Aberrant right hepatic duct draining into the cystic duct: clinical outcomes and management

Abstract

Background. Aberrant right hepatic duct (ARHD) draining into cystic duct (CD) is relatively rare but clinically important because of its susceptibility to injuries during cholecystectomy. These injuries are often-times missed or diagnosed late and as a result can develop serious complications. Methods. Four consecutive patients diagnosed with ARHD draining into CD were identified for inclusion. Results. The mean age of patients was 42.5 years. The diagnosis in one of the patient was incidental during a routine endoscopic retrograde cholangiopancreatography (ERCP). Other three patients were diagnosed post-cholecystectomy- one presented with suspected intra-operative biliary injury, one with persistent bile leak and another with recurrent cholangitis. Inadequate filling of the segment of liver on ERCP with dilation of intrahepatic ducts in the corresponding segment on imaging was present in two patients with complete obstruction of ARHD which was managed surgically. In another patient, the partially obstructed ARHD was managed by endoscopic therapy. Conclusion. ARHD draining into the CD can have varied clinical manifestations. In appropriate clinical settings, it should be suspected in patients with persistence of bile leak early after cholecystectomy, segmental dilation of intrahepatic-bile ducts on imaging and paucity of intrahepatic filling in a segment of liver on ERCP.

Figure 1

(a) Endoscopic retrograde cholangiopancreatography (ERCP) showing aberrant right hepatic duct filled through cystic duct stump. (b) Magnetic resonance cholangiopancreatography demonstrating dilated intrahepatic ducts in the right lobe of liver. (c) the guidewire placed across the stricture in the aberrant right aberrant bile duct for balloon dilation. (d) Two biliary stents placed-one through the cystic stump into the aberrant right hepatic duct and the other through the common hepatic duct into the right hepatic biliary system.

Figure 2

(a) Computed tomography (CT)-scan showing dilated intrahepatic branches in right lobe of liver. (b) Endoscopic retrograde cholangiopancreatography (ERCP) showing paucity of intrahepatic filling in right lobe of liver in an otherwise normal looking ERCP. (c) Percutaneous transhepatic cholangiopancreatography (PTC) showing dilation of intrahepatic branches in the liver segment drained by the aberrant branch isolated by surgical clips.

Figure 3

Endoscopic retrograde cholangiopancreatography (ERCP) demonstrating aberrant right hepatic duct draining a segment of right lobe of liver and emptying into cystic duct (arrow).

Figure 4

(a) Endoscopic retrograde cholangiopancreatography (ERCP) showing staples close to common bile duct with inadequate filling of intrahepatic ducts in right lobe of liver. (b) Operative photograph-probe in the torn aberrant duct (curved arrow) and ostium on the surface of cystic duct stump (line arrow).