Management of Accessory Hepatic Ducts in Choledochal CystsBy K.L. Narasimhan, S.K. Chowdhary, and K.L.N. Rao

Chandigarh, India

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

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

INDEX WORDS: Choledochal cysts, accessory hepatic ducts.

ACCESSORY 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 importanceof intraoperative identification of the accessory duct andits appropriate management. We encountered 2 childrenwhose AHDs were reconstructed successfully during ex-cision of choledochal cyst.

CASE REPORTS

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

Case 1

A 2-year-old girl had abdominal distension, fever, and intermittentjaundice of 4 months’ duration. On examination she was anicteric, andthere was a cystic right upper quadrant mass extending down into thepelvis. The total serum bilirubin level was 2.8 mg/dL and conjugatedfraction was 2.1 mg/dL. The serum alkaline phosphatase was raised.The prothrombin time was prolonged, and this was corrected withpreoperative injection vitamin K. Abdominal ultrasound scan showed adilated common bile duct suggestive of choledochal cyst (type 1). CTscan of the abdomen showed a huge choledochal cyst, but the accessoryhepatic duct was not seen. A preoperative cholangiogram showed ahuge fusiform choledochal cyst.

At surgery, a fusiform choledochal cyst 15 cm � 8 cm � 7 cm3 wasnoted, which was excised. The common hepatic duct was 1.5 cm in

diameter, and there was a 4-mm accessory hepatic duct arising from theleft lobe. Both the ducts were implanted separately into the Roux loop(Fig 1). Postoperative HIDA scan of the liver showed good hepatocytefunction 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 andabdominal pain of 6 months duration. On examination, he was anic-teric. The liver was enlarged 3 cm below the costal margin in the midclavicular line. Liver function tests showed a serum bilirubin level of2.3 mg/dL (conjugated fraction, 1.9 mg/dL). The liver enzyme levelswere normal, and the alkaline phosphatase value was marginally raised.The endoscopic retrograde cholangiopancreaticogram (ERCP) showeda long fusiform choledochal cyst (Fig 2). The coagulation profile wasnormal. The child was operated on after administrated preoperativevitamin K injection and antibiotics.

During excisional surgery for choledochal cyst, an accessory hepaticduct draining the left lobe was encountered behind the common hepaticduct separated by the right hepatic artery (Fig 3). The common hepaticduct and the AHD were joined together as illustrated and implantedinto the Roux loop (Fig 3). Postoperative HIDA scans showed goodhepatocyte function and drainage into the intestines. The child is well2 years after the surgery.

DISCUSSION

An AHD is an extrasegmental or subsegmental bileduct that often drains a part of the liver and joins thebiliary system at any level such as the cystic duct, gallbladder, 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 unrecognizedpreoperatively and missed during surgery. This mayresult in bile leakage from the drain or biliary peritonitisafter excisional surgery for CC.2-5 There are reports inwhich the AHD joined the common bile duct very lowdown close to the junction with pancreatic duct and was

From the Department of Pediatric Surgery, Postgraduate Institute ofMedical 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 Company0022-3468/01/3607-0032$35.00/0doi:10.1053/jpsu.2001.24767

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

very small. This was missed during excisional surgery.These patients presented with persistent postoperativepain and recurrent pancreatitis. They were picked up bya postoperative ERCP. These patients have been treatedsuccessfully with sphincterotomy and without open sur-gery.4,5

There are few reports of AHD in associated withcholedochal cysts.4,5 They are rarely diagnosed preoper-atively. There is one report of AHD being diagnosed byintraoperative cholangiography.4 It is not easy to detectan accessory hepatic duct, because it may be markedly

displaced by the dilated choledochal cyst or may beovershadowed by the dense shadow of the choledochalcyst. It also is difficult to detect accessory hepatic duct byultrasound scan and CT scan preoperatively. Hence,attention must be paid to the possible presence of anAHD during every operation for CC. Care must be takennot to damage it, and, when found, it must be anasto-mosed meticulously to a Roux loop with a rim of theductal tissue. Reconstructive surgery almost always isfeasible, 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 andmeticulously reconstructed.

REFERENCES

1. Benson EA, Page RE: A practical reappraisal of the anatomy ofthe extrahepatic bile ducts and arteries. Br J Surg 63:853-860, 1976

2. Goor DA, Ebert PA: Anomalies of the biliary tree: Report of arepair of an accessary bile duct and review of the literature. Arch Surg104:302-309, 1972

3. Johnston EV, Anson BJ: Variations in the formation of vascularrelationships in the formation of vascular relationship of the bile ducts.Surg Gynecol Obstet 94:669-686, 1952

4. Duh YC, Lai HS, Chen WJ: Accessory hepatic duct associatedwith a choledochal cyst. Pediatr Surg Int 12:54-56, 1997

5. Ng WT, Wong MK, Kong CK: Long accessory hepatic ductassociated with congenital dilatation of the common bile duct. Am JGastroenterol 88:619-628, 1993

Fig 1. Diagrammatic representation of CHD and AHD is reim-

planted into the Roux loop in case 1.

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.

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

1093ACCESSORY HEPATIC DUCTS IN CHOLEDOCHAL CYSTS