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.
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.