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Management of Accessory Hepatic Ducts in Choledochal Cysts

By K.L. Narasimhan, S.K. Chowdhary, and K.L.N. Rao

Chandigarh, India

This report describes the surgical management of 2 children with fusiform choledochal cysts who had accessory hepatic ducts (AHD) identified during excisional surgery for fusiform choledochal cysts (CC).Two children presenting with a triad of recurrent jaundice, fever, and abdominal pain were inves- tigated and found to have type 1 choledochal cyst. Preoper- ative imaging and intraoperative cholangiography missed the AHD in both cases. In one of the patients, the main and the accessory ducts were separated by the right hepatic artery. In both the patients the accessory ducts were recon- structed successfully into a Roux loop along with the main common hepatic duct. Follow-up studies showed no evi-

dence of biliary tract obstruction or atrophic changes in the liver. There was satisfactory uptake and drainage on hepatic scintigraphy. During excision of CC, AHD may be encoun- tered. These may be missed on preoperative imaging. AHD may have a close relationship with neighboring vascular structures in the porta. Accessory hepatic ducts should be anticipated, identified, and reimplanted into the Roux loop during excisional surgery. J Pediatr Surg 36:1092-1093. Copyright © 2001 by W.B. Saunders Company.

INDEX WORDS: Choledochal cysts, accessory hepatic ducts.

A CCESSORY HEPATIC DUCTS (AHD) may be en- countered during excisional surgery of choledochal

cyst (CC). These are seldom seen on preoperative imag- ing and can be missed during excisional surgery for CC. The aim of this presentation is to discuss the importance of intraoperative identification of the accessory duct and its appropriate management. We encountered 2 children whose AHDs were reconstructed successfully during ex- cision of choledochal cyst.

CASE REPORTS

Of the 15 choledochal cysts operated on by the first author, 2 patients had associated accessory hepatic ducts.

Case 1

A 2-year-old girl had abdominal distension, fever, and intermittent jaundice of 4 months’ duration. On examination she was anicteric, and there was a cystic right upper quadrant mass extending down into the pelvis. The total serum bilirubin level was 2.8 mg/dL and conjugated fraction was 2.1 mg/dL. The serum alkaline phosphatase was raised. The prothrombin time was prolonged, and this was corrected with preoperative injection vitamin K. Abdominal ultrasound scan showed a dilated common bile duct suggestive of choledochal cyst (type 1). CT scan of the abdomen showed a huge choledochal cyst, but the accessory hepatic duct was not seen. A preoperative cholangiogram showed a huge fusiform choledochal cyst. At surgery, a fusiform choledochal cyst 15 cm 8 cm 7 cm 3 was noted, which was excised. The common hepatic duct was 1.5 cm in

From the Department of Pediatric Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India. Address reprint requests to Dr K.L. Narasimhan, Associate Profes- sor, Department of Pediatric Surgery, PGIMER, Chandigarh 160 012, India. Copyright © 2001 by W.B. Saunders Company

0022-3468/01/3607-0032$35.00/0

doi:10.1053/jpsu.2001.24767

diameter, and there was a 4-mm accessory hepatic duct arising from the left lobe. Both the ducts were implanted separately into the Roux loop (Fig 1). Postoperative HIDA scan of the liver showed good hepatocyte function and unobstructed drainage of the radiotracer into the intes- tines. The child is anicteric and well 3 years after the surgery.

Case 2

A 2 1/2-year-old boy presented with recurrent attacks of fever and abdominal pain of 6 months duration. On examination, he was anic- teric. The liver was enlarged 3 cm below the costal margin in the mid clavicular line. Liver function tests showed a serum bilirubin level of 2.3 mg/dL (conjugated fraction, 1.9 mg/dL). The liver enzyme levels were normal, and the alkaline phosphatase value was marginally raised. The endoscopic retrograde cholangiopancreaticogram (ERCP) showed a long fusiform choledochal cyst (Fig 2). The coagulation profile was normal. The child was operated on after administrated preoperative vitamin K injection and antibiotics. During excisional surgery for choledochal cyst, an accessory hepatic duct draining the left lobe was encountered behind the common hepatic duct separated by the right hepatic artery (Fig 3). The common hepatic duct and the AHD were joined together as illustrated and implanted into the Roux loop (Fig 3). Postoperative HIDA scans showed good hepatocyte function and drainage into the intestines. The child is well 2 years after the surgery.

DISCUSSION

An AHD is an extrasegmental or subsegmental bile duct that often drains a part of the liver and joins the biliary system at any level such as the cystic duct, gall bladder, common hepatic duct, or common bile duct. 1 The incidence varies from 1% to 31% in different oper- ative and autopsy series. 1 AHD may be unrecognized preoperatively and missed during surgery. This may result in bile leakage from the drain or biliary peritonitis after excisional surgery for CC. 2-5 There are reports in which the AHD joined the common bile duct very low down close to the junction with pancreatic duct and was

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Journal of Pediatric Surgery, Vol 36, No 7 (July), 2001: pp 1092-1093

ACCESSORY HEPATIC DUCTS IN CHOLEDOCHAL CYSTS

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ACCESSORY HEPATIC DUCTS IN CHOLEDOCHAL CYSTS 1093 Fig 1. Diagrammatic representation of CHD and AHD is

Fig 1. Diagrammatic representation of CHD and AHD is reim- planted into the Roux loop in case 1.

very small. This was missed during excisional surgery. These patients presented with persistent postoperative pain and recurrent pancreatitis. They were picked up by a postoperative ERCP. These patients have been treated successfully with sphincterotomy and without open sur- gery. 4,5 There are few reports of AHD in associated with choledochal cysts. 4,5 They are rarely diagnosed preoper- atively. There is one report of AHD being diagnosed by intraoperative cholangiography. 4 It is not easy to detect an accessory hepatic duct, because it may be markedly

ACCESSORY HEPATIC DUCTS IN CHOLEDOCHAL CYSTS 1093 Fig 1. Diagrammatic representation of CHD and AHD is

Fig 2. ERCP in case 2 shows fusiform choledochal cyst.

ACCESSORY HEPATIC DUCTS IN CHOLEDOCHAL CYSTS 1093 Fig 1. Diagrammatic representation of CHD and AHD is

Fig 3. (A) Diagrammatic representation of the AHD separated from common hepatic duct by right hepatic artery in case 2. (B) The main and accessory hepatic ducts were anastomosed side to side before being implanted into the Roux loop.

displaced by the dilated choledochal cyst or may be overshadowed by the dense shadow of the choledochal cyst. It also is difficult to detect accessory hepatic duct by ultrasound scan and CT scan preoperatively. Hence, attention must be paid to the possible presence of an AHD during every operation for CC. Care must be taken not to damage it, and, when found, it must be anasto- mosed meticulously to a Roux loop with a rim of the ductal tissue. Reconstructive surgery almost always is feasible, and simple ligation of AHD is not recom- mended. However, AHD drains only a part of the liver, and ligation may result in atrophy of the involved seg- ments, cholangitis, or liver abscess. During every oper- ation for excision of CC, AHD must be looked for and meticulously reconstructed.

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