S2544 Bile Leak from the Duct of Luschka Following Liver Transplantation

Abstract

Introduction: Bile leaks following cadaveric orthotropic liver transplantation (OLT) have a reported incidence of 2.7%. Leaks most commonly occur at the choledochocholedochostomy and cholangiojejunostomy sites. Bile leaks from an accessory cystic duct (duct of Luschka) represent the second most common etiology of post-cholecystectomy leaks but a rare etiology following OLT with an incidence of 0.74%. Only 2 cases of bile leaks following OLT from duct of Luschka are reported. Case Description/Methods: We report a case of an infected biloma secondary to a biliary leak from an accessory cystic duct following cadaveric OLT in a 35-year-old male transplanted for alcoholic cirrhosis. Intra-operatively, standard cavo-cavostomy, portal vein, and arterial anastomoses were performed. A donor cholecystectomy was performed by sharp dissection and standard cystic artery and duct ligation. A combined cyst and hepatic donor duct to recipient common bile duct anastomosis eliminated a pre-existing size mismatch. Immunosuppression consisted of a methylprednisolone, tacrolimus, and mycophenolate mofetil. On post-operative day 15, persistent alkaline phosphatase elevation to 185 U/L and hyperbilirubinemia to 5.1 mg/dL prompted evaluation with a magnetic resonance cholangiopancreatogram. This demonstrated fluid collections in the gallbladder fossa (7.3x7.6 cm) and within the porta hepatis (6.2x4.9 cm), no biliary duct dilatation and patent vasculature. He developed a low-grade fever and blood cultures eventually yielded Vancomycin-sensitive E. Faecium (VSE). An endoscopic retrograde cholangiopancreatogram (ERCP) was performed demonstrating no biliary duct stricture but an active leak from an accessory cystic duct (duct of Luschka) (Figure 1). A 5-mm biliary sphincterotomy was followed by a 10 Fr stent placement 9 cm into the common hepatic duct. Ultrasound-guided aspiration of the porta hepatis and gallbladder fossa collections confirmed the biloma diagnosis and fluid cultures of the latter demonstrated VSE. Percutaneous drains were inserted, and intravenous Vancomycin was continued. Four days following ERCP, alkaline phosphatase improved to 155 U/L, aspartate aminotransferase to 19 U/L, alanine aminotransferase to 28 U/L and bilirubin to 3.0 mg/dL. Discussion: An accessory cystic duct occurs in 5-30% of the population and is a critical anatomic variation to consider during cadaveric OLT. We also illustrate the feasibility of a combined endoscopic and radiologic therapeutic approach in case such a leak arises.Figure 1.: Fluoroscopic image demonstrating active extravasation from an accessory cystic duct (duct of Luschka) during the endoscopic retrograde cholangiopancreatogram (ERCP).