Duct of Luschka
Bile leak is among the most common complications of cholecystectomy. The possible reasons for bile leakage following laparoscopic cholecystectomy are the injury of the common bile duct, the insufficient treatment of cystic duct (non competent or non closing, or spontaneously removing clip, stumpnecrosis due to electrocoagulation near to clip, rupture adjacent to the clip) or the opening of an aberrant bile duct. The latter often may occur in case of the anatomic variation described by Hubert von Luschka (1820-1875) a German anatomist as the duct named after Luschka . Bile ducts of Luschka (also called supravesicular ducts) are small bile ducts in the gallbladder bed . Although they do not drain any liver parenchyma, they can be a source of bile leak or biliary peritonitis after cholecystectomy. In one series, post-operative bile leakage from accessory biliary duct occurred in 1% of patients, either from the gallbladder bed (duct of Luschka) or from an aberrant cholecystohepatic duct entering Hartmann's pouch. By careful dissection, accessory ducts were noticed and clipped in a total of 2.7% of patients .
Minor Biliary Leaks: Natural Course
In favorable cases the accessory bile duct closes by itself, but occasionally developing biloma and/or biliary peritonitis need to be operated on. Endoscopic therapy is empiric; a systematic approach to management of bile leak has not been established. Meticulous laparoscopic technique in order to recognize all structures during laparoscopic cholecystectomy is the main method to prevent biliary injury. Depending of availability, endoscopic sphincterotomy and biliary drainage allow diagnosis and treatment of bile leakage, preserving the effectiveness of laparoscopic procedure.
The severity of bile leak can be classified by endoscopic retrograde cholangiography into low grade (leak identified only after intrahepatic opacification) or high grade (leak observed before intrahepatic opacification). Therapy was based on this distinction. Biliary sphincterotomy alone was done for low-grade leaks and stent placement was done for high-grade leaks. In one study, a total of 207 patients (127F, 80M; median age 57 yrs) with bile leak were referred for endoscopic management; 134 had undergone laparoscopic, and 72 had open cholecystectomy. Patients presented at a median of 9 days (range 1-50 days) after surgery. Symptoms included pain (56%), jaundice (16%), fever (11%), and abdominal distension (7%). Persistent percutaneous drainage was present in 48%. Endoscopic retrograde cholangiography identified the leak site in 204 patients: cystic duct stump, 159 patients (78%); duct of Luschka, 26 (13%); other, 19 (9%) .
In a study by Sandha et al, among 104 patients with low-grade leaks, 75 had sphincterotomy alone; improvement occurred in 68 patients (91%). Subsequent treatment was required in 7 patients (6 stent, 1 surgery). Stents were placed in the remaining 29/104 patients for the following reasons: biliary stricture (11/29); coagulopathy, precluding sphincterotomy (8/29); severe sepsis (3/29); inadequate drainage after prior sphincterotomy (2/29); and unclear reasons (5/29) .
In the same study (Sandha et al), of 100 patients with high-grade leaks, 97 had stent placement. Persistent leakage necessitated another stent insertion in 4 patients. Closure of the leak was documented by endoscopic retrograde cholangiography in all 97 patients. Three patients with leaks not amenable to endoscopic treatment were referred for surgery. Bile-duct stones were identified in 41 patients (28, low-grade group; 13, high-grade group) and were extracted in all cases. Overall, complications occurred in 3 patients (2 pancreatitis, 1 perforation) and were managed conservatively with no mortality. The authors proposed a simple, practical endoscopic classification system for bile leak after cholecystectomy. This classification has clinical relevance for selection of optimal endoscopic management .
In another study, the site of bile extravasation was the cystic duct in 50/64 cases, ducts of Luschka in 4/64 cases, common bile duct in 6/64 cases and common hepatic duct in 4/64 cases . Retained bile duct stones were detected in 21/64 cases and papillary stenosis in 4/64 cases. Endoscopic sphincterotomy was performed in 25/64 cases, with stones extraction and nasobiliary drainage in 21/64 cases, and placement of stent in the remainder. Bile leaks resolved in 96.9% of patients, after endoscopic procedure. Two cases of mild pancreatitis were associated with endoscopic (ERCP) treatment .
Notes & References
 Batorfi J, Baranyay F, Simon E, Beznicza H, Kolonics G. Laparoscopic treatment of bile leakage from the Luschka duct after laparoscopic cholecystectomy. Orv Hetil. 2004 May;145:1061-4.
 De Palma GD, Galloro G, Iuliano G, Puzziello A, Persico F, Masone S, Persico G. Leaks from laparoscopic cholecystectomy. Hepatogastroenterology. 2002;49:924-5.
 Pisanu A, Altana ML, Piu S, Uccheddu A. Bile leak from the accessory biliary duct following laparascopic cholecystectomy. G Chir. 2003;24:115-8.
 Sandha GS, Bourke MJ, Haber GB, Kortan PP. Endoscopic therapy for bile leak based on a new classification: Results in 207 patients. Gastrointest Endosc. 2004 Oct;60(4):567-74.
 Sharif K, de Ville de Goyet J. Bile duct of Luschka leading to bile leak after cholecystectomy--revisiting the biliary anatomy. J Pediatr Surg. 2003;38:E21-23.
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