Cystic Remnant Research Articles

Right Ventricular Outflow Tract Obstruction After Sinus of Valsalva Aneurysm Repair

Sinus of Valsalva aneurysm (SVA) is a rare cardiac lesion especially in the western countries and older population. We report an unusual case of a 60-year-old Caucasian male with SVA, acute decompensation, and a pressurized prolapsed aortic leaflet cystic remnant via a small supracristal VSD causing recurrent right ventricular outflow tract obstruction following a Bentall procedure

The Significance of Cyst Remnants After Endoscopic Colloid Cyst Resection

Controversy surrounds the fate of cyst remnants after endoscopic colloid cyst resection. Our study evaluated recurrence rates in patients with total endoscopic resection of colloid cysts vs those with coagulated cyst remnants. Sixty-five consecutive patients and 67 procedures for endoscopic resection of colloid cysts from 1995 to 2011 were reviewed. Degree of resection was based on intraoperative assessment and postoperative magnetic resonance imaging (MRI). Recurrence rates were compared between patients with complete resection those with coagulated cyst remnants. Data analysis was performed of 56 patients and 58 procedures, with no follow-up in 9 patients. All patients had MRI-defined complete resection. On intraoperative assessment, 9 procedures had coagulated remnants and 45 procedures had complete resection (4 data unknown). The overall recurrence rate was 6.89% (4/58), 33.3% (3/9) with cyst remnants, and 2.2% (1/45) with total resection (P = .0124). Maximum follow-up was 144 months (mean, 40.4 months). Mean follow-up was 66.0 months for cyst remnant cases, and 33.5 months for totally resected cases. There was no mortality or permanent morbidity. Transient morbidity included memory deficit (n = 2), aseptic meningitis (n = 1), and local wound infection (n = 1). Endoscopic colloid cyst resection results in a low overall recurrence rate. Immediate postoperative MRI was insufficient for assessing degree of resection and was a poor predictor of recurrence. Ablation of cyst remnants rather than total removal is associated with a significantly higher rate of recurrence. The primary goal of endoscopic surgery should, therefore, be removal of all cyst contents and wall remnants.

Laparoscopic surgery for choledochal cysts

Laparoscopic cystectomy has become a common procedure for choledochal cysts. The cyst should be removed completely just above the confluence of the common biliopancreatic channel at the distal end and approximately 5 mm from the confluence of the right and left hepatic ducts at the proximal end to avoid complications of the cystic remnant. The operation is feasible and safe. The rate of conversion to open surgery is low. The rate of complication under skill laparoscopic surgeons is also low, even lower than in open surgery. There was no difference between hepaticoduodenostomy and hepaticojejunostomy concerning the rate of cholangitis. Gastritis due to bilious reflux occurred with a low rate in hepaticoduodenostomy. Both techniques could be used for choledochal cysts; however, hepaticoduodenostomy should be applied for choledochal cysts without intrahepatic dilatation of biliary tract.

Benign Urachal Remnant Cyst with Difficulty of Preoperative Diagnosis: Case Report

Benign Urachal Remnant Cyst with Difficulty of Preoperative Diagnosis: Case Report

Alterations in Cross-sectional Imaging and Cyst Fluid Genetics Following Endoscopic Ultrasound Guided Pancreatic Cyst Ablation with Ethanol and Paclitaxel: ACG Governors Award for Excellence in Clinical Research

Purpose: To evaluate changes in pancreatic cyst fluid DNA, frequency of cyst resolution, and complications following EUS-guided pancreas cyst ablation (EUS-PCA) with ethanol and paclitaxel (PTX). Methods: In a single center prospective study, consecutive patients with a 1-5 cm pancreatic cyst having ≤5 septations (irrespective of pancreatic duct [PD] communication) were considered. Exclusion criteria: active pancreatitis, necrosis, varices, ascites, coagulopathy, or dilated PD. Baseline evaluation: MRI or CT, EUS imaging and cyst fluid cytology, CEA and DNA analysis (PathFinderTG®, RedPath IP, Inc; Pittsburgh, PA). Initial cyst ablation using a 22G needle, EUS-guided lavage for 3-5 minutes with 100% ethanol then reaspirated and injected with an equal volume of 2 mg/mL paclitaxel, which was left in place. Three months later, repeat EUS for remnant cyst measurement, FNA of cyst fluid for cytology and DNA analysis with a second ablation if cyst size was ≥10 mm. This second ablation was considered on a case-by-case basis for patients with preceding ablation-induced pancreatitis. Three and 12 months later, pancreas protocol CT was performed. Baseline and post-ablation 3D volume CT or MRI images were interpreted by a single radiologist. Complete response (CR), partial response (PR), and a persistent cyst: CT or MRI with <5% of the original volume (OV), 5-25% of OV, and >25% of OV, respectively. Results: Twenty two patients (15 F; median 66 yrs) with cysts in the head (18), body (8), and tail (4) who initially refused or were ineligible for surgery were enrolled. EUS cyst morphology: median maximum diameter 25 mm (range:14-43), septated in eight (36%), and mural nodules in six (27%). Median cyst CEA: 315 ng/mL (range: 0.2-75508). Baseline cyst fluid DNA (n=22) had mutations in 11 (50%): Kras alone in five, Kras + 1 allelic loss [AL] in one, 2 ALs in two, and 1 AL in three. Clinical diagnoses: IPMN in 12, MCN in 6, and SCN 4. Initial ablation was done in all patients. Three had no follow up: one with single Kras who refused, one with single AL who had surgery, one without mutations who had post-treatment peritonitis. In the remaining 19, post-ablation EUS showed a median 77% decrease (range: -99.7 to 72.8) in cyst volume. Post ablation cyst fluid (n=19) showed elimination of all baseline mutations in eight, new ALs in three, and no changes in eight without a baseline mutation. Per protocol post-ablation CT volume (n=20): CR 10 (50%), PR (25%), persistent (25%). Complications for EUS-PCA (n=31): abdominal pain (23%), pancreatitis (10%), peritonitis (3%), gastric wall cyst (3%). Conclusion: In this series, EUS-PCA with ethanol and PTX may eliminate mutant DNA, lead to complete or partial CT resolution in 75% of cysts but result in potentially serious complications in 16% of injections. Disclosure: John DeWitt - Grant Support: PathFinderTG®, RedPath IP, Inc; Pittsburgh PA; Consultant: Boston Scientific, Cook Endoscopy; Julia LeBlanc - Speakers' Bureau, Cook Endoscopy. Stuart Sherman - Consultant, Boston Scientific, Cook Endoscopy Syd Finkelstein - Medical Director, RedPath Integrated Pathology. Mohammad Al-Haddad - Speaker's Bureau, Boston Scientific. This research was supported by an industry grant from RedPath IP, Inc; Pittsburgh PA.

Treatment of an 18‐year‐old mare for bilateral, branchial remnant cysts

SummaryThis report describes the treatment of an aged mare for bilateral, branchial remnant cysts by marsupialisation and sclerotherapy the cysts. Treatment to resolve the cysts was prolonged, but the mare had no long‐term complications.

Durable Remission of Inoperable Liver Metastasis from Rectal Cancer after Hepatic Arterial Infusion of Oxaliplatin and 5-Fluorouracil in Combination with Intravenous Cetuximab

At diagnosis of a cT3N0M1 adenocarcinoma of the rectum with synchronous inoperable liver metastases, a 59-year-old man was treated with preoperative radiotherapy (5×5 Gy), followed by laparoscopy-assisted anterior resection of the rectum with total mesorectal excision. At the first postoperative evaluation, a new lung metastasis was detected. First-line chemotherapy with folfiri (5-fluorouracil, irinotecan, leucovorin) resulted in transient stabilization of the metastatic liver disease. At progression, oxaliplatin and 5-fluorouracil-folinic acid were administered by intrahepatic arterial infusion, in combination with intravenous cetuximab. A partial radiologic response was obtained, with complete metabolic response on fluorodeoxyglucose positron-emission tomography, and normalization of carcinoembryonic antigen values. The solitary lung metastasis was sequentially treated with radiotherapy and resection. Five years after the initial diagnosis, this patient remains free from progression, with residual cystic remnants of the liver metastases visible on conventional computed tomography imaging, but not enhancing with fluorodeoxyglucose positron-emission tomography.

Rathke cleft cysts

Rathke cleft cysts (RCCs) are benign, cystic remnants of the craniopharyngeal duct that are typically located in the sellar and suprasellar region. RCCs are often discovered incidentally; they have been identified in up to 22 % of the population according to routine autopsy specimens. Despite their relatively high prevalence, they produce clinical symptoms in a minority of patients, comprising only 2–9 % of all sellar lesions undergoing surgical resection. They show a slight female preponderance. The typical age at the time of clinical presentation is generally between 40 and 50 years.

531 Alterations in Pancreatic Cyst Fluid DNA Analysis Following Endoscopic Ultrasound Guided Ablation With Ethanol and Paclitaxel

EUS-guided pancreatic cyst ablation leads to: 1) image-defined resolution in 33-62% and; 2) variable pathological epithelial ablation but the effect on cyst fluid DNA is unknown. To evaluate changes in pancreatic cyst fluid DNA following cyst ablation with ethanol and paclitaxel (PTX). In a single center prospective study, consecutive patients with a 1-5 cm pancreatic cyst with ≤5 septations (regardless of pancreatic duct (PD) communication) were enrolled. Exclusion criteria: active pancreatitis, necrosis, portal hypertension, ascites, coagulopathy or dilated PD. Baseline evaluation: EUS imaging and cyst fluid, cytology, CEA and DNA analysis (PathFinderTG®, RedPath IP, Inc; Pittsburgh PA). At initial ablation, cysts were lavaged with a 22G needle for 3-5 minutes with 99% ethanol, reaspirated and injected with an equal volume of 2mg/mL paclitaxel (Bedford Laboratories; Bedford, OH) which was left in place. Three months later, repeat EUS for cyst measurement and FNA of remnant cyst fluid for cytology and repeat DNA analysis was done. 18 patients (13F, median 65 yrs) with cysts in the uncinate in 3, head in 5, neck 2, body in 5, and tail 3 were enrolled. EUS cyst morphology: median maximum diameter 2.4 cm (range: 1.4-4.3), septated in 8/18 (44%), mural nodules in 5/18 (28%). Median cyst CEA was 1307 ng/mL (range: 0.2-75508). Clinical diagnoses were: IPMN in 11, MCN in 6 and SCN 1. Baseline cyst fluid DNA (n=18): median amount (optical density, OD) of 4.6 ng/uL (1.6-1078), median quality (cycle threshold, CT) of 29.3 (24.3-32) cycles and mutations in 11/18 (Kras alone in five, Kras + 1 allelic loss [AL] in one, 2 AL's in two and 1 AL in three). Ablation was done in 18 without follow up in two (1 with single kras; 1 with single AL) who refused (n=1) or had surgery (n=1). In the remaining 16, post-ablation EUS revealed a median 76.1% decrease (range: −99.3 to 72.8) in cyst volume. Post-ablation cyst DNA quantity (n=16) was increased in 9, decreased in 5 and could not be assessed in 2 while DNA quality increased in 5, decreased in 9 and could not be assessed in 2. Post ablation cyst fluid showed elimination of all 4 isolated Kras mutations, the single Kras + 1 AL, both with two AL's and one with a single AL. One with a single AL had elimination of the original mutation but two new AL's were noted in the post ablation specimen. For the 7 without a baseline mutation, post ablation DNA analysis showed no mutations in six and a new AL in 1/7. Ablation of pancreatic cysts is associated with elimination of mutant DNA (kras point mutations and LOH) in cyst fluid which presumably reflects epithelial cell loss. Newly detected mutations in post-ablation specimens may signify: 1) cyst epithelial cell polyclonal differentiation and/or; 2) identification of unablated mutations not detected by initial DNA analysis.

Surgical Experience of 204 Cases of Adult Choledochal Cyst Disease over 14 Years

This study presents our 14-year surgical experience with adult choledochal cyst disease (CCD), focusing on the clinical outcomes after surgical treatment. Medical records of 204 adult patients who had undergone surgery for CCD were reviewed retrospectively. Median patient age was 40.2 years, and 157 (77%) of the patients were female. Todani classification was type I in 116 patients (56.9%), type II in 1 patient (0.5%), type IVa in 86 patients (42.2%), and type V in 1 patient (0.5%). Extrahepatic cyst excision and hepaticojejunostomy were performed in 185 patients (90.7%). Major perioperative complications occurred in 5 patients (2.5%), resulting in no mortality. Late complications occurred in 48 patients (23.6%). Concurrent cancer was diagnosed in 20 patients (9.8%). Mean age of patients with or without biliary cancer was 48.1±13.2 years and 39.1±11.8 years, respectively (P=0.001). Anomalous union of the pancreaticobiliary duct was more frequently associated with gallbladder cancer than with bile duct cancer. De novo malignancy at the cyst remnant occurred in 2 patients (1%). The survival outcomes in CCD patients with concurrent biliary cancer were comparable to those in cancer patients without CCD. As a result of diverse features of adult CCD, various clinical problems occurred after surgical excision. Surgical treatment for adult patients with CCDs having complex features should be individualized to maintain a balance between risk of surgery and potential risk of late complications.

Laparoscopic management of urachal cyst associated with umbilical hernia

The urachal cyst is a rare clinical entity of a urachal remnant. It is usually asymptomatic but can present with haematuria, tumour, urachal stone and infection. We present a case of a 63-year-old lady with a body mass index (BMI) of 49 who presented with a painful swelling in the umbilical region associated with an umbilical hernia. An ultrasound and computed tomography (CT) scan showed a suspected herniation of an umbilical remnant cyst through a paraumbilical defect. Laparoscopy confirmed the urachal cyst of 3 cm in size with a band connected with the cyst down to the urinary bladder associated with a 3-cm paraumbilical hernia. We removed the cyst and repaired the hernia laparoscopically uneventfully, after which her recovery was perfect. Radiological and laparoscopic pictures have not been reported in the English literature before. Although this condition is very rare, we suggest that it should be considered in the differential diagnosis of painful paraumbilical swelling. CT scanning and laparoscopy seems to be valuable, especially in obese patients.

Extensive scrotal calcinosis

Case reportA 46-year-old man was referred to our clinic complainingof nodular lesions located on the scrotum that had graduallyenlarged over a period of 6 years. Due to poor psychosocialand cultural conditions, the patient did not seek medicaladvice until the nodules reached massive dimensions(Figs. 1 and 2). Physical examination revealed multiplenodules on the scrotal skin ranging between 1 to 3 cm indiameter. These were firm and mobile on palpation. Thenodules were only present on the scrotal skin. The patienthad no history of trauma, inflammatory disease or meta-bolic disorders. Urinalysis and blood chemistry tests werewithin normal limits. Subtotal excision of the scrotal wallwas performed. The skin was sutured with 3/0 absorbablesutures in horizontal mattress fashion. The histopathologi-cal examination revealed multiple calcified masses withinthe superficial and mid dermis. Epidermal cyst or eccrinecyst remnants were not observed within or around thelesions. The cosmetic results were excellent. No newlesions were observed during a 6-month follow-up (Fig. 3).DiscussionScrotal calcinosis (SC) was first described by Lewinski in1883 and more than 100 cases have been reported but itspathogenic mechanism is unclear. Clinically, there are hardyellowish nodules that vary in size: from 1 mm to severalcentimetres. Lesions can be solitary or multiple, locatedwithin scrotal skin and can share the characteristics ofepidermoid cysts. Although these nodules are usuallyasymptomatic, they can cause itching [1]. Disease occursusually in middle age and has a slowly growing pattern.Patients attend clinics primarily for aesthetic concerns andsuspicion of malignant disease [2].Whether SC is truly idiopathic or may be the result ofcalcification of preexisting cysts remains a controversialissue. Epidermal or eccrine cyst dystrophic calcificationswere generally accused but cases without any cysticcomponent have been reported. Ito et al. reported a caseof SC originating from eccrine epithelial cysts. This eccrineorigin was discovered via an immunohistochemical studyusing antibodies against carcinoembryonic antigen, epithe-lial membrane antigen and gross cystic disease fluidprotein-15 [3].Song et al. detected epidermal cysts with intact walls in apatient and established the following pathogenic mecha-nism. Cysts are formed, calcification of the intracystickeratinous content occurs with enlargement of the cyst anda subsequent attenuation of the wall. The structure of thecysts becomes indeterminate, along with rupture of theirwalls and the exposure of their contents. This triggers amononuclear cell inflammation or foreign body granulomawith resorption of the cyst walls and of the keratinousmaterial. Finally, only calcified deposits remain [4].Wright et al. conclude that the condition is trulyidiopathic, after failing to show positive staining with

Branchial remnant cysts of mature and juvenile horses

This clinical report describes 8 cases of branchial remnant cysts (BRC) in the horse. The horses presented with bimodal age distribution, with 5 cases in mature horses (age 8-21 years) and 3 in foals (age 1, 6 and 10 months). Mature cases presented for dysphagia or intermittent oesophageal obstruction (2/5), and retropharyngeal swelling (3/5), whereas respiratory stridor and visible mass were presenting complaints in the foals. Presence of a right-sided (5/8) or dorsally located (2/8) palpable retropharyngeal mass of 3-35 cm diameter was noted clinically; one left-sided mass was identified as an incidental finding at necropsy. Ultrasonography typically revealed a thick-walled cyst containing hypoechoic fluid with dependent hyperechoic masses consistent with blood clots. Radiographs and upper airway endoscopy were also consistent with a retropharyngeal mass. Fluid cytology revealed chronic haemorrhage in 6/8 cases, and squamous epithelial cells in one case. Histopathology in all cases demonstrated an epithelium-lined cyst with no smooth muscle or thyroid tissue. Two cases was subjected to euthanasia; one due to concurrent laryngeal anomalies and one due to financial constraints. The remaining 5 cases were treated via surgical excision. Post operatively, right laryngeal hemiplegia was observed in 4/5 cases. All previous reports of BRC in the horse have described juvenile individuals. Brachial remnant cyst should be considered a differential diagnosis for mature horses with masses of the throatlatch area and can be definitively diagnosed by the presence of squamous epithelium in aspirated fluid or by histopathology of the excised mass. Right recurrent laryngeal nerve damage is a common complication of surgery.

Case Report: CT diagnosis of thymic remnant cyst/thymopharyngeal duct cyst

A 4-year-old boy presented with history of left anterolateral neck swelling since birth. He was clinically diagnosed to have a branchial cleft cyst. A CT scan revealed findings suggestive of a thymic remnant cyst. The lesion was excised and the diagnosis was confirmed by histopathology.

Bilateral neck cysts as an isolated sonographic finding in the antenatal detection of fetal aneuploidy: a case report.

Isolated fetal lateral neck cysts can represent a cystic hygroma or a developmental remnant cyst. In the absence of an increased nuchal translucency or associated malformations the risk of aneuploidy has been considered negligible. Still, dysmorphology in aneuploid fetuses might not be evident except at a later stage. We report on a case of isolated fetal bilateral neck cysts where aneuploidy was suspected and confirmed despite the lack of associated morphologic abnormalities.

Bilateral neck cysts as an isolated sonographic finding in the antenatal detection of fetal aneuploidy: a case report

Isolated fetal lateral neck cysts can represent a cystic hygroma or a developmental remnant cyst. In the absence of an increased nuchal translucency or associated malformations the risk of aneuploidy has been considered negligible. Still, dysmorphology in aneuploid fetuses might not be evident except at a later stage. We report on a case of isolated fetal bilateral neck cysts where aneuploidy was suspected and confirmed despite the lack of associated morphologic abnormalities.

Chronic dietary exposure to environmental organochlorine contaminants induces thyroid gland lesions in Arctic foxes (Vulpes lagopus)

The impact of dietary organochlorine (OC) exposure on thyroid gland pathology was studied in farmed male Arctic foxes (Vulpes lagopus). The exposed group (n=16) was fed a diet based on wild minke whale (Balaenoptera acutorostrata) blubber as a main fat source in order to mimic the exposure to OC cocktails in the Artic environment. This resulted in an exposure of approximately 17 microg Sigma OC/kg day and a Sigma OC residue adipose tissue and liver concentration of 1700 and 4470 ng/gl.w., respectively, after 16 months of exposure. Control foxes (n=13) were fed a diet with pork (Sus scrofa) fat as a main fat source containing significantly lower OC concentrations. The food composition fed to the control and exposed group was standardized for nutrient contents. Four OC-related histopathological changes were found: (1) flat-epithelial-cell true thyroid cysts (TC) characterized by neutral content; (2) remnants of simple squamous epithelial-cell embryonic ducts containing neutral debris (EDN); (3) remnants of stratified squamous epithelial-cell embryonic ducts containing acid mucins often accompanied with debris of leukocyte inflammatory nature (EDM) and (4) disseminated thyroid C-cell hyperplasia (HPC). Of these, the prevalence of TC, EDN and HPC was significantly highest in the exposed group (chi(2) test: all p<0.04). The study shows that the OC mixture in minke whale blubber may cause development of thyroid gland cysts, C-cell hyperplasia and increase the prevalence of cystic remnants of embryonic ducts. The mechanism causing these effects could include endocrine disruption of the hypothalamus-pituitary-thyroid (HPT) axis, a disturbance of the calcium homeostasis/metabolism or energy metabolism or immune suppression. Because concentrations of OCs are higher in wild Arctic foxes, it is likely that these animals could suffer from similar OC-induced thyroid gland pathological and functional changes.

Enlargement and Transformation of Thyroglossal Duct Cysts in Response to Radiotherapy: Imaging Findings

Thyroglossal duct cyst remnants (TGDC) are a common midline neck mass that is mostly encountered in childhood. Enlargement after an upper respiratory tract infection or, rarely, cancer within TGDC, is a well-documented phenomenon. In the pediatric population, it rarely presents a diagnostic quandary. However, in an adult population, especially one treated for head and neck cancer with radiation therapy (RT), any enlarging cystic mass would be concerning and would raise the specter of metastatic disease. We propose that inflammation associated with RT results in secretory stimulation and/or obstruction of a persistent thyroglossal duct, resulting in changes within a pre-existing TGDC. We present a case series of 8 patients with subclinical TGDC treated with RT for various head and neck cancers, in which we radiographically observed enlargement or cystic transformation (more cystlike appearance) of the cyst. In all patients there was in retrospect a small thyroglossal remnant, though not necessarily a discernible cyst, that was observed after radiotherapy to enlarge and become more cyst-like. In patients with pre-existing TGDC undergoing RT to the neck, enlargement and cystic transformation may be encountered radiographically and should not be misinterpreted as a tumor. Our series bolsters a recently reported description of the same phenomenon.

Adnexal Masses in Adolescent Girls With Pelvic Pain: Report on 63 Cases

Pelvic pain is the most common gynecological symptom in adolescent girls presenting with an adnexal mass and the leading reason for hospital admission. A single center retrospective study, carried out in the years 2005–2006, enrolled 63 girls ranging in age from 15 to 20 years who were hospitalized for pelvic pain associated with an adnexal mass. Their average age was 15 years, and the masses averaged 54.5 mm in diameter. Acute pelvic pain prompted hospitalization in 80% of cases. Forty-nine patients, more than three fourths of the total, were operated on, all but 4 of them laparoscopically. The remaining 14 patients were followed up expectantly for what was presumed to be a functional cyst; none were readmitted for surgical intervention. Two converting laparotomies (4%) were carried out. The most common histopathologic findings, each present in approximately one fourth of patients, were benign epithelial ovarian cyst and mature cystic teratoma. A borderline ovarian tumor was found in 4% of cases. The incidence of acute ovarian torsion was 9.5% and that of true ovarian neoplasia, 55%. None of the tumors were malignant. Comparatively infrequent findings included ruptured endometrioma, embryogenic duct remnant cyst, and luteinized cyst. No patient had to be readmitted for postoperative complications. The median time in hospital was 2.6 days. True ovarian neoplasia remains a common indication for surgery in adolescent girls with pelvic pain. Most cases are benign, and minimal-access surgery should be carried out whenever possible. Comprehensive ultrasound study, along with pelvic examination and estimates of tumor markers, may permit better selection of those patients expected to benefit from surgery.

Surgical options in the management of cystic duct avulsion during laparoscopic cholecystectomy

BackgroundAvulsion of cystic duct during laparoscopic cholecystectomy (LC) is not a common intraoperative complication, but may be encountered by any laparoscopic surgeon. Surgeons are rarely familiar with management of this condition.MethodsPatients with gall stone related problems who were scheduled for LC at the minimal invasive surgery unit of a tertiary referral hospital during a 5 years period (April 2002–April 2007) were prospectively enrolled.Results12 cases were identified (incidence: 1.15%). All 12 patients had gallbladder inflammation. Five patients had acute and seven patients had chronic cholecystitis. The avulsed cystic duct (ACD) was managed by clipping in 4, intracorporeal suturing in 3, converting to open surgery with suture ligation in 2, and lonely external drainage in 3 patients. Bile leakage had ceased within 3 days in 2, 14 days in one, and 20 days in the other patient. Bile volume increased gradually in one of the patients, which stopped only after endoscopic sphincterotomy (ES) at 25th postoperative day. No major late complication or mortality occurred.ConclusionACD during LC is a rare complication. Almost all standard methods of treatment yield to successful outcomes with low morbidity. According to the situation, ACD may be successfully managed laparoscopically. Available cystic stump remnant was clipped. Intracorporeal suture ligation was performed when short length of stump precluded clipping. Deeply retracted cystic duct with active bile leak led to conversion to open surgery. With minimal or no bile leak at ACD stump, closed tube drainage of sub-hepatic area was attempted. Persistent bile leak was assumed to be controlled by ES, successfully accomplished in one patient.