PMC2926673_01
Main gallbladder (white arrow) and cystic structure with multiple stones and debris (black arrow) were confirmed by ultrasonography.
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fig1
It was filled with stones and debris (Figure 1).
Normal gallbladder (white arrow) and cystic structure (black arrow) were confirmed also by MRCP, but the communication with the biliary tree could not be confirmed.
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fig2
Magnetic resonance cholangiopancreatography (MRCP) showed findings similar to those of ultrasonography and CT, but the communication between the cystic structure and the hepatic duct could not be defined (Figure 2).
By ERCP the right and left hepatic ducts were displaced (a). With the supplementary injection of radiopaque material, accessory gallbladder could be visualized (b). Cholangiography through ENBD tube conducted the following day showed cystic duct (white arrow) arising from the left hepatic duct (c). Thereafter, an accessory gallbladder was visualized (d).
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fig3
By endoscopic retrograde cholangiopancreatography (ERCP) the right hepatic duct and the left hepatic duct were compressed to the left and right, respectively, and with the supplementary injection of radiopaque material an accessory gallbladder with multiple stones was visualized between the left and right hepatic duct (Figures 3(a) and 3(b)). By cholangiography through the endoscopic nazobiliary drainage (ENBD) tube, cystic duct and accessory gallbladder arising from left hepatic duct could be visualized (Figures 3(c) and 3(d)).
By PET-CT abnormal accumulation of F18-FDP at location considered to be accessory gallbladder could be visualized.
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By positron emission computed tomography (PET-CT) a cystic structure resembling a gallbladder between the left lobe and right lobe of the liver could be visualized together with accumulation of F18-fluroradeoxyglucose (F18-FDP) (Figure 4).
After removing the accessory gallbladder as well as possible, when physiological saline solution was injected into the left hepatic duct, there was a vigorous emission of this solution from the accessory gallbladder (white arrow). After confirming the exit of the cystic duct toward the accessory gallbladder, the exit was ligated.
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fig5
After confirming the exit of the cystic duct toward the accessory gallbladder, ligation was made (Figure 5).
Microscopic image of main gallbladder (a), accessory gallbladders ((b), (c)), and tubular adenocarcinoma in the accessory gallbladder (d). Lobular hyperplasia or adenosis was observed in the accessory gallbladder, but the basic structure of gallbladder (mucosal layer, muscular layer, and submucosal layer) could be seen in both gallbladders. Tubular adenocarcinoma infiltrating into the submucosal layer could be confirmed.
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fig6
Well differentiated tubular adenocarcinoma was observed in the resected accessory gallbladder with infiltration into the subserosal layer (Figure 6).