Subvesical Duct Research Articles

Routine Use of Indocyanine Green Fluorescence Cholangiography in Cholecystectomy at Marginal Cost and High Dividends: Subvesical Duct Identified

Routine Use of Indocyanine Green Fluorescence Cholangiography in Cholecystectomy at Marginal Cost and High Dividends: Subvesical Duct Identified

The enhanced recovery after surgery (ERAS) protocol in elderly patients with acute cholecystitis: A retrospective study.

Enhanced recovery after surgery (ERAS) protocol is a perioperative management theory aimed at reducing the injury of surgical patients and accelerating postoperative recovery. It has been widely recognized and applied in elective surgery. This study aimed to evaluate the clinical value of the ERAS protocol during the perioperative period of laparoscopic cholecystectomy in elderly patients with acute cholecystitis. This study aimed to evaluate the clinical value of the ERAS protocol during the perioperative period of laparoscopic cholecystectomy in elderly patients with acute cholecystitis. We collected medical data from 126 elderly patients with acute cholecystitis from October 2018 to August 2021. Among the 126 patients, 70 were included in the ERAS group and 56 in the traditional group. We analyzed the clinical data and postoperative indicators of the 2 groups. No significant differences were observed regarding the general characteristics of the 2 groups (P > .05). The ERAS group had significantly earlier time to first flatus, time to first ambulation, and time to solid intake, compared with the traditional group (P < .001); additionally, the ERAS group had significantly shorter stay and gentler feeling of postoperative pain (P < .001). Furthermore, the ERAS group had significant incidences of lower postoperative lung (P = .029) and abdominal cavity infection (P = .025) compared to the traditional group. No significant difference was observed regarding the incidences of other postoperative complications between the 2 groups (P > .05). The ERAS protocol helps reduce elderly patients' stress reactions and accelerate postoperative recovery. Thus, it is effective and beneficial to implement the ERAS protocol during the perioperative period of elderly patients with acute cholecystitis.

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.

Risk identification and technical modifications reduce the incidence of post-cholecystectomy bile leakage: analysis of 5675 laparoscopic cholecystectomies

PurposeThe main sources of post-cholecystectomy bile leakage (PCBL) not involving major duct injuries are the cystic duct and subvesical/hepatocystic ducts. Of the many studies on the diagnosis and management of PCBL, few addressed measures to avoid this serious complication. The aim of this study was to examine the causes and mechanisms leading to PCBL and to evaluate the effects of specific preventative strategies.MethodsA prospectively maintained database of 5675 consecutive laparoscopic cholecystectomies was analysed. Risk factors for post-cholecystectomy bile leakage were identified and documented and technical modifications and strategies were adopted to prevent this complication. The incidence, causes and management of patients who suffered bile leaks were studied and their preoperative characteristics, operative data and postoperative outcomes were compared with patients where potential risks were identified and PCBL avoided and with the rest of the series.ResultsTwenty-five patients (0.4%) had PCBL (7 expected and less than half requiring reintervention): 11 from cystic ducts (0.2%), 3 from subvesical ducts (0.05%) and 11 from unconfirmed sources (0.2%). The incidence of cystic duct leakage was significantly lower with ties (0.15%) than with clips (0.7%). Fifty-two percent had difficulty grades IV or V, 36% had empyema or acute cholecystitis and 16% had contracted gallbladders. Twelve patients required 17 reinterventions before PCBL resolved; 7 percutaneous drainage, 6 ERCP and 4 relaparoscopy. The median hospital stay was 17 days with no mortality. Hepatocystic ducts were encountered in 72 patients (1.3%) and were secured with loops (54.2%), ties (25%) or sutures (20.8%) with no PCBL. Eighteen sectoral ducts were identified and secured.ConclusionLigation of the cystic duct reduces the incidence of PCBL resulting from dislodged endoclips. Careful blunt dissection in the proper anatomical planes avoiding direct or thermal injury to subvesical and sectoral ducts and a policy of actively searching for hepatocystic ducts during gallbladder separation to identify and secure them can reduce bile leakage from such ducts.

Subvesical duct and hepaticocholecystic duct in one patient

Our aim is to present the importance of mobile Handheld Lung Ultrasound (HLUS) in COVID-19 patients at the bedside, which is a pre-screening tool with high diagnostic value that can provide triage of symptomatic patients at home (pre-hospital), emergency services, Intensive Care Units (ICU). In this context, the current role and importance of HLUS at the bedside in COVID-19 pneumonia has been summarized.

Endoscopic treatment of post-cholecystectomy bile leaks: a tertiary center experience.

Post-cholecystectomy bile leak is relatively a well-known surgical complication. Several potential treatment modalities for such leaks are used. The early use of ERCP to exclude significant bile duct injury and to treat the leak by various endoscopic means is supported by a large bulk of data. However, there is no consensus as to the optimal endoscopic intervention. A retrospective review of ERCP database was done to identify all cases of bile leak related to cholecystectomy. Patient records including surgical and endoscopic reports were reviewed, and telephone interviews were conducted to collect data. During the period 2004-2016, 100 patients (53 men, 47 women; mean age, 55years) with post-cholecystectomy bile leak were referred for ERCP. Cholecystectomy was done laparoscopically in 82 patients (with an open conversion rate of 13%). In the majority of cases (77%), the leak was diagnosed by ongoing bile flow from the drains. The most common symptoms were pain (17%) and fever (4%). The most common site of the leak was the cystic duct stump (79%) followed by subvesical ducts (7%). Low grade leaks were seen in 84% of cases. Treatment included stent insertion alone (9%), sphincterotomy alone (11%), combination stent/sphincterotomy (76%) and others (1%). Failed ERCP was encountered in 3%. Endoscopic therapy was successful in 90 patients (90%). In subgroup analysis, success rate of procedures with stent insertion (with or without sphincterotomy) is significantly higher compared to procedures without stent insertion (95.3% vs 72.7%, p < 0.05). The failure rate of sphincterotomy alone procedures (3/11, 27%) is much higher compared to procedures with stent insertion (4/85, 5%) with p < 0.05. Four patients (4%) developed post-ERCP pancreatitis (mild to moderate) and one patient (1%) suffered from retroperitoneal perforation. The optimal endoscopic intervention for post-cholecystectomy bile leak should include temporary insertion of a biliary stent.

Management of bile leak from subvesical duct (duct of Luschka) during laparoscopic cholecystectomy.

Management of bile leak from subvesical duct (duct of Luschka) during laparoscopic cholecystectomy.

Subvesical duct injury resolved by percutaneous drainage

Subvesical duct injury resolved by percutaneous drainage

Conducto subvesicular, nomenclatura anatómica para el conducto de Luschka y su importancia clínica. Revisión de tema

Introducción: El conducto subvesicular fue descrito por Hubert Luschka como pequeños ductos biliares derivados de la pared de la vesícula biliar. Algunos autores lo describen como un ducto que lleva el drenaje desde el parénquima hepático hasta la vesícula, otros utilizan el término describiéndolo como un conducto que drena desde el parénquima hepático hasta las vías biliares extrahepaticas. Se planteó una revisión bibliográfica de la descripción anatómica del epónimo conducto de Luschka y de la terminología anatómica propuesta conducto subvesicular o subvesical, dada su importancia clínica como causa de fuga biliar. Metodología: Se realizó una revisión bibliográfica en bases de datos y bibliotecas electrónicas. Con ventana de tiempo personalizada desde 2006 hasta 2016, se obtuvo un total de 82 artículos, posteriormente se realizó un resumen analítico especializado, seleccionando un total de 46.Resultados: No se encontró consenso en la descripción anatómica del epónimo, ni en la descripción de la terminología internacional. Las lesiones de la vía biliar durante la colecistectomía se presentan como una complicación poco frecuente (0.1 - 1.5%); sin embargo, tienen repercusiones en varios ámbitos y una morbi-mortalidad considerable. Conclusiones: Se evidenció discrepancia en la nomenclatura utilizada para la descripción de estos conductos, puesto que se denomina de manera indiscriminada como conducto de Luschka a todos los ductos biliares que se encuentran en la fosa biliar. La relevancia clínica radica en que es la segunda causa de fuga biliar iatrogénica y la asociación entre el conducto subvesical y carcinomas ductales. Aún se necesitan más estudios principalmente locales para identificar su incidencia y prevenir complicaciones.

Temporary Placement of a Newly Designed, Fully Covered, Self-Expandable Metal Stent for Refractory Bile Leaks

Bile leaks remain a significant cause of morbidity for patients undergoing laparoscopic cholecystectomy. Leakage from an injured duct of Luschka (subvesical duct) follows the cystic duct as the most common cause of postcholecystectomy bile leaks. Although endoscopic sphincterotomy, plastic-stent placement, or nasobiliary-drain placement are effective in healing biliary leaks, in patients in whom leakage persists and the symptoms worsen despite conventional endoscopic treatment, re-exploration with laparoscopy and ligation of the injured subvesical duct should be considered. We present herein the case of a 31-year-old woman with refractory bile leakage from a disrupted subvesical duct after cholecystectomy that could not be managed with endoscopic sphincterotomy and plastic-stent placement. A newly designed, fully covered, self-expandable metal stent (FC-SEMS) was successfully placed for the treatment of refractory bile leaks in this patient. It appears that temporary placement of an FC-SEMS is technically feasible and provides an effective alternative to surgical therapy for refractory bile leaks after cholecystectomy.

Incidence, Pattern and Management of Bile Duct Injuries during Cholecystectomy: Experience from a Single Center

Background: The incidence and pattern of bile duct injury (BDI) may be underreported because of the heterogeneous referral from multiple institutions. Methods: Retrospective analysis of data from 5,782 cholecystectomies performed between 1989 and 2007 was done. BDI were categorized into Strasberg types. Results: Fifty-seven (1%) patients sustained BDI. Ten of 57 (18%) patients had minor BDI (type A-10), 25/57 (44%) had major BDI (type C-3, type D-14, type E-8) and BDI could not be classified in the remaining 22/57 (39%) patients. Twenty-one of 25 (84%) major BDI were detected at operation – 21/57 (37%) injuries were detected and repaired intra-operatively. The other 36/57 (63%) injuries were detected after operation – 11 were managed expectantly, 5 had endoscopic stenting, 3 underwent percutaneous drainage of bilioma, 1 had a laparoscopic clipping of the subvesical duct, 4 underwent laparotomy and 12 required a combination of interventions. Five of the 57 (9%) patients died. At follow-up, 1 patient developed bile duct stricture which was managed endoscopically. All other patients were doing well at the last follow-up. Conclusions: In experienced centers, most of the major BDI can be detected and managed during cholecystectomy. Good results can be achieved by judicious selection of a combination of interventions in the majority of patients.

Anatomical assessment of bile ducts of Luschka in human fetuses

Bile ducts of Luschka (also called subvesical or supravesicular ducts) can cause bile leakage during laparoscopic cholecystectomy, especially if surgery is carried out in ignorance of such variations. The aim of this study was to clarify the clinical anatomy of these ducts in human fetuses and frequency of the ducts locating near gallbladder fossa. Thirty-two fetal cadaver livers were dissected and the gallbladders were separated from the livers and ducts were investigated under a surgical microscope. All observed ducts were examined microscopically and connective tissue cords were excluded. Bile ducts of Luschka locating near cystic fossa were found in 7 of 32 fetuses (21.9%). Three of the seven ducts ran towards to liver segment 5 (S5); three ducts were found in the gallbladder fossa; and one duct ran towards to liver segment 4 (S4). Also it was found that three of the seven ducts drained into the subsegmental duct of S5, two ducts drained into the right hepatic duct, one duct drained into the right anterior branch bile duct, and one duct drained into the subsegmental duct of S4. Subvesical ducts running along the gallbladder fossa between the gallbladder and the liver parenchyma were found in a relatively high incidence in fetuses than adults. Awareness and knowledge about incidence of such ducts alerts the surgeon during laparoscopic cholecystectomy. Therefore morbidity due to bile leaks can be reduced.

Bile leaks from the duct of Luschka (subvesical duct): a review

Gallstone disease remains the most common disease of the digestive system in Western societies and laparoscopic cholecystectomy one of the most common surgical procedures performed. Bile leaks remain a significant cause of morbidity for patients undergoing this procedure. These occur in 0.2-2% of cases. The bile ducts of Luschka, or subvesical ducts, are small ducts which originate from the right hepatic lobe, course along the gallbladder fossa, and usually drain in the extrahepatic bile ducts. Injuries to these ducts are the second most frequent cause of postcholecystectomy bile leaks. A literature search using MEDLINE's Medical Subject Heading terms was used to identify recent articles. Cross-references from these articles were also used. Subvesical bile duct leaks can be detected by drip-infusion cholangiography using computed tomography preoperatively, direct visualization or cholangiography intraoperatively, and fistulography, endoscopic retrograde cholangiopancreatography (ERCP), and magnetic resonance cholangiopancreatography with intravenous contrast postoperatively. 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 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. Subvesical duct leaks occur after cholecystectomy regardless of gallbladder pathology or urgency of operation. They have been encountered more frequently in the era of laparoscopic cholecystectomy. Intraoperative cholangiography does not detect all such leaks. Staying close to the gallbladder wall during its removal from the fossa is the only known prophylactic measure. ERCP and stent placement are the most common effective diagnostic and therapeutic methods used. Intraoperative and perioperative adjunctive measures, such as fibrin glue instillation and pharmacologic relaxation of the sphincter of Oddi, can potentially be used in lowering the incidence of subvesical bile leaks.

Heterogeneity of Subvesical Ducts or the Ducts of Luschka: A Study Using Drip‐infusion Cholangiography‐Computed Tomography in Patients and Cadaver Specimens

The objective of this study was to examine the heterogeneity of the subvesical duct or the ducts of Luschka as well as the reliability of drip-infusion cholangiography with computed tomography (DIC-CT) for their identification. DIC-CT was used in 277 consecutive patients (135 men, 142 women) and for the dissection and histologic study of 10 cadaver livers. We found 32 subvesical ducts in 28 (10.1%) of 277 patients. Irrespective of whether the terminals were extra- or intraparenchymal, the subvesical ducts often (17/32 ducts, 15/28 patients) drained into a subsegmental duct of S5 or S4. Notably, some displayed an "intermediate" course along the gallbladder fossa with an intraparenchymal origin and terminated at S5. Such ducts tended to be seen in the elderly. Another 15 ducts drained into a thick, centrally located duct, such as the right sectorial or hepatic duct. The anatomic study demonstrated that the subvesical duct likely included the cystic vein-concomitant duct. A major type of subvesical duct, characterized by an intermediate course along its bed, appeared to result from degenerative exposure of a peripheral duct with aging. The subvesical duct draining into the thick duct included both a "daughter branch," such as seen in the lung, and the so-called anomaly. Such ducts can be demonstrated with DIC-CT, but the incidence might be limited. However, the cystic vein/concomitant duct was difficult to identify radiologically. Consequently, although presurgical radiology is useful for avoiding bile leakage after laparoscopic cholecystectomy, surgeons should be aware of its limitations.

The subvesical duct of Luschka: A source of bile leakage following gallbladder removal

We describe a case of bile leakage following laparoscopic cholecystectomy further complicated by iatrogenic central bile duct obstruction. The site of leakage was identified not from the site of the inadvertent proper hepatic duct ligation but from a damaged aberrant subvesical duct communicating with the gallbladder fossa. The anatomy of these subvesical ducts is explained as is their surgical importance with relation to the aetiology of bile leaks after cholecystectomy.

Papillary adenocarcinoma of the subvesical duct

This is, to our knowledge, the first report of papillary adenocarcinoma originating in the subvesical bile duct. A 77-year-old man was referred to our hospital for further evaluation of liver dysfunction. Serum liver function test results on admission included: aspartate aminotransferase, 99 IU/l; alanine aminotransferase, 149 IU/l; lactate dehydrogenase, 438 IU/l; alkaline phosphatase, 992 IU/l; leucine aminopeptidase, 320 IU/l; and gamma-glutamyl transpeptidase, 593 IU/l. Serum carbohydrate antigen (CA) 19-9 value was high (80 U/ml). Abdominal ultrasonogram, computed tomographic scan, and percutaneous transhepatic cholangiogram demonstrated a mass in the common hepatic duct, and dilatation of the intrahepatic bile ducts. A laparotomy was performed on May 14, 1997. The tumor originated in the dilated subvesical duct that joined the common hepatic duct, and projected into the common hepatic duct. The patient underwent cholecystectomy, resection of the subvesical duct and the common hepatic duct, dissection of regional pericholedochal lymph nodes, and Roux-en-Y hepaticojejunostomy. The resected tumor presented macroscopically as a papillary mass measuring 4.0 x 2.0 cm. The pathological diagnosis was papillary adenocarcinoma. The immunostaining positivity rates for MIB-1 and p53 protein were 49.6% and 33.8%, respectively.

Role of relaparoscopy in the management of minor bile leakage after laparoscopic cholecystectomy.

Bile leakage in the absence of major ductal injury may occur from the liver bed or from the cystic duct remnant after cholecystectomy. The early limitations of minimally invasive surgery led to reliance on endoscopic methods to manage this complication. However, repeat laparoscopy permits drainage of the bile collection and direct control of the site of leakage in selected situations. Details of 15 patients with bile leakage after laparoscopic cholecystectomy were recorded prospectively and are reviewed. Postoperative bile leakage occurred after 15 (0.8 per cent) of 1779 laparoscopic cholecystectomies. Two patients with bile in drainage fluid had spontaneous resolution. Ten patients with a subvesical duct leak had repeat laparoscopy. The leak was successfully controlled by suturing in eight patients, and by a laparoscopically placed drain in two. One patient required a subsequent laparotomy for a loculated pelvic collection. Three patients had cystic duct stump leakage. This was managed successfully by laparoscopy in one case but required endoscopic management in two. Laparoscopy is useful in the management of minor bile leaks after laparoscopic cholecystectomy. Selection of appropriate patients relies on a characteristic clinical presentation after an otherwise uncomplicated cholecystectomy.

Post-cholecystectomy external biliary fistula.

External biliary fistula (EBF) following bile duct injury is a serious complication of cholecystectomy. From January 1989 to December 1994, 37 patients with post-cholecystectomy external biliary fistula were seen at this centre. There were 14 partial, 22 complete and one sub-vesical duct of Luschka injury. Sixteen patients had a controlled EBF at presentation; 10 patients had intra-abdominal collections and seven patients presented with peritonitis. A staged approach to the management of these patients was adopted in which the initial management aimed at creating a 'controlled' fistula. This approach comprised conservative treatment (n = 9), percutaneous catheter drainage of intra-abdominal collections (n = 10), biliary drainage (n = 6), and surgical intervention (n = 7). One patient died because of progressive liver failure in spite of intensive management. Definitive management comprised the surgical repair of biliary strictures wherever indicated, after waiting for the acute problems to settle. By adopting a staged approach along with a judicious use of endoscopy, radiology and surgery that were based on clinical circumstances, it was possible to achieve satisfactory results for this otherwise distressing condition.

Accessory gallbladder bed (Subvesical duct or duct of Luschka's) biliary leaks after laparoscopic cholecystectomy

Accessory gallbladder bed (Subvesical duct or duct of Luschka's) biliary leaks after laparoscopic cholecystectomy