, are small ducts (1-2mm diameter) which originate from the right hepatic lobe, course along the gallbladder fossa and usually drain into the extra hepatic bile ducts. They occur in about 10% of the population and were originally described by Ferrein in 1753 and in more detail by the German anatomist, Hubert von Luschka, in 1863 (2). Injury to these ducts is the second commonest cause of post cholecystectomy bile leak. Recent studies suggest that about 27% of clinically relevant bile leaks are caused by inadvertent injury to a subvesical bile duct with an estimated incidence of clinically relevant subvesical bile duct leaks after cholecystectomy in 1 of every 633 operations (3).
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. In his textbook, Luschka described two different tubular structures associated with the wall of the gallbladder (2). The first type of tubular structure consisted of intra-mural glands draining into the gallbladder lumen, later termed “Luschka crypts.” The second type of tubular structure consisted of a network of microscopic ducts within the soft tissue surrounding the gallbladder. Over the years, small subvesical bile ducts were termed“ducts of Luschka” despite the discrepancy with Luschka’s original publication.
Schnelldorfer et al state that the term “ducts of Luschka” should be abandoned and replaced by the “correct” term of “subvesical bile duct” (3). The variability in anatomic location of subvesical bile ducts puts them at risk during hepato-biliary operations. In general, most subvesical bile ducts are part of the biliary system of the right hepatic lobe and part of the duct traverses in close contact with the gallbladder fossa.
Four distinct anatomical variations of subvesical ducts have been described (3):
Type 1—segmental or sectorial subvesical bile duct.
Bile duct with unusual superficial course in proximity to gallbladder fossa, but otherwise typical anatomy
Type 2—accessory subvesical bile duct.
Bile duct supernumerary from the formal biliary tree
Type 3— hepaticocholecystic bile duct.
Bile duct that drains directly into the gallbladder
Type 4—aberrant subvesical bile duct.
Network of small bile ducts within the connective tissue/capsule of the gallbladder fossa
Subvesical bile duct leaks can be detected by drip-infusion cholangiography using computed tomography (DIC-CT) preoperatively, direct visualization or cholangiography intraoperatively, and fistulography, ERCP, and MRCP with intravenous contrast postoperatively (1,4). 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/or 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.