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

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). Com- mon 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 seg- ment of the liver. Most aberrant ducts arise from the right lobe of the liver. These ducts are from 1 to 2 mm in diam- eter and most commonly drain into the common hepatic CHD or cystic duct within 30 mm of the cystic angle. 1 Izuishi and coauthors 2 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. 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. A B C 972 © 2006 by the American College of Surgeons ISSN 1072-7515/06/$32.00 Published by Elsevier Inc. doi:10.1016/j.jamcollsurg.2006.04.007

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Transcript of Aberrant Right Hepatic Duct Originating from the Right Posterior Duct with Low Insertion into the...

Page 1: Aberrant Right Hepatic Duct Originating from the Right Posterior Duct with Low Insertion into the Common Bile Duct

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berrant Right Hepatic Duct Originating from the Right Posterior Ductith Low Insertion into the Common Bile Ductonzalo Pérez, MD, Ricardo O Escárcega, MD, Julio Gargantua, MD, Salvador Fuentes-Alexandro, MD

ospital de Especialidades, Puebla, México

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9722006 by the American College of Surgeons

ublished by Elsevier Inc.

60-year-old man, who had a cholecystectomy 4 yearsarlier, had right upper quadrant pain, mild jaundice,nd fever. ERCP and sphincterotomy revealed a biliaryuct anomaly (A). Abdominal CT showed a 0.97-cmvoid image consistent with choledocolithiasis (B). Com-on bile duct (CBD) exploration through a Kocher’s

ight subcostal incision identified the stone seen on theT through palpation of the CBD. The aberrant ductas found to be inserted low, rotating posteriorly and

nto the CBD. An earthy, brown, friable stone (B, inset)as removed by choledocotomy. Intraoperative cholan-iography (C) revealed an aberrant right hepatic ductriginating from the right posterior duct (RPD) withow insertion into the CBD. Segments VI and VII arerained by this aberrant duct, while segments V and VIIIre drained by the right anterior duct (RAD) and thesual junction with the left hepatic duct (LHD) to formhe hepatic duct (CHD). A stricture is shown distally,hich may account for the dilatation of all the ducts.ive months postoperatively, the patient was well, witho episodes of upper quadrant pain or jaundice.The aberrant bile duct does not communicate with

ther biliary segments, and drains only a particular seg-ent of the liver. Most aberrant ducts arise from the right

obe of the liver. These ducts are from 1 to 2 mm in diam-ter and most commonly drain into the common hepaticHD or cystic duct within 30 mm of the cystic angle.1

zuishi and coauthors2 studied 113 patients using multisliceT cholangiography and reported that the incidence of aosterior segmental duct joining directly into the commonile duct was 7% in their series (8/113). The overall inci-ence of aberrant bile ducts was 16% (18/113), which ishe incidence reported by other authors.

EFERENCES

. Suhocki PV, Meyers W. Injury to aberrant bile ducts during cho-lecystectomy: a common cause of diagnostic error and treatmentdelay. AJR 1999;172:955–959.

. Izuishi K, Toyama Y, Nakano S, et al. Preoperative assessment ofthe aberrant bile duct using multislice computed tomographycholangiography. Am J Surg 2005;189:53–55.

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