Anomalous Low Insertion of Cystic Duct Causing Obstructive Jaundice: a Diagnostic and Treatment Dilemma—Report of a Case Series and Management Protocol

Abstract

Anomalous low insertion of cystic duct (LICD) is present in 10.4% of cases. Its preoperative detection is possible with MRCP (95% accuracy). Commonly they present as post-cholecystectomy cholangitis ( Mirizzi's syndrome). Only few small case reports are available in the literature to serve as a guideline for its management. We present the management of 35 cases of LICD done by a single surgeon in the last 10-year period. Thirty four out of 35 cases were post cholecystectomy. We streamlined our surgical management depending on biliary dilatation (cut off 1 cm). Open or laparoscopic CD clearance after slitting CD vertically and obliterating the CD pouch with sutures including the common wall + / − choledocho-duodenostomy if bile duct is more than a centimetre. We did open surgery in 20 cases and laparoscopic in 15. Our follow up duration was 2 months to 3 years with a serial ultrasound and LFT yearly. No recurrence of symptom and/or stricture was noted in all cases except one case had pancreatic duct stones in ampulla that required ERCP. Our 30-day mortality was 1/35 cases (3%) due to severe CRE sepsis. LICD presenting as Mirizzi’s syndrome is a complex surgical problem. We recommend MRCP in all cases. With our surgical approach either open or laparoscopic, by obliterating the CD pouch + / − biliary bypass can cure this problem forever, but we need much larger studies to establish a care pathway for LICD.