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 77-year-old woman presented to the outpatient department of our hospital complaining of recurrent epigastric pain.\nPatient’s symptoms started a month ago with recurrent episodes, with no history of fever, chills, or vomiting.\nThe patient had a history of laparoscopic cholecystectomy for cholelithiasis 2 years earlier at another hospital. She had undergone endoscopic retrograde cholan-giopancreatography (ERCP) twice for choledocholithiasis before undergoing cholecystectomy.\nThe patient did not have a history of drinking or smoking. There was no remarkable family medical history.\nPhysical examination did not reveal tenderness or signs of peritoneal irrigation, and the bowel sounds were normal. At the outpatient clinic, her temperature was 36.7 °C, pulse rate was 70 beats/min, and blood pressure was 122/82 mm Hg.\nBlood analysis showed normal complete blood cell count, liver function test and C-reactive protein.\nComputed tomography (CT) imaging revealed a dilated CBD that harboured multiple choledocholithiasis (Figure ). After admission, ERCP was subsequently performed, and the stones were extracted using a Dormia basket (MTW Endoskopie, Wesel, Germany) (Figure ) after endoscopic papillary balloon dilatation by a CRETM balloon dilatation catheters (Boston Scientific Corporation, Natick, MA, United States). A 5 Fr endoscopic nasobiliary drainage (ENBD) catheter (ENBD-5, Cook Medical, Bloomington, IN, United States) was inserted at the end of the procedure. A day after the ERCP, tubography via the ENBD catheter was performed to confirm the presence of residual stones in the bile duct. However, no definite filling defects were observed on tubography (Figure ). The patient was discharged without any complications of ERCP. A day after discharge, she visited the emergency department with complaints of severe epigastric pain and fever. Her temperature was 38.2 °C, pulse rate was 79 beats/min, and blood pressure was 149/85 mm Hg. Laboratory findings were suggestive of cholestasis [aspartate aminotransferase, 210 U/L (normal: 0–35 U/L); alanine aminotransferase, 134 U/L (0-35); alkaline phosphatase, 201 U/L (30-120); gamma glutamyl transferase, 184 U/L (9-64); total bilirubin, 2.77 mg/dL (0.3-1.2); direct bilirubin, 1.32 mg/dL (0-0.2); and C-reactive protein 6.91 mg/dL]. A CT scan demonstrated another dilated extrahepatic bile duct draining the right lobe of the liver, which also contained stones in the distal portion (Figure ). An urgent ERCP was performed as the stones were impacted at the ampulla (Figure ), and the stones with pus were retrieved using a balloon catheter (Escort II® Double Lumen Extraction Balloon, Cook Medical, Bloomington, IN, United States). A 10 Fr, 5 cm endoscopic retrograde biliary drainage tube (Cotton-Leung Biliary Stent, Cook Medical, Bloomington, IN, United States) was then placed in the CBD.\nMagnetic resonance cholangiopancreatography (MRCP) was performed to evaluate the delicate structures of the CBD and to check for any remnant stones. MRCP revealed DCBD independently draining the left and right lobes of the liver, that created a short segment intrapancreatic CBD (Figure ) without a communicating channel, that was consistent with the DCBD Type Va as classified by Choi et al[,]. Residual choledocholithiasis was also noted in the right CBD. There was no evidence of anomalous union of the pancreaticobiliary duct on MRCP.