Duct Of Luschka Research Articles

Duct of Luschka leak: A postoperative complication of cholecystectomy.

Bile leakage is a serious early postoperative complication of cholecystectomy. A leak in the duct of Luschka, though rare, can cause significant patient morbidity after a cholecystectomy. Early recognition of this uncommon complication allows for early therapeutic intervention.

One-step technique for endoscopic ultrasound-guided hepaticogastrostomy using a partially covered metal stent for superficial bile duct access.

One-step technique for endoscopic ultrasound-guided hepaticogastrostomy using a partially covered metal stent for superficial bile duct access.

Transpancreatic Sphincterotomy After Double Guidewire Technique Was Noninferior to Primary Transpancreatic Sphincterotomy in Difficult Biliary Cannulation.

When unintentional pancreatic duct access occurs during difficult biliary cannulation, the double guidewire (DGW) or transpancreatic sphincterotomy (TPS) may be utilized. DGW can be easily switched to TPS due to the existing guidewire in the pancreatic duct. However, the efficacy of TPS after DGW, named sequential DGW-TPS technique, versus primary TPS has not been assessed. Our aim was to compare the benefits and adverse events of sequential DGW-TPS technique and primary TPS. We performed a comparative retrospective cohort study that enrolled a total of 117 patients with native papillae. The patients were divided into one of 2 groups according to the primary bile duct access technique (sequential DGW-TPS or primary TPS), both with pancreatic stenting. Between November 2017 and May 2023, a total of 84 patients were grouped into sequential DGW-TPS and 33 into primary TPS. The overall post-ERCP pancreatitis (PEP) rate was 4.3% in the entire cohort, with no statistical differences were observed between the groups in terms of PEP rates (P = 0.927), PEP severity (P = 1.000), first biliary cannulation success (P = 0.621), overall cannulation success (P = 1.000), hyperamylasemia incidence (P = 0.241), elevated amylase levels (P = 0.881), and postoperative hospital stay (P = 0.185). Furthermore, these results remained consistent in multivariable regression analysis. The sequential DGW-TPS technique showed a comparable safety and biliary cannulation success rate to primary TPS in difficult biliary cannulation. Given the potential long-term complications associated with TPS, DGW should be first if inadvertent pancreatic access occurs, with TPS serving as second only if DGW fails.

Biliary Leak from Ducts of Luschka: Systematic Review of the Literature

Injury to the Luschka ducts (LDs), also named “subvesicular” ducts, is an under-reported cause of biliary leak following laparoscopic cholecystectomy (LC). A systematic literature search according to PRISMA guidelines was conducted in PubMed, EMBASE and Cochrane Library including all publications that described a bile leak from an LD. A total of 136 articles were retrieved from the searched databases. After the removal of duplicates and non-eligible papers, 48 studies reporting 231 leaks were included: 20 (41.6%) case reports, 2 (4.3%) comparative studies, 7 (14.9%) meeting abstracts and 19 (40.4%) retrospective cohort articles. The rate of LD leak ranges from 0.05% to 1.9%, but injury to a duct of Luschka was the second most common cause of biliary leakage in all the cohort studies (5.5% to 41%). In 21 (43.7%) cases, the leak was successfully treated with a sphincterotomy through Endoscopic Retrograde Cholangiopancreatography (ERCP) plus or minus stenting, and in 12 (25%), re-laparoscopy was necessary.

Laparoscopic Common Bile Duct Exploration for Multiple Large Common Bile Duct Stones: A Case Report with Review of Literature

Endoscopic retrograde cholangio pancreatography (ERCP) followed by laparoscopic cholecystectomy (LC) in 2 different sessions, is the widely followed standard sequence of surgical procedures for concurrent gall bladder and common bile duct (CBD) stone disease, across the world. However, being highly technical, skillful and technology dependant, ERCP, sometimes, does not succeed even in the best of hands. This can happen due to abnormal local anatomy (eg. Previous Billroth II gastrectomy, previous surgical scars which distort the duodenum etc.) and unfriendly stone morphology such as a very large stone or a large number of stones. Failure to extract/retrieve bile duct stones at ERCP is an indication for CBD exploration (open or laparoscopic) at surgery. Herein, we present one such case of a 67 year old woman who had previously undergone surgery – laparoscopic cholecystectomy for gall stone disease 3 years back. She presented to us with a common bile duct loaded with multiple large stones. Inspite of undergoing ERCP (2 attempts over 48 hours), a common bile duct access could not be achieved endoscopically, thereby rendering endotherapy unsuccessful. She then underwent a successful totally laparoscopic CBD exploration, using standard laparoscopy instruments, some endoscopy accessories like endo-balloon & dormia basket and intraoperative fluoroscopy.

Abnormality of the Bile Tract (Luschka Duct): Case Report and Literature Review

Abnormality of the Bile Tract (Luschka Duct): Case Report and Literature Review

Endoscopic ultrasound-rendezvous versus percutaneous-endoscopic rendezvous endoscopic retrograde cholangiopancreatography for bile duct access: Systematic review and meta-analysis.

Endoscopic ultrasound (EUS) or percutaneous-assisted antegrade guidewire insertion can be used to achieve biliary access when standard endoscopic retrograde cholangiopancreatography (ERCP) fails. We conducted a systematic review and meta-analysis to evaluate and compare the effectiveness and safety of EUS-assisted rendezvous (EUS-RV) and percutaneous rendezvous (PERC-RV) ERCP. We searched multiple databases from inception to September 2022 to identify studies reporting on EUS-RV and PERC-RV in failed ERCP. A random-effects model was used to summarize the pooled rates of technical success and adverse events with 95% confidence interval (CI). In total, 524 patients (19 studies) and 591 patients (12 studies) were managed by EUS-RV and PERC-RV, respectively. The pooled technical successes were 88.7% (95% CI 84.6-92.8%, I2 = 70.5%) for EUS-RV and 94.1% (95% CI 91.1-97.1%, I2 = 59.2%) for PERC-RV (P = 0.088). The technical success rates of EUS-RV and PERC-RV were comparable in subgroups of benign diseases (89.2% vs. 95.8%, P = 0.068), malignant diseases (90.3% vs. 95.5%, P = 0.193), and normal anatomy (90.7% vs. 95.9%, P = 0.240). However, patients with surgically altered anatomy had poorer technical success after EUS-RV than after PERC-RV (58.7% vs. 93.1%, P = 0.036). The pooled rates of overall adverse events were 9.8% for EUS-RV and 13.4% for PERC-RV (P = 0.686). Both EUS-RV and PERC-RV have exhibited high technical success rates. When standard ERCP fails, EUS-RV and PERC-RV are comparably effective rescue techniques if adequate expertise and facilities are feasible. However, in patients with surgically altered anatomy, PERC-RV might be the preferred choice over EUS-RV because of its higher technical success rate.

Duct of Luschka: A case report

Duct of Luschka: A case report

Surgical Audit of Common Bile Duct Injury During Laparoscopic Cholecystectomy in Tertiary Care Center

Objective: The current study conducted a surgical evaluation of laparoscopic cholecystectomy in a tertiary care hospital. Methods: A descriptive retrospective study was conducted at the department of surgery, JPMC between dates. All cases of patients who were above 18 years, had cholecystitis or cholelithiasis, and underwent cholecystectomy between 1st January 2013 and 31 December 2014 at Jinnah Postgraduate Medical Center were included. Only cases with complete history, examination and investigations were included. Cases with incomplete information were excluded. Sociodemographic information such as age and gender, clinical information related to biliary duct injury (BDI), causes of BDI, and risk factors for BDI were included in the study. Data was entered and analyzed using SPSS version 21. The findings were narrated in tabulated form. Result: A cumulative count of 21 bile duct injuries (BDIs) was documented, leading to an overall occurrence rate of 3.1%. Most patients (76.2% or 16 individuals) had significant injuries that affected the common bile duct (CBD), main biliary confluence, or main bile ducts. A total of 5 patients, accounting for 23.8% of the cases, had modest injuries that specifically impacted the cystic duct or smaller peripheral or Luschka ducts. The cause of the BDI was diagnosed in 71.4% of instances. Inadequate identification of anatomical features associated with the hepatic pedicle, comprising 33.3% of reported cases, was the most frequently cited cause. Subsequently, it was observed that inflammatory alterations in the gallbladder constituted 26.7% of the cases, while anatomical anomalies accounted for 13.3%. Similarly, the inappropriate application of monopolar coagulation was responsible for an additional 13.3% of the cases. Furthermore, undefined technical errors and challenges encountered during intraoperative hemorrhage management were each attributed to 6.7% of the cases. Conclusion: The present study revealed bile duct injury to be a serious and prevalent complication of laparoscopic cholecystectomy in our center. Therefore, further assessment should be taken in order to avoid occurrence of BDI in patients presenting to the public tertiary care hospitals. Keywords: Surgical audit, minimal invasive surgery, laparoscopic cholecystectomy, preoperative complications, postoperative complications, conversion to open cholecystectomy.

Improving the Safety of Laparoscopic Cholecystectomy with Indocyanine Green Dye Using Critical View of Safety Plus.

During a laparoscopic cholecystectomy, the critical view of safety is obtained through dissection of the gallbladder from the liver until there is anterior and posterior visualization of the cystic duct and cystic artery. This view is used to allow for proper identification of the cystic duct and artery that will be clipped and incised during the operation. Indocyanine green (ICG) can be used during the operation to directly visualize the biliary tract because of its excretion through the biliary system and elimination via the GI tract. Using a laparoscope capable of visualizing ICG allows for identification of bile duct anatomy to include: common hepatic bile duct, cystic duct, and aberrant, or accessory bile ducts. Additionally, visualization of the biliary structures using ICG prior to clipping and incision will allow for identification and prevention of missed biliary anatomy which could reduce incidence of bile leak, a known complication of cholecystectomies. We propose that visualization of the critical view of safety with ICG fluoroscopy be termed the critical view of safety plus. We hypothesized that using the critical view of safety plus method for laparoscopic cholecystectomy will yield better scores and increase the decision of the control surgeon to choose to cut and proceed with the operation when compared with the traditional critical view of safety. Comparision of operative photos of critical view of safety and critical view of safety plus which were randomized, double blinded, and graded by a single control surgeon. Our study consisted of fifty patients of which 72% female (n = 36) and 28% male (n = 14). The ethnic background included 76% non-Hispanic (n = 38) and 24% Hispanic or of Latino/a origin (n = 12). The average age of our patient was 49 years old (range 20 to 93 years old). Inclusion criteria consisted of patients undergoing laparoscopic cholecystectomy greater than or equal to 18 years old. Exclusion criteria included allergy to indocyanine dye or iodine and pregnancy. The scores were evaluated using Chi-squared and paired T-test analysis using MedCalc, MedCalc Sofware Ltd, Belgium. The decision to cut and proceed with the operation was chosen 29 times (58%) when viewing the critical view of safety plus vs 22 times (44%) with the critical view of safety (χ2 = 65.822, p < 0.0001). The decision to proceed with further dissection to isolate the cystic duct viewing the critical view of safety plus was chosen 8 times (16%) vs 11 times (22%) with critical view of safety (χ2 = 65.822, p < 0.0001) as shown in Fig. 2. The comparison of total scores with critical view of safety plus vs critical view of safety showed an average of 4.36 vs 4.04, p = 0.0733. The critical view of safety plus and critical view of safety individual criteria scores are: "two structures connected to the gallbladder" (average 1.54 vs 1.50, p = 0.598), "cystic plate clearance" (average 1.42 vs 1.28, p = 0.018), and "hepatocystic triangle clearance" (average 1.4 vs 1.26, p =0.0334). We recommend routine use of ICG fluoroscopy to obtain the critical view of safety plus to allow for improved visualization of the biliary tree, identification of aberrant biliary anatomy, and the potential to reduce risk of bile duct injury.

Endoscopic retrograde cholangiopancreatography versus conservative treatment of biliary leakage due to injury of Luschka duct during laparoscopic cholecystectomy

Background Gallstones remain the most common disease of gastrointestinal tract in the world. Laparoscopic cholecystectomy is one of the most common performed surgical operations. Bile leaks remain a significant cause of morbidity for patients undergoing laparoscopic cholecystectomy and these occur in 0.3–0.8% of cases. The ducts of Luschka, or subvesical ducts, are small ducts originate from the right hepatic lobe, course along the gallbladder bed, and usually drain into the extrahepatic bile ducts. Injury of these ducts is the second most frequent cause of postcholecystectomy bile leakage after cystic duct leak. Aim The aim of this study is to compare between conservative and endoscopic retrograde cholangiopancreatography (ERCP) treatment of leaked injured Luschka duct as regarding outcomes, effectiveness, and cost. Patients and methods Retrospective study included patients with postcholecystectomy biliary leakage due to Luschka duct injury from June 2015 to December 2022. Results A total of 20 patients were included in this study and classified into two groups: group A with conservative treatment was successful in eight cases within 2–3 weeks and two cases reoperated, one with relaparoscopy with drainage and one cases reoperated with open exploration and ligation of leaked duct while group B with 10 cases treated with ERCP, all patients treated successfully with ERCP sphincterotomy and stent placement and leaks stopped and discharged within third or fourth day without any morbidity, no mortality in both groups. Conclusion Treatment of biliary leakage due to injured Luschka (subvesical duct) with ERCP sphincterotomy and stent placement is safe and effective without any morbidity or mortality.

Эндоскопическая ультрасонография и транспапиллярные вмешательства у пациентов с парапапиллярными дивертикулами

Aim: to evaluate the possibilities of diagnosed during endoscopic ultrasound (EUS) in clarifying diagnosis of peripapillary diverticula (PD) and optimization of treatment tactics depending on the type of mutual location of the diverticulum and the major duodenal papilla (MDP). Patients and Methods: the study included 304 patients (186 (61.2%) female patients) with peripapillary duodenal diverticulum (PDD). By the criterion of the diverticulum and MDP mutual location, patients were divided into three groups: 195 (64.1%) patients with suprapapillary diverticulum, 59 (19.4%) — with diverticulum of the "butterfly" type, 50 (16.5%) — with intradiverticular MDP. Anatomical features of various diverticula types and associated pathology of periampullary region were studied on the basis of endosonography data, as well as the treatment results of biliary diseases, technical success and complications of transpapillary interventions in various types of diverticula were analyzed. Results and Discussion: patients with intradiverticular MDP were significantly older (69.8±4.4 years). In this group, the size of diverticula (21 mm) and dilatation of choledochus (18 mm) were larger. Patients in this group were significantly more commonly diagnosed with stenosis of the MDP and secondary choledocholithiasis. Indications for endoscopic papillosphincterotomy in patients with PDD were choledocholithiasis — 124 (57.1%), stenosis of the MDP — 44 (20.3%), diverticular compression in terminal choledochus — 49 (22.6%), EUS. The complication rate of transpapillary interventions did not significantly differ and amounted to 2.8%. However, the share of failures during MDP standard biliary cannulation and lithoextraction was higher in the intradiverticular MDP and amounted to 34.5% and 8.8%, respectively, which forced the use of rendezvous procedures that were used in 10 (34.5%) patients of this group. Conclusion: EUS is a highly informative method of diagnostic clarification in PD, providing direct visual inspection of the papillary zone and its echocardiogram. The use of EUS at the initial stage of diagnostics allows to significantly optimize the treatment tactics, determining the indications for transpapillary interventions and ensuring their rational choice. The greatest technical difficulties and failures are expected to occur during manipulations on the intradiverticular MDP, which forces the use of rendezvous procedures, antegrade common bile duct access and laparotomic interventions. KEYWORDS: peripapillary diverticulum, endoscopic ultrasound, transpapillary interventions endoscopic papillosphincterotomy, biliary hypertension. FOR CITATION: Belozerov V.A., Grigoriev N.N., Prokopov V.A., Belozerova D.E. Endoscopic ultrasound and transpapillary interventions in patients with peripapillary diverticula. Russian Medical Inquiry. 2023;7(5):258–263 (in Russ.). DOI: 10.32364/2587-6821-2023-7-5-3.

Outcome of percutaneous transhepatic biliary interventions in the management of biliary enteric anastomotic strictures with hepatolithiasis

To evaluate percutaneous transhepatic biliary interventions (PTBI) using the ADDFREE (Access-Drain-Dilate-Flush-REpeat periodically-Evaluate and remove) technique and its outcomes in patients with biliary enteric anastomotic strictures (BEAS) and hepatolithiasis. A retrospective review was undertaken of patients having hepatolithiasis with BEAS who underwent PTBI with a therapeutic intent (from January 2010 to January 2021) was performed. The technical and clinical successes of PTBI were analysed. Technical success was divided into duct access, crossing of BEAS, stricture resolution, and calculi clearance. Improvement of liver function tests, resolution of leucocytosis and presenting complaints were considered as clinical success. The patients were followed-up for a minimum duration of 6-months. Eighteen patients received PTBI in form of the ADDFREE technique. Hepatolithiasis was bilobar (44.4%), unilobar in multiple ducts (unilobar-m; 27.8%) and unilobar in a single duct (unilobar-s; 27.8%) along with anastomotic stricture. The average number of sessions of stone clearance for bilobar, unilobar-m, and unilobar-s was 4.4 (±1.6), 3.6 (±2.4), and 1.5 (±0.5), respectively. Clinical success was observed in 14 (77.8%), while one patient had recurrence of calculi and received repeat treatment. Bile culture was positive for bacterial organisms in 17 (94.4%) patients. No major complication were seen while minor complication were seen in five patients consisting of self-limiting haemobilia (n=1), per-catheter bile leak (n=2) and aggravation of cholangitis (n=2). PTBI, consisting of bile duct access, cholangioplasty, and calculi clearance, is a safe and effective technique for the treatment of patients having hepatolithiasis secondary to BEAS.

Slim-endoscopy-stabilized (SOS)-rendezvous-ERC via EUS-transgastric bile duct access: Utilization for severe pancreatitis with consecutive obstructive jaundice and inaccessible major papilla

After failed biliary cannulation via standard ERC-approach EUS-based rendezvous-ERC (EUS-RV-ERC) is a valid alternative. One of the challenging factors in this setting is the management of the guidewire. Here we propose a method, where a slim endoscope is used to stabilize the guidewire and optimize wire manipulation in a patient who underwent EUS-RV-ERC via a transgastric approach.

Choque séptico de origen biliar en la Unidad de Cuidados Intensivos

Se presenta un caso de choque séptico de origen biliar en un paciente de sexo masculino de 76 años, con antecedente de colecistitis aguda y su correspondiente resolución quirúrgica. Ingresa a la Unidad de Cuidados Intensivos (UCI) del Hospital General San Vicente de Paúl, de Ibarra, con apoyo de dispositivo de ventilación con presión positiva, RASS -5 con efectos de sedoanalgesia, presencia de acceso venoso central yugular derecho, abdomen con presencia de bolsa de Bogotá y sonda vesical permeable. Luego de 16 días en UCI, a pesar de tratamiento médico, evoluciona tórpidamente y fallece. Cabe recalcar que no se efectuaron exámenes post mortem. En términos generales, la sepsis biliar constituye la disfunción multiorgánica originada en el contexto de infección de la vía biliar principal (VBP) o vía biliar accesoria (VBA). En este caso se revisa la cronología de un paciente con diagnóstico de choque séptico de origen biliar, la clínica y el manejo. En efecto, establecer el diagnóstico tardío de colecistitis aguda determina consecuencias graves como la perforación vesicular, sepsis grave o choque séptico de origen biliar con el mal pronóstico consecuente. El tratamiento es quirúrgico y consiste en colecistectomía, lavado quirúrgico y drenaje, e incluso en la reparación de las complicaciones que se presenten. Gran parte de la mejora en la mortalidad asociada con el shock séptico está relacionada con el reconocimiento precoz combinado con la reanimación con líquidos intravenosos y la administración de antibióticos.

Managements of Subvesical Bile Duct (Duct of Luschka) Leakage after Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy(LC) is the most common operation for gallbladder disease. Bile leakage is a serious complication in LC. Subvesical bile duct (Duct of Luschka) injury is 2nd frequent reasons after cystic duct stump leakage.

Delay in Resection of Choledochal Cysts Highlights the Significance of Malignancy Potential: A Case Report

Risks of choledochal cysts include obstructive jaundice, cholangitis, and malignancy. Therefore, cysts are typically resected especially if symptomatic. A 69 year old female who presented with cholangitis due to a common bile duct stone. Past medical history significant for type III choledochal cyst and recurrent cholangitis. Previous surgical interventions included biliary bypass at age 10 and revision in early 20s; choledochal cyst was not resected at either surgery. Imaging suggested hepaticojejunostomy stricture leading to recurrent cholangitis. Initially patient was very hesitant to undergo any further surgical intervention and opted for close surveillance. Shortly after patient develop rigors and while still reluctant to undergo large procedure did consent to choledochal cyst resection and hepaticojejunostomy revision. During the operation, choledochal cyst identified, mobilized and approximately 80% of it was excised. Hepaticojejunostomy appeared to incorporate remnant gallbladder based on intraoperative evaluation. Cholangiogram was attempted through duct of Luschka but was not completed due to difficult angle and subsequently ligated. New hepaticojejunostomy was created using original roux limb and good biliary drainage of right and left hepatic lobes demonstrated on completion cholangiogram. Final pathology significant for poorly differentiated adenocarcinoma, biliary type in choledochal cyst and remnant gallbladder; additionally bile duct margin showed invasive adenocarcinoma. Patient then underwent a completion pancreaticoduodenectomy with partial hepatectomy for complete oncologic resection. In adults presenting with a symptomatic choledochal cyst, excision should be recommended treatment. Risk of malignancy is present in biliary tree despite resection. Thus, the entire biliary tree should be inspected for multiple areas of neoplasm.

Troubleshooting Difficult Bile Duct Access: Advanced ERCP Cannulation Techniques, Percutaneous Biliary Drainage, or EUS-Guided Rendezvous Technique?

Despite experienced hands and availability of various well-designed catheters and wires, selective bile duct cannulation may still fail in 10–20% of cases during endoscopic retrograde cholangiopancreatography (ERCP). In case standard ERCP cannulation technique fails, salvage options include advanced ERCP cannulation techniques such as double-guidewire technique (DGW) with or without pancreatic stenting and precut papillotomy, percutaneous biliary drainage (PBD), and endoscopic ultrasound-guided Rendezvous (EUS-RV) ERCP. If the pancreatic duct is inadvertently entered during cannulation attempts, DGW technique is a reasonable next step, which can be followed by pancreatic stenting to reduce risks of post-ERCP pancreatitis (PEP). Studies suggest that early precut papillotomy is not associated with a higher risk of PEP, while needle-knife fistulotomy is the preferred method. For patients with critical clinical condition who may not be fit for endoscopy, surgically altered anatomy in which endoscopic biliary drainage is not feasible, and non-communicating multisegmental biliary obstruction, PBD has a unique role to provide successful biliary drainage efficiently in this particular population. As endoscopic ultrasound (EUS)-guided biliary drainage techniques advance, EUS-RV ERCP has been increasingly employed to guide bile duct access and cannulation with satisfactory clinical outcomes and is especially valuable for benign pathology at centres where expertise is available. Endoscopists should become familiar with each technique’s advantages and limitations before deciding the most appropriate treatment that is tailored to patient’s anatomy and clinical needs.

S2544 Bile Leak from the Duct of Luschka Following Liver Transplantation

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).

S1644 A Curious Case of Duodenal Mass Causing Malignant Biliary Obstruction and White Bile

Introduction: We describe a case of a duodenal mass causing malignant biliary obstruction and the use of LAMS cholecystoduodenostomy for gallbladder drainage revealing white bile. Case Description/Methods: An 83 year-old male developed orange colored urine and stool for 3 weeks. CA 19-9 was 8,381 U/mL and direct bilirubin was 43.7 mg/dL. CT Abdomen and Pelvis with contrast showed a dilated common bile duct to 1.6cm with narrowing at the ampulla, dilated intrahepatic ducts, and a duodenal mass. ERCP demonstrated a large duodenal ulcerated mass from D1 to D3 and replaced the medial aspect of the duodenal wall. Despite probing the mass with guidewire, bile duct access was unsuccessful. Biopsies showed poorly differentiated adenocarcinoma with mucinous and signet ring cell features (Figure 1A). EUS showed a 4x6cm obstructing polypoid mass in the duodenum (star) with invasion into the distal common bile duct (arrow) resulting in a dilated common bile duct (circle) (Figure 1B). Subsequent LAMS cholecystoduodenostomy was performed for drainage (arrow) (Figure 1C). White bile (clear bile) was noted upon deployment into the gallbladder (star) (Figure 1D). Discussion: White bile in malignant biliary obstruction occurs because the biliary epithelium secretes mucus into bile despite the obstruction, resulting in colorless fluid. White bile has been associated with worse survival in these patients.Figure 1.: (a) duodenal adenocarcinoma with mucinous and signet ring cell features (b) duodenal adenocarcinoma (star) invading the distal common bile duct (arrow) resulting in a dilated common bile duct (circle) (c) LAMS deployment (arrow) within the dilated gallbladder while creating the cholecystoduodenostomy (d) White bile (star) draining through the LAMS.