Management of Calculi in the Common Hepatic Duct and Accessory Right Hepatic Duct with T-Tube and C-Tube Drainage: A Case Report

Abstract

Introduction

Biliary tract stones are a common clinical condition. The primary clinical symptoms include intermittent pain in the right upper quadrant and upper abdomen. During acute episodes, the pain may become persistent. A small number of patients may also present with jaundice.

Case Presentation

An 80-year-old male was admitted to the hospital due to right upper quadrant pain persisting for over 12 h. Examination revealed that the patient had common bile duct stones with cholangitis, as well as gallbladder stones with cholecystitis. The patient’s biliary anatomy showed the cystic duct opening into an accessory right hepatic duct, which formed a low confluence with the common hepatic duct to become the common bile duct. Surgical intervention was therefore performed. We managed the stones in this anatomically complex biliary configuration by placing a C-tube through the cystic duct, performing primary closure of the accessory right hepatic duct, and placing a T-tube in the common hepatic duct.

Conclusion

The patient recovered well postoperatively. By placing the C-tube and performing primary closure of the accessory right hepatic duct, we reduced the incidence of bile leakage and concurrently lowered the risk of soft tissue infection at the incision site and intra-abdominal infection. Furthermore, the placement of a C-tube offers an alternative approach for managing accidental bile duct injury during biliary surgery.

Introduction

Cholelithiasis is a highly prevalent clinical condition [1]. Typically, gallstones do not cause clinical symptoms; however, approximately 10%–25% of patients with gallstones develop clinical manifestations such as biliary pain or acute cholecystitis, and about 1%–2% of symptomatic patients may experience severe complications [2, 3]. When gallstones migrate into the common bile duct, most patients exhibit clinical symptoms and complications, primarily presenting as pain, jaundice, and potentially cholangitis in severe cases [4, 5]. Currently, laparoscopic cholecystectomy is recognized as the gold standard for treating gallbladder stones [6, 7]. However, no consensus exists for the management of common bile duct stones [8, 9]. Multiple treatment options are available clinically, with laparoscopic surgery and endoscopic therapy being the most frequently utilized approaches. We present a case report detailing the management of calculi in a patient with complex biliary anatomy. Through the placement of both a C-tube and T-tube, primary repair of the accessory right hepatic duct was performed. This approach not only reduced the incidence of bile leakage but also enhanced the patient’s postoperative recovery experience.

Case Presentation

An 80-year-old male patient was admitted with persistent right upper quadrant pain lasting 12 h – his first episode of such discomfort – accompanied by fever but without nausea, vomiting, or significant jaundice. His medical history included surgical resection for gastric carcinoma without adjuvant therapy, and long-standing rheumatoid arthritis managed with leflunomide and aceclofenac enteric-coated tablets. Preoperative contrast-enhanced CT revealed an enlarged gallbladder with fluid accumulation, gallstones, a distal common bile duct stone, dilation of the intrahepatic and extrahepatic bile ducts, and an accessory right hepatic duct running parallel to the common hepatic duct. MRCP demonstrated partial overlap between the accessory right hepatic duct and the common hepatic duct, which converged distally to form the common bile duct, with calculi observed in the gallbladder and distal common bile duct (Fig. 1). Laboratory findings, white blood cell count: 9.02 × 10⁹/L (neutrophils: 95.20%), C-reactive protein: 16.8 mg/L, procalcitonin: 0.648 ng/mL, total bilirubin: 63.5 µmol/L (direct: 25.1 µmol/L, indirect: 16.7 µmol/L), alanine aminotransferase: 475.9 U/L, gamma-glutamyl transferase: 436 U/L, alkaline phosphatase: 283 U/L, amylase: 118 U/L, lipase: 152 U/L. The patient’s temperature was 38.4°C. Based on comprehensive evaluation of the patient’s symptoms, imaging findings, and laboratory investigations, the diagnosis was established as choledocholithiasis with cholangitis and cholecystolithiasis with cholecystitis. Given the presence of gallbladder and common bile duct stones on CT and MRI, abnormal liver function tests, and right upper quadrant pain in a patient with a history of total gastrectomy for gastric cancer, other causes of abdominal pain and hepatic dysfunction were effectively ruled out. Anatomical variation was identified: the cystic duct originated from the accessory right hepatic duct, which formed a low-positioned confluence with the common hepatic duct to create the common bile duct. The patient was diagnosed preoperatively with gallbladder stones complicated by common bile duct stones. Anatomical characteristics revealed that the cystic duct originated from an accessory right hepatic duct, which converged with the common hepatic duct at a low position to form the common bile duct. Subsequently, laparoscopic cholecystectomy combined with common hepatic duct exploration and lithotomy were carried out. Unexpectedly, during the operation, stones were also detected in the accessory right hepatic duct. The origin of these stones might be attributed to fragmented common bile duct stones that had been flushed into the accessory right hepatic duct or to gallbladder stones. Multiple attempts were made to extrude the stones in the accessory right hepatic duct into the lower segment of the common bile duct, yet all were unsuccessful. Consequently, after incising the accessory right hepatic duct to remove the stones from both the accessory right hepatic duct and the common bile duct, considering the proximity of the incisions of the common hepatic duct and the accessory right hepatic duct, the placement of a double T-tube might lead to insufficient drainage due to mutual compression, increasing the risk of bile leakage and causing discomfort to the patient. Ultimately, a C-tube was inserted through the cystic duct stump into the accessory right hepatic duct and secured with a slip knot to relieve luminal pressure. The incision of the accessory right hepatic duct was primarily sutured. The C-tube effectively mitigated the risk of bile leakage and circumvented the drawbacks of the double T-tube (Fig. 2).

Fig. 1.

a, b Preoperative contrast-enhanced CT images of the patient. a The upper red arrow indicates the common hepatic duct, while the lower red arrow marks the accessory right hepatic duct. b The left red arrow points to a gallbladder stone, and the right red arrow identifies a common bile duct stone. c Preoperative MRCP image: upper red arrow: accessory right hepatic duct; middle red arrow: common bile duct; lower red arrow: common bile duct stone. d An anatomical schematic diagram of the biliary tract.

Fig. 2.

a The left red arrow indicates the accessory right hepatic duct, while the right red arrow points to the common hepatic duct. b A black stone within the common bile duct was flushed out by water. c A black stone is visible within the accessory right hepatic duct. d The red arrow marks the cystic duct.

Based on our prior research, the C-tube removal time in our center ranges from 12 to 15 days postoperatively, while T-tube removal occurs between 30 and 40 days. Patients with C-tubes exhibit lower rates of skin/soft tissue infections and intra-abdominal infections compared to those with T-tubes. No significant differences were observed in bile leakage, postoperative cholangitis, gallstone recurrence, pancreatitis, or biliary stricture rates between the two groups [10]. Postoperatively, the patient received ceftizoxime 1.5 g twice daily, glutathione 1,800 mg once daily, and intravenous fluids including potassium chloride and glucose. Serial monitoring of complete blood count, liver/kidney function, and electrolytes revealed elevated white blood cell and neutrophil counts, prompting antibiotic escalation to imipenem-cilastatin 1 g every 6 h. Following targeted therapy, the patient’s parameters normalized substantially. On postoperative day 8, cholangiography demonstrated no contrast extravasation and confirmed patency of the distal common bile duct (Fig. 3). The patient was discharged on postoperative day 17 without complications. After discharge, the patient returned to the hospital for follow-up examinations, and all indicators showed a positive trend. Follow-up evaluations revealed no adverse outcomes. The patient expressed satisfaction with the therapeutic outcomes. The patient’s perspective was positive, as the disease was closely monitored during the follow-up.

Fig. 3.

a Label 1 indicates the left hepatic duct, label 2 denotes the right hepatic duct, and label 3 refers to the accessory right hepatic duct. The left red arrow represents the C-tube, while the right red arrow marks the T-tube. b Contrast agent flowing smoothly through both the C-tube and T-tube into the duodenum.

Discussion

Gallstones are a relatively common clinical condition, with 10%–15% of cases accompanied by common bile duct stones [11]. In clinical practice, especially in cases of acute cholecystitis and acute common bile duct stones, the risk of biliary injury is higher due to severe inflammation and adhesions during acute episodes, which increase the likelihood of intraoperative bile duct damage. Although the incidence of bile duct injury ranges between 0.1% and 2.3%, once it occurs, it can lead to high rates of disability, mortality, and increased hospitalization costs [12].

Existing studies suggest several approaches for managing severe complications such as bile duct injury during surgery. The most common methods include endoscopic retrograde cholangiopancreatography (ERCP), primary end-to-end anastomosis (with or without T-tube drainage), choledochoduodenostomy, and Roux-en-Y hepaticojejunostomy. However, ERCP has its limitations, as its success rate can be affected by factors such as the number and size of stones, the diameter of the common bile duct, and others. Additionally, ERCP disrupts the physiological function of the sphincter of Oddi and repeated intubation can induce spasms and edema of the duodenal papilla, leading to permanent duodenal reflux, which increases the risk of biliary infection and stone recurrence. Biliary reconstruction surgeries, such as choledochoduodenostomy and Roux-en-Y hepaticojejunostomy, not only carry the risks of anesthesia and surgery but may also result in complications such as bile leakage, anastomotic obstruction, cholangitis, digestive dysfunction, and jaundice. Long-term issues, such as recurrent bile duct stones, are also possible, and these procedures are often complex and time-consuming.

Primary anastomosis with a T-tube has its drawbacks, including significant bile loss, which can lead to water, electrolyte, and acid-base imbalances, as well as skin erosion around the T-tube drainage site. Residual fragments of the T-tube in the bile duct and the prolonged presence of the T-tube in the body can cause discomfort, prolonged hospitalization, and inconvenience, increasing both patient suffering and treatment costs. Primary suturing without a T-tube may result in adhesions, scar stenosis, and narrowing of the bile duct, leading to increased pressure, bile leakage, and bile peritonitis, causing postoperative complications. Therefore, in cases of common bile duct stones, after complete stone removal, primary suturing combined with the placement of a C-tube through the cystic duct into the common bile duct, secured with a sliding knot, may reduce bile duct pressure and lower the risk of bile leakage.

Our research center has demonstrated that patients with a C-tube have shorter postoperative hospital stays and earlier tube removal compared to those with a T-tube, while also experiencing lower rates of intra-abdominal and soft tissue infections. The advantages of the C-tube include its placement through the cystic duct into the common bile duct, allowing for primary suturing of the bile duct and preserving its anatomical and functional integrity. Both the C-tube and T-tube can drain bile, preventing postoperative bile stasis. However, the C-tube is thinner and more flexible, providing a better patient experience.

This case report highlights a patient with not only complex biliary anatomy but also an unusual stone location, presenting significant surgical challenges. Clinicians may have limited experience with such abnormal anatomical variations and stone positions. Therefore, it is essential to raise awareness of such cases in clinical practice. In this instance, we employed a combination of a T-tube and a C-tube, resulting in a favorable postoperative recovery and effectively addressing the challenges posed by the complex biliary anatomy.

Statement of Ethics

Ethical approval is not required for this study in accordance with local or national guidelines. Written informed consent was obtained from the patient for publication of this case report and any accompanying images. The CARE Checklist has been completed by the authors for this case report, attached as online supplementary material (for all online suppl. material, see https://doi.org/10.1159/000547520).

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Funding Sources

This study was not supported by any sponsor or funder.

Author Contributions

In this manuscript, there are two first authors, and their contributions to this project are equal. Jiang Zhu and Penghao Shu are responsible for writing the manuscript and participating in the surgical process. In addition, Xin Sui is the corresponding author of this manuscript. Xin Sui guided the surgery and provided suggestions for the writing of the manuscript. Dijian Ma, Zhenghui Sui, and Jie Zhang collected and mapped the images for the manuscript. Xiaowei Wang and Qiyuan Hu also contributed. All authors have contributed to the content of the manuscript and approved the submitted version.

Funding Statement

This study was not supported by any sponsor or funder.

Data Availability Statement

All data generated or analyzed during this study are included in this article and its online supplementary material files. Further inquiries can be directed to the corresponding author.