Surgical and endoscopic management of remnant cystic duct lithiasis after cholecystectomy--a case series

Gallbladder remnant: A potential source for biliary stones postcholecystectomy; a case report in a child with sickle cell disease

Stone formation in a gallbladder remnant is a rare postcholecystectomy complication. This report describes the case of gallstones in a gallbladder remnant of an adolescent with sickle cell disease (SCD) years after laparoscopic cholecystectomy. A 15-year-old female with SCD presented to our gastroenterology clinic with concerns of recurrent choledocholithiasis despite cholecystectomy 2 years before presentation. About 4 months before presentation to our clinic, she was evaluated at the referring physician's emergency department for recurrent severe abdominal pain of 1 month duration. After admission to the hospital, common bile duct stones were seen on magnetic resonance cholangiopancreatography (MCRP) imaging and subsequently removed via endoscopic retrograde cholangiopancreatography (ERCP). On review of her MRCP and ERCP at our hospital, a remnant of gallbladder containing multiple stones was identified. She subsequently underwent a laparoscopic resection of the gallbladder remnant. Clinicians should consider biliary duct imaging in children with biliary colic following cholecystectomy, especially those with history of chronic hemolysis.

Length of the Remnant Cystic Duct and Bile Duct Stone Recurrence: a Case‒Control Study

BACKGROUND

Since the introduction of the Critical View of Safety approach in laparoscopic cholecystectomy, exposure of the common bile duct, and common hepatic duct is not recommended, therefore, the length of the cystic duct remnant is no longer controlled. The aim of this case‒control study is to evaluate the relationship between the length of the cystic duct remnant and the risk for bile duct stone recurrence after cholecystectomy.

METHODS

All MRIs with dedicated sequences of the biliary tract taken between 2010 and 2020 from patients who underwent prior cholecystectomy were reviewed. The length of the cystic duct remnant was measured and compared between the patients with and without bile duct stones using multivariate logistic regression analysis.

RESULTS

A total of 362 patients were included in this study, 23.5% of whom had bile duct stones on MRI. The cystic duct remnant was significantly longer in the patients with stones than in the control group (median 31 mm versus 18 mm, P < 0.001). In the MRIs performed > 2 years after cholecystectomy, the cystic duct remnant was also significantly longer in the patients with bile duct stones (median 32 mm versus 21 mm, P < 0.001). A cystic duct remnant ≥ 15 mm in length increased the odds of stones (OR = 2.3, P = 0.001). Overall, the odds of bile duct stones increased with an increasing cystic duct remnant length (≥ 45 mm, OR = 5.0, P < 0.001).

CONCLUSIONS

An excessive cystic duct remnant length increases the odds of recurrent bile duct stones after cholecystectomy.

Improvement of the algorithm for diagnostics of postcholecystectomy syndrome taking into account functional and organic changes in the area of the large duodenal nipple

The aim. Improving the algorithm for diagnosing patients with postcholecystectomy syndrome (PCS), taking into account functional and organic changes in the major duodenal papilla (MDP). Materials and methods. 208 patients with PCS were examined. Laparoscopic cholecystectomy (CE) was performed in 172 patients in history, open CE was performed in 36 patients. 47 patients had obstructive jaundice, 84 had signs of biliary hypertension without an increase in bilirubin, 77 had no signs of biliary hypertension and an increase in bilirubin. The following instrumental research methods were used: abdominal organs ultrasound examination (AO USE), duodenoscopy, endoscopic retrograde cholangiopancreatography (ERCP), computed tomography (CT). In the main group, to study the morphofunctional changes in MDP, duodenoscopy with parietal impedancemetry, ultrasound of the hepatobiliary zone with a choleretic load were used. Results. In the main group, 34 patients underwent ultrasound of the hepatobiliary zone and Vater's nipple area with a choleretic breakfast according to Boyden according to the method of Grigoriev P.Ya. in our modification, 21 patients had an expansion of the choledochus by 2 mm. At the same time, taking meverin led to a decrease in the diameter of the choledochus, which indicated functional changes in the MDP. In 13 patients, the expansion of the choledochus, observed when taking a choleretic breakfast, persisted with the use of antispasmodics, which indicated the presence of an organic pathology of MDP. Duodenoscopy with impedancemetry was performed in 41 patients: 20 patients had 760–820 Ohm, which indicated the presence of functional changes, 12 patients had inflammatory changes in the MDP and 703–760 Ohm were detected, 9 patients with cicatricial fibrous changes had indicators impedance measurement 640–703 Ohm. The use of ultrasound with a choleretic breakfast and duodenoscopy with parietal impedancemetry in patients of the main group made it possible to identify functional and organic (inflammatory, fibrous) changes in the MDP, which made it possible to develop a therapeutic algorithm using both conservative therapy and the use of various options for transpapillary endoscopic interventions. Conclusions. Conducting an in-depth diagnosis of morpho-functional changes in MDP using parietal impedancemetry of MDP and ultrasound of the hepatobiliary zone with choleretic load allows us to identify both functional and morphological changes in MDP, which makes it possible to develop a therapeutic algorithm using drug therapy and transpapillary endoscopic techniques.

Robotic-assisted completion cholecystectomy: A safe and effective approach to a challenging surgical scenario - A single center retrospective cohort study

BACKGROUND

Reoperation following a previous subtotal or aborted cholecystectomy presents a challenging surgical scenario that has traditionally required an open completion cholecystectomy. The aim of this study was to describe an institutional experience with a robotic-assisted approach to completion cholecystectomy.

METHODS

A database was retrospectively audited to identify all patients who underwent robotic-assisted cholecystectomy performed by two hepatopancreatobiliary surgeons at a single centre from 2010 to 2019.

RESULTS

Twenty six patients who underwent a robotic-assisted completion cholecystectomy were identified. Median operative time was 142 min (48-247 min) with a blood loss of 50 cc (0-500 cc). Minor complications (Clavien-Dindo ≤ II 90 days) occurred in three patients (11.5%) with no major complication or mortality reported. Median hospital length of stay was 1 day (0-6 days) with one patient readmitted.

CONCLUSION

This study represents to our knowledge the largest series of robotic-assisted completion cholecystectomies to date. The robotic approach appears to be a safe and effective procedure associated with a low morbidity and high success rate.

MRI evaluation of bile duct injuries and other post-cholecystectomy complications

Laparoscopic cholecystectomy is one of the most common procedures performed each year and can be associated with various post-operative complications. Imaging is integral to diagnosis and management of patients with suspected cholecystectomy complications, and a thorough understanding of normal and abnormal biliary anatomy, risk factors for biliary injury, and the spectrum of adverse events is crucial for interpretation of imaging studies. Magnetic resonance cholangiography (MRC) enhanced with hepatobiliary contrast agent is useful in delineating biliary anatomy and pathology following cholecystectomy. In this article, we provide a protocol for contrast-enhanced MR imaging of the biliary tree. We also review the classification and imaging manifestations of post-cholecystectomy bile duct injuries in addition to other complications such as bilomas, retained/dropped gallstones, and vascular injuries.

Factors related to residual gallbladder calculi formation using computed tomography and magnetic resonance imaging combined with clinical data

Objective

We aimed to investigate risk factors related to remnant gallbladder (RGB) stones.

Methods

This retrospective study included 73 patients with RGB, in groups with and without RGB calculi. Univariate analyses were used to identify nine variables associated with RGB calculi: sex, age, body mass index (BMI), time to detection, surgical method, length of RGB, angle of RGB and common hepatic duct (CHD), choledocholithiasis, and remnant cholecystitis. Multivariate logistic regression was performed to assess independent predictors of RGB stones. A receiver operating characteristic (ROC) curve was used to estimate model accuracy and determine cut-off values of independent predictors.

Results

We enrolled 73 patients, 33 with and 40 without RGB stones. Univariate analyses showed that age, BMI, time to detection, length of RGB, angle of RGB and CHD were predictors for RGB calculi. Multivariate analyses indicated that time to detection, length of RGB, and angle of RGB and CHD were independent predictors for RGB calculi. The area under the ROC curve of the model was 0.940. Cut-off values of the three indicators were 1.5 years, 2.25 cm, and 22.5°, respectively.

Conclusion

Time to detection, length of RGB, and angle of RGB and CHD were independent predictors of RGB calculi.

Remnant Cystic Duct Disease After Cholecystectomy: A Case Series

BACKGROUND

Remnant cystic duct (RCD) may be responsible for postcholecystectomy syndrome. We present our experience with the management of remnant cystic duct disease (RCDD) after cholecystectomy.

METHODS

Over a period of 5 years, 10 patients underwent reoperation for RCDD in our hospital. Cystic duct was identified by intraoperative exploration.

RESULTS

There were 4 men and 6 women ranging in age from 37 to 76 years (median, 60.40 y). All 10 had biliary pain, 5 had jaundice, and 2 had pancreatitis. The time from initial cholecystectomy to reoperation ranged from 4 to 28 years (median, 12.22 y). Eight patients had an abnormal liver function. Six of these 8 patients (75%) were diagnosed by magnetic resonance cholangiopancreatography. In 7 patients treated by completed cholecystectomy (6 by laparoscopy and 1 by laparotomy), pathology proved the presence of an RCD and chronic cholecystitis. The other 3 patients were treated by removing stones. All patients had 6- to 14-day hospital stays after reoperation, except for 1 patient with a 3-day stay.

CONCLUSIONS

RCDD may be a more reasonable explanation for a source of postcholecystectomy syndrome. Magnetic resonance cholangiopancreatography has a role in the diagnosis of RCDD. We believe that excision of diseased RCD is necessary and that laparoscopic surgery is feasible.

Post-Cholecystectomy Mirizzi Syndrome: A Case Report and Review of the Literature

Patient: Female, 44

Final Diagnosis: Post-cholecystectomy Mirizzi syndrome

Symptoms: Abdominal pain • nausea • vomiting

Medication: Tramadol • hydromorphone • prochlorperazine

Clinical Procedure: US • MRCP • ERCP• choledochoscopy

Specialty: Gastroenterology and Hepatology

Acupuncture for the postcholecystectomy syndrome: Protocol for a systematic review and meta-analysis

BACKGROUND

Postcholecystectomy syndrome (PCS) is a term used to describe the persistence of biliary colic or right upper quadrant abdominal pain with a variety of postoperative gastrointestinal symptoms. Acupuncture and related treatments have shown clinical effects for PCS in many studies. But the systematic reviews and meta-analyses for them are lacking. We aim to evaluate the efficacy and safety of acupuncture on the treatment of PCS.

METHODS

We will search 8 electronic databases, including the Web of Science, PubMed, Cochrane Library, Embase, and 4 Chinese databases (CBM, Wanfang, VIP, and CNKI databases), and additional sources (WHO ICTRP, ChiCTR, Clinical Trials, Grey Literature Database), for potentially eligible studies. Literature retrieval, screening, and data extraction will be conducted by 2 researchers independently. In case of disagreement, a 3rd party shall be consulted to assist judgment. We will use RevmanV.5.3 to perform a fixed effect meta-analysis on the data of clinical homogeneity studies, and evidence's level will be assessed through the method for GRADE.

RESULTS

This systematic review and meta-analysis will put a high-quality synthesis of the efficacy and safety of acupuncture treatment in PCS.

CONCLUSION

The conclusion of this systematic review will provide evidence to assess acupuncture therapy is an efficacy and safe intervention to treat and control PCS.

ETHICS AND DISSEMINATION

Since this article does not involve patients' private data, no ethical approval is required. The agreement will be disseminated by peer-reviewed journals or conference reports.

TRIAL REGISTRATION NUMBER

PROSPERO CRD4201929287.

Prospective study on changes in the donor gallbladder contraction function after left lateral lobe hepatectomy

This study aimed to evaluate the feasibility of donor gallbladder preservation in liver transplantation. Conventional removal of the donor gallbladder is applied in a majority of pediatric liver transplantation. A total of 42 donors who underwent gallbladder preservation in liver transplantation from October 2013 to December 2015 at the Beijing Friendship Hospital, China, were enrolled for the study. The changes in gallbladder volume and the gallbladder EF of donors before and after surgery were measured through ultrasound, and the changes in the donor gallbladder contraction function before and after surgery were evaluated to help verify the feasibility of gallbladder preservation in living donor left lateral lobe hepatectomy. The gallbladder emptying index dropped to 42.67% in 2 weeks after surgery and gradually increased with the length of recovery time, which could reach 69.14% in 3 months after surgery. At that time, 97.6% of the donors were considered to have recovered their gallbladder contraction function. The gallbladder contraction function at an early stage after gallbladder preservation in liver transplantation is not obviously improved, but it can recover to a normal level in 1 month after surgery, indicating that the gallbladder preservation in hepatectomy of living donor can effectively guarantee the gallbladder contraction function.

Etiologies of Long-Term Postcholecystectomy Symptoms: A Systematic Review

BACKGROUND

Cholecystectomy does not relieve abdominal symptoms in up to 40% of patients. With 700,000 cholecystectomies performed in the US, annually, about 280,000 patients are left with symptoms, making this a serious problem. We performed a systematic review to determine the different etiologies of long-term postcholecystectomy symptoms with the aim to provide guidance for clinicians treating these patients.

METHODS

A systematic search of the literature was performed using MEDLINE, EMBASE, and Web of Science. Articles describing at least one possible etiology of long-term symptoms after a laparoscopic cholecystectomy were included in this review. Long-term symptoms were defined as abdominal symptoms that were present at least four weeks after cholecystectomy, either persistent or incident. The etiologies of persistent and incident symptoms after LC and the mechanism or hypothesis behind the etiologies are provided. If available, the prevalence of the discussed etiology is provided.

RESULTS

The search strategy identified 3320 articles of which 130 articles were included. Etiologies for persistent symptoms were residual and newly formed gallstones (41 studies, prevalence ranged from 0.2 to 23%), coexistent diseases (64 studies, prevalence 1-65%), and psychological distress (13 studies, no prevalence provided). Etiologies for incident symptoms were surgical complications (21 studies, prevalence 1-3%) and physiological changes (39 studies, prevalence 16-58%). Sphincter of Oddi dysfunction (SOD) was reported as an etiology for both persistent and incident symptoms (21 studies, prevalence 3-40%).

CONCLUSION

Long-term postcholecystectomy symptoms vary amongst patients, arise from different etiologies, and require specific diagnostic and treatment strategies. Most symptoms after cholecystectomy seem to be caused by coexistent diseases and physiological changes due to cholecystectomy. The outcome of this research is summarized in a decision tree to give clinical guidance on the treatment of patients with symptoms after cholecystectomy.

Role of Cholecystectomy in Choledocholithiasis Patients Underwent Endoscopic Retrograde Cholangiopancreatography

There are no clinical guidelines for the timing of cholecystectomy (CCY) after performing therapeutic endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis. We tried to analyze the clinical practice patterns, medical expenses, and subsequent outcomes between the early CCY, delayed CCY, and no CCY groups of patients. 1827 choledocholithiasis patients who underwent therapeutic ERCP were selected from the nationwide population databases of two million random samples. These patients were further divided into early CCY, delayed CCY, and no CCY performed. In our analysis, 1440 (78.8%) of the 1827 patients did not undergo CCY within 60 days of therapeutic ERCP, and only 239 (13.1%) patients underwent CCY during their index admission. The proportion of laparoscopic CCY increased from 37.2% to 73.6% in the delayed CCY group. There were no significant differences (p = 0.934) between recurrent biliary event (RBE) rates with or without early CCY within 60 days of ERCP. RBE event-free survival rates were significantly different in the early CCY (85.04%), delayed CCY (89.54%), and no CCY (64.45%) groups within 360 days of ERCP. The method of delayed CCY can reduce subsequent RBEs and increase the proportion of laparoscopic CCY with similar medical expenses to early CCY in Taiwan’s general practice environment.

Resection of gallbladder remnants after subtotal cholecystectomy: presentation and management

BACKGROUND

Subtotal cholecystectomy (SC) involves removal of a portion of the gallbladder typically due to hazardous inflammation. While this technique reliably prevents common bile duct (CBD) injury, future procedures can be required if the gallbladder remnant becomes symptomatic. The morbidity associated with resection of gallbladder remnants in patients that previously underwent SC is reviewed.

METHODS

Records for patients having undergone redo cholecystectomy for symptomatic gallbladder remnants in a tertiary care system from 2013 to 2017 were retrospectively reviewed.

RESULTS

Fourteen patients underwent repeat cholecystectomy. Five surgeons dictated the initial procedure as a subtotal cholecystectomy. All patients returned with symptomatic cholelithiasis between zero months and seven years after the index cholecystectomy. Redo cholecystectomy was attempted laparoscopically in two patients but ultimately required an open approach in all. One patient had a recognized CBD injury requiring a hepaticojejunostomy, and a second patient had a minor wound infection. Symptoms resolved in 13/14 patients.

CONCLUSIONS

Redocholecystectomy (RC) for gallbladder remnants has been detailed in case reports, but no sizable North American series have been presented. These results illustrate a drawback to the reconstituting technique of SC. RC effectively resolves symptoms but requires adherence to safe principles of cholecystectomy and is one indication for an open approach.

A systematic review of the aetiology and management of post cholecystectomy syndrome

BACKGROUND

10% of patients who undergo a cholecystectomy go on to develop post-cholecystectomy syndrome (PCS). The majority of these patients may suffer from extra-biliary or unrelated organic disorders that may have been present before cholecystectomy. The numerous aetiological causes of PCS result in a wide spectrum of management options, each with varying success in abating symptoms. This systematic review aims to provide a summary of the causative aetiologies of post cholecystectomy syndrome, their incidences and efficacy of available management options.

METHODS

The Medline, Embase and Cochrane databases were searched for studies patients who developed PCS symptoms following laparoscopic cholecystectomy, published between 1990 and 2016. The aetiology, incidence and management options were extracted, with separate collation of randomised control trials and non-randomised studies that reported intervention. Outcomes included recurrent symptoms following intervention, unscheduled primary and secondary care attendances and complications.

RESULTS

Twenty-one studies were included (15 case series, 2 cohort studies, 1 case control, 3 RCTs). Five studies described medical treatment (nifedipine, cisapride, opiates); seven studies described endoscopic or surgical intervention. Early presentation of PCS (<3 years post-cholecystectomy) was more likely to be gastric in origin, and later presentations were found to be more likely due to retained stones. Sphincter of Oddi dysfunction (SOD) accounted for a third of cases in an unselected population with PCS.

CONCLUSIONS

Causes of post cholecystectomy syndrome are varied and many can be attributed to extra-biliary causes, which may be present prior to surgery. Early symptoms may warrant early upper gastrointestinal endoscopy. Delayed presentations are more likely to be associated with retained biliary stones. A large proportion of patients will have no cause identified. Treatment options for this latter group are limited.

Clinical patterns of postcholecystectomy syndrome

Backgrounds/Aims

Postcholecystectomy syndrome represents a heterogeneous group of symptoms and findings in patients who have previously undergone cholecystectomy. It is rare and under-reported in Saudi Arabia. It can be attributed to many complications such as bile duct injury, biliary leak, retained common bile duct stones, recurrent bile duct stones, and bile duct strictures. In this study, we aimed to analyze the causes and evaluate the approach to postcholecystectomy syndrome in our local Saudi Arabian community because of the vast number of cases encountered in our hospital for gallbladder clinical conditions and its related complications.

Methods

A prospective cohort database analysis of 272 patients who were diagnosed and treated for postcholecystectomy syndrome between January 2000 and December 2013 were reviewed.

Results

The incidence rate of postcholecystectomy syndrome was 19.8%. The male to female ratio was 1:1.45. The mean age was 37.41±7.12 years. The most common causes were as follows: No obvious cause in 50 (18.4%) patients, Helicobacter pylori infection in 43 (15.8%), pancreatitis in 42 (15.4%), peptic ulcer disease in 41 (15.1%), recurrent common bile duct (CBD) stone in 26 (9.6%), retained CBD stone in 22 (8.1%), bile leakage in 19 (7%), stenosis of the sphincter of Oddi in 12 (4.4%), cystic duct stump syndrome in 11 (4%), and CBD Stricture in 5 (1.8%). The mortality rate was 0%.

Conclusions

Any clinical presentation of postcholecystectomy should not be underestimated and be thoroughly investigated. Multidisciplinary collaboration is crucial for the best outcome and a safe approach for all the patients.

The outcome of laparoscopic subtotal cholecystectomy in difficult cases - A case series

INTRODUCTION

Laparoscopic subtotal cholecystectomy (LSC) is a widely used technique for managing cholelithiasis with severe cholecystitis. The increasing popularity its utilization is due to the good safety profile and acceptable results. This case series evaluates the short- and long-term results of Indonesian patients who underwent LSC with an objective to determine whether the procedure can be a standard approach for difficult cholecystectomy in our institution.

PRESENTATION OF CASE

Thirty-four Indonesian patients (26 men, 8 women) with the mean age of 54.6 years (median 54 years, range 30-84 years) who underwent LSC were retrospectively analyzed. Nineteen patients are suffering from type II diabetes mellitus and fourteen patients with suspected choledocoholithiasis underwent ERCP prior to LSC. The major postoperative diagnosis was acute cholecystitis (16 patients), followed by gallbladder empyema (10 patients), chronic cholecystitis (5 patients), history of cholangitis (1 patient), Mirizzi's syndrome (1 patient) and stone retention post-ERCP (1 patient).

DISCUSSION

The mean operating time was 158minutes (median 150minutes, range 60-240minutes), mean length of hospital stay of 4.6days (median 3days, range 2-33days) and drain usage for 3.6days (median 3.0days, range 1-19days). Postoperatively there was one case of bilioenteric fistula, one case of stone retention and two cases of prolonged upper gastrointestinal symptoms. There is no case of biliary leakage, peritonitis or wound infection.

CONCLUSION

The outcome of LSC in this case series is comparable with other publications showing a general favorability of LSC. Further studies are needed to elucidate the clinical benefits of several LSC technical points such as stump closure, posterior wall diathermy and drain usage. Based on this preliminary finding, LSC can be applied as a standard procedure for difficult cases in our institution.

A case report of choledocholithiasis 33 years after cholecystectomy

•

Choledocholithiasis may present as many as 33 years after a patient has undergone a cholecystectomy.

•

Potential etiologies of choledocholithiasis after cholecystectomy include surgical clip migration, remnant cystic duct lithiasis, and primary choledocholithiasis.

•

Choledocholithiasis is rare after a patient has undergone a cholecystectomy, but must be ruled out nevertheless.

Introduction

Choledocholithiasis after cholecystectomy is rare and often attributed to surgical clip migration and subsequent nidus formation.

Presentation of case

This case demonstrates choledocholithiasis following cholecystectomy with a latency period of 33 years.

Discussion

The patient presented with pain of the right upper quadrant (RUQ). Subsequent abdominal-pelvic CT imaging revealed dilation of the common bile duct. Further Endoscopic Retrograde Cholangiopancreatography was indicative of choledocholithiasis. Additional findings included a long cystic duct remnant and surgical clips in the RUQ.

Conclusion

The patient underwent biliary sphincterotomy and sludge and stone fragments were swept from the biliary tree. To our knowledge, a latency of 33 years between cholecystectomy and choledocholithiasis has never been reported before, at least not in a patient without coexisting duodenal diverticulum, a condition associated with lithiasis of the common bile duct. Our case raises discussion of potential etiologies for such long latency, including surgical clip migration, remnant cystic duct lithiasis, and primary choledocholithiasis; and further details the incidence of such long latency periods following cholecystectomy

Combined Endoscopic and Laparoscopic Management of Postcholecystectomy Mirizzi Syndrome from a Remnant Cystic Duct Stone: Case Report and Review of the Literature

Mirizzi syndrome has been defined in the literature as common bile duct obstruction resulting from calculi within Hartmann's pouch or cystic duct. We present a case of a 78-year-old female, who developed postcholecystectomy Mirizzi syndrome from a remnant cystic duct stone. Diagnosis of postcholecystectomy Mirizzi syndrome was made on endoscopic retrograde cholangiography (ERCP) performed postoperatively. The patient was treated with a novel strategy by combining advanced endoscopic and laparoscopic techniques in three stages as follows: Stage 1 (initial presentation): endoscopic sphincterotomy with common bile duct stent placement; Stage 2 (6 weeks after Stage 1): laparoscopic ultrasonography to locate the remnant cystic duct calculi followed by laparoscopic retrieval of the calculi and intracorporeal closure of cystic duct stump; Stage 3 (6 weeks after Stage 2): endoscopic removal of common bile duct stent along with performance of completion endoscopic retrograde cholangiogram. In addition, we have performed an extensive review of the various endoscopic and laparoscopic management techniques described in the literature for the treatment of postcholecystectomy syndrome occurring from retained cystic duct stones.