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 57-year-old man was referred to our hospital for further evaluation of pneumobilia. He was complaining of nausea for 1 month. He had no past medical history of note. On admission, physical examination was unremarkable. Initial laboratory findings were normal. On abdominal CT, diffuse pneumobilia was evident, and a communication was suspected between the duodenal bulb and the extrahepatic bile duct. For confirmation, ERCP was performed. ERCP showed an ectopic opening of the major papilla of Vater in the duodenal bulb (). We cannulated the ectopic opening and injected contrast media via the orifice. We found that the CBD and MPD were communicating with the duodenal bulb (). After 9 months, abdominal CT scan showed focal nodular wall thickening with enhancement of the gallbladder (). Consequently, the patient underwent radical cholecystectomy with hepaticojejunostomy as gallbladder cancer was suspected. Histopathological examination revealed a moderately differentiated adenocarcinoma arising from the gallbladder and extending into the perimuscular connective tissue (). After the operation, he was discharged without complications.