LAUSR

A 35-year-old man was admitted to our hospital with abdominal pain after eating. A double bile duct structure was revealed bymagnetic resonance cholangiopancreatography. The relationship and alignment of the double bile ducts appeared to be poorly represented (▶Fig. 1). Endoscopic retrograde cholangiopancreatography (ERCP) was performed, and showed two separate openings in the zone of the major duodenal papilla (▶Fig. 2, ▶Video 1). The cholangiogram revealed that the patient had two common bile ducts (CBDs) that converged in the middle section of the bile duct, and the stones were disclosed in both ducts. Meanwhile, the pancreatic duct converged into the left CBD (▶Fig. 3). We diagnosed type II double common bile duct (DCBD) [1] with anomalous pancreaticobiliary junction (APBJ) and cholelithiasis (▶Fig. 4 a). The patient underwent laparoscopic Roux-en-Y hepaticojejunostomy due to the risk of cholangiocarcinoma. Interestingly, we discovered during the operation that the left CBD shown by the cholangiogram was in fact the cystic duct (▶Fig. 5, ▶Video 1). This indicated that the cystic duct formed a fistula with the CBD, and the pancreatic duct met the cystic duct. This suggested a deviation in our initial diagnosis. Based on the information above, we concluded that the cystic duct around the CBD on the left drained independently into the duodenum while forming a fistula with the duct in the middle. In fact, the cystic duct was where the pancreatic duct converged. The patient was eventually diagnosed with type II Mirizzi syndrome [2] in conjunction with a specific type of APBJ (▶Fig. 4b). Both Mirizzi syndrome and DCBD are rare diseases of the biliary system, and ERCP is the current gold standard for diagnosVideo 1 A rare case: Mirizzi syndrome with anomalous pancreaticobiliary junction. ▶ Fig. 1 Magnetic resonance cholangiopancreatography showing one bile duct structure on the left side of the distal common bile duct, but the two were not connected. Gallstones appeared to be shown in both bile ducts (arrow). ▶ Fig. 2 Endoscopic views showing two separate openings in the zone of the papilla. The guidewire could enter from one opening and pass through the other opening. E-Videos