A 48-year-old female was admitted to Madhubani Medical College and Hospital with complaints of recurrent pain in the right upper abdomen for approximately six years. The pain had been intermittent in nature and had persisted since she underwent an open cholecystectomy seven years earlier. In addition to the chronic pain, she gave a history of episodic yellowish discoloration of the eyes for nearly six years, suggesting repeated biliary obstruction of varying severity. One week before admission, she developed clay-colored stools, and over the preceding five days, she noticed high-colored urine. She also had vomiting for three to four days before presentation. There was no mention of hematemesis, melena, abdominal distension, or altered bowel habits. Taken together, her symptoms suggested recurrent biliary obstruction with recent worsening.

On admission, routine laboratory investigations revealed a hemoglobin level of 9.1 g/dL, indicative of anemia, while the total leukocyte count (5330/mm³) and platelet count (282,000/mm³) were within normal limits. Biochemical parameters showed a total bilirubin of 1.58 mg/dL and direct bilirubin of 1.05 mg/dL, which were only mildly elevated; however, in the context of a documented history of intermittent jaundice, these findings were consistent with episodic biliary obstruction. Liver enzymes were deranged, with elevated transaminases (serum glutamic-oxaloacetic transaminase (SGOT), 111.62 U/L, and serum glutamic-pyruvic transaminase (SGPT), 69.6 U/L) and a raised alkaline phosphatase level of 323 U/L, suggesting a predominantly cholestatic pattern of liver injury. Renal function tests, serum electrolytes, total protein, and albumin levels were within normal limits, indicating preserved renal function and adequate nutritional and hepatic synthetic status. In view of the anemia, one unit of B-positive packed red blood cells was transfused preoperatively. Overall, the laboratory profile supported a diagnosis of recurrent biliary obstruction with preserved physiological reserve for surgical intervention (Table 1).

According to the MRCP report, which was performed preoperatively, findings were consistent with choledocholithiasis with upstream biliary dilatation and a cystic duct stump calculus (Figure 1). The imaging demonstrated a T2 hypointense filling defect measuring approximately 1.4 cm within the distal CBD, associated with dilatation of the proximal CBD, common hepatic duct, right and left hepatic ducts, and intrahepatic biliary radicals, indicating significant biliary obstruction. In addition, a second T2 hypointense calculus of similar size was identified in the region of the cystic duct stump, suggesting remnant duct pathology following prior cholecystectomy. The overall radiological impression was choledocholithiasis with proximal biliary dilatation, in association with a cystic duct stump calculus. These findings were clinically important, as they provided a clear anatomical basis for the patient’s long-standing recurrent biliary symptoms and played a crucial role in guiding subsequent surgical planning.

In view of the preoperative imaging findings and the patient’s history of recurrent obstructive biliary symptoms, surgical intervention was planned, with an initial intent to perform choledochoduodenostomy to address the ductal obstruction. However, upon entering the abdominal cavity, the operative field was found to be significantly distorted by dense adhesions, with bowel loops and omentum firmly plastered over the liver, indicating longstanding inflammatory changes and a technically challenging reoperative scenario. Careful and meticulous adhesiolysis was undertaken, during which a cystic duct remnant-CBD fistulous communication was identified, likely resulting from chronic inflammation and pressure effects of long-standing impacted calculi. Further exploration of the operative field revealed an impacted stone located within the gallbladder stump/cystic duct stump region, correlating with the preoperative MRCP findings. In view of the dense adhesions, altered biliary anatomy, and the presence of a fistulous tract, proceeding with the originally planned choledochoduodenostomy was deemed unsafe due to the high risk of complications. Consequently, the surgical strategy was judiciously modified, and the CBD was opened to allow direct exploration. The impacted calculus was carefully extracted from the stump region (Figure 2), ensuring adequate ductal clearance and addressing the primary source of obstruction. This intraoperative decision-making highlights the importance of flexibility and individualized surgical planning in complex reoperative biliary surgery.

After ensuring satisfactory ductal clearance following CBD exploration, a T-tube was inserted into the CBD and securely positioned to facilitate controlled external biliary drainage (Figure 3). The use of T-tube drainage was considered appropriate in this complex reoperative setting, as it provided decompression of the biliary system, allowed postoperative monitoring of bile output, and enabled access for cholangiographic evaluation to confirm ductal patency and exclude residual stones or leaks. Following placement of the T-tube, meticulous hemostasis was achieved, and the abdomen was closed in layers.

Postoperatively, the patient was managed under close in-hospital monitoring, with regular assessment of vital parameters, abdominal examination, and T-tube output to ensure adequate biliary drainage. Her recovery remained clinically stable and uneventful, with no evidence of immediate postoperative complications such as bile leak, hemorrhage, sepsis, or features of persistent biliary obstruction. She was observed for a total duration of 10 days, during which appropriate supportive care, including analgesia, fluid management, and nutritional support, was provided, along with meticulous drain monitoring and serial clinical evaluations. Prior to discharge, a T-tube cholangiogram was performed to assess the integrity and patency of the biliary tree. The study demonstrated free and unobstructed flow of contrast into the duodenum, with no evidence of residual calculi, strictures, or contrast extravasation, thereby confirming successful ductal clearance and absence of leak (Figure 4). In view of her stable clinical condition and satisfactory cholangiographic findings, the patient was deemed fit for discharge with the T-tube in situ and was advised regular follow-up for subsequent management.

Since the patient was clinically stable and tolerating treatment well, she was discharged with the T-tube in situ and advised follow-up.