A tension mucocele was created in three hepatic homografts by ligating a low-lying cystic duct during transplant cholecystectomy and by incorporating its outflow end into the anastomosis of the common hepatic duct to the recipient common duct or Roux limb of jejunum. The consequent complication of obstruction of the biliary tract that necessitated reoperation and excision of the mucocele in all three patients can be avoided by the simple expedient of completely removing the cystic duct when feasible or providing egress to the secretion of the cystic duct as described

Iwatsuki, S

Koneru, B

Marsh, JW

Sher, L

Starzl, TE

Tzakis, AG

Zajko, AB

English

PubMed

D-Scholarship@Pitt

OBSTRUCTING MUCOCELE OF THE CYSTIC DUCT AFTER TRANSPLANTATION OF THE LIVER Baburao Koneru, tv1.D., Newark ) New Jersey) Albert B. Zajko, M.D., Linda Sher, M.D., J. Wallis Marsh, M.D., Andreas G. Tzakis, M.D., Shunzaburo Iwatsuki, M.D., and Thomas E. Starzl, M.D., PH.D., F.A.C.S., Pittsburgh) Pennsylvania Reprint from SURGERY, Gynecology &- Obstetrics, May, 1989, Vol. 168,394-396 Copyright , 1989 , by The Franklin H . Marlin Memorial Foundation OBSTRUCTING MUCOCELE OF THE CYSTIC DUCT AFTER TRANSPLANTATION OF THE LIVER Baburao Koneru, M.D., N ewark) New Jersey) Albert B. Zajko, M.D., Linda Sher , M.D ., J. Wallis Marsh, M.D., Andreas G. Tzakis, M.D., Shunzaburo Iwatsuki , M.D., and Thomas E. Starzl, M.D., PH.D., F.A.C.S., Pittsburgh) Pennsylvania A tension m ucocele was created.in thl'ee hepatic ho-mografts by ligating a low-lying cystic duct during transplant cholecystectomy and by mcorporating its outflow end Into the anastomosis of the common hepatic duct to the recip ient common duct or Roux lim b of JeJunum, The consequen t complicat ion of obstruction of the biliary tl'act that necessItated reoperation and excision of the mucocele in all three patients can be avoided by the simple expedient of completely remov-ing the cystic du ct when fe asible 01' providing egress to th e secretion of the cystic duct as desaibed. THE LEVEL of the junction of the cystic and common hepatic ducts is variable. In about 20 per cent of the instances, the cystic duct commonly descends for a considerable distance either along the right side or directly posterior to the common duct before emptying into the latter structure (1 , 2). When a liver with this anomaly is removed for transplantation, the surgeon sees a double lumen. A common way of dealing with this situation after performing homograft cholecystectomy has been to leave a long remnant of the cystic duct and to incorporate the orifice of the presenting cystic duct into the suture line of a hepaticocholedo-chostomy or a hepaticojejunostomy. Such a procedure creates a blind cystic duct remnant and a potential mucocele. In this study , we report three instances in which such a muco-cele obstructed the common hepatic duct of the homograft, necessitating operative revision of the reconstruction of the biliary tract. This compli-cation is preventable. METHODS Patient material. The three patients were 45, 63 and 50 yea rs old at the time of the transplan-From the Departments or Surgery, Radiology and the Unive rsity Hea lth Center or Pittsburgh , the University or Pitt sburgh . Supported by Research Grants rrom the Vetera ns Administration and Project Grant N o. Am 29961 rrom the National Institutes or Health, 'Beth esda, Maryland. Reprint requests: Dr. Baburao Koneru, University Hospit al, 150 Bergen Street, E 325, Newa rk , New Jersey, 07103. tations, three years, two weeks and three weeks previous to the diagnosis of the complication . Recurrent bouts of cholangitis prompted percu-taneous cholangiography in one patient. In the remaining two patients, bilirubin elevatioris were the indication for cholangiography. Typical studies are shown in Figures 1 and 2, with evi-dence of external compression and a string sign of the homograft distal bile duct. In retrospect, all of the patients could have had a correct diagnosis made from these roentgenographic findings, but in prospect, the diagnosis was suspected in none. Operative procedure. Through an appropriate plane, the homograft duct was dissected free. The mucocele was excised . Excision necessitated re-section of the distal part of the common hepatic duct in all of the three patients. Hepaticojejunos-tomy to a Roux limb was reperformed upon two patients who had undergone this operation pri-marily, and in the third patient, a previous hepaticocholedochostomy was converted to hep-aticojejunostomy using a fresh Roux limb. In-ternal plastic stents were placed across the anas-tomoses . The procedures were easy , and there were no serious intraoperative complications. RESULTS Recovery was complete in two of the three pa-tients, Bilirubin levels that were 3.2 and 4.5 mil-ligrams per deciliter in those two patients fell to normal levels after six and seven days. The only complication occurred in one patient. This patient had a leak of the bili a ry tract develop postoperatively that required further revision of the hepaticojejunostomy. After this , an anasto-motic stricture developed and was managed by percutaneous balloon dilation. Currently, the patient is well with normal liver functions and with no biliary drainage catheters. DISCUSSION The anomaly of a double-barrelled common duct and cystic duct combination was observed in 394 Koneru e/ al.: OBSTRUCTING MUCOCELE OF CYSTIC DUCT AFTER TRANSPLANTATION 395 FIG. 1 FIG. 2 FIG. J. Extrinsic mass affect on homograft common hepatic du ct (a rrows ) is demonstrated on lra nshe pa ti c cholangiogram (lateral view). The hepa ti coc holedochostomy (large arrowhead) is pa-tent. The remnant of the donor cystic duct is not identified; the remnant of the recipient cystic duct is fi lled (sm a ll arrow head). FIG. 2. Extrinsic mass affect on homograft distal common hepatic duct and hepaticojejunostomy (arrow) demonstrated on catheter cholangiogram a fter tra nshepa tic drainage. The remnant of the donor cyst ic duct is not identified. hepatic homografts more than 20 years ago (3). In that era, a commonly used method of reconstruc-tion of the biliary tract with hepatic transplanta-tion was cholecystoduodenostomy, and two pa-tients died when a ligat ure closing the transected common duct end a lso closed off the cystic duct , which was expected to allow bile outRow through a b the gallbladder a nd into the duodenum. There was virtually little notice taken in the literature of the early 1960s or before this time about this anomaly (4). Since then , articles have been writ-ten in the English language describing this ana-tomi c variation (1, 2) , usuall y pointing out that it cannot be reli ably recognized during cholecystec-c FIG. 3. a, band c, Illustrations of various techniques to preve nt a blind cystic duct remnant. 396 Surgery, Gynecology &' Obstetrics' May 1989 . Volume 168 tomy except with operative cholangiography or else warning that the anomaly predisposes to re-tention of a long remnant of the cystic duct. In relation to hepatic transplantation, Krom and others briefly mentioned in one report (5) a pa-tient having obstruction of the biliary tract with operative findings similar to ours. When a transected cystic duct is encountered during preparation of a liver for transplantation, the cystic duct should be excised completely even if it is close to the common duct. Usually, there is not a true transmural fusion, and separation is possible (Fig. 3a). If not, as much of the bile duct as necessary must be sacrificed in preference to creating the blind mucosa-lined sac that caused obstruction in the three patients we studied. If excision of the cystic duct is deemed too dangerous, its central end can be incorporated in the anastomotic suture line, but the other end must not be ligated, as illustrated in Figure 3b). Another alternative in the few patients mani-f esting true transm ural fusion is to excise the common septum between the cystic and common hepatic ducts for a short distance and then per-form the biliary anastomosis (Fig. 3c). SUMMARY Tension mucocele of the remnant of the cystic duct is another complication of the biliary tract that occurs after orthotopic hepatic transplanta-tion. It is less common than bile leak and ob-struction caused by strictures. Tension mucocele of the remnant is preventable in a given allograft anatomic situation either by completely excising the remnant of the cystic duct or after one of the other steps outlined . " ~D K . "\ REFERENCES ~ 1. LINDNER, H. H., and GREEN, R.<B.'Embry.ology and surgical anatomy of extrahepatic bilX' fY tfact. Surg. Clin. North. Am., 1964, 44. 1273-1285. T 2. KUNE, G. A. The inAuence of struct 'e and funct~n 'i.Q the surgery of the biliary tract. Ann. R. ColI. Surg. , ~ngKI 1970, 47: 78-91-3. STARZL, T. E. Intra and postoperative complications and care. In: Experience in Hepatic Transplantation. With the assistance of C. W. Putnam. Pp. 144-158. Phila-delphia: W. B. Saunders Co. , 1969. 4. FLINT, E. R. Abnormaltities of the right hepatic, cystic, and gastroduodenal arleries and of the bile ducts. Br. J. Surg., 1922, 10: 509-519 . 5. KROM, R. A. F., KINGMA , L. M., HAAGSMA, E. B., and others. Choledochocholedochostomy, a relatively safe procedure in orthotopi~ver transplantation. Surgery, 1985, 97: 552-556. ., . . ---

Obstructing mucocele of the cystic duct after transplantation of the liver

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Obstructing mucocele of the cystic duct after transplantation of the liver

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