Double Common Bile Duct with Choledocholithiasis

Min, Hhung Rae; Park, Yeung Rae; Yoo, Chang Hyun

Abstract

An esophageal perforation is a condition requiring emergency treatment. Although previously spontaneous ruptures were the most common etiology, as endoscopic and radiologic diagnosis and treatment have developed recently, iatrogenic ruptures due to instrumentation have increased to become the most common cause of esophageal perforations. Generally, the treatment of esophageal stenosis is composed of esophageal dilatation using a Maloney or a Mercury dilator and medical treatment for reflux esophagitis. Recently, balloon-catheter dilatation of the esophagus has produced safe and excellent results, and self-expansible metallic stents has been very useful in controlling malignant strictures of the esophagus with low mortality and morbidity. We experienced an esophageal perforation after balloon dilatation and the insertion of a self-expanding silicone-covered Gianturco stent to the site of the esophageal stenosis which was due to reflux esophagitis. The abdomen was opened through an upper midline incision. There was a 3-cm-long longitudinal laceration on the distal esophagus which was closed transversely as with a Heinecke-Mikulicz pyloroplasty after a debridement. To reinforce the site of esophageal laceration and to prevent esophageal reflux, the gastric fundus was pulled and sutured over the esophageal sutures, and the second-layer mattress suture was made 1 cm proximal to the first sutures, including central ligaments of the diaphragm. To prevent bile reflux, we converted from a Billroth-II to a Roux- en-Y gastrojejunostomy. We followed up for 30 months and found no signs of any esophageal stenosis or gastroesophageal reflux. Surgeons rarely encounter variability of the extrabiliary system. However we experienced an anomaly of the extrahepatic bile duct, an incompletely septated double ductus choledochus consisting of two chambers, a proximal-blinded right-down-sided chamber and a left-upper-sided one, which drained from both intrahepatic bile ducts. A large stone was in the proximal-blinded lower choledochus which contained the cystic duct orifice. In this case, several problems were met. First, an exact preoperative diagnosis of the anomalous anatomy was not made with ultrasonogram and computed tomography. Second, the palpable stone was not visualized even on choledochotomy of the left-upper-sided chamber. Third, a surgical decision had to be made whether the septum should be removed. We performed a complete septotomy to prevent bile stasis in the down chamber. Here, we present a description of this rare extrahepatic bile duct anomaly, along with a review of the literature.