DUPLICATED GALLBLADDER IN AN ELDERLY PATIENT WITH CHOLEDOCHOLITHIASIS

Objectives: First described in 1676 by Blasius et al, duplication of the gallbladder represents a rare congenital anomaly that is infrequently encountered. In this congenital morphology, duplication of the gallbladder has been reported to occur in one out of 4000 people. However, this incidence, from a study in 1926, is unexpectedly high given the current number of biliary procedures performed annually. While the presence of an accessory gallbladder does not necessarily confer symptomatology, this pathology is frequently discovered incidentally with routine imaging or surgical procedures. When symptoms are present, they mimic those experienced in typical gallbladder pathologies including cholecystitis, cholelithiasis, choledocholithiasis, or cholangitis. Here we present an intriguing case of an 89 year old female who presented with symptoms and imaging consistent with choledocholithiasis. However, upon review of Magnetic Resonance Imaging (Image 1) and Endoscopic Retrograde Cholangiopancreatography, the patient was found to have a duplicated gallbladder. She was referred to surgery for early cholecystectomy given her cholelithiasis and choledocholithiasis. After shared decision making with the patient, she elected for cholecystectomy. She underwent uncomplicated cholecystectomies which highlighted a rare anatomical variant. Upon laparoscopy, she was noted to have unique and independent cystic ducts which drained separately into the common bile duct. Additionally, she was noted to have a singular cystic artery with innumerable branches supplying both the cephalad and caudal gallbladders (Image 2). Following successful cholecystectomies, the patient had unremarkable post-operative course and was doing well at follow-up. While it is known that biliary anatomy is highly variable - posing challenges for surgeons worldwide - in this uncommon aberrancy, there is no consistent anatomical morphology, further complicating treatment. Numerous anatomical classifications have been described, including Boyden’s classification which characterizes the pathology based upon cystic ductal drainage. Interestingly, the patient described here was noted to have an “H-shaped” or “Ductular type” of gallbladder duplication. While the reported incidence of gallbladder duplication is relatively high, our institutional experience does not reflect similar rates. This case highlights a distinct pathology that is rarely described along with our successful surgical management.

Methods:

Results:

Conclusion: