A 54-year-old male presented to a primary care physician with a complaint of indigestion. He underwent gastrofiberscopy, which revealed a small circumferential ulceroinfiltrative ill-defined mucosal lesion at the anterior wall of the antrum. Biopsy specimens were taken from the ulceroinfiltrative lesion, and showed adenocarcinoma. He was diagnosed with gastric cancer and referred to our hospital for an operation. We didn't detect any abnormal findings physically or in the laboratory. Abdominal CT scan showed mild gastric mucosal thickening in the anterior wall of the gastric antrum. We decided to perform laparoscopic assisted distal gastrectomy. During the surgery, we incidentally detected bile leak from the tubular structure around the hepatoduodenal ligament, and therefore converted to open surgery (). We performed intraoperative cholangiogram by cannulizing into the tubular duct, and confirmed that the tubular duct was the accessory bile duct with an ectopic drainage into the stomach, which was connected with the proximal common bile duct and linked with the left intrahepatic duct (). In the specimen, the ACBD was independent of the cancer lesion (). The ACBD was resected afterward. The patient was discharged without complications, and is doing well until now.
A 61-year-old man was admitted to our hospital because of abdominal discomfort since 3 days. He had been in good health without any previous medical history of note. About 23 years ago, he had undergone primary repair of bowel rupture. Physical examination did not show any abnormalities. Initial laboratory data showed elevated serum total bilirubin 1.48 mg/dL, serum aspartate aminotransferase 980 IU/L, serum alanine transaminase 274 IU/L, and serum C-reactive protein 10.8 mg/L. Serum amylase and lipase were within normal limits. Serum was negative for hepatitis B and C markers. Abdominal computed tomography (CT) scan showed multiple CBD stones with dilated bile duct and MPD. On esophagogastroduodenoscopy, the major papilla of Vater was not found in the second duodenal portion. It was finally located in the duodenal bulb (). Endoscopic retrograde cholangiopancreatography (ERCP) was successfully performed via cannulation of the ectopic opening in the duodenal bulb. Dilated CBD with multiple stones was directly visualized radiographically () by injecting contrast media via the orifice. The patient underwent dilatation of the papilla with a balloon catheter (CRE wire-guided balloon dilator 12 to 15 mm; Boston Scientific, Marlborough, MA, USA), and a basket was used to remove the stones (). He was discharged without complications after the procedure.