LS is an uncommon cause of obstructive jaundice, resulting from extrinsic compression of the distal CBD by a periampullary DD. As highlighted in the systematic review by Love et al^[9^], only 17 well-documented cases have been reported to date, with a mean patient age of 70 years. The majority of patients presented with right upper quadrant pain (64.7%), jaundice (68.8%), and CBD dilatation (100%). However, the clinical presentation and laboratory findings remain highly variable, often leading to diagnostic uncertainty. A comparison of patient demographics, presentations, and management outcomes is summarized in Table 1.

In the present case, the patient’s symptoms and imaging findings: cholelithiasis, mild ductal dilatation, and suspected CBD sludge, initially suggested cholecystitis with choledocholithiasis. This is consistent with the diagnostic pitfalls described by Love et al, in which imaging findings of periampullary diverticula are often misinterpreted as choledocholithiasis or even pancreatic head lesions due to their proximity and overlapping radiological features. In retrospect, the DD was visible on MRCP but was overlooked during the initial assessment. This underscores the importance of direct surgeon review of imaging studies in their digital format, rather than relying solely on printed reports or radiologists’ interpretations. Printed MRCP images are often displayed in thicker slices, which may obscure subtle findings such as small air bubbles or the diverticular sac adjacent to the distal CBD. When reviewing digital thin-slice MRCP sequences, periampullary diverticula often present as extraluminal outpouchings containing fluid or air, which appear as signal voids on T2-weighted images. This finding should be distinguished from intraductal filling defects such as CBD stones or sludge. Additionally, alternative imaging modalities can be valuable, such as endoscopic ultrasound, which is highly sensitive for differentiating diverticula from biliary stones or neoplasms, while CT with oral contrast can help visualize the diverticular sac.

Another crucial learning point concerns the timing and coordination of multidisciplinary management. Ideally, once the intraoperative MRCP re-evaluation suggested a DD, the patient should have undergone a same-session ERCP within the same anesthetic period, which is feasible in hospitals equipped with a hybrid operating theater. As discussed by Love et al, ERCP remains the gold standard for both the diagnosis and treatment of LS, allowing direct visualization of the diverticulum and immediate therapeutic intervention through lavage, sphincterotomy, balloon sweep, or stenting. In our institution, however, ERCP was delayed until the following day due to infrastructural limitations, necessitating separate scheduling in a different suite. Despite this, the patient had an uneventful recovery after sphincterotomy and balloon sweep. For centers lacking hybrid operating theaters, ensuring seamless coordination to minimize obstruction time is crucial. This can be achieved by prioritizing ERCP slots for the next day and utilizing intraoperative cholangiography to confirm ductal clearance if ERCP is delayed.

Endoscopic therapy, as demonstrated by Love et al and corroborated by multiple reports in their review, offers excellent outcomes with minimal morbidity. Among the 17 cases analyzed, 46.7% were successfully managed endoscopically, while only a minority required definitive diverticulectomy. Endoscopic lavage or balloon sweep to remove food debris from the diverticular cavity, such as in this case, has been shown to achieve symptom resolution and normalization of laboratory findings. These outcomes highlight that surgery should be reserved for refractory or recurrent cases or when complications such as perforation or recurrent cholangitis occur.

Our experience also reinforces the broader implication that careful imaging interpretation and timely multidisciplinary coordination can prevent unnecessary surgical exploration. Surgeons should maintain a high index of suspicion for LS when encountering unexplained biliary dilatation without intraductal obstruction, especially when MRCP shows periduodenal air or cystic structures near the ampulla.