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Surgical management of cystic duct stump calculi causing post-cholecystectomy syndrome: A prospective study
Saket Kumar, Nishant Kurian, Rakesh Kumar Singh, Venkat Rao Chidipotu, Sanjay Kumar, Amarjit Kumar Raj, Manish Mandal
Department of Surgical Gastroenterology, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
|Date of Submission||16-Feb-2022|
|Date of Acceptance||29-Apr-2022|
|Date of Web Publication||07-Jun-2022|
Room 172, Department of Gastrosciences, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna - 800 020, Bihar
Source of Support: None, Conflict of Interest: None
Aim: Remnant cystic duct stump calculi are an uncommon but important cause of 'post-cholecystectomy syndrome'. High index of suspicion is needed to diagnose this condition in a symptomatic post-cholecystectomy patient. We present our experience with the surgical management of this condition.
Patients and Methods: This prospective study included 19 patients with residual gallstone disease who underwent completion cholecystectomy between August 2016 and October 2021. Investigations included abdominal ultrasound and magnetic resonance cholangiopancreatography. The demographic, clinical, surgical and early post-operative variables of these patients were prospectively maintained and analysed.
Results: The study included 14 women and 5 men. The mean age was 42.1 years (range, 14–80 years). The median duration between index surgery and completion cholecystectomy was 36 months (range, 2–178 months) (interquartile range, 105 months). The follow-up duration was 2 months. The initial surgery was open cholecystectomy in 17 and laparoscopic cholecystectomy in 2 patients. All patients with residual stump stone presented with pain, while 10 out of 19 patients complained of dyspepsia. Completion cholecystectomy could be performed laparoscopically in 16 cases, whereas 3 patients underwent open surgery. The mean operative time was 80 min (range, 55–140 min), and the mean blood loss was 100 ml (range, 50–160 ml). The mean hospital stay was 3 days (range, 2–10 days). No post-operative mortality or major morbidity was recorded in any of our patients.
Conclusion: Laparoscopic excision of the cystic duct stump is feasible and safe even after previous open cholecystectomy. It is increasingly becoming the treatment of choice where expertise is available.
Keywords: Cystic duct stump stone, endoscopic retrograde cholangiopancreatography, laparoscopic cholecystectomy, post-cholecystectomy syndrome
|How to cite this URL:|
Kumar S, Kurian N, Singh RK, Chidipotu VR, Kumar S, Raj AK, Mandal M. Surgical management of cystic duct stump calculi causing post-cholecystectomy syndrome: A prospective study. J Min Access Surg [Epub ahead of print] [cited 2022 Jul 3]. Available from: https://www.journalofmas.com/preprintarticle.asp?id=346838
| ¤ Introduction|| |
Stone formation in the remnant cystic duct is an infrequent but important cause of post-cholecystectomy syndrome., Florcken first reported the clinical significance of this entity in 1912. Patients may present with biliary colic, dyspepsia, jaundice or recurrent acute pancreatitis after variable period of index cholecystectomy., In symptomatic patients, re-surgery in the form of completion cholecystectomy is indicated to alleviate the symptoms.
Earlier, such patients were managed by open completion cholecystectomy because of anticipated difficulties in re-surgery and risk of bowel or biliary injury. However, with increasing expertise in laparoscopic surgery, completion cholecystectomy is now amenable to minimally invasive approach.,, There are still only a handful of studies in the medical literature that describe laparoscopic technique of residual gallstone disease management.
The purpose of this study is to prospectively analyse the presentation, management and outcomes of patients undergoing re-surgery for residual gallstone disease (cystic duct/gallbladder stump calculi).
| ¤ Patients and Methods|| |
The study was conducted at a tertiary care teaching hospital in North India. Approval for conducting the study was obtained from the institutional ethics committee. In this study, a prospective analysis of patients who underwent completion cholecystectomy for residual gallstone disease between August 2016 and October 2021 was done. The data were collected and analysed for demographics, clinical presentation, details of previous surgery and outcomes following completion cholecystectomy.
Patients with post-cholecystectomy syndrome with suspicion of residual gallstone disease were evaluated with ultrasound and/or magnetic resonance cholangiopancreatography (MRCP) [Figure 1]. The residual gallstone was defined as radiologically visible cystic duct or gallbladder stump containing a stone in its lumen. Symptomatic patients with radiologically confirmed residual gallstone disease underwent completion cholecystectomy. Pre-operative workup of patients included routine blood investigations including liver function test. Patients who had undergone cholecystostomy or common bile duct (CBD) exploration in their index surgery were excluded from the study. For patients with associated choledocholithiasis, we performed endoscopic retrograde cholangiopancreatography and CBD clearance before they were included in the study.
|Figure 1: MRCP picture showing residual gallbladder stump (yellow arrow) with a stone in its lumen. MRCP: Magnetic resonance cholangiopancreatography|
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Follow-up was done on outpatient department basis 1- and 2-month post-discharge, and patients were assessed for resolution of symptoms.
All patients received prophylactic antibiotics preoperatively. Surgery was performed under general anaesthesia with the patient in supine position. Pneumoperitoneum was created using Hasson's open technique. Standard four ports used for laparoscopic cholecystectomy were used for redo surgery also. Due to earlier surgery, adhesions in the subhepatic area are expected. Apart from omentum, stomach, duodenum and hepatic flexure of the colon are usually found adherent to the gallbladder bed, obscuring access to the Calot's triangle [Figure 2]a. After separating the omental adhesions, liver is identified as the landmark for initiating the dissection in the Calot's region. Adhesiolysis is done in a lateral-to-medial manner. It is pertinent to stay close to the undersurface of the liver. Cephalic traction on the undersurface of the liver using a grasper-held gauze piece greatly aids in exposing the Calot's region [Figure 2]b. Dissection ensues using a combination of blunt and sharp dissection. The adherent viscera are carefully separated from the gallbladder fossa. Once the gallbladder remnant or cystic duct stump is identified, dissection is carried out to demonstrate the cystic-CBD junction [Figure 2]b. Cranial traction applied to the gallbladder/cystic duct stump facilitates this dissection and also reduces the chance of iatrogenic biliary duct injury. In our view, the safety measures described for avoiding bile duct injury in routine cholecystectomy should also be applied for completion cholecystectomy cases. Delineation of cystic duct, cystic artery and obtaining critical view of safety is usually feasible when performed by an expert surgeon. After sufficient length has been obtained, cystic duct and artery are clipped and transected separately [Figure 2]c and [Figure 2]d. The stump is then dissected from the liver bed with the help of monopolar cautery or harmonic scalpel. Abdominal drain is routinely placed in the gallbladder fossa before concluding the surgery.
|Figure 2: (a) Omental and gastric adhesions in the gallbladder fossa; (b) delineation of cystic duct stump (yellow arrow). An instrument-held gauze piece used for traction and exposure (blue arrow); (c) the cystic duct stump clipped and excised; (d) resected cystic duct stump showing sludge and previously placed metal clip in its lumen. CBD: Common bile duct|
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Descriptive and categorical data were expressed as mean or median (with interquartile range) and percentage, respectively.
| ¤ Results|| |
A total of 19 patients with symptomatic residual gallstone disease underwent re-surgery in our department between August 2016 and October 2021. Index surgery in all these patients was performed at other centres. The operative records of only 12 patients were available, all of whom had undergone open cholecystectomy. The most common presenting symptom was abdominal pain (100%), followed by dyspepsia in 52.6% of patients. One patient who had choledocholithiasis presented with jaundice and had to undergo endoscopic retrograde cholangiopancreatography (ERCP) stone clearance before surgery. The demographic profile and clinical presentation of patients included in the study are summarised in [Table 1].
The median time interval between the initial cholecystectomy and the diagnosis of retained stone in residual gallbladder/cystic duct stump in our series was 36 months (2 months–15 years). On routine investigation, only one patient had deranged liver function test in the form of raised serum bilirubin and alkaline phosphatase levels.
Of 19 patients in our series, 16 could be managed successfully with laparoscopic completion cholecystectomy. Three patients underwent upfront open completion cholecystectomy. Two of these patients presented with discharging cutaneous sinuses tracking to the gallbladder fossa. As the sinus tract also had to be excised in these patients, it was decided to proceed with open completion cholecystectomy in them. One patient had to undergo open surgery, as during the COVID-19 pandemic, we had suspended all laparoscopic procedures for a few months and he was operated during this time. The details of intraoperative parameters are listed in [Table 2].
None of the patients undergoing laparoscopic surgery required extra port insertion other than what were routinely used. Postoperatively, pain management was done with non-steroidal anti-inflammatory drugs. Only two patients required additional opioid analgesic for pain relief. Feeding was resumed 4 h postoperatively in all patients, and 16 patients resumed diet without any complaints. Three patients had post-operative nausea and vomiting, which needed antiemetic administration and could resume full diet only from post-operative day 1.
There was no mortality or major morbidity in our series. Three patients developed superficial surgical site infection (Clavien–Dindo Grade II) in post-operative period. Two of them had undergone sinus tract excision during completion cholecystectomy. All these patients were managed conservatively.
An abdominal drain was routinely placed at the end of surgery and was removed after 1–3 days. The criterion for drain removal was output <50 ml, which was not bilious/haemorrhagic.
Patients were followed up at 1- and 2-month post-operative. All patients remained symptom free in the follow-up period.
| ¤ Discussion|| |
Cholecystectomy is widely accepted as the 'gold standard' for the management of symptomatic gallstone disease. It provides effective symptom relief in 85%–90% of cases. However, gallstone-related symptoms might recur or persist in approximately 10%–15% of patients after cholecystectomy, a condition commonly referred to as post-cholecystectomy syndrome. A wide range of biliary as well as extra-biliary factors have been implicated in the causation of post-cholecystectomy syndrome and hence pose a diagnostic challenge to the treating surgeon., Remnant gallbladder and long cystic duct stump (>1 cm) are an uncommon but important cause of post-cholecystectomy syndrome. Remnant gallbladder has been defined as 'a wider part of free end of remnant cystic duct, giving the impression of a diminutive gallbladder'. Practically, these two entities are difficult to distinguish on clinical, radiological and even histopathological basis. Collectively, these account for approximately 2%–16% of post-cholecystectomy syndrome in most of the large series.
The natural history and clinical significance of retained cystic duct or remnant gallbladder is not well established. Many of these patients remain asymptomatic, whereas others may present with acute or chronic symptoms. Rogy et al. studied the role of residual cystic duct in the causation of post-cholecystectomy syndrome and concluded that mere presence of long cystic duct is hardly ever a cause of recurrent symptoms. Walsh et al. observed that retained stones in the gallbladder or cystic duct remnant can be a cause of recurrent biliary symptoms. However, in a recent retrospective series of 272 patients suffering from post-cholecystectomy syndrome, 11 were found to have cystic duct stump syndrome. Of these 11 patients, only 4 were reported to have retained stump calculi. All 19 patients in our series had retained stones in the gallbladder or cystic duct remnant. Furthermore, the timing of presentation also varies widely, with some patients presenting as early as 3 weeks and others after 25 years of index cholecystectomy.,,
Long cystic duct stump or gallbladder remnant can be left behind after both open and laparoscopic surgeries. However, dividing the cystic duct close to the gallbladder is advocated in laparoscopic cholecystectomy to prevent bile duct injury. This increases the possibility of leaving behind a gallbladder or long cystic duct remnant. Ideally, the length of cystic duct stump should not be more than 0.5 cm. For this reason, many researchers are now advocating to routinely demonstrate the cystic duct-CBD junction before clipping and dividing the cystic duct.,,
The clinical presentation of residual gallbladder or cystic duct stump calculi can be variable. Symptoms such as biliary colic, dyspepsia, nausea and jaundice are frequently encountered. Uncommonly, the patient can present with acute pancreatitis, Mirizzi syndrome or even malignancy of the remnant cystic duct.,, Large series published in the recent past have reported upper abdominal pain, jaundice and biliary colic to be the most common presenting symptom of retained gallstones.,, In our study, all patients were symptomatic, and common presentation included abdominal pain in all cases (100%), dyspepsia in 52.94% of cases and jaundice in 5.88% of cases. Contrary to the reports of higher occurrence of retained gallbladder or cystic duct stump in laparoscopic surgery, the majority (94.11%) of the patients in our study had index cholecystectomy by the open technique. A similar observation was made by other researchers as well.,,, This suggests that remnant gallbladder or cystic duct stones are frequently encountered even after open cholecystectomy. Mistaken identification of gallbladder and cystic duct junction and subtotal cholecystectomies are the factors responsible for incomplete gallbladder removal. Yin et al. have postulated that the small incision used in open cholecystectomy may result in inadequate exposure of Calot's area, leading to incomplete gallbladder excision.
Ultrasound is considered the first-line investigation for the evaluation of post-cholecystectomy syndrome and is helpful in detecting residual gallstone disease. However, in 10%–40% of cases, cystic duct or CBD stones may be missed on ultrasound scan.,,, MRCP is one of the most accurate modalities for the diagnosis of cystic duct stump or gallbladder remnant. Apart from confirming the diagnosis and providing the anatomy of the entire biliary tree, it can detect conditions such as choledocholithiasis or Mirizzi syndrome., In our series, all patients underwent ultrasonography of abdomen followed by MRCP to confirm the diagnosis.
In the present study, ultrasound detected the cystic duct stump or remnant gallbladder in all cases. However, stones were reported in only 14 cases. MRCP, on the other hand, detected the retained calculi in all cases. Computed tomography scan is not routinely used to evaluate this condition but can be considered an alternative where MRCP is not available or is contraindicated.
Endoscopic ultrasound is another diagnostic modality that may be indicated in patients with high suspicion of remnant stump calculi with negative ultrasound/MRCP report. ERCP, due to its invasiveness, is now rarely indicated solely for diagnostic purpose.
Once the diagnosis of remnant gallbladder is established, surgical excision is indicated to alleviate the symptoms and to avoid potential complications such as acute pancreatitis, cholangitis and Mirizzi syndrome.
The surgery can be performed by both open approach and minimally invasive technique, although the latter is becoming a favoured approach these days.,,, Other modalities of management include conservative approach, ERCP clearance of remnant stones or extracorporeal shockwave lithotripsy. These are applied usually in those patients in whom surgery is contraindicated.
The first laparoscopic completion cholecystectomy was reported by Gurel et al. in 1995. Till recently, laparoscopic approach for remnant cystic duct excision was considered not only difficult but also potentially hazardous. The omental, duodenal and sometimes colonic adhesions in the gallbladder bed, along with dense fibrosis in the Calot's triangle, make the laparoscopic re-surgery an arduous task. However, several publications in the last two decades have established the safety and feasibility of laparoscopy approach for completion cholecystectomy.,,,,,
One should be cautious when creating intra-peritoneal access and pneumoperitoneum in the reoperative cases. We, therefore, fashioned the umbilical port by Hasson's open technique or by making the initial access through the Palmer's point and then introducing umbilical port under direct vision.
Meticulous dissection and knowledge of anatomy is vital in carrying out this procedure successfully. Identification of colon and duodenum and proper delineation of bile duct is important to avoid any inadvertent injury. With vast expertise in laparoscopic surgery at our centre, none of the patients had injury to bowel or bile duct. The cystic duct-CBD junction was identified in all patients, and cystic duct and cystic artery could be clipped and divided separately. None of the patients in our study required conversion to open procedure. All cases could be completed with standard four ports without a need of extra port.
Three patients in the present series underwent upfront open completion cholecystectomy. Two of these patients had a cutaneous fistula communicating with gallbladder remnant. Open completion cholecystectomy with excision of the fistula tract was performed in both the cases. Another patient was operated during the peak of COVID-19 pandemic, and surgery was done by open technique due to safety concerns.
One patient with concomitant choledocholithiasis underwent ERCP clearance, followed by laparoscopic completion cholecystectomy. ERCP clearance of cystic duct stump was not attempted in any of our patients.
The average operative time for open completion cholecystectomy was 100 min (range, 80–150 min), whereas for laparoscopic procedure, it was 75 min (range, 40–120 min). However, the average blood loss in the laparoscopy group was 80 ml (range, 50–125 ml), which was much less as compared to 125 ml (range, 90–200 ml) in the open re-surgery group. However, none of the patients needed a blood transfusion. The mean hospital stay was 2 days (range, 1–5 days) in the laparoscopy group compared to 8 days (range, 4–10 days) in the open completion cholecystectomy group. Other researchers have reported a similar finding in their series of completion cholecystectomy.,,,,
| ¤ Conclusion|| |
Based on the above reports, it can be concluded that laparoscopic completion cholecystectomy for residual gallstone disease is a safe procedure and can be performed with minimum morbidity at centres with adequate experience in advanced laparoscopic procedures.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]