Aberrant Right Hepatic Duct Originating from the Right Posterior Duct with Low Insertion into the Common Bile Duct

Aberrant Right Hepatic Duct Originating from the Right Posterior Duct with Low Insertion into the Common Bile Duct Gonzalo Pérez, MD, Ricardo O Escárcega, MD, Julio Gargantua, MD, Salvador Fuentes-Alexandro, MD Hospital de Especialidades, Puebla, México A 60-year-old man, who had a cholecystectomy 4 years earlier, had right upper quadrant pain, mild jaundice, and fever. ERCP and sphincterotomy revealed a biliary duct anomaly (A). Abdominal CT showed a 0.97-cm ovoid image consistent with choledocolithiasis (B). Common bile duct (CBD) exploration through a Kocher’s right subcostal incision identified the stone seen on the CT through palpation of the CBD. The aberrant duct was found to be inserted low, rotating posteriorly and into the CBD. An earthy, brown, friable stone (B, inset) was removed by choledocotomy. Intraoperative cholangiography (C) revealed an aberrant right hepatic duct originating from the right posterior duct (RPD) with low insertion into the CBD. Segments VI and VII are drained by this aberrant duct, while segments V and VIII are drained by the right anterior duct (RAD) and the usual junction with the left hepatic duct (LHD) to form the hepatic duct (CHD). A stricture is shown distally, which may account for the dilatation of all the ducts. Five months postoperatively, the patient was well, with no episodes of upper quadrant pain or jaundice. The aberrant bile duct does not communicate with other biliary segments, and drains only a particular segment of the liver. Most aberrant ducts arise from the right lobe of the liver. These ducts are from 1 to 2 mm in diameter and most commonly drain into the common hepatic CHD or cystic duct within 30 mm of the cystic angle.1 Izuishi and coauthors2 studied 113 patients using multislice CT cholangiography and reported that the incidence of a posterior segmental duct joining directly into the common bile duct was 7% in their series (8/113). The overall incidence of aberrant bile ducts was 16% (18/113), which is the incidence reported by other authors.

A

B

REFERENCES 1. Suhocki PV, Meyers W. Injury to aberrant bile ducts during cholecystectomy: a common cause of diagnostic error and treatment delay. AJR 1999;172:955–959. 2. Izuishi K, Toyama Y, Nakano S, et al. Preoperative assessment of the aberrant bile duct using multislice computed tomography cholangiography. Am J Surg 2005;189:53–55.

C © 2006 by the American College of Surgeons Published by Elsevier Inc.

972

ISSN 1072-7515/06/$32.00 doi:10.1016/j.jamcollsurg.2006.04.007