This patient had a repeat open cholecystectomy with removal of the gallbladder remnant. After an extensive adhesiolysis, the remnant was found, attached to the right hepatic duct by a rather long cystic duct just proximal to the bifurcation (as shown by preoperative ERCP). The gallbladder remnant had operative clips attached and was adherent to the hepatic artery. Within the remnant, a 1.5×1.0× 0.7-cm stone was found. The patient has had no recurrence of symptoms 3 years after the reoperation.
Gallbladder remnants after cholecystectomy that cause significant symptoms are extremely rare. The presentation is similar to simple symptomatic cholelithiasis or cholecystitis, and distinct from the Mirizzi syndrome (extrinsic gallstone compression of the common hepatic duct resulting in obstruction). Both gallbladder remnants and the Mirizzi syndrome make operative intervention difficult because of the added risk of biliary tract injury. Partial cholecystectomy has been described as an alternative to complete cholecystectomy or cholecystostomy for both high-risk1 and low-risk2 patients. Often partial cholecystectomy is performed for chronic cholecystitis (50%), Mirizzi syndrome (35%), or acute cholecystitis (10%).2
The patient’s presentation is consistent with either a cystic duct remnant or a gallbladder remnant. In the prelaparoscopic era these entities were indications for reoperation of the extrahepatic biliary tract in 0.3%3 to 5%4 cases. Symptoms recurred 3.8 to 4.3 years after cholecystectomy.3 Commonly, dilated remnants were found adhering to a dilated common bile duct, or occurred in the setting of an anatomic variation of the cystic duct insertion into the common bile duct.3 While there are no pathognomic symptoms, postcholecystectomy right upper quadrant symptoms suggest a remnant. The addition of radiating pain to the shoulder, food intolerance, nausea, or jaundice increase the likelihood of a remnant. In the laparoscopic era, with attempts to remain distant from the common bile duct, ligation of the cystic duct as near to the infundibulum as possible may be a predisposition to a cystic duct remnant.5
Patients who undergo partial cholecystectomy, or those with a cystic duct remnant, are at risk of inadequate calculi removal or new calculi formation with recurrent symptoms years after the original operation. This may cloud the future clinical presentation, as in this case. Narrowing of the gallbladder distal to the infundibulum, with inflammation (acute or chronic), a cystic duct adherent to the common bile duct, or a rushed operation may obscure the anatomic structures of the cystic duct. Whether a cholecystectomy is performed laparoscopically or open, meticulous and complete dissection is needed to identify crucial anatomy and ensure complete gallbladder removal. The potential for a retained gallbladder remnant should be considered when recurrent symptoms of biliary colic are seen years after cholecystectomy. Caution should be exercised when deciding whether to perform a partial cholecystectomy, weighing the advantages of the procedure against the potential adverse consequences.
References
1 M. Schein, Partial cholecystectomy in the emergency treatment of acute cholecystitis in the compromised patient, J R Coll Surg Edinb 36 (1991), pp. 295–297.
2 M.D. Ibrarullah, L.K. Kacker and S.S. Sikora et al., Partial cholecystectomy–safe and effective, HPB Surg 7 (1993), pp. 61–65.
3 F. Glenn and G. Johnson Jr, Cystic duct remnant, a sequela of incomplete cholecystectomy, Surg Gynecol Obstet 101 (1955), pp. 331–345.
4 J.T. Bordley and T.T. White, Causes for 340 reoperations on the extrahepatic bile ducts, Ann Surg 189 (1979), pp. 442–446.
5 C. Shaw, D.M. O’Hanlon, H.M. Fenlon and G.P. McEntee, Cystic duct remnant and the ‘post-cholecystectomy syndrome’, Hepatogastroenterology 51 (2004), pp. 36–38.
Bryan A. Whitson and Seth I. Wolpert
Journal of the American College of Surgeons Volume 205, Issue 6, December 2007, Pages 814-815
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