Type of publication:
Conference abstract
Author(s):
*Lakshmipathy G.; *Pattar J.; *Jain R.;
Citation:
British Journal of Surgery. Conference: Annual Congress of the Association of Surgeons of Great Britain and Ireland. Edinburgh United Kingdom. 112(Supplement 13) (pp xiii122-xiii123), 2025. Date of Publication: 01 Aug 2025.
Abstract:
Clinical Details: 61-year-old man with obesity and type II diabetes, presents with abdominal pain and obstructive jaundice. MRCP showed gallstones and 12mm common hepatic duct (CHD) stone. However, ERCP could not identify calculus in the then thought CHD. Second MRCP and bloods demonstrated the same CHD stone and worsening bilirubin. Therefore, laparoscopic cholecystectomy and common bile duct (CBD) exploration were done; with the extraction of three proximal CBD stones and flushing two distal CBD stones. Operative choledochoscopy of CBD and the then presumed CHD were considered clear. Post-operatively, bilirubin climbed and MRCP confirmed the persistent CHD stone and identified anatomical variation in drainage of right posterior sectoral duct (RPSD). Subsequently, ERCP could not retrieve the large CHD calculus and spyglass ERCP referral was made. Discussion(s): Negative operative choledochoscopy and endoscopy of CHD occurred because of preferential entry into aberrant RPSD rather than CHD. This aberrant RPSD drained into cystic duct, which is type 5 variation in prevalence-based classification of anatomical biliary variants or type 3C of Choi classification. Aberrant RPSD is the least prevalent bile duct variant seen in 0.6% of patients. Type 4 and 5 variants are relevant in operative choledochoscopies and ERCP, as RPSD could be mistaken for CHD. This case demonstrates a rare anatomical variation of the biliary tree which can derail surgeons and endoscopists in diagnosing and managing patients with choledocholithiasis. We therefore emphasise high index of suspicion and utilise three-dimensional reconstruction of biliary tree, pre-procedurally in all cases of CBD exploration.
DOI: 10.1093/bjs/znaf166.475
