title: Variations in biliary ductal and hepatic vascular anatomy and their relevance to the surgical management of choledochal cysts.
abstract: OBJECTIVE
  An aberrant biliary ductal and vascular anatomy presents a technical challenge for choledochal cyst (CDC) surgery. Mismanagement may have unfavourable implications. This study highlights the spectrum, approach to their identification and management.
  
  
  METHODS
  Forty of 117 (34 %) cases were identified to have an aberrant biliary ductal (n = 17) or arterial (n = 26) anatomy; 3 had both. The pancreaticobiliary anatomy was defined by an intraoperative cholangiogram (IOC) before January 2005 and a preoperative magnetic resonance cholangiopancreatogram (MRCP) subsequently.
  
  
  RESULTS
  IOC missed 3 of 4 aberrant biliary ducts, while an MRCP accurately delineated 10 of 13 aberrant bile ducts. The significant biliary anomalies were: an aberrant right sectoral/segmental duct joining the common hepatic duct (CHD) or the cyst itself (n = 14), cystic duct (n = 1) and cystic duct-CHD junction (n = 1). The aberrant duct was incorporated into the biliary-enteric anastomosis (B-EA) by: (i) double ostia B-EA (n = 1), (ii) ductoplasty with single ostium B-EA for aberrant duct and CHD (n = 2), and (iii) transection of the CHD/cyst distal to the aberrant duct orifice with a single ostium B-EA (n = 13). The arterial anomalies were (i) replaced or accessory right hepatic artery (RHA) (n = 11) and (ii) RHA crossing anterior to the cyst (n = 15), which was repositioned posterior to the B-EA.
  
  
  CONCLUSIONS
  It is important to consciously look for, appropriately identify and manage aberrant biliovascular anatomy. MRCP facilitates accurate preoperative delineation of aberrant duct anatomy. All major aberrant ducts need to be incorporated into the B-EA and aberrant arteries should not be ligated.
authors.affiliation: Department of Pediatric Surgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, 226014, India. richalal@gmail.com
authors.forename: Richa
authors.initials: R
authors.lastname: Lal
authors.forename: Anu
authors.initials: A
authors.lastname: Behari
authors.forename: Ranjit Hari Vijaya
authors.initials: RH
authors.lastname: Hari
authors.forename: Sadiq S
authors.initials: SS
authors.lastname: Sikora
authors.forename: Surender Kumar
authors.initials: SK
authors.lastname: Yachha
authors.forename: Vinay Kumar
authors.initials: VK
authors.lastname: Kapoor
mesh_terms: D000015:Abnormalities, Multiple / Q000601:surgery*; D000293:Adolescent; D001652:Bile Ducts / Q000002:abnormalities* / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D015529:Choledochal Cyst / Q000601:surgery*; D006499:Hepatic Artery / Q000002:abnormalities* / Q000601:surgery*; D006801:Humans; D007223:Infant