Innovative Intervention for Biliary Drainage in a Patient with Rare Anomalous Biliary Anatomy

Abstract

Introduction: Anomalies of the hepatobiliary ductal system are not uncommon. Accessory ducts are sometimes seen and rarely drain a large enough area of liver to cause significant obstruction. In a review of over 2,000 cases from nine studies, Berci et al reported 12% prevalence of anomalous biliary ducts. Puente et al reported a prevalence of 18.5% of congenital abnormalities of the biliary tract and 6.5% of anomalous hepatic ducts. We report a case of low insertion of an accessory left hepatic duct into the common bile duct (CBD), which is a rare anomaly with no reported cases in literature, and its significant obstruction from a pancreatic adenocarcinoma, stenting, and good outcome post-procedure. Case Report: A 65-year-old woman with history of diabetes mellitus and hypertension who initially presented with abdominal pain and weight loss was found to have stage IV pancreatic head adenocarcinoma. Her CA 19-9 level was 16,667 at presentation. After failure of initial chemotherapy, patient was found to have elevated liver function tests (LFT) including elevated total bilirubin. CT imaging showed dilated CBD. MRCP done to delineate the pancreaticobiliary anatomy showed intra- and extrahepatic duct dilatation with aberrant biliary duct anatomy and dilated accessory left hepatic duct draining the lateral segments (2 and 3) of the left hepatic lobe, inserting directly into the common bile duct at a low insertion point just proximal to ampulla of Vater. This aberrant duct measured 6 mm. The common bile duct measured 11 mm. Endoscopic retrograde cholangiopancreatography (ERCP) was then performed with dilation of distal stenosis. Using the two guidewire technique, two 6 cm x 8 mm covered metal stents were placed in the common bile duct and the aberrant left hepatic duct. Good biliary drainage was established. Patient improved significantly within a few days from deeply jaundiced state to near normal. The LFT's normalized over the next few weeks. Patient was subsequently able to resume chemotherapy treatments for control of disease progression. Patient continues to remain symptom-free as of this report at 9 months post-insertion of stents. Discussion: Anatomical variants of the hepatobiliary tree can be clinically challenging for the endoscopists performing ERCP. An innovative ERCP was performed and two metallic stents were placed into the main bile duct and the accessory left hepatic duct. Our success with bilateral biliary drainage with double metallic stents in improving the quality of life shows that this innovative intervention should be considered in patients with anomalous biliary anatomy.