Cholelithiasis and Cholecystitis in a Retained Gallbladder Remnant after Cholecystectomy

Abstract

A 54-year-old man presented with acute epigastric pain radiating into his right back, and left shoulder pain with bilious emesis and diaphoresis. He had no previous episodes. Pertinent history was: occasional alcohol consumption; Type 2 diabetes mellitus, controlled on two oral agents; an open cholecystectomy 24 years earlier; and a hospitalization for acute onset of chest pain. Laboratory tests revealed aw hite blood cell count of 14,300/ L, lipase 45 U/L, bilirubin 0.7 mg/dL, ALT 20 U/L, and AST 13 U/L. CT revealed inflammation at the gallbladder fossa with the appearance of a small gallbladder remnant (A, white arrow). ERCP showed a cystic duct coming off the right hepatic duct (B, white arrow identifies the spiral Heister’s valves) with a large contrast filling defect (B, black arrow) and surgical clips. 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 1.51.0 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,anddistinctfromtheMirizzisyndrome(extrinsicgallstone 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-risk 1 and low-risk 2 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. Symptomsrecurred3.8to4.3yearsaftercholecystectomy. 3