A 64-year-old female presented to the surgical emergency unit with a day's history of right upper quadrant pain. Her physical examination revealed right upper quadrant tenderness with no rebound tenderness or muscular guarding. Other systemic findings were normal. Laboratory test showed leukocytosis of 17 × 10³/µL and elevated C-reactive protein of 51 mg/L (0–5 ml/L). Other laboratory values including serum amylase, bilirubin and transaminases were normal. Abdominal ultrasound revealed thickened gallbladder (GB) wall (4.7 mm) with a 25 mm gallstone. A diagnosis of acute calculous cholecystitis was made and intravenous fluid and antibiotic treatment were initiated. Laparoscopic cholecystectomy was considered after 48 h of observation. During surgery a standard 4-port technique was used after pneumoperitoneum using the Veress needle. GB wall was found to be inflamed with omental adhesions. Using the critical view of safety approach, the cystic artery and cystic duct were separately identified, clipped and transected. After careful dissection of the GB from the liver bed small amount of bile was observed oozing from a spot proximal to the ligated cystic duct stump. Irrigation of the spot revealed a small tear at what was thought to be the common hepatic duct. A 5-Fr drainage catheter (50 cm long, 1.4 mm in diameter) was placed into the opened duct and exteriorized through the mid-clavicular 5 mm port site for post-operative drainage. A tube cholangiography done on post-operative Day 7 showed duplication of the common hepatic duct proximal to the cystic duct stump with the injury occurring on the right-sided duct (Fig. ). A magnetic resonance cholangiopancreatography (MRCP) was taken which confirmed the presence of the duplicated common hepatic duct with the cystic duct stump distal to the duplication (Fig. ). No PBM was observed. Her post-operative course was uneventful with an average biliary drainage output of about 300 ml. Drainage tube was clamped on post-operative Day 9 and finally removed 4 weeks after surgery. No complication was observed and patient is currently doing well.
An 81-year-old woman presented with a 2-day history of chills and fever. She had been admitted two years ago with jaundice and fever. On a CT scan, the distal CBD, a large gallbladder (GB) and cystic duct stones were revealed. Urgent endoscopic retrograde cholangiopancreatography (ERCP) to remove the distal CBD stone was performed. Multiple CBD stones were extracted using a basket and balloon sweep. After the stones were removed, there was no filling defect on the CBD during balloon cholangiography. The patient refused cholecystectomy. She was not followed up after discharge from the hospital. On the next presentation, the laboratory tests revealed a slightly elevated aspartate aminotransferase level (45 IU/L) and an increased value of C-reactive protein (15.3 mg/I). The total bilirubin level, the alkaline phosphatase level, the gamma-glutamyltransferase level and the WBC count were all within the normal ranges. The presumed diagnosis was recurrent CBD stones, and an ERCP for recurrent CBD stones was planned. Transabdominal ultrasonography demonstrated a dilated extrahepatic bile duct filled with echogenic lesions that showed posterior acoustic shadowing, which was suggestive of bile duct stones (). On the more medial view of the sagittal sonogram, another mildly dilated extrahepatic bile duct was seen, but no stone was noted (). The sonographic findings led us to presume that the stone-filled aberrant right hepatic duct drained into the common hepatic duct. A contrast-enhanced CT scan was performed using a 64-MDCT scanner (LightSpeed VCT, GE Healthcare, Milwaukee, WI) and it showed two separate extrahepatic bile ducts (). Multiple stones were noted in a posterolaterally located bile duct and these stones extended to right intrahepatic bile ducts. There was a large stone in the GB and the cystic duct joined to a posterolaterally-located extrahepatic bile duct. The MinIP images were obtained on a postprocessing workstation (Advantage Windows workstation [version 4.3], GE Healthcare, Milwaukee, WI). The MinIP image (coronal oblique with a 5.3 mm thickness slab) revealed double extrahepatic bile ducts that combined to create a CBD in the pancreatic head portion with a communicating channel in the hilar portion (). MRCP performed with a 1.5-T Intera scanner (Philips Medical Systems, The Netherlands) failed to depict the precise anatomy of this anomaly due to the impacted stones (). There was no AUPBD on the MRCP. ERC was subsequently performed to remove the multiple stones in one of the double extrahepatic bile ducts. An ERC image also disclosed duplication of the extrahepatic bile duct with multiple stones in the posterolaterally located duct and the right intrahepatic ducts (). However, we failed to gain access to the right CBD and to remove the CBD stones.\nTo remove the remnant stones, duct exploration with insertion of a T-tube and cholecystectomy was performed. On a cholangiogram obtained during the subsequent operation, there was no evidence of remnant stones in the bile ducts (). The patient's postoperative recovery was uneventful.