Combined pancreatic duct and upper gastrointestinal and biliary tract drainage in chronic pancreatitis

In 55 patients undergoing pancreaticojejunostomy for intractable abdominal pain, common bile duct obstruction occurred in 29% (16/55) and duodenal obstruction occurred in 15% (8/55). Serum alkaline phosphatase and total and direct serum bilirubin levels were significantly higher in patients with intrapancreatic common bile duct stenosis. Transient upper gastrointestinal (UGI) tract obstruction was common with chronic pancreatitis; however, if symptoms persisted beyond 2 weeks, fixed duodenal obstruction was likely. Endoscopic retrograde cholangiopancreatography and UGI roentgenograms and endoscopy were useful in confirming mechanical obstruction to the biliary and UGI tracts, respectively. There was no difference in operative mortality and morbidity from combined drainage procedures compared with pancreaticojejunostomy alone. The biliary and UGI tracts should be investigated in symptomatic patients both before and after pancreaticojejunostomy. Combined drainage of the pancreatic duct and UGI and biliary tract is safe and effective treatment for obstructing complications of chronic pancreatitis.     

Selective drainage for pancreatic, biliary, and duodenal obstruction secondary to chronic fibrosing pancreatitis.

Twenty-eight patients underwent surgery for intractable pain, duodenal or extrahepatic biliary obstruction secondary to chronic pancreatitis. Eleven had pancreatic duct obstruction alone, six biliary obstruction alone, seven combined pancreatic and biliary, two combined biliary and duodenal, one combined pancreatic and duodenal, and one simultaneous pancreatic, biliary, and duodenal obstruction. Pancreatitis was secondary to alcohol in all but one case. The following operations were performed: longitudinal pancreatojejunostomy (20), choledochoduodenostomy (8), choledochojejunostomy (7), cholecystojejunostomy (1), and gastrojejunostomy (4). Of the 20 patients with pancreatic duct drainage, pain relief was complete in 11 and partial in six. Initial incomplete relief of pain, or recurrence, stimulated further diagnostic procedures, leading to improvement or correction of the problem in five patients. A significant (p less than 0.01) fall in alkaline phosphatase (935 +/- 228 to 219 +/- 61 U/L) occurred following surgery. One patient was subsequently found to have pancreatic carcinoma. Two patients were lost to follow-up and four patients died (one perioperative and three late). In conclusion, the possibility of pancreatic, biliary, and duodenal obstruction must be considered in symptomatic patients with chronic pancreatitis. Surgery must be individualized. Drainage procedures, either alone or in combination, are associated with a low morbidity and improved clinical condition and may be preferable to resection in the surgical management of these patients.     

Surgical treatment of chronic pancreatitis

We studied the course of 100 consecutive patients who underwent surgery for pain or biliary obstruction from chronic pancreatitis or both between 1958 and 1982. Patients with pancreatic pseudocysts were excluded. Ten patients had pancreatic resection after previous pancreatic surgery had failed to control pain. Ten of 47 patients (21 percent) studied between 1972 and 1981 had bile duct entrapment from chronic pancreatitis and required biliary bypass operations. The results of longitudinal pancreaticojejunostomy were good in 67 percent of the patients, fair in 18 percent of the patients, and poor in 15 percent of the patients. The results of partial pancreatectomy were good in 60 percent of the patients (all with disease limited to the tail), fair in 20 percent of the patients, and poor in 20 percent of the patients. The results of subtotal pancreatectomy were good in 31 percent of the patients, fair in 37 percent of the patients, and poor in 32 percent of the patients. The results of pancreatic resection in patients with previous unsuccessful surgery for pain relief were good in only 10 percent of the patients. Biliary obstruction is present in many patients with chronic pancreatitis and must be treated surgically to prevent the development of biliary cirrhosis. Hemipancreatectomy is useful in patients with disease limited to the tail. The results of subtotal pancreatectomy are discouraging, especially in patients with a previous unsuccessful operation for pain. When the pancreatic duct is dilated, however, longitudinal pancreaticojejunostomy gives long-lasting relief of pain in most patients.     

慢性胰腺炎胰,胆管梗阻的处理：附6例报告

在３７例慢性胰腺炎病人中，８例合并胆道梗阻（２２％），４例合并主胰管梗阻（１１％）；６列同时或异时合并胰、胆管梗阻（１９％）。其中１例在发现胰管扩张１年后，出现胆管梗阻；２例同时发现胰、胆管梗阻。３例因黄疸在外院先行胆道手术，术后腹痛持续，影像检查证实尚伴有胰管梗阻，而再次行胰管减压手术。未合并胆石和（或）胆管炎的单纯胆道梗阻一般不引起严重的腹痛。对腹痛症状较重，而又无胆管结石的慢性胰腺炎病人应特别警惕是否同时合并胰管梗阻。     

Role of pancreaticojejunostomy in the treatment of chronic pancreatitis. A study of 105 operated patients]

105 patients with intractable pain due to chronic pancreatitis were selected for treatment by lateral pancreatico-jejunostomy (according to the procedure of Partington Rochelle) after pre operative endoscopy had revealed a dilatation of the main pancreatic duct (mean : 6 mm). Pancreatico-jejunostomy was the unique procedure in 59 patients; it was associated with a biliary or duodenal diversion in 46 others patients. 2 patients died post-operatively and 12 required a second operation some years subsequent to the pancreatic drainage, for biliary stenosis due to the progress of the sclerosis. 8 of the 22 late death were in direct relation with the persistence of alcohol intake and 4 others died from an extra pancreatic cancer. Peptic ulcer complicating pancreatico-jejunostomy appeared in three patients and two of them died from hemorrhage. Mean observation time was 65 years. Long term results were excellent or improved in 93.4% what pain relief concern, but the progression of exocrine or endocrine pancreatic insufficiency indicates that decompression of the dilated pancreatic duct does not prevent continuing destruction of pancreatic glandular tissue. In spite of these good results, the rational for duct drainage as a mean to decrease the intraductal pressure secondary to stricture is unclear. Neither the patency of the anastomosis, nor the presence or not of pancreatic lithiasis or the size of the dilated pancreatic duct seem to be crucial for pain relief after pancreatico-jejunostomy. Notwithstanding of the dubiousness of the mechanism of action of the drainage procedure, pancreato-jejunostomy remains the most effective procedure for relief of pain in chronic pancreatitis with dilated duct.     

Ductal drainage or resection for chronic pancreatitis

We report a 10 year review comparing the results of pain relief after three procedures for chronic pancreatitis: Whipple pancreatoduodenectomy, modified Puestow side-to-side longitudinal pancreaticojejunostomy and distal pancreatic resection. Results of follow-up review at 6 months, 2 years and 5 years were tabulated. Five year follow-up data were available on more than 80 percent of patients. The proportion of good results for pain relief decreased with the passage of time regardless of the procedure performed. Although equally good results are obtained after either pancreatoduodenectomy or pancreaticojejunostomy, we conclude that in the presence of a dilated duct, the procedure of choice is pancreaticojejunostomy. If the duct is not dilated, we then favor pancreatoduodenectomy, after which the pain relief is significantly better (p = 0.05) than after distal resection. Our data show that, for all factors evaluated, the poorest pain relief was obtained after distal resection. Therefore that procedure has limited value when used specifically for relief of pain in chronic pancreatitis, except in the uncommon circumstance when the disease is confined to the distal part of the gland. Our study also shows that patients who have more radical distal resection have no better pain relief than those who have 50 percent distal resection.     

Local Resection of the Pancreatitic Head for Pancreatic Pseudocysts

Background  Local resection of the head (LRPH) has improved markedly the clinical outcome of patients that undergo surgery for chronic pancreatitis. LRPH is often combined with a lateral pancreatojejunostomy for complete duct drainage. Randomized controlled trials have confirmed the superiority of the Frey and Beger operations compared to pancreatoduodenectomy. Appropriate patient selection is critical to an excellent outcome. Patients with an enlarged pancreatic head or duodenal or biliary obstruction are ideal candidates for LRPH. In addition, patients with symptomatic pseudocysts in the pancreatic head can be adequately treated with these operations. Procedure  The procedure described herein includes a generous pancreatic head resection to ensure pain relief, a pancreatic ductotomy onto the body and tail of the gland for complete drainage, and an intrapancreatic biliary sphincteroplasty for decompression of an obstructed bile duct. Conclusions  Perioperative hemorrhage is a potential major complication associated with LRPH. The long-term outcome is an excellent pain relief and improves overall quality of life.     

Surgery for Nonalcoholic Chronic Pancreatitis

n = 49), biliary obstruction ( n = 12), duodenal obstruction ( n = 10), portal hypertension ( n = 11), cysts ( n = 14), and pancreatic ascites ( n = 3). Thirty-four patients with a dilated pancreatic duct underwent pancreaticojejunostomy; cysts were drained internally in eight, and biliary and duodenal obstruction was bypassed. Ten patients also underwent surgery for portal hypertension. Four (7%) patients died during the postoperative period. Of the remaining 54 patients, 48 (89%) were followed up for a median period of 63 months (range 6 months to 10 years). Six died: four of pancreatic cancer, one of cerebrovascular accident, and one of malnutrition. Of the 34 surviving patients operated for pain, 30 (88%) felt better, of whom 24 (71%) had complete relief of pain; 14 (41%) recorded a weight gain. Pancreatic decompression results in immediate and lasting pain relief in most patients with nonalcoholic chronic pancreatitis.     

Gastric outlet and duodenal obstruction from inflammatory pancreatic disease

During a ten-year period, 16 patients with gastric outlet and duodenal obstruction due to inflammatory pancreatic disease were seen. The cause of obstruction was chronic pancreatitis in ten patients, pseudocysts with associated pancreatitis in five patients, and pancreatic abscess in one patient. All patients had nausea and vomiting, 14 had abdominal pain, and five had weight loss greater than 4.5 kg. Diagnosis was made by plain abdominal film in one case, upper gastrointestinal tract roentgenographic series in 15 cases, and endoscopy in 11 cases. Mobilization of the duodenum relieved the obstruction in two patients. Fixed obstruction remained in 14 patients. This was relieved by gastrojejunostomy in 12 patients. Gastrojejunostomy was combined with drainage of a pseudocyst in three patients, a dilated pancreatic duct in three patients, and a dilated common bile duct in four patients. Obstruction was relieved by pseudocyst drainage in two patients. Associated common duct and pancreatic duct obstruction must be identified preoperatively.     

Chronic pancreatitis: results of a protocol of management

Thirty-five patients with chronic pancreatitis of varying cause have been treated according to a protocol first introduced in 1979. At the end of a mean follow up time of 2.1 years, only 54% of patients were found to have derived benefit defined by pain relief and improved quality of life. Patients with alcoholic pancreatitis did particularly poorly, and alcoholics who continued to drink almost never benefited. Patients with dilated pancreatic ducts were more likely to do well than those with small ducts, and pancreaticojejunostomy had a satisfactory record of pain relief. Patients with biliary pancreatitis generally did well with cholecystectomy and clearance of the common bile duct. The 40-80% pancreatectomy had a poor record for pain relief, and produced diabetes in the majority of patients in whom it was used. Nothing will reverse the established pathology of chronic pancreatitis, which remains an unsatisfactory condition to treat.     

Groove pancreatitis masquerading as pancreatic carcinoma.

The clinicopathologic and radiologic features of groove pancreatitis masquerading as pancreatic carcinoma in eight Japanese patients were reviewed. All patients were men with a mean age of 58 years. Three patients complained of abdominal pain whereas others had jaundice. The jaundice fluctuated in one patient. Four patients had several episodes of pancreatitis, and four patients were alcoholics. Radiologically, a duodenal stricture was evident in five patients, biliary stenosis in six, pancreatic duct stenosis in four, and a mass in the pancreatic head in six. The biliary stenosis was characterized by smooth tapering, which improved after biliary drainage in three cases. Of the four patients who underwent angiography, two showed an encasement of vessels, one a hypervascular mass, and the other no abnormality. All patients underwent a pancreatoduodenectomy for suspected pancreatic carcinoma. However, the histopathologic diagnosis was chronic pancreatitis confined to the groove between the distal common bile duct, duodenum, and pancreas. The duodenum showed scarring and hyperplasia of the Brunner's gland. The biliary stenosis was produced by fibrosis and chronic inflammation around the distal common bile duct. Groove pancreatitis presents various clinical features, such as biliary obstruction, duodenal stenosis, and pancreatic mass, and often masquerades as pancreatic head carcinoma. This condition should be kept in mind when making a diagnosis of pancreatic head carcinoma to avoid an unnecessary radical operation.     

Endoscopic sphincterotomy and removal of pancreatic duct stones

Chronic pancreatitis may be associated with pancreatic duct dilatation and ductal stones. Such stones are undoubtedly the result of chronic pancreatitis and stasis within the ductal system and may themselves serve to exacerbate ductal obstruction and recurrent episodes of pancreatitis. Endoscopic sphincterotomy has been used to relieve common duct obstruction secondary to biliary stones. This report suggests that sphincterotomy may also be used to approach selected patients who have pancreatic duct stones and recurrent pancreatitis. The technique involves a preliminary ERCP followed by standard endoscopic sphincterotomy with the papillatome positioned in the bile duct. A balloon catheter is then directed into the pancreatic duct orifice to extract ductal calculi. Although the main duct may be cleared, side branches are more difficult, and perhaps unnecessary, to clear. This method has provided relief of pain in a limited series of patients and may mark the beginning of a more aggressive approach to pancreatic endoscopy.     

Extrahepatic biliary obstruction associated with pancreatitis.

A total of 40 patients with pancreatitis had associated extrahepatic biliary obstruction. Eighteen had biliary-induced pancreatitis. Comprehensive correction of the biliary tract disease, including cholecystectomy, common duct exploration and, when indicated, transduodenal sphincteroplasty, resulted in a high recovery rate (83%) with no recurrence of pancreatitis. Twenty-two patients had chronic pancreatitis with involvement of the terminal biliary tract by a long tapering stenosis. Nineteen of these patients had chronic fibrocalcific pancreatitis secondary to chronic alcohol abuse. In five patients, the stenosis produced a high grade obstruction which required biliary bypass with choledochoduodenostomy (four) or cholecystoduodenostomy (one). The remaining 14 patients maintained patency of the biliary tract following correction of the underlying pancreatic pathology. The latter consisted of drainage (nine) or resection (five) of 14 associated pseudocysts (present in 64% of the 22 patients), combined with side-to-side pancreaticojejunostomy to decompress an obstruction of the major pancreatic duct. In assessing the degree of terminal bile duct stenosis, calibration of the duct with Bakes dilators or rubber catheters was a useful aid. Two of the 22 patients ultimately proved to have carcinomas, producing obstruction of the pancreatic duct in the head of the gland. Both were treated initially with choledochoduodenostomy. This possibility must be considered in the management of these patients.     

Surgical treatment of chronic pancreatitis

Debilitating abdominal or back pain remains the most common indication for surgery in patients with chronic pancreatitis. The surgical approach to chronic pancreatitis should be individualized based on pancreatic and ductal anatomy, pain characteristics, baseline exocrine and endocrine function, and medical co-morbidity. No single approach is ideal for all patients with chronic pancreatitis. Pancreatic ductal drainage with pancreaticojejunostomy targets patients with a dilated pancreatic duct and produces good early postoperative pain relief; however, 30%–50% of patients experience recurrent symptoms at 5 years. Resection for chronic pancreatitis should be considered (1) when the main pancreatic duct is not dilated, (2) when the pancreatic head is enlarged, (3) when there is suspicion of a malignancy, or (4) when previous pancreaticojejunostomy has failed. Re-sectional strategies include pancreaticoduodenectomy, distal pancreatectomy, total pancreatectomy, duodenum-preserving pancreatic head resection (Beger procedure), or local resection of the pancreatic head with longitudinal pancreaticojejunostomy (Frey procedure). Superior results are obtained when the pancreatic head is resected, either completely (pancreaticoduodenectomy) or partially (Beger or Frey procedure). Although pylorus-preserving pancreaticoduodenectomy remains the gold standard resection procedure, there is evidence that newer operations, such as the Beger resection, may be as effective in regard to pain relief and better in respect to nutritional repletion and preservation of endocrine and exocrine function. Received: April 20, 2002 / Accepted: May 13, 2002 Offprint requests to: H.A. Reber     

十二指肠镜治疗慢性胰腺炎

目的探讨十二指肠镜手术在慢性胰腺炎中的治疗作用。方法2000年1月～2006年12月,我院共经十二指肠镜治疗67例慢性胰腺炎。19例仅有乳头狭窄而胰管扩张不明显者,先行十二指肠乳头括约肌切开(EST);48例胰管扩张者同时做EST和胰管括约肌切开(EPS)。21例胆总管下段狭窄者置入胆管塑料内支架(ERBD),38例胰管有明显狭窄者置入胰管塑料内支架(ERPD),其中同时置入胆胰管双支架12例。27例胰管结石者先行EPS后用探条扩张狭窄段,再用网篮或气囊取石,若取石困难则做ERPD,平均每3个月复查一次ERCP并取石,若仍未取出则再置入内支架。结果插管成功完成ERCP诊治62例,插管成功率92.5%(62/67)。60例术后腹痛消失或缓解,治疗有效率为96.8%(60/62),2例无效,术后腹痛无缓解,均为胰管多处狭窄,内支架置入失败。21例ERBD、38例ERPD患者腹痛症状术后明显缓解,平均随访39.5月(5～70个月),症状未复发。27例胰管结石中19例取出。术后并发一过性高淀粉酶血症15例,急性胰腺炎5例,出血3例,无穿孔发生,无中转手术或死亡。结论十二指肠镜手术是慢性胰腺炎的首选治疗措施,具有安全、...     

Surgical treatment of chronic pancreatitis

The results of surgery for chronic pancreatitis in fifty-seven patients treated between 1958 and 1972 were reviewed. The findings have been used to outline a surgical strategy for the management of this disease.Operations on the biliary tract gave disappointing results. Biliary disease must be treated when present, but this will not always lessen chronic pancreatic pain.The surgical treatment of pseudocysts by internal drainage was uncomplicated in the short run, but almost half the patients continued to have pain months or years later.Direct operations on the pancreas are most successful in chronic pancreatitis. Sphincterotomy, splanchnicectomy, gastric operations, and caudal pancreaticojejunostomy are no longer recommended. When the pancreatic duct is dilated, longitudinal pancreaticojejunostomy (Puestow operation) will effect improvement in 80 to 90 per cent of patients. Pancreatitis localized to the tail of the gland is optimally treated by hemipancreatectomy. Subtotal (95 per cent) pancreatectomy is reserved for diffuse pancreatitis when the pancreatic duct is small or when previous longitudinal pancreaticojejunostomy is unsuccessful.     

Management of Biliary and Duodenal Complications of Chronic Pancreatitis

Biliary stricture and duodenal obstruction have been increasingly recognized as complications of chronic pancreatitis. The anatomical relationship of the distal common bile duct and the duodenum with the head of the pancreas is the main factor for their involvement in chronic pancreatitis. In hospitalized patients with pancreatitis, the incidence of biliary stricture and duodenal obstruction is reported to be about 6% and 1.2%, respectively. For patients requiring an operation for chronic pancreatitis the incidence increases to 35% for biliary stricture and 12% for duodenal obstruction. Fibrosis around the distal common bile duct can cause stenosis with obstruction of bile flow. Clinically, the presentation of these patients ranges from being asymptomatic with elevated alkaline phosphatase or bilirubin, or both, to being septic with cholangitis. Jaundice, cholangitis, hyperbilirubinemia, and persistent elevation of serum alkaline phosphatase occur more frequently in patients with pancreatitis with a biliary stricture. A twofold elevation of alkaline phosphatase is a marker of possible common duct stenosis in patients with chronic pancreatitis. The incidence of both biliary cirrhosis and cholangitis in these patients is about 10%. ERCP reveals a characteristic long, smoothly tapered stricture of the intrapancreatic common bile duct. In duodenal obstruction, the factors that convert self-limiting edema to chronic fibrosis and stricture formation are unknown, but ischemia superimposed on inflammation may be the major cause. These patients present with a prolonged history of nausea and vomiting. Barium studies typically show a long constricting lesion of the duodenum, and endoscopy reveals reactive inflammatory changes in a narrowed duodenum. Operation is indicated in patients with common bile duct strictures secondary to chronic pancreatitis when there is evidence of cholangitis, biliary cirrhosis, common duct stones, progression of stricture, elevation of alkaline phophatase and/or bilirubin for over a month, and an inability to rule out cancer. The operation of choice is either choledochoduodenostomy or choledochojejunostomy. A cholecystoenterostomy is less favored because of its higher failure rate (23%). Endoscopic stenting plays a role in patients who are unfit for surgery, but it is not recommended as definitive therapy. For duodenal obstruction, failure to resolve the obstruction with 1–2 weeks of conservative therapy is an indication for bypass. The operation of choice is a gastrojejunostomy. Not uncommonly, combined obstruction of the pancreatic duct, common bile duct, and duodenum will develop. Combined drainage procedures or resection are used to manage these problems.     

Outcome of lateral pancreaticojejunostomy in the management of chronic pancreatitis with nondilated pancreatic ducts

Lateral pancreaticojejunostomy has demonstrated variable success in the management of chronic pancreatitis associated with ductal dilation, but its role in patients with nondilated ducts is poorly defined. The aim of this study was to assess the outcome of lateral pancreaticojejunostomy in chronic pancreatitis with nondilated pancreatic ducts. The records of all patients who underwent lateral pancreaticojejunostomy with a pancreatic duct measuring less than 7 mm in diameter were reviewed. Seventeen patients underwent lateral pancreaticojejunostomy for chronic pancreatitis and intractable pain between 1995 and 1996. Endoscopic retrograde cholangiopancreatography demonstrated features of chronic pancreatitis that were mild in seven patients, moderate in five, and severe in four. Postoperative complications occurred in two patients (11.7%). There were no deaths. Mean length of follow-up was 10.3 months (range 3 to 16 months). Rehospitalization for recurrent pancreatitis or pain was necessary in 59% of patients. Emergency room visits were reported by 76%. Narcotic use continued in 88%, with 76% of the patients reporting their pain as the same or worse than before the operation, and 65% continuing to view their health status as poor. In chronic pancreatitis patients with a nondilated pancreatic duct, lateral pancreaticojejnnostomy appears to be of little benefit with respect to pain relief, subsequent hospitalization, continued narcotic use, or overall health status. Presented at the Thirty-Eighth Annual Meeting of The Society for Surgery of the Alimentary Tract, Washington, D.C., May 11–14, 1997.     

Organ-preserving surgery in chronic pancreatitis: the duodenum-preserving pancreatic head resection

Chronic pancreatitis is a inhomogeneous disease of multifactorial genesis and a variable clinical course. Upper abdominal pain is the leading clinical symptom of the majority of the patients. The primary treatment of these patients is conservative, but if the treatment fails in pain relief or organ complications occur surgical treatment is indicated. The most common organ complications due to chronic pancreatitis are stenosis of the common bile duct and the pancreatic duct, duodenal stenosis, stenosis of the portal vein with portal hypertension, pancreatic pseudocysts and the development of pancreatic fistula. Due to the pathophysiological concept of an elevated duct pressure as a source of pain, duct decompression by drainage procedures is the favored surgical procedure by many surgeons. Nevertheless, even in patients with a dilated pancreatic main duct, only half of the patients will benefit from drainage operations. Long-term severe upper abdominal pain and complications of the neighboring organs due to an inflammatory mass in the head of the pancreas should be indicative for resective procedures which should be organ-preserving as much as possible and take into account the endocrine function of the pancreatic gland. Simultaneous multiple organ resections like pylorus-preserving partial duodenopancreatectomy or total pancreatectomy are not necessary for a benign disease and should be only performed in patients with proven malignancy. The aim of the surgical procedure is to reduce pain and frequency of relapsing pancreatitis without impairing the endocrine function of the pancreatic gland.     

Right posterior branch draining into intra-pancreatic common duct: the triple duct sign

Simultaneous dilatation of pancreatic duct (PD) and common bile duct (CBD) is often seen on radio imaging in pancreatic head malignancy or chronic pancreatitis. This is called double duct sign. However, dilatation of aberrant bile duct along with PD and CBD resulting in triple duct sign on radio imaging has not been reported in literature till date. We report a case of 45 years old male with surgical jaundice due to pancreatic head mass. Computed tomography (CT) scan revealed three dilated ducts in the head of pancreas. Besides PD and biliary duct, the third duct was pre-operatively thought to be long cystic duct with low insertion in common hepatic duct (CHD). Intra-operative findings revealed an unusually long and dilated aberrant right posterior sectoral duct with low insertion into intra-pancreatic CHD. Patient underwent Whipple’s procedure with two separate biliary anastomosis besides pancreaticojejunostomy. Histopathology of specimen revealed chronic pancreatitis. Retrospective analysis shows that Magnetic Resonance Cholangiopancreatogram (MRCP) should have been done for correct pre-operative delineation of this anatomical anomaly. In conclusion, pre-operative detection of triple duct dilatation on CT scan should be further investigated with MRCP for anatomical variations of the biliary tract. This can guide operative planning and prevent inadvertent biliary injuries.