The patient is a 79-year-old white man who had a laparoscopic converted to open cholecystectomy performed approximately 3 weeks before transfer to our facility. Details of the original operation noted a gangrenous perforated gallbladder requiring an open conversion. The cholecystectomy was performed using a retrograde fundus-down approach, with inability to obtain the critical view. A tubular structure, thought to be a duct of Luschka, was also identified and ligated in addition to the cystic artery and duct. A single drain was placed, and the procedure was completed in an otherwise standard fashion.\nPostoperatively, the patient had persistent high-output bilious drainage. He was discharged on postoperative Day 6 with a drain in place. He returned to the outside facility approximately 4 days later with jaundice, weakness, fatigue and pain. A computed tomography (CT) scan of the abdomen and a nuclear cholescintigraphy scan confirmed a biliary leak with free intra-abdominal fluid consistent with biliary peritonitis (Fig. ). The patient was transferred to our critical care unit for further management.\nThe patient was placed on broad spectrum antibiotics and treated for atrial fibrillation with rapid ventricular response. Laboratory workup revealed a bilirubin level of 17 mg/dl, as well as profound protein–calorie malnutrition with an albumin of 1.9 gm/dl. A percutaneous cholangiogram was performed confirming a hilar ligation of his hepatic duct with inability to pass a wire or catheter distally. A right posterior and right anterior percutaneous cholangiogram catheter was placed for definitive biliary diversion (Fig. ). The patient was then managed with high calorie, high protein enteral nutrition through a nasogastric Dobhoff tube for approximately 7 days until able to tolerate appropriate oral intake for discharge. He was scheduled for follow-up in 2 weeks.\nAt follow-up, the patient had improved substantially. Repeat CT scan confirmed appropriate drainage of all abdominal fluid collections. His bilirubin improved to 1.2 mg/dl with an albumin of 3.1 gm/dl and prealbumin of 17.3 gm/dl. At this visit, he was scheduled for definitive biliary reconstruction approximately 2 months after his initial operation.\nDuring this operation, the porta was dissected and the common and proper hepatic arteries were identified and preserved. We were unable to palpate the previously placed percutaneous biliary catheters due to the high placement above the hilum at the level of multiple clips. We transected the CBD distally and removed numerous clips, finally noting bile drainage, but were unable to identify a cholangiogram catheter. We then identified a second tubular structure more lateral to the duct. We elected to transect this tissue, identifying a second extrahepatic bile duct. The anterior percutaneous catheter was identified proximally within the duct. An on-table cholangiogram with fluoroscopy was performed noting two separate extrahepatic biliary systems, draining the right and left lobes of the liver, respectively (Figs and ). Both distal ducts were ligated to definitively close the orifice to the duodenum and prevent spillage. A Roux limb of jejunum was created and anastomosed in a retrocolic fashion to the two separate hepatic ducts at the level of the hilum. A drain was placed, and there was no evidence of bile leakage.\nThe patient was discharged on postoperative Day 6 with normal hepatic function, normal bilirubin and no further complications. A follow-up cholangiogram at his postoperative clinic visit showed normal intrahepatic ducts with no evidence of stricture or leak, signifying successful repair of his injury with bypass of his duplicated biliary anatomy (Fig. ). His cholangiogram catheters were removed, and he was discharged from the clinic.
A 63-year-old woman from rural Nepal presented with a history of right upper abdominal pain, epigastric discomfort, bloating, and dyspepsia for 4 years, followed by intermittent fever and jaundice for a month. She had an increase in severity of pain, yellowish discoloration of body, vomiting, and fever for 1 week but had no history of anorexia or weight loss. She had no significant past medical and surgical history. On general examination she had icterus. Her vital parameters were within the normal range. An examination of her abdomen revealed a non-distended soft abdomen with negative Murphy’s sign and her gall bladder was not palpable.\nBiochemical parameters showed hemoglobin 13.4 gm/dl, total leukocyte count 12,600/mm3, platelets 158,000/mm3, total bilirubin 7.9 mg/dl, direct bilirubin 5.4 mg/dl, alanine aminotransferase (ALT) 196 U/L, aspartate aminotransferase (AST) 146 U/L, alkaline phosphatase (ALP) 273 U/L, serum amylase 50 U/L, and lipase 100 U/L. An abdominal ultrasonogram showed multiple calculi in her gallbladder (largest 6 mm), dilated common bile duct (CBD) measuring 13 mm with dilated intrahepatic biliary ducts (IHBDs), and suspected calculi/mass in distal CBD. A contrast-enhanced computed tomography (CECT) scan of her abdomen revealed similar findings and could not differentiate mass or stone in distal CBD. Endoscopic retrograde cholangiopancreatography (ERCP) was planned with the aim of extracting the stone and, if present, a biopsy from the mass. ERCP was unsuccessful on account of difficult anatomy. Magnetic resonance cholangiopancreatography (MRCP) reported the following: IHBDs from the right lobe of the liver drained into the right hepatic duct that formed a separate CBD with the cystic duct opening into it; the IHBDs from the left lobe of the liver drained into the left hepatic duct that formed a separate CBD. Both CBDs appeared mildly dilated proximally and descended separately until a point where a stone was noted. Below this point, the CBD could not be traced so the type of anomaly was inconclusive (Fig. ).\nDue to radiological findings that were suspicious of double CBD (DCBD), our patient was then planned for exploratory laparotomy to assess and confirm the radiological findings, and for definitive diagnosis and treatment of the condition. Intraoperative findings were contracted gall bladder with multiple tiny calculi, two separate draining bile ducts, which were fused just before opening to the ampulla, common duct with a calculus of 1 × 1 cm2, and cystic duct opening into the right duct (Fig. ). So the diagnosis of type Va DCBD with cholelithiasis and choledocholithiasis was made. Following this, cholecystectomy was done, the common duct was explored and the stone was extracted. The right duct was divided just proximal to the opening of the cystic duct and the left duct was also divided at the same level. After closing distal common bile duct stump, reconstruction was done by hepatic ductoplasty (joining two ducts) with hepaticojejunostomy in Roux-en-Y fashion. Her postoperative period was uneventful and she was discharged after 1 week and was doing well at 6-month follow-up.\nHistologic examination of the resected specimens revealed chronic inflammatory changes in the gallbladder and common bile duct with no evidence of malignancy.