Recurrent abdominal pain after laparoscopic cholecystectomy
LESSONS LEARNED
Remnant cystic duct stones are uncommon
The estimated incidence of a retained calculus within the cystic duct remnant after cholecystectomy is less than 2.5%.2,36 In a series of 322 patients who underwent repeat surgery because of postcholecystectomy syndrome, Rogy et al36 found only 8 who had a stone in the cystic duct or gallbladder remnant, and in a series of 371 patients, Zhou el al2 found 4 who had a stone in the cystic duct remnant.
Stones in the cystic duct remnant are difficult to diagnose
Diagnosing stones in surgical remnants of the cystic duct or gallbladder can be difficult. The sensitivity of abdominal ultrasonography in detecting cystic duct stones is low—only 27% in one study, with a specificity of 100% and an accuracy of 75%.37 Ultrasonography may occasionally suggest cystic duct stones by showing an acoustic shadow in the anatomic region of the cystic duct. However, the results should be interpreted with caution.
Determining the accuracy of ERCP and MRCP in detecting cystic duct remnant stones is also difficult, as few cases have been reported and data may be conflicting. In a review of seven patients confirmed to have retained stones in a surgical remnant, Walsh et al17 found that ERCP correctly diagnosed the retained stone in only four out of six patients; MRCP was done in one patient, and it was read as normal.
In three cases of stones in a postsurgical gallbladder remnant, Hassan and Vilmann38 reported that ERCP and MRCP failed to identify the gallbladder remnant in two out of three cases, likely because the remaining structures are small. The diagnosis was finally made by endoscopic ultrasonography, which the authors concluded was a valuable method to visualize a small gallbladder remnant with stones.
Greater suspicion is needed in patients with typical biliary colic after cholecystectomy
Retained gallbladder remnant is described in the literature as a latent complication. The main problem is not the remnant itself but the chance that it harbors retained stones, which can lead to dilatation and inflammation of the remnant.
The patient can develop symptoms of acute cholecystitis or even acute cholangitis if the stone migrates to the common bile duct. Symptoms can develop as early as 2 weeks or as late as 25 years after laparoscopic cholecystectomy.
Endoscopic ultrasonography may be the best way to look for these remnant stones and to evaluate the bile duct and pancreas. Therefore, it should be part of the diagnostic algorithm in the evaluation of postcholecystectomy pain.
Mixed results with ERCP for extracting cystic duct stones
In case reports of cystic duct calculi after cholecystectomy, ERCP by itself has had mixed results. This traditional means of removing stones may succeed, as in our case. However, the success rate depends largely on anatomic factors such as the position of the stone in the cystic duct, the degree of stone impaction, the diameter of the cystic duct, and the number of valves in the duct.17
Stones in the cystic duct that cannot be extracted with ERCP may benefit from fragmentation techniques in situ via holmium laser followed by endoscopic extraction.
Repeat cholecystectomy is generally advised for any residual gallbladder, and it can be done laparoscopically.
