Double common bile duct with cholelithiasis

Abstract

Double common bile duct is a rare congenital anomaly among biliary anomalies. The anomaly has an important clinical implication because of its association with biliary tract obstruction. In addition, if one of the two common bile ducts is mistaken for the cystic duct during surgery, residual stones and bile duct injury are likely to occur. Here, we report a case of double choledochal variation (Type Vb) with choledochal calculi. An 82-year-old woman was admitted to the hospital due to mild pain in the upper abdomen accompanied by vomiting for 3 days. Magnetic resonance imaging suggested common bile duct lithiasis, variation of the common bile duct and moderate biliary tract dilation. Laparoscopy combined with choledochoscopic lithotomy was performed for choledocholithotomy. During the operation, left and right choledocholithotomy was performed, and all the gallstones were removed via choledochoscope. The patient’s post-operative recovery was good, and no recurrence of cholelith had been observed at the time of writing.

INTRODUCTION

Double common bile duct (DCBD) is an extremely rare condition among anatomical variations in the biliary tract system. To date, no more than 100 cases of DCBD variation have been reported.[1] Here, we report a case of successful treatment of double choledochal variation (Type Vb) with choledochal lithiasis via laparoscopy combined with choledochoscope. This case highlights the importance of recognition of this condition to avoid missed diagnosis and bile duct injury during surgery, coupled with the need for magnetic resonance cholangiopancreatography (MRCP) examination before surgery.

CASE PRESENTATION

The study was approved by the Ethics Committee of Meizhou People’s Hospital (2021-C-50), and informed consent has been signed. An 82-year-old woman was admitted for repeated epigastrium mild pain for 6 years aggravated with vomiting for 3 days. She had undergone hysterectomy due to ectopic pregnancy at the age of 32 years and subtotal gastrectomy (Billroth II) due to gastric perforation at the age of 40 years. Due to calculus of gallbladder with acute cholecystitis, cholecystectomy was performed at the age of 52 years. After admission, physical examination revealed only two surgical scars measuring about 15 cm and 8 cm at the middle and lower abdomen, respectively, and epigastric tenderness without rebound pain. Laboratory test results indicated alanine aminotransferase of 321 U/L, AST of 118 U/L and Dbil of 10.2 mmol/L. MRCP indicated sediment samples at the bottom of the choledochal duct and thickening of the tube wall at the end of the choledochal duct. The common bile duct in the upper of the pancreas was bisected by a membrane, and communicated in the common hepatic duct. The findings were thought to be congenital variations [Figure 1]. The patient underwent endoscopic retrograde cholangiopancreatography on day 6 after admission. During surgery, a variety of methods were used to try to insert a Zebra guidewire into the bile duct. Unfortunately, none of the methods were successful. The patient was in too much pain to tolerate surgery, so we stopped operating. We performed choledochal incision and stone extraction by laparoscopy combined choledochoscope. Intra-operative exploration revealed that the common bile duct was separated by a septum, in which the left and right hepatic ducts communicated in the upper common bile duct each other. Then, the left and right choledochs merged at the bottom of bile duct. During the operation, the left and right bile ducts were incised separately. The bile duct was rinsed, the gallstones were removed, the right side choledoch was stitched for a continuous period and the left bile duct was retained with a 20 Fr T-tube for drainage [Figure 2]. On day 2 after surgery, the patient was given a liquid diet and got out of bed for exercise by herself. The patient was discharged on the post-operative day 10 with a T-tube. Two months later, the T-tube was removed without any complications.

Figure 1.

MRCP showing a septum between the right and left choledoch, as well as the pancreatic duct and duodenum. MRCP: Magnetic resonance cholangiopancreatography

Figure 2.

(a) Operative findings: DCBD variation was observed in which the left and right hepatic ducts and lower bile duct communicated with each other, which got into the duodenum. (b and c) The left and right bile ducts were cut separately. (d) The right side choledoch was stitched for a continuous period and the left bile duct was retained with a 20 Fr T-tube for drainage. DCBD: Double common bile duct

DISCUSSION

The earliest classification of DCBD was developed by Goor and Ebert based on anatomical structure.[2] The classification currently used is based on morphology proposed by Choi in 2007, who described additional variants.[3] This case presents an extremely rare congenital anomaly of the biliary system in an adult patient. To our knowledge, this is the first case to report a double choledochal variation with calculi treated by laparoscopy and choledochoscope in the Asian population, and only the third case reported to be Vb in the world.[4] MRCP is a non-invasive examination and has obvious advantages in bile duct imaging compared with other examinations, especially in cases of bile duct variation.[5]

Although DCBD variation was detected by MRCP in the present case, the patient had a history of multiple abdominal surgeries and various other diseases, which made diagnosis and treatment a great challenge. In order to remove the choledochal calculi and relieve the biliary obstruction, laparoscopy combined choledochoscope was selected as the surgical programme. The results showed that the common bile duct was bisected by a septum from the opening of the cystic duct to the bottom of the common bile duct, which was a DCBD variation of Type Vb.

In summary, this article reports a rare case of DCBD of type Vb. This case reminds us of the need for MRCP in the management of bile duct surgery, as well as the need for timely discovery and understanding of the corresponding biliary variation to formulate a reasonable surgical programme. Surgeons should be familiar with this kind of variation. We hope this case provides useful information in dealing with choledochal variation with cholelithiasis, thereby reducing misdiagnosis and biliary injury in the future.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.