Management of Accessory Hepatic Ducts in Choledochal Cysts

By K.L. Narasimhan, S.K. Chowdhary, and K.L.N. Rao

Chandigarh, India

This report describes the surgical management of 2 children

with fusiform choledochal cysts who had accessory hepatic
ducts (AHD) identified during excisional surgery for fusiform
choledochal cysts (CC).Two children presenting with a triad
of recurrent jaundice, fever, and abdominal pain were investigated and found to have type 1 choledochal cyst. Preoperative imaging and intraoperative cholangiography missed
the AHD in both cases. In one of the patients, the main and
the accessory ducts were separated by the right hepatic
artery. In both the patients the accessory ducts were reconstructed successfully into a Roux loop along with the main
common hepatic duct. Follow-up studies showed no evi-

dence of biliary tract obstruction or atrophic changes in the

liver. There was satisfactory uptake and drainage on hepatic
scintigraphy. During excision of CC, AHD may be encountered. These may be missed on preoperative imaging. AHD
may have a close relationship with neighboring vascular
structures in the porta. Accessory hepatic ducts should be
anticipated, identified, and reimplanted into the Roux loop
during excisional surgery.
J Pediatr Surg 36:1092-1093. Copyright 2001 by W.B.
Saunders Company.

diameter, and there was a 4-mm accessory hepatic duct arising from the
left lobe. Both the ducts were implanted separately into the Roux loop
(Fig 1). Postoperative HIDA scan of the liver showed good hepatocyte
function and unobstructed drainage of the radiotracer into the intestines. The child is anicteric and well 3 years after the surgery.

CCESSORY HEPATIC DUCTS (AHD) may be encountered during excisional surgery of choledochal
cyst (CC). These are seldom seen on preoperative imaging and can be missed during excisional surgery for CC.
The aim of this presentation is to discuss the importance
of intraoperative identification of the accessory duct and
its appropriate management. We encountered 2 children
whose AHDs were reconstructed successfully during excision of choledochal cyst.
CASE REPORTS

Of the 15 choledochal cysts operated on by the first author, 2 patients

had associated accessory hepatic ducts.

Case 1
A 2-year-old girl had abdominal distension, fever, and intermittent
jaundice of 4 months duration. On examination she was anicteric, and
there was a cystic right upper quadrant mass extending down into the
pelvis. The total serum bilirubin level was 2.8 mg/dL and conjugated
fraction was 2.1 mg/dL. The serum alkaline phosphatase was raised.
The prothrombin time was prolonged, and this was corrected with
preoperative injection vitamin K. Abdominal ultrasound scan showed a
dilated common bile duct suggestive of choledochal cyst (type 1). CT
scan of the abdomen showed a huge choledochal cyst, but the accessory
hepatic duct was not seen. A preoperative cholangiogram showed a
huge fusiform choledochal cyst.
At surgery, a fusiform choledochal cyst 15 cm 8 cm 7 cm3 was
noted, which was excised. The common hepatic duct was 1.5 cm in

INDEX WORDS: Choledochal cysts, accessory hepatic ducts.

Case 2
A 2 1/2-year-old boy presented with recurrent attacks of fever and
abdominal pain of 6 months duration. On examination, he was anicteric. The liver was enlarged 3 cm below the costal margin in the mid
clavicular line. Liver function tests showed a serum bilirubin level of
2.3 mg/dL (conjugated fraction, 1.9 mg/dL). The liver enzyme levels
were normal, and the alkaline phosphatase value was marginally raised.
The endoscopic retrograde cholangiopancreaticogram (ERCP) showed
a long fusiform choledochal cyst (Fig 2). The coagulation profile was
normal. The child was operated on after administrated preoperative
vitamin K injection and antibiotics.
During excisional surgery for choledochal cyst, an accessory hepatic
duct draining the left lobe was encountered behind the common hepatic
duct separated by the right hepatic artery (Fig 3). The common hepatic
duct and the AHD were joined together as illustrated and implanted
into the Roux loop (Fig 3). Postoperative HIDA scans showed good
hepatocyte function and drainage into the intestines. The child is well
2 years after the surgery.

DISCUSSION

From the Department of Pediatric Surgery, Postgraduate Institute of

Medical Education and Research, Chandigarh, India.
Address reprint requests to Dr K.L. Narasimhan, Associate Professor, Department of Pediatric Surgery, PGIMER, Chandigarh 160 012,
India.
Copyright 2001 by W.B. Saunders Company
0022-3468/01/3607-0032$35.00/0
doi:10.1053/jpsu.2001.24767

An AHD is an extrasegmental or subsegmental bile

duct that often drains a part of the liver and joins the
biliary system at any level such as the cystic duct, gall
bladder, common hepatic duct, or common bile duct.1
The incidence varies from 1% to 31% in different operative and autopsy series.1 AHD may be unrecognized
preoperatively and missed during surgery. This may
result in bile leakage from the drain or biliary peritonitis
after excisional surgery for CC.2-5 There are reports in
which the AHD joined the common bile duct very low
down close to the junction with pancreatic duct and was

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

ACCESSORY HEPATIC DUCTS IN CHOLEDOCHAL CYSTS

1093

Fig 1. Diagrammatic representation of CHD and AHD is reimplanted into the Roux loop in case 1.

very small. This was missed during excisional surgery.

These patients presented with persistent postoperative
pain and recurrent pancreatitis. They were picked up by
a postoperative ERCP. These patients have been treated
successfully with sphincterotomy and without open surgery.4,5
There are few reports of AHD in associated with
choledochal cysts.4,5 They are rarely diagnosed preoperatively. There is one report of AHD being diagnosed by
intraoperative cholangiography.4 It is not easy to detect
an accessory hepatic duct, because it may be markedly

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.

displaced by the dilated choledochal cyst or may be

overshadowed by the dense shadow of the choledochal
cyst. It also is difficult to detect accessory hepatic duct by
ultrasound scan and CT scan preoperatively. Hence,
attention must be paid to the possible presence of an
AHD during every operation for CC. Care must be taken
not to damage it, and, when found, it must be anastomosed meticulously to a Roux loop with a rim of the
ductal tissue. Reconstructive surgery almost always is
feasible, and simple ligation of AHD is not recommended. However, AHD drains only a part of the liver,
and ligation may result in atrophy of the involved segments, cholangitis, or liver abscess. During every operation for excision of CC, AHD must be looked for and
meticulously reconstructed.
REFERENCES

Fig 2.

ERCP in case 2 shows fusiform choledochal cyst.

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104:302-309, 1972
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relationships in the formation of vascular relationship of the bile ducts.
Surg Gynecol Obstet 94:669-686, 1952
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