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.
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.