Description

      A 81-years old man was admitted to our Hospital for acute abdominal pain, presented after a fatty meal. Laboratory values showed a small increase of bilirubin (22 mmol/L) and alanine-aminotransferase (63 U/l). Ultrasounds revealed a dilated gallbladder containing stones and sludge. A mild dilatation of the Common Bile Duct (CBD) and intrahepatic biliary tree were also recorded. Magnetic resonance cholangiography showed a long cystic duct with a medial insertion in the CBD, just above the Vater’s ampulla, containing a stone (Figure A, big arrow); another stone was seen in the distal CBD (Figure A, small arrow). Preoperative endoscopic retrograde cholangiography with sphincterotomy was performed and stones from the CBD and the cystic duct were removed (Figure B). The patient underwent laparoscopic cholecystectomy. Post-operative course was uneventful. Anatomical variations of cystic duct insertion are common but low medial insertion, just above the Vater’s ampulla, is a very rare variant. This kind of insertion is associated with an increased risk of stones formation in consequence of bile stasis and bacterial overgrowth. The knowledge of these variants is important for surgeons to avoid intraoperative biliary injuries. Inadvertent section of the CBD, biliary strictures, retained stones or appearance of “cystic duct remnant syndrome” are possible post-operative complications.