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 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 2  |  Issue : 2  |  Page : 195-198

Pathogenesis and prevention of residual gall bladder: Report of three cases and review of literature


1 Department of Surgery, Government Medical College and Hospital, Chandigarh, Punjab, India
2 Department of Surgery, Maharishi Markendeshwar Institute of Medical Sciences and Research, Mullana (Distt-Ambala) Haryana, India

Date of Web Publication11-Nov-2014

Correspondence Address:
Rikki Singal
C/o Dr. Kundan Lal Hospital, Ahmedgarh, Dist-Sangrur, Pin code-148 021, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2321-4848.144337

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  Abstract 

Cholecystectomy is a common surgery performed for uncomplicated symptomatic gall stones as a definitive procedure. For complicated cases, partial or modified subtotal cholecystectomy has been described as an easy, safe, and definitive option. But, insufficient cholecystectomy leaving behind gall bladder may lead to persistence or recurrence of the biliary symptoms. We are presenting three cases, in which open partial cholecystectomy had been performed at a peripheral hospital on patients admitted with agonizing biliary type of pain. All the patients underwent re-exploration and successful removal of residual gall bladder tissues, leading to complete resolution of symptoms. The patients were doing well at one year of follow-up.

Keywords: Cholecystectomy, calculi, reformed gall bladder, surgery


How to cite this article:
Dalal U, Dalal AK, Singal R, Attri AK, Mendiratta G. Pathogenesis and prevention of residual gall bladder: Report of three cases and review of literature . Arch Med Health Sci 2014;2:195-8

How to cite this URL:
Dalal U, Dalal AK, Singal R, Attri AK, Mendiratta G. Pathogenesis and prevention of residual gall bladder: Report of three cases and review of literature . Arch Med Health Sci [serial online] 2014 [cited 2019 Oct 19];2:195-8. Available from: http://www.amhsjournal.org/text.asp?2014/2/2/195/144337


  Introduction Top


Cholecystectomy whether open, laparoscopic, antegrade, or retrograde, when performed correctly, has a very low complication rate in experienced surgeon's hands. However, this procedure can be potentially dangerous as there is greatest risk of potential injury to the bile ducts and nearby vessels. It becomes major in complicated cases (e.g. acutely inflamed phlegmonous mass, frozen Calot's triangle with adhesions, cirrhotic patients with portal hypertension) and to overcome this, a partial/ subtotal/ modified subtotal cholecystectomy is considered as safe and definitive procedure. The mucosa of the remainder wall is fulgurated, and the cystic duct is identified and ligated from within the gall bladder. [1],[2] In present, we discuss our experience in three cases where the patients underwent open partial cholecystectomy and surprisingly, in majority, the procedure was not performed correctly.


  Case Reports Top


Case 1

A 36-year-old woman was admitted with right upper quadrant pain. She had undergone open cholecystectomy at periphery in 1998 for symptomatic cholelithiasis. The patient experienced recurrent episodes of similar pain even 6 years after surgery and reported to us in September 2004. Physical examination revealed right subcostal scar of open cholecystectomy. Abdominal ultrasound revealed a 3.2 × 2 cm cystic structure in relation to the common bile duct and differential diagnoses of choledochal cyst type II or gall bladder remnant were kept.

Surgical re-intervention done and findings were, dense adhesions of transverse colon, pylorus, and first part of duodenum with the cystic structure of 3 × 4 cms size in Calot's area [Figure 1]. This structure later on confirmed to be the residual gall bladder as the cystic duct and normal common bile duct could be identified separately. Completion cholecystectomy was done after ligating the cystic duct and the cystic artery. Histopathology was compatible with the gall bladder remnant with stone. Post-operative recovery was uneventful with complete resolution of symptoms after 15 months of follow-up.
Figure 1: Per-operative photograph of showing remainder gall bladder adherent to the pylorus and first part of duodenum

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Case 2

A 62-year-old female presented with complaint of dull aching pain on right upper abdomen and one recent attack of severe agonizing pain. She underwent open cholecystectomy in 1998 at another hospital and was referred to our hospital in March 2005. There was a right subcostal scar of open cholecystectomy. Abdominal ultrasound showed 3.5 × 4 cms size cystic structure in gall bladder area with echogenic shadows and post-acoustic shadow and normal common bile duct.

She underwent surgical re-exploration, and there was a 5 × 4 cms size cystic gall bladder remnant with dense adhesion of surrounding structure with it [Figure 2]. Cystic duct and artery could be located separately, and complete cholecystectomy was done successfully. Histopathology confirmed remnant of the gall bladder with stones. There is complete relief from the symptoms, and at follow-up after 10 months, the patient is asymptomatic.
Figure 2: Intraoperative photograph of showing remainder gall bladder

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Case 3

A 35-year-old woman underwent open cholecystectomy at periphery for symptomatic gall stone disease in 2001. But, she was never relieved of the biliary pain. On presentation to our hospital in June 2005, she was having mild icterus. Serum bilirubin was 2.84 mg%, SGOT- 158 U/L, and SGPT was 144 U/L. Abdominal ultrasound revealed a cystic structure of size 3 × 3 cms in gall bladder fossa with echogenic shadow and a prominent proximal bile duct. Endoscopic retrograde cholangiopancreatography revealed a stricture in the bile duct at the junction of upper two-third and lower one-third. The magnetic resonant cholangio pancreaticography (MRCP) showed a cystic structure communicating with the common bile duct.

Surgical re-exploration through the previous surgery scar confirmed gall bladder remnant with stones, low insertion of cystic duct, and common bile duct stricture [Figure 3]. Completion cholecystectomy and choledochoduodenostomy with biopsy of the stricture was done. Histopathology confirmed the gall bladder remnant and non-specific chronic inflammation of the common bile duct. Post-operative stay was uneventful, and patient is asymptomatic at follow-up after 8 months.
Figure 3: Intraoperative photograph of remainder gall bladder

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  Discussion Top


Cholecystectomy may be hazardous when in the initial steps of the surgery gall bladder is not visualized or only the fundus of the gall bladder can be recognized, the region of the infundibulum cannot be delineated, in cases of frozen Calot's with associated woodiness, empyema gall bladder, cirrhosis, and Mirrizi's type I syndrome. In these cases, safety of the main bile ducts and vessels is a common concern. Partial cholecystectomy has been described as easy, safe, but definitive option in these cases i.e. opening the gall bladder, evacuation of the contents, excising the gall bladder wall towards the cystic duct leaving part or the entire wall, which lies directly in relation to the liver and/or structures in the porta. [1],[2] Dissection in Calot's triangle is avoided completely, and hemostasis is achieved with either diathermy or an oversewing suture depending on the condition of the wall of gall bladder. The objective of complete cholecystectomy is achieved by destroying the mucosa of the remainder gall bladder by diathermy. The cystic duct if seen is over-sewn from within the gall bladder and if not seen, a drain is kept. The Hartmann lumen may also be obliterated by two or three rows of purse string sutures in its mucosa [Figure 4]. The procedure is less burdensome and combines the merits of cholecystectomy and cholecystostomy; however, unlike cholecystostomy, no second surgery is required.
Figure 4: Diagrammatic presentation showing correct technique of partial cholecystectomy

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Total relief of pre-operative symptoms after cholecystectomy is achieved in 85% of cases. [3] The incidence of "Post cholecystectomy syndrome" (PCS) i.e. persistence of gastrointestinal symptoms after cholecystectomy has been reported in the range of 10-40%. Although in majority of these cases the underlying cause remains undiagnosed, however, specific anatomical causes are choledocholithiasis, biliary stricture, dysfunction of sphincter of oddi, chronic pancreatitis, gall bladder duplication, type 2 choledochal cysts, and secondary dilatation of the cystic duct stump. [4],[5],[6],[7]

Insufficient cholecystectomy and reformation of calculi in the remainder of gall bladder and cystic duct stump stone have been reported in the literature, and the incidence is said to be more in this era of laparoscopic cholecystectomy, which favors long cystic duct stump. [8] The most frequent cause of insufficient cholecystectomy is the woodiness in Calot's, the mechanism being leaving the part or whole of the Hartmann's, rather than identifying and closing the cystic duct from within this gall bladder remnant and destroying its mucosa. This incorrect removal of the gall bladder is frequently done by the surgeons inadvertently, thinking it to be partial cholecystectomy. In author's observation, most of the surgeons are not aware of the exact technique of partial/ subtotal cholecystectomy.

The dictionary meaning of the term partial means incomplete, unfinished, fragmentary or limited. In various other general surgery procedures, where we use the term partial/ subtotal/ near total/ hemi, we leave behind a part of the functioning organ or tissue e.g. partial cystectomy, subtotal or near total or hemi thyroidectomy and gastrectomy or hemicolectomy, etc. However, practically no functioning residual gall bladder is left behind in partial/ subtotal/ modified subtotal cholecystectomy. By these terms, it is mispercepted i.e. leaving the cuff of infundibulum, evacuations of the contents, and then closing this cuff primarily [Figure 5].
Figure 5: Incorrect partial cholecystectomy resulting in reformed gall bladder

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Various diagnostic modalities are transabdominal ultrasonography, computed tomography (CT) scan, endoscopy retrograde cholangio pancreaticography (ERCP), MRCP, and endoscopic ultrasound (EUS). [9],[10] Transabdominal ultrasound for post-cholecystectomy syndrome is explained to be less sensitive than EUS because of the larger size of the surrounding structure in gall bladder area. Routine use of intraoperative cholangiogram remains controversial.

For specific causes like reformed gall bladder, reintervention is always indicated, and completion cholecystectomy either by open surgery or by laparoscopic surgery offers complete relief from the symptoms. [11] We did completion cholecystectomy by open re-exploration through the previous cholecystectomy incision scar and in third case, because of the associated common bile duct stricture at the junction of upper two third and lower one third and dilated common bile duct (CBD), choledochoduodenostomy was also done. The bile duct stricture in this case was because of the continued inflammation in the remnant gall bladder and its stone. There were no procedure-related complications, and all patients had uneventful post-operative recovery. At a median follow-up of one year, all have achieved complete stone clearance and are symptom-free.

Conclusion- The ideal way is to accurately identify and ligate the cystic duct from within the remainder gall bladder and fulgurate the mucosa of this remainder gall bladder in the liver bed and or in Calot's area. The remainder gall bladder should never be closed primarily to avoid reformation of the gall bladder and the stones. It is recommended that exact technique should be described in every surgery text books under the title of "Technique of gall bladder removal in difficult cases" rather than labeling it as partial/ subtotal/ modified subtotal cholecystectomy.

 
  References Top

1.Ibrarullah MD, Kacker LK, Sikora SS, Saxena R, Kapoor VK, Kaushik SP. Partial cholecystectomy - safe and effective. HPB Surg 1993;7:61-5.  Back to cited text no. 1
    
2.Cottier DJ, Mckay C, Anderson JR. Subtotal cholecystectomy. Br J Surg 1991;78:1326-8.  Back to cited text no. 2
    
3.Tantia O, Jain M, Khanna S, Sen B. Post cholecystectomy syndrome: Role of cystic duct stump and re-intervention by laparoscopic surgery. J Minim Access Surg 2008;4:71-5.  Back to cited text no. 3
    
4.Walsh RM, Pansky JL, Dumot J. Retained gall bladder/cystic duct remnant calculi as a cause of post cholecystectomy pain. Surg Endosc 2002;16:981-4.  Back to cited text no. 4
    
5.Shaw C, O'Haulon DM, Fenton HM, McEntee GP. Cystic duct remnant and the 'post cholecystectomy syndrome. Hepatogastroenterology 2004;51:36-8.  Back to cited text no. 5
    
6.Colye WJ, Pinean BC, Tarnasky PR, Knapple WL, Aabakken L, Hoffman BJ, et al. Evaluation of unexplained acute and acute recurrent pancreatitis using endoscopic retrograde cholangio-pancreaticography, sphincter of Oddi manometry and endoscopic ultrasound. Endoscopy 2002;34:617-23.  Back to cited text no. 6
    
7.Mergener K, Claveen PA, Branch MS, Baillie J. Stone in a grossly dilated cystic duct stump: A rare cause of post-cholecystectomy pain. Am J Gastroenterol 1999;94: 229-31.  Back to cited text no. 7
    
8.Rieger R, Wayand W. Gall bladder remnant after laparoscopic cholecystectomy. Surg Endosc 1995;9:844.  Back to cited text no. 8
    
9.Hassan H, Vilmann P. Insufficient cholecystectomy diagnosed by endoscopic ultrasonography. Endoscopy 2004;36:236-8.  Back to cited text no. 9
    
10.Singal R, Mittal A, Gupta S, Singh B, Jain P. Management of gall bladder perforation evaluation on Ultrasonographyreport of six rare cases with review of literature. J Med Life 2011;14:364-71.  Back to cited text no. 10
    
11.Topazian M, Salem RR, Robert ME. Painful cystic duct remnant diagnosed by endoscopy ultrasound. Am J Gastroenterol 2005;100:491-5.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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