Double common bile duct malformation with choledocholithiasis treated by laparoscopic common bile duct exploration with primary suture: a case report

Double common bile duct malformation with choledocholithiasis treated by laparoscopic common bile duct exploration with primary suture: a case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Double common bile duct malformation with choledocholithiasis treated by laparoscopic common bile duct exploration with primary suture: a case report Haodong Zhang, Zihan Qiu, Changyu Yao, Wenbing Sun, Jian Kong This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7801187/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 20 Mar, 2026 Read the published version in BMC Surgery → Version 1 posted 14 You are reading this latest preprint version Abstract Double common bile duct (DCBD) represents an exceedingly rare congenital anomaly of the biliary anatomy. Recently, our hospital admitted a patient diagnosed with DCBD, which was further complicated by the presence of choledocholithiasis. Preoperative imaging studies indicated a Type II classification. The patient underwent a laparoscopic exploration of the common bile duct for the purpose of stone extraction, followed by primary suture closure. The patient was discharged following a successful recovery. case report double common bile duct cholelithiasis anatomical variation Figures Figure 1 Figure 2 Figure 3 Introduction DCBD is a rare anatomical variant defined by the presence of a septum within the common bile duct or the existence of two distinct common bile ducts[ 1 ]. Typically, one of these ducts drains normally into the duodenal papilla, while the other, referred to as the accessory common bile duct (ACBD), may open into various regions of the upper gastrointestinal tract. DCBD is frequently associated with conditions such as biliary stones, choledochal cysts, pancreaticobiliary maljunction (PBM), and upper gastrointestinal tumors[ 2 ]. The first documented case of DCBD was reported by Vesalius in 1543[ 3 ]. Currently, only isolated case reports have been published globally, and the precise incidence of this condition remains undetermined. This report presents a case of a patient diagnosed with DCBD complicated by common bile duct stones. Preoperative imaging indicated a Type II classification. The patient subsequently underwent laparoscopic cholecystectomy, common bile duct exploration for stone removal, and primary suture of the bile duct, ultimately being discharged following a successful recovery. Case report A 46-year-old female patient presented with a one-month history of intermittent pain in the right upper quadrant. Initially, she was admitted to a local hospital, where she received conservative treatment for "acute cholecystitis" over a period of 17 days, resulting in symptomatic improvement. However, the pain recurred following discharge, particularly after the consumption of greasy foods. Subsequently, she was referred to a higher-level local hospital. Diagnostic imaging, including ultrasound, contrast-enhanced computed tomography (CT), and magnetic resonance cholangiopancreatography (MRCP), revealed a double common bile duct malformation accompanied by calculi in both ducts. Despite receiving fasting, fluid restriction, anti-inflammatory, and symptomatic treatments, her condition showed minimal improvement, necessitating her transfer to our facility for further evaluation and management. Past Medical History: The patient underwent a hysterectomy for uterine fibroids five years prior. Additionally, she was diagnosed with allergic rhinitis and chronic bronchitis three years ago. Physical Examination: The examination revealed no icterus of the skin or sclera, There was no enlargement of superficial lymph nodes throughout the body, and no edema in the lower limbs. There was tenderness and rebound tenderness in the right upper quadrant, with a positive Murphy's sign. The liver and spleen were not palpable below the costal margins. Laboratory Results: WBC 7.6x10 9 /L, RBC 4.6x10¹²/L, PLT 316x10 9 /L, Total Bilirubin 9.8 µmol/L, Direct Bilirubin 3.5 µmol/L, ALT 34.5 U/L, AST 28.1 U/L, ALP 124.9 U/L, GGT 124.7 U/L, Albumin 40.0 g/L, CEA 0.46 ng/mL, AFP 4.77 ng/mL, CA-199 6.90U/mL. The MRCP findings indicated a distended gallbladder with a thickened wall and focal filling defects within the lumen. The upper common bile duct exhibited bifurcation, while the mid-to-lower segments demonstrated a double duct configuration, accompanied by filling defects within the lumens. These findings are suggestive of cholelithiasis, choledocholithiasis, and a double common bile duct malformation (Fig. 1 A, 1 B and 1 D). Furthermore, the CT scan confirmed the presence of a double-lumen common bile duct, characterized by slight wall thickening and enhancement at the termini of the bilateral ducts, which was interpreted as a developmental variation (Fig. 1 C). On the fifth day of admission, the patient underwent a laparoscopic cholecystectomy (Fig. 2 H), accompanied by exploration of the common bile duct for the removal of calculi, and primary suturing of the bile duct. Intraoperative assessment revealed a dilated common bile duct, measuring approximately 1 cm in diameter. A longitudinal incision of approximately 1.2 cm was made on the anterior wall of the common bile duct, resulting in the observation of bile outflow. A choledochoscope was subsequently introduced, which identified multiple stones within the distal segment of the common bile duct. Further exploration unveiled an additional ductal opening on the posterior wall (Fig. 2 A). Notably, the two bile ducts were found to run parallel to one another in the patient's sagittal plane, corroborating the findings from preoperative imaging. Exploration of the secondary bile duct also revealed the presence of several stones, all of which were successfully removed (Fig. 2 B and 2 C). The distal ends of both common bile ducts were found to be patent, and the sphincter of Oddi demonstrated adequate contraction and relaxation (Fig. 2 D and 2 E). The anterior wall of the common bile duct was then sutured closed (Fig. 2 F and 2 G). During the initial three postoperative days, the abdominal drain outputs measured 140 mL, 350 mL, and 250 mL, respectively, with the presence of bile indicating a potential biliary leak. Subsequent abdominal CT scans revealed no fluid accumulation within the abdominal cavity (Fig. 3 B and 3 C). Under conservative management, the drain output progressively decreased. Consequently, the abdominal drain was removed on the fifth postoperative day (Fig. 3 A). The patient was discharged on seventh post-operative day in fair health. Discussion DCBD is an uncommon congenital anomaly, the pathogenesis of which remains poorly understood. It is hypothesized to be associated with the random bifurcation of the hepatic diverticulum during the initial week of embryonic development[ 4 ]. In the initial stages of human embryonic development, the anatomical presence of two bile ducts is considered normal. Nevertheless, the failure of the second duct to undergo regression results in the persistence of an accessory extrahepatic bile duct[ 5 ]. Patients typically remain asymptomatic, with the condition often being incidentally identified during imaging studies or surgical procedures. Although the incidence rate is not well-documented, existing literature indicates a geographical correlation, with approximately two-thirds of reported cases originating from Asia, predominantly Japan[ 6 ]. In this particular case, the patient presented with recurrent upper abdominal pain and was successfully treated through minimally invasive surgical intervention. In 1972, Goor and Ebert[ 7 ] initially categorized DCBD into four distinct types, a classification that was subsequently refined by Saito et al.[ 8 ] in 1988. Choi[ 9 ] further expanded this classification in 2007 by introducing an additional variant, resulting in the following comprehensive classification: Type I involves a septum within the common bile duct that divides it into two lumens. Type II is characterized by the bifurcation of the common bile duct into two ducts near its terminus. Type III describes two bile ducts draining independently, with (IIIa) or without (IIIb) intrahepatic communication. Type IV involves two bile ducts draining independently with one or more extrahepatic communications. Type V is defined by two bile ducts joining before entering the duodenum, with (Va) or without (Vb) communication. According to this classification system, the case under consideration is identified as Type II, wherein the bile duct bifurcates distally into two branches that enter the duodenum. However, Yamashita et al.[ 10 ] posited that the location of the opening of the ACBD holds more clinical importance than its anatomical morphology. The ACBD may open into various sections of the gastrointestinal tract, such as the duodenum, pancreatic duct, stomach, or diaphragm. This anatomical anomaly is frequently linked with complications including bile duct stones, choledochal cysts, PBM, and malignancies of the upper gastrointestinal tract. In a review of 47 cases of double common bile duct (DCBD) from Japan, Yamashita reported an incidence of gallstones at 27.7%, choledochal cysts at 10.6%, PBM at 29.8%, and cancer at 25.5%, with the latter predominantly comprising gastric, pancreatic, ampullary, and gallbladder cancers. An ACBD opening into the stomach is frequently associated with gastric cancer, whereas pancreatic and biliary cancers are commonly associated with PBM. In the present case, the ACBD opened into the horizontal part of the duodenum, and choledocholithiasis was identified and subsequently removed through intraoperative choledochoscopy. Owing to insufficient awareness of DCBD among surgeons, there is a risk of misdiagnosis or oversight of this condition. Accurate preoperative identification of such anomalies is imperative to avert inadvertent discovery and potential bile duct injury during surgical procedures. Comprehensive preoperative imaging is indispensable in this context. Techniques such as endoscopic retrograde cholangiopancreatography (ERCP), MRCP, and CT are instrumental in facilitating precise diagnosis. Among these modalities, MRCP offers distinct advantages: it is non-invasive, obviates the need for intravenous contrast, and, crucially, provides a comprehensive anatomical depiction of the biliary system in a single image[ 5 , 11 ]. In the case under discussion, preoperative MRCP effectively delineated the patient's biliary anatomy, leading to a suspected diagnosis of DCBD based on existing literature, which was then confirmed via intraoperative choledochoscopy. Consequently, MRCP should be considered the primary investigative modality for patients with suspected biliary anomalies. Currently, there is no established consensus regarding the optimal treatment for DCBD. Patients diagnosed with DCBD, particularly those with coexisting PBM, are at an elevated risk for recurrent cholangitis, biliary obstruction, and malignancy due to the anatomical alterations. Although several case reports suggest resection of the accessory common bile duct or extrahepatic bile ducts, the efficacy and long-term outcomes of these interventions remain uncertain[ 2 , 6 ]. In the case under discussion, preservation of both bile ducts was undertaken, with only stone removal and primary suture of the bile duct performed, leading to the patient's recovery. Nonetheless, the long-term prognosis associated with the preservation of both bile ducts necessitates ongoing follow-up. Conclusion We report a case study of Type II DCBD complicated by the presence of choledocholithiasis. The patient successfully underwent a laparoscopic cholecystectomy, followed by an exploration of the common bile duct for stone extraction and primary closure, resulting in a favorable outcome. The integration of preoperative MRCP with intraoperative choledochoscopy can significantly enhance the diagnostic precision for DCBD. The accumulation of long-term clinical data and follow-up is imperative for developing individualized treatment strategies for patients with varying types of DCBD in the future. Abbreviations DCBD Double common bile duct ACBD Accessory common bile duct PBM Pancreaticobiliary maljunction CT computed tomography MRCP magnetic resonance cholangiopancreatography ERCP Endoscopic retrograde cholangiopancreatography Declarations Ethics approval and consent to participate Not Applicable. Consent for publication Written informed consent was obtained from the participant on July 20th 2025, for publication of this article and any accompanying tables/images. A copy of the written consent is available for review by the Editor of this journal. Availability of data and materials All data is contained within the manuscript and its additional files. Competing interests The authors declare that they have no competing interests. Funding Not Applicable. Authors' contributions Author 1: made substantial contributions to conception and design and has been involved in drafting the manuscript. JK has been involved in revising the manuscript critically for important intellectual content. All authors read and approved the final manuscript. Acknowledgements Not Applicable. Clinical trial number Not Applicable. References Bancu A, Poundall T, Santos C, Higashi Y, Zaitoun AM, Lobo DN. An unusual variant of type I common bile duct duplication associated with ampullary carcinoma. Arch Clin Cases. 2024;11(2):56–60. McDermott J, Gonzalez SE, Medina Alonso Z, Oquendo Figueroa JA, Nunez A, Ahmed I. The Presence of Type Va Double Common Bile Duct in a Male Patient: A Case Report. Cureus. 2024;16(10):e72801. Bilgi Kirmaci M, Balli E, Dayanç M, Yilmaz S. Case Report: A rarely observed anomaly of the common bile duct-common bile duct duplication. Front Med (Lausanne). 2025;12:1584728. Doan TT, Pham DT, Van Nguyen C, Tran TT, Van Nguyen H. Double common bile duct - A rare case report and review of literature. Int J Surg Case Rep. 2025;133:111519. Hwang JS, Ko SW. Duplication of the common bile duct manifesting as recurrent pyogenic cholangitis: A case report. World J Gastroenterol. 2021;27(4):371–6. Yamada K, Ishikawa T, Ohno E, Iida T, Suzuki H, Uetsuki K, Yashika J, Yoshikawa M, Takami H, Inokawa Y, et al. Double common bile duct associated with pancreaticobiliary maljunction. Nagoya J Med Sci. 2021;83(3):655–61. Goor DA, Ebert PA. Anomalies of the biliary tree. Report of a repair of an accessory bile duct and review of the literature. Arch Surg. 1972;104(3):302–9. Saito N, Nakano A, Arase M, Hiraoka T. [A case of duplication of the common bile duct with anomaly of the intrahepatic bile duct]. Nihon Geka Gakkai Zasshi. 1988;89(8):1296–301. Choi E, Byun JH, Park BJ, Lee MG. Duplication of the extrahepatic bile duct with anomalous union of the pancreaticobiliary ductal system revealed by MR cholangiopancreatography. Br J Radiol. 2007;80(955):e150–154. Yamashita K, Oka Y, Urakami A, Iwamoto S, Tsunoda T, Eto T. Double common bile duct: a case report and a review of the Japanese literature. Surgery. 2002;131(6):676–81. Lian T, Liu G, Zhang Y. Double common bile duct with cholelithiasis. J Minim Access Surg. 2023;19(2):307–9. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 20 Mar, 2026 Read the published version in BMC Surgery → Version 1 posted Editorial decision: Revision requested 20 Nov, 2025 Reviews received at journal 08 Nov, 2025 Reviews received at journal 06 Nov, 2025 Reviews received at journal 01 Nov, 2025 Reviewers agreed at journal 30 Oct, 2025 Reviewers agreed at journal 28 Oct, 2025 Reviewers agreed at journal 26 Oct, 2025 Reviewers agreed at journal 23 Oct, 2025 Reviewers agreed at journal 23 Oct, 2025 Reviewers invited by journal 23 Oct, 2025 Editor invited by journal 13 Oct, 2025 Editor assigned by journal 10 Oct, 2025 Submission checks completed at journal 10 Oct, 2025 First submitted to journal 07 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7801187","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":538706214,"identity":"03f9d9f2-3c4b-4af2-8804-0bf8af5a4489","order_by":0,"name":"Haodong Zhang","email":"","orcid":"","institution":"Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Haodong","middleName":"","lastName":"Zhang","suffix":""},{"id":538706215,"identity":"db8186d9-2041-4bb9-ae25-b10e6b26e476","order_by":1,"name":"Zihan Qiu","email":"","orcid":"","institution":"Capital Medical 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06:32:31","extension":"html","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":41620,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7801187/v1/c47bbe802b8a9c0998787802.html"},{"id":95171414,"identity":"3bb361a1-e059-4371-a3f5-95b8839b7896","added_by":"auto","created_at":"2025-11-05 06:32:30","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":4383145,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePreoperative radiological images.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(A) Magnetic Resonance Cholangiopancreatography (MRCP) reveals the presence of two distinct common bile ducts terminating in the duodenum. (B) MRCP identified a calculus in the distal common bile duct. (C) CT scan shows a double common bile duct. (D) MRCP shows a double common bile duct.\u003c/p\u003e","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-7801187/v1/b537957db72cbcd9a0089640.png"},{"id":95171423,"identity":"154df2e2-6648-45a1-8495-7dc2808863ed","added_by":"auto","created_at":"2025-11-05 06:32:31","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":13338273,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe intraoperative procedure and the findings obtained through choledochoscopy.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(A) During the surgical procedure, an incision of the common bile duct exposed a double-lumen configuration. (B) Soft yellow stones were extracted from the common bile duct. (C) Detection of bile duct stones via choledochoscopy. (D,E) Choledochoscopy showed two common bile ducts entering the duodenum. (F,G) After removal of the stones, the bile duct was closed by primary suture. (H) The whole gallbladder was successfully removed.\u003c/p\u003e","description":"","filename":"Fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7801187/v1/e14bfd58e566bf313f55cb7f.jpg"},{"id":95226257,"identity":"a4954948-4d5b-4c67-ad08-829d5b01f7c3","added_by":"auto","created_at":"2025-11-05 16:30:47","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1644701,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePostoperative imaging results and variations in abdominal drainage output.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(A) POD 2's CT images. (B) POD 6's CT images. (C) Drainage output changes on POD 1-5.\u003c/p\u003e","description":"","filename":"Fig3.png","url":"https://assets-eu.researchsquare.com/files/rs-7801187/v1/828acc4028e34fc2e190a4a1.png"},{"id":105223547,"identity":"f35b8887-86fb-43fb-8223-7aedead476f8","added_by":"auto","created_at":"2026-03-23 16:08:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":36519321,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7801187/v1/d5a8d6c0-c2d4-4216-89e2-ce2a73e20d67.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Double common bile duct malformation with choledocholithiasis treated by laparoscopic common bile duct exploration with primary suture: a case report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDCBD is a rare anatomical variant defined by the presence of a septum within the common bile duct or the existence of two distinct common bile ducts[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Typically, one of these ducts drains normally into the duodenal papilla, while the other, referred to as the accessory common bile duct (ACBD), may open into various regions of the upper gastrointestinal tract. DCBD is frequently associated with conditions such as biliary stones, choledochal cysts, pancreaticobiliary maljunction (PBM), and upper gastrointestinal tumors[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The first documented case of DCBD was reported by Vesalius in 1543[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Currently, only isolated case reports have been published globally, and the precise incidence of this condition remains undetermined. This report presents a case of a patient diagnosed with DCBD complicated by common bile duct stones. Preoperative imaging indicated a Type II classification. The patient subsequently underwent laparoscopic cholecystectomy, common bile duct exploration for stone removal, and primary suture of the bile duct, ultimately being discharged following a successful recovery.\u003c/p\u003e"},{"header":"Case report","content":"\u003cp\u003eA 46-year-old female patient presented with a one-month history of intermittent pain in the right upper quadrant. Initially, she was admitted to a local hospital, where she received conservative treatment for \"acute cholecystitis\" over a period of 17 days, resulting in symptomatic improvement. However, the pain recurred following discharge, particularly after the consumption of greasy foods. Subsequently, she was referred to a higher-level local hospital. Diagnostic imaging, including ultrasound, contrast-enhanced computed tomography (CT), and magnetic resonance cholangiopancreatography (MRCP), revealed a double common bile duct malformation accompanied by calculi in both ducts. Despite receiving fasting, fluid restriction, anti-inflammatory, and symptomatic treatments, her condition showed minimal improvement, necessitating her transfer to our facility for further evaluation and management. Past Medical History: The patient underwent a hysterectomy for uterine fibroids five years prior. Additionally, she was diagnosed with allergic rhinitis and chronic bronchitis three years ago. Physical Examination: The examination revealed no icterus of the skin or sclera, There was no enlargement of superficial lymph nodes throughout the body, and no edema in the lower limbs. There was tenderness and rebound tenderness in the right upper quadrant, with a positive Murphy's sign. The liver and spleen were not palpable below the costal margins. Laboratory Results: WBC 7.6x10\u003csup\u003e9\u003c/sup\u003e/L, RBC 4.6x10\u0026sup1;\u0026sup2;/L, PLT 316x10\u003csup\u003e9\u003c/sup\u003e/L, Total Bilirubin 9.8 \u0026micro;mol/L, Direct Bilirubin 3.5 \u0026micro;mol/L, ALT 34.5 U/L, AST 28.1 U/L, ALP 124.9 U/L, GGT 124.7 U/L, Albumin 40.0 g/L, CEA 0.46 ng/mL, AFP 4.77 ng/mL, CA-199 6.90U/mL. The MRCP findings indicated a distended gallbladder with a thickened wall and focal filling defects within the lumen. The upper common bile duct exhibited bifurcation, while the mid-to-lower segments demonstrated a double duct configuration, accompanied by filling defects within the lumens. These findings are suggestive of cholelithiasis, choledocholithiasis, and a double common bile duct malformation (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA, \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB and \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eD). Furthermore, the CT scan confirmed the presence of a double-lumen common bile duct, characterized by slight wall thickening and enhancement at the termini of the bilateral ducts, which was interpreted as a developmental variation (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC). On the fifth day of admission, the patient underwent a laparoscopic cholecystectomy (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eH), accompanied by exploration of the common bile duct for the removal of calculi, and primary suturing of the bile duct. Intraoperative assessment revealed a dilated common bile duct, measuring approximately 1 cm in diameter. A longitudinal incision of approximately 1.2 cm was made on the anterior wall of the common bile duct, resulting in the observation of bile outflow. A choledochoscope was subsequently introduced, which identified multiple stones within the distal segment of the common bile duct. Further exploration unveiled an additional ductal opening on the posterior wall (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA). Notably, the two bile ducts were found to run parallel to one another in the patient's sagittal plane, corroborating the findings from preoperative imaging. Exploration of the secondary bile duct also revealed the presence of several stones, all of which were successfully removed (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB and \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC). The distal ends of both common bile ducts were found to be patent, and the sphincter of Oddi demonstrated adequate contraction and relaxation (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eD and \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eE). The anterior wall of the common bile duct was then sutured closed (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eF and \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eG). During the initial three postoperative days, the abdominal drain outputs measured 140 mL, 350 mL, and 250 mL, respectively, with the presence of bile indicating a potential biliary leak. Subsequent abdominal CT scans revealed no fluid accumulation within the abdominal cavity (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB and \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eC). Under conservative management, the drain output progressively decreased. Consequently, the abdominal drain was removed on the fifth postoperative day (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA). The patient was discharged on seventh post-operative day in fair health.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDCBD is an uncommon congenital anomaly, the pathogenesis of which remains poorly understood. It is hypothesized to be associated with the random bifurcation of the hepatic diverticulum during the initial week of embryonic development[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In the initial stages of human embryonic development, the anatomical presence of two bile ducts is considered normal. Nevertheless, the failure of the second duct to undergo regression results in the persistence of an accessory extrahepatic bile duct[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Patients typically remain asymptomatic, with the condition often being incidentally identified during imaging studies or surgical procedures. Although the incidence rate is not well-documented, existing literature indicates a geographical correlation, with approximately two-thirds of reported cases originating from Asia, predominantly Japan[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In this particular case, the patient presented with recurrent upper abdominal pain and was successfully treated through minimally invasive surgical intervention.\u003c/p\u003e\u003cp\u003eIn 1972, Goor and Ebert[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] initially categorized DCBD into four distinct types, a classification that was subsequently refined by Saito et al.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] in 1988. Choi[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] further expanded this classification in 2007 by introducing an additional variant, resulting in the following comprehensive classification: Type I involves a septum within the common bile duct that divides it into two lumens. Type II is characterized by the bifurcation of the common bile duct into two ducts near its terminus. Type III describes two bile ducts draining independently, with (IIIa) or without (IIIb) intrahepatic communication. Type IV involves two bile ducts draining independently with one or more extrahepatic communications. Type V is defined by two bile ducts joining before entering the duodenum, with (Va) or without (Vb) communication. According to this classification system, the case under consideration is identified as Type II, wherein the bile duct bifurcates distally into two branches that enter the duodenum.\u003c/p\u003e\u003cp\u003eHowever, Yamashita et al.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] posited that the location of the opening of the ACBD holds more clinical importance than its anatomical morphology. The ACBD may open into various sections of the gastrointestinal tract, such as the duodenum, pancreatic duct, stomach, or diaphragm. This anatomical anomaly is frequently linked with complications including bile duct stones, choledochal cysts, PBM, and malignancies of the upper gastrointestinal tract. In a review of 47 cases of double common bile duct (DCBD) from Japan, Yamashita reported an incidence of gallstones at 27.7%, choledochal cysts at 10.6%, PBM at 29.8%, and cancer at 25.5%, with the latter predominantly comprising gastric, pancreatic, ampullary, and gallbladder cancers. An ACBD opening into the stomach is frequently associated with gastric cancer, whereas pancreatic and biliary cancers are commonly associated with PBM. In the present case, the ACBD opened into the horizontal part of the duodenum, and choledocholithiasis was identified and subsequently removed through intraoperative choledochoscopy.\u003c/p\u003e\u003cp\u003eOwing to insufficient awareness of DCBD among surgeons, there is a risk of misdiagnosis or oversight of this condition. Accurate preoperative identification of such anomalies is imperative to avert inadvertent discovery and potential bile duct injury during surgical procedures. Comprehensive preoperative imaging is indispensable in this context. Techniques such as endoscopic retrograde cholangiopancreatography (ERCP), MRCP, and CT are instrumental in facilitating precise diagnosis. Among these modalities, MRCP offers distinct advantages: it is non-invasive, obviates the need for intravenous contrast, and, crucially, provides a comprehensive anatomical depiction of the biliary system in a single image[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In the case under discussion, preoperative MRCP effectively delineated the patient's biliary anatomy, leading to a suspected diagnosis of DCBD based on existing literature, which was then confirmed via intraoperative choledochoscopy. Consequently, MRCP should be considered the primary investigative modality for patients with suspected biliary anomalies.\u003c/p\u003e\u003cp\u003eCurrently, there is no established consensus regarding the optimal treatment for DCBD. Patients diagnosed with DCBD, particularly those with coexisting PBM, are at an elevated risk for recurrent cholangitis, biliary obstruction, and malignancy due to the anatomical alterations. Although several case reports suggest resection of the accessory common bile duct or extrahepatic bile ducts, the efficacy and long-term outcomes of these interventions remain uncertain[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In the case under discussion, preservation of both bile ducts was undertaken, with only stone removal and primary suture of the bile duct performed, leading to the patient's recovery. Nonetheless, the long-term prognosis associated with the preservation of both bile ducts necessitates ongoing follow-up.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe report a case study of Type II DCBD complicated by the presence of choledocholithiasis. The patient successfully underwent a laparoscopic cholecystectomy, followed by an exploration of the common bile duct for stone extraction and primary closure, resulting in a favorable outcome. The integration of preoperative MRCP with intraoperative choledochoscopy can significantly enhance the diagnostic precision for DCBD. The accumulation of long-term clinical data and follow-up is imperative for developing individualized treatment strategies for patients with varying types of DCBD in the future.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDCBD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDouble common bile duct\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eACBD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAccessory common bile duct\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePBM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePancreaticobiliary maljunction\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ecomputed tomography\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMRCP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003emagnetic resonance cholangiopancreatography\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eERCP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEndoscopic retrograde cholangiopancreatography\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the participant on July 20th 2025, for publication of this article and any accompanying tables/images. A copy of the written consent is available for review by the Editor of this journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data is contained within the manuscript and its additional files.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthor 1: \u0026nbsp;made substantial contributions to conception and design and has been involved in drafting the manuscript. JK has been involved in revising the manuscript critically for important intellectual content. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBancu A, Poundall T, Santos C, Higashi Y, Zaitoun AM, Lobo DN. An unusual variant of type I common bile duct duplication associated with ampullary carcinoma. Arch Clin Cases. 2024;11(2):56\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMcDermott J, Gonzalez SE, Medina Alonso Z, Oquendo Figueroa JA, Nunez A, Ahmed I. The Presence of Type Va Double Common Bile Duct in a Male Patient: A Case Report. Cureus. 2024;16(10):e72801.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBilgi Kirmaci M, Balli E, Dayan\u0026ccedil; M, Yilmaz S. Case Report: A rarely observed anomaly of the common bile duct-common bile duct duplication. Front Med (Lausanne). 2025;12:1584728.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDoan TT, Pham DT, Van Nguyen C, Tran TT, Van Nguyen H. Double common bile duct - A rare case report and review of literature. Int J Surg Case Rep. 2025;133:111519.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHwang JS, Ko SW. Duplication of the common bile duct manifesting as recurrent pyogenic cholangitis: A case report. World J Gastroenterol. 2021;27(4):371\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYamada K, Ishikawa T, Ohno E, Iida T, Suzuki H, Uetsuki K, Yashika J, Yoshikawa M, Takami H, Inokawa Y, et al. Double common bile duct associated with pancreaticobiliary maljunction. Nagoya J Med Sci. 2021;83(3):655\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGoor DA, Ebert PA. Anomalies of the biliary tree. Report of a repair of an accessory bile duct and review of the literature. Arch Surg. 1972;104(3):302\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSaito N, Nakano A, Arase M, Hiraoka T. [A case of duplication of the common bile duct with anomaly of the intrahepatic bile duct]. Nihon Geka Gakkai Zasshi. 1988;89(8):1296\u0026ndash;301.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChoi E, Byun JH, Park BJ, Lee MG. Duplication of the extrahepatic bile duct with anomalous union of the pancreaticobiliary ductal system revealed by MR cholangiopancreatography. Br J Radiol. 2007;80(955):e150\u0026ndash;154.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYamashita K, Oka Y, Urakami A, Iwamoto S, Tsunoda T, Eto T. Double common bile duct: a case report and a review of the Japanese literature. Surgery. 2002;131(6):676\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLian T, Liu G, Zhang Y. Double common bile duct with cholelithiasis. J Minim Access Surg. 2023;19(2):307\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"case report, double common bile duct, cholelithiasis, anatomical variation","lastPublishedDoi":"10.21203/rs.3.rs-7801187/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7801187/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eDouble common bile duct (DCBD) represents an exceedingly rare congenital anomaly of the biliary anatomy. Recently, our hospital admitted a patient diagnosed with DCBD, which was further complicated by the presence of choledocholithiasis. Preoperative imaging studies indicated a Type II classification. The patient underwent a laparoscopic exploration of the common bile duct for the purpose of stone extraction, followed by primary suture closure. The patient was discharged following a successful recovery.\u003c/p\u003e","manuscriptTitle":"Double common bile duct malformation with choledocholithiasis treated by laparoscopic common bile duct exploration with primary suture: a case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-05 06:32:26","doi":"10.21203/rs.3.rs-7801187/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-20T07:37:49+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-08T16:06:04+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-06T09:58:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-01T12:57:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"128904924352751299448368244124331557528","date":"2025-10-30T17:01:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"57543572813806971896771693130137486711","date":"2025-10-29T02:46:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"101822700601109612036209350639398699726","date":"2025-10-26T06:00:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"227959525175847600637240256333883204053","date":"2025-10-24T01:25:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"302194530756080182532549714111573539164","date":"2025-10-23T14:14:50+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-23T14:05:29+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-13T10:17:06+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-11T03:47:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-11T03:45:46+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2025-10-07T15:51:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"838383e0-bcb8-457d-a158-ff88607cf5c7","owner":[],"postedDate":"November 5th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-23T16:04:32+00:00","versionOfRecord":{"articleIdentity":"rs-7801187","link":"https://doi.org/10.1186/s12893-026-03638-0","journal":{"identity":"bmc-surgery","isVorOnly":false,"title":"BMC Surgery"},"publishedOn":"2026-03-20 15:59:12","publishedOnDateReadable":"March 20th, 2026"},"versionCreatedAt":"2025-11-05 06:32:26","video":"","vorDoi":"10.1186/s12893-026-03638-0","vorDoiUrl":"https://doi.org/10.1186/s12893-026-03638-0","workflowStages":[]},"version":"v1","identity":"rs-7801187","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7801187","identity":"rs-7801187","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}