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Double barrelled common bile duct: A threat to biliary surgery
Double Barrelled Common Bile Duct: A Threat to Biliary Surgery Andrus J. Voitk, MD, Winnipeg, Manitoba, Canada
An increasing incidence of cholelithiasis in the western hemisphere has made cholecystectomy the most common major operation performed by general surgeons. Consequently, familiarity with the anatomic variations of portal structures has of necessity become part of the general surgeon’s armamentariurn. Most of these anomalies are apparent, provided that adequate care is exercised in the dissection and demonstration of structures. This familiarity, coupled with the dependence on ability to demonstrate unexpected anomalies by dissection, has created a sense of confidence in the surgeon approaching biliary tract surgery. As a result, the surgeon may overlook anatomic variations not readily apparent by the usual dissection and exposure. The purpose of this report is to alert the surgeon to one such anomaly, the double barrelled common bile duct. This anomaly can arise in one of three ways: a long cystic duct may course parallel to the common bile duct posteriorly, where this is not always apparent; the cystic and common ducts may be enveloped in a common fibrous adhesive sheath; or the cystic duct may join the common duct externally yet retain a common inner wall or septum dividing the two for some length distally. (Figure 1.) This anomaly usually goes unrecognized, for it generally presents no difficulty in the usual cholecystectomy. Situations exist, however, in which a new communication between the gut and biliary tree must be established. Here, often because of expedience or technical ease, the communication is made via the gallbladder rather than the common bile duct, the latter being merely ligated. In such a situation, failure to recognize the double
barrel
anomaly
may result
tablish biliary drainage. Starzl and Putnam [I] attribute liver transplantation I encountered Whipple
two
resections;
in failure two deaths
directly
to this technical
similar
incidents
these two patients
during
to esafter error. two
form the basis
of this report.
From the Department of Surgery of the University of Manitoba, Winnipeg, Manitoba, Canada. This work was supported in pari by the Medical Research Council of Canada. Present address and reprint requests: 34 Market Street, Orilla. Ontario, Canada L3V 3C9.
VolwM
131, May 1976
Case Reports Case I. A seventeen year old boy was shot in the abdomen; the bullet entered the right lower rib cage and was lodged in the left lumbar area. In its course, the bullet had traversed the right lobe of the liver, the duodenal loop in two places, the head of the pancreas, and the left kidney. There was no major vessel injury, but massive blood loss from the liver and pancreas was encountered. Partial right hepatectomy was performed and Whipple resection of duodenum and pancreas had to be undertaken for hemostasis. Proximal jejunum was anastomosed end-to-end to the tail of the pancreas, followed by cholecystojejunostomy and gastroenterostomy. No gross urine or blood leak was obvious from the left kidney, and it was drained extraperitoneally. A sm::ll common bile duct was instrumental in the decision for cholecystojejunostomy; the common duct was ligated approximately 1.5 cm distal to its junction with the cystic duct. Sump drains were left behind and the abdomen closed. Abdominal distention and obstructive jaundice necessitated reexploration one week postoperatively. Several liters of bile were drained from the abdomen with no obvious source of leak. The gallbladder yielded white bile on aspiration and the ligated common duct stump was distended with hepatic bile. Choledochojejunostomy resulted in an uneventful recovery. When the common bile duct was opened, an inner septum could be seen that divided its distal lumen from that of the cystic duct. Comment: The small caliber of the healthy common bile duct suggested use of the gallbladder for anastomosis in the interests of time in this severely stressed patient. The anomaly of a common inner septum was not recognized, which created the situation depicted in Figure 1. It is interesting to note that in spite of obvious increase in abdominal girth and several liters of bile in the abdomen, both sump drains failed to drain. The bile was sterile on culture. It is easy to imagine quite a different outcome for this boy had this bile collection become infected. No obvious source of the bile was found and it is presumed to have arisen from retrograde flow through the resected liver edge. Establishing antegrade drainage eliminated further bile collection. Obstruction had rendered the previously small common bile duct quite distended, and anastomosis was technically easy. Case II. A thirty-nine year old nonalcoholic man underwent Whipple resection for debilitating pancreatitis localized to the head of the pancreas only. The common bile duct was ligated 3 cm distal to the external entrance of the
611
Figure 1. Cut section iii&rating the common septum between cystk and common bile ducts that leads to a double barreiied common duct. 7Ytis anomaiy not is evident from the outside and, as depicted, may go undetected even on inspection of the cut end of the distai common duct (after Starzi ad Putnati [I] ).
F&w 2. Photograph and fine drawing of an operative choiangkgram performed by injection of contrast material under pressure into the gaiibia#sr by nsedie. Note extravasated contrast material around the gaiibladder (shown as stippiing on fine this in a drawing). Some of coiiected suicus beside the common bile duct (arrow), thus giving the false appearance of a patent communication between gallbladder and common duct. Reoperation was necessary in this patient to reiieve the obstmctive jaundice.
cystic duct and the less elegant but more expedient cholecystojejunostomy was planned. A cholangiogram, predicated on the earlier experience (case I), was done to determine biliary continuity before anastomosis. (Figure 2.) Dye was introduced into the gallbladder by needle puncture and the needle removed for the x-ray films. X-ray film (Figure 2) was interpreted as showing communication of dye between the gallbladder, cystic duct, and common bile duct, and consequently the biliary tract was drained via the gallbladder. Obstructive jaundice became evident, and on the fourth postoperative day the double barrel anomaly was confirmed at laparotomy. Choledochojejunostomy was followed by an uneventful recovery marred only by wound infection.
612
Comment: Review of the operative cholangiogram revealed extravasated dye around the gallbladder. (Figure 2.) The dye supposed to be in the common bile duct failed to extend into hepatic radicles. In view of the clinical course, we can only conclude that the dye interpreted to be inside the common bile duct is in fact some of the extravasated dye lying in a sulcus along the outside of the duct. Dye was injected under pressure to ensure filling of the duct system, and on withdrawal of the needle, extravasation occurred in the face of complete obstruction. A system of cholangiography must be employed that avoids extravasation [2], if we are to rely on radiographic demonstration of patent communication between the biliary tree and the gallbladder before use of the latter for drainage.
The Amerlcan Journal ol Surgery
Double Barrelled Common Bile Duct
Comments In establishment of biliary drainage via the gallbladder, patent communication between cystic and common bile ducts must be ensured. Anatomic variants not obvious from external inspection may thwart this aim and jeopardize the patient’s life. In the patients described, the possibility was fortunately discovered at reexploration and the error corrected. As illustrated by Starzl and Putnam [I], the patient is not always so fortunate and the error may elude discovery even at reoperation, only to show up at postmortem examination. Liver transplantation, Whipple resection, and bypass for distal common bile duct stricture or carcinoma are three procedures in which the gallbladder is frequently used for anastomosis. In these cases, awareness of the anomalies described herein is of vital importance to the successful outcome of the operation. Patent communication between the cystic and common hepatic ducts can be confirmed by either passing a probe into the common hepatic duct through the opened gallbladder or carrying out an operative cholangiogram, as well as by inspecting the cut end of the common bile duct before ligation.
Vo&lm 131, May 1976
Because of the vi,tal importance of this knowledge, routine radiographic confirmation of a patent biliary drainage system is mandatory, using a technic which avoids spillage or extravasation of contrast material
PI.
Summary The frequency of cholecystectomies has given the surgeon familiarity and confidence when dealing with biliary anomalies. Internal anomalies are not equally recognized, for they play little role in cholecystectomy. Recognition of internal anomalies is of prime importance, however, when the biliary tree is drained through the gallbladder. Radiographic confirmation of a patent drainage’ system, avoiding spillage of contrast material, should be routinely employed in these situations to obviate potentially lethal complications due to technical error. References 1. Starzl TE, Putnam CW: Liver homotransplantation. p 488. Textbook of Surgery (Sabiston DC Jr, ed). Philadelohia. WB Saunders, 1972: 2. Voitk AJ: Alternate technic for operative cholangiography. Am JSurg 130: 371, 1975.
613
An increasing incidence of cholelithiasis in the western hemisphere has made cholecystectomy the most common major operation performed by general surgeons. Consequently, familiarity with the anatomic variations of portal structures has of necessity become part of the general surgeon’s armamentariurn. Most of these anomalies are apparent, provided that adequate care is exercised in the dissection and demonstration of structures. This familiarity, coupled with the dependence on ability to demonstrate unexpected anomalies by dissection, has created a sense of confidence in the surgeon approaching biliary tract surgery. As a result, the surgeon may overlook anatomic variations not readily apparent by the usual dissection and exposure. The purpose of this report is to alert the surgeon to one such anomaly, the double barrelled common bile duct. This anomaly can arise in one of three ways: a long cystic duct may course parallel to the common bile duct posteriorly, where this is not always apparent; the cystic and common ducts may be enveloped in a common fibrous adhesive sheath; or the cystic duct may join the common duct externally yet retain a common inner wall or septum dividing the two for some length distally. (Figure 1.) This anomaly usually goes unrecognized, for it generally presents no difficulty in the usual cholecystectomy. Situations exist, however, in which a new communication between the gut and biliary tree must be established. Here, often because of expedience or technical ease, the communication is made via the gallbladder rather than the common bile duct, the latter being merely ligated. In such a situation, failure to recognize the double
barrel
anomaly
may result
tablish biliary drainage. Starzl and Putnam [I] attribute liver transplantation I encountered Whipple
two
resections;
in failure two deaths
directly
to this technical
similar
incidents
these two patients
during
to esafter error. two
form the basis
of this report.
From the Department of Surgery of the University of Manitoba, Winnipeg, Manitoba, Canada. This work was supported in pari by the Medical Research Council of Canada. Present address and reprint requests: 34 Market Street, Orilla. Ontario, Canada L3V 3C9.
VolwM
131, May 1976
Case Reports Case I. A seventeen year old boy was shot in the abdomen; the bullet entered the right lower rib cage and was lodged in the left lumbar area. In its course, the bullet had traversed the right lobe of the liver, the duodenal loop in two places, the head of the pancreas, and the left kidney. There was no major vessel injury, but massive blood loss from the liver and pancreas was encountered. Partial right hepatectomy was performed and Whipple resection of duodenum and pancreas had to be undertaken for hemostasis. Proximal jejunum was anastomosed end-to-end to the tail of the pancreas, followed by cholecystojejunostomy and gastroenterostomy. No gross urine or blood leak was obvious from the left kidney, and it was drained extraperitoneally. A sm::ll common bile duct was instrumental in the decision for cholecystojejunostomy; the common duct was ligated approximately 1.5 cm distal to its junction with the cystic duct. Sump drains were left behind and the abdomen closed. Abdominal distention and obstructive jaundice necessitated reexploration one week postoperatively. Several liters of bile were drained from the abdomen with no obvious source of leak. The gallbladder yielded white bile on aspiration and the ligated common duct stump was distended with hepatic bile. Choledochojejunostomy resulted in an uneventful recovery. When the common bile duct was opened, an inner septum could be seen that divided its distal lumen from that of the cystic duct. Comment: The small caliber of the healthy common bile duct suggested use of the gallbladder for anastomosis in the interests of time in this severely stressed patient. The anomaly of a common inner septum was not recognized, which created the situation depicted in Figure 1. It is interesting to note that in spite of obvious increase in abdominal girth and several liters of bile in the abdomen, both sump drains failed to drain. The bile was sterile on culture. It is easy to imagine quite a different outcome for this boy had this bile collection become infected. No obvious source of the bile was found and it is presumed to have arisen from retrograde flow through the resected liver edge. Establishing antegrade drainage eliminated further bile collection. Obstruction had rendered the previously small common bile duct quite distended, and anastomosis was technically easy. Case II. A thirty-nine year old nonalcoholic man underwent Whipple resection for debilitating pancreatitis localized to the head of the pancreas only. The common bile duct was ligated 3 cm distal to the external entrance of the
611
Figure 1. Cut section iii&rating the common septum between cystk and common bile ducts that leads to a double barreiied common duct. 7Ytis anomaiy not is evident from the outside and, as depicted, may go undetected even on inspection of the cut end of the distai common duct (after Starzi ad Putnati [I] ).
F&w 2. Photograph and fine drawing of an operative choiangkgram performed by injection of contrast material under pressure into the gaiibia#sr by nsedie. Note extravasated contrast material around the gaiibladder (shown as stippiing on fine this in a drawing). Some of coiiected suicus beside the common bile duct (arrow), thus giving the false appearance of a patent communication between gallbladder and common duct. Reoperation was necessary in this patient to reiieve the obstmctive jaundice.
cystic duct and the less elegant but more expedient cholecystojejunostomy was planned. A cholangiogram, predicated on the earlier experience (case I), was done to determine biliary continuity before anastomosis. (Figure 2.) Dye was introduced into the gallbladder by needle puncture and the needle removed for the x-ray films. X-ray film (Figure 2) was interpreted as showing communication of dye between the gallbladder, cystic duct, and common bile duct, and consequently the biliary tract was drained via the gallbladder. Obstructive jaundice became evident, and on the fourth postoperative day the double barrel anomaly was confirmed at laparotomy. Choledochojejunostomy was followed by an uneventful recovery marred only by wound infection.
612
Comment: Review of the operative cholangiogram revealed extravasated dye around the gallbladder. (Figure 2.) The dye supposed to be in the common bile duct failed to extend into hepatic radicles. In view of the clinical course, we can only conclude that the dye interpreted to be inside the common bile duct is in fact some of the extravasated dye lying in a sulcus along the outside of the duct. Dye was injected under pressure to ensure filling of the duct system, and on withdrawal of the needle, extravasation occurred in the face of complete obstruction. A system of cholangiography must be employed that avoids extravasation [2], if we are to rely on radiographic demonstration of patent communication between the biliary tree and the gallbladder before use of the latter for drainage.
The Amerlcan Journal ol Surgery
Double Barrelled Common Bile Duct
Comments In establishment of biliary drainage via the gallbladder, patent communication between cystic and common bile ducts must be ensured. Anatomic variants not obvious from external inspection may thwart this aim and jeopardize the patient’s life. In the patients described, the possibility was fortunately discovered at reexploration and the error corrected. As illustrated by Starzl and Putnam [I], the patient is not always so fortunate and the error may elude discovery even at reoperation, only to show up at postmortem examination. Liver transplantation, Whipple resection, and bypass for distal common bile duct stricture or carcinoma are three procedures in which the gallbladder is frequently used for anastomosis. In these cases, awareness of the anomalies described herein is of vital importance to the successful outcome of the operation. Patent communication between the cystic and common hepatic ducts can be confirmed by either passing a probe into the common hepatic duct through the opened gallbladder or carrying out an operative cholangiogram, as well as by inspecting the cut end of the common bile duct before ligation.
Vo&lm 131, May 1976
Because of the vi,tal importance of this knowledge, routine radiographic confirmation of a patent biliary drainage system is mandatory, using a technic which avoids spillage or extravasation of contrast material
PI.
Summary The frequency of cholecystectomies has given the surgeon familiarity and confidence when dealing with biliary anomalies. Internal anomalies are not equally recognized, for they play little role in cholecystectomy. Recognition of internal anomalies is of prime importance, however, when the biliary tree is drained through the gallbladder. Radiographic confirmation of a patent drainage’ system, avoiding spillage of contrast material, should be routinely employed in these situations to obviate potentially lethal complications due to technical error. References 1. Starzl TE, Putnam CW: Liver homotransplantation. p 488. Textbook of Surgery (Sabiston DC Jr, ed). Philadelohia. WB Saunders, 1972: 2. Voitk AJ: Alternate technic for operative cholangiography. Am JSurg 130: 371, 1975.
613