Gallbladder Remnant Research Articles

Endoscopic retrograde removal of gallbladder remnant calculus

Endoscopic retrograde removal of gallbladder remnant calculus

Endoscopic Retrograde Removal of Gallbladder Remnant Calculi

Endoscopic Retrograde Removal of Gallbladder Remnant Calculi

Mini-invasive Treatment of Complications Following Laparoscopic Cholecystectomy

Background: Even though laparoscopic cholecystectomy (LC) has become the customary method for treating gallstones, some incidents and complications appear rather more frequently than with the open technique. Several aspects of these complications and their treatment possibilities are analysed.Materials and Methods: Over the last 9 years 9542 laparoscopic cholecystectomies have been performed, of which 13.9% were carried out for acute cholecystitis, 38.4% in obese patients and 7.6% in patients aged > 65 years. Results: The main postoperative complications were bile leakage and choleperitoneum (54 cases), haemorrhage (15 cases), subhepatic abscess (10 cases) and retained bile duct stones (11 cases). Classic re-interventions were practiced in 28.8% of cases with complications. Mini-invasive techniques were used in 42.2% of cases with complications: laparoscopic re-interventions (15 cases) for choleperitoneum, haemoperitoneum and subhepatic abscess and endoscopic sphincterotomy (22 cases) for prolonged bile leak on subhepatic drain and for early diagnosed remnant lithiasis of the common bile duct. All cases healed. Another 26 patients were treated conservatively.Discussion: With a precise diagnosis and a good indication, the mini-invasive treatment of complications was completed with good results. 16 laparoscopic re-operations and 22 endoscopic sphyncterotomies were performed (for the treatment of bile leakage and remnant gallbladder stones).

Laparoscopic resection of gallbladder remnant: Case report

Recurrent symptomatic cholelithiasis can arise from residual gallbladder after a previous incomplete cholecystectomy. Diagnosis relies on a high index of suspicion and appropriate investigations such as ultrasound, computed tomography scan, endoscopic retrograde cholangiopancreatography or magnetic resonance cholangiopancreatography (MRCP). A case of symptomatic gallbladder remnant with gallstone 3 years after a previous laparoscopic cholecystectomy, which was managed successfully with laparoscopic resection, is described. The predisposing factors and preventive measures for such a rare complication are discussed. Chinese Abstract imageimage

Retained gallbladder/cystic duct remnant calculi as a cause of postcholecystectomy pain.

Pain following cholecystectomy can pose a diagnostic and therapeutic dilemma. We reviewed our experience with calculi retained in gallbladder and cystic duct remnants that present with recurrent biliary symptoms. Over the last 6 years, seven patients were referred to us for the evaluation of recurrent biliary colic or jaundice. There were four men and three women ranging in age from 35 to 70 years. All seven had biliary pain similar to the symptoms that precede cholecystectomy; two of them also had also associated jaundice and one had pancreatitis. The time from cholecystectomy to onset of symptoms ranged from 14 months to 20 years (median, 8.5 Years). Four had undergone laparoscopic cholecystectomy and three had had an open cholecystectomy; none had an operative cholangiogram. Five of seven underwent diagnostic endoscopic retrograde cholangiography (ERC), which revealed obvious filling defects in the cystic duct or gallbladder remnant. The final patient was diagnosed by laparoscopic ultrasound after eight negative radiographic studies. Four patients underwent laparotomy and resection of a retained gallbladder and/or cystic duct. Two patients were treated with extracorporeal shock-wave lithotripsy (ESWL); one of them also required endoscopic biliary holmium laser lithotripsy. One patient underwent successful repeat laparoscopic cholecystectomy. There were no treatment-related complications. At a median follow-up of 11.5 months, all have achieved complete stone clearance and are asymptomatic. Retained gallbladder and cystic duct calculi can be a source of recurrent biliary pain, and a heightened suspicion may be required to make the diagnosis. This entity can be prevented by accurate identification of the gallbladder-cystic duct junction at cholecystectomy and by routine use of cholangiography. A variety of therapeutic options can be employed to obtain a successful outcome.

Mirizzi Syndrome.

The complete and definitive treatment of patients with Mirizzi syndrome is surgical. The treatment goals are the removal of the gallbladder with the offending stone(s) and the repair of the bile duct defect. A high index of suspicion for early recognition of this condition is paramount to prevent bile duct injury. Biliary anatomy is delineated precisely by preoperative and intraoperative imaging tests. The dissection of the gallbladder is conducted in an antegrade, fundus-first fashion. Extensive dissection of Calot's triangle is avoided. Instead, the gallbladder is opened, the impacted stone(s) is removed backward, and the confirmation of the presence a cholecystocholedochal fistula is established by direct inspection. A coexistent gallbladder carcinoma is excluded by taking frozen sections. In patients without biliary fistula (Mirizzi type I), simple cholecystectomy suffices to relieve the bile duct obstruction. In patients with biliary fistula (Mirizzi type II), the size of the fistula determines the type of repair. In general, small fistulas are repaired by choledochoplasty using a cuff of gallbladder remnant, whereas large bile duct defects require bilioenteric reconstruction (Roux-en-Y hepaticojejunostomy or choledochoduodenostomy). In patients unfit for surgery, biliary decompression is effectively accomplished by placement of stents using endoscopic or percutaneous techniques. Lithotripsy and removal of the offending stone can also be carried out in patients with Mirizzi type II. In general, nonsurgical treatment of Mirizzi syndrome is incomplete and places the patients on a path of intensive follow-up, multiple procedures, and the risk to continue suffering from complications of symptomatic gallstone disease. However, nonsurgical treatment allows for valuable time to prepare high-risk patients for a more elective and safer operation.

Mirizzi's Syndrome: Experience from a Multi-Institutional Review

P.L. Mirizzi described in 1948 a partial or spastic obstruction of the common hepatic duct secondary to an impacted gallstone in the cystic duct or infundibulum of the gallbladder. The modern definition of Mirizzi's syndrome is thought to include four components: anatomic arrangement of the cystic duct at the gallbladder neck such that it runs parallel to the common hepatic duct; impaction of a stone in the cystic duct or neck of the gallbladder; mechanical obstruction of the common hepatic duct by the stone itself or by secondary inflammation; and intermittent or constant jaundice causing possible recurrent cholangitis and, if longstanding, secondary biliary cirrhosis. Intermittent symptomatology may make Mirizzi's syndrome difficult to diagnose preoperatively or intraoperatively. Bilio-biliary fistulas may or may not be present. Diagnosis and choice of operative repair may be best accomplished by open operative technique. Over a 24-year period two faculty members from Louisiana State University (LSU) Medical Center-Shreveport at Monroe and LSU Baton Rouge treated 4180 cases of cholelithiasis at six Louisiana university and private hospitals. Eleven cases of Mirizzi's syndrome were diagnosed on the basis of operative and preoperative notes with detailed description of size and extent of biliobiliary fistulas when they were present. These 11 cases were reviewed and followed from one to 20 years. Presentation, workup, operative findings, choice of operative repair, choice of operative approach, and complications were evaluated by retrospective chart review. Review of the pertinent literature for informative and comparative purposes was also completed. These 11 cases ranged from Csendes Type I to III. There were no Type IV cases. They were ultimately diagnosed and managed by classical open technique. Four laparoscopic procedures were converted to open technique following initial inspection. All four were converted to open as a result of inability to delineate structures in and adjacent to the triangle of Calot due to marked scarring in the subhepatic space. No iatrogenic injuries or major complications occurred. Mirizzi's syndrome occurs in fewer than 0.5 per cent of patients with cholelithiasis. Removal of stones with partial cholecystectomy and use of gallbladder or cystic duct remnant to oversew or repair Mirizzi fistulas should be considered. Roux-en-y hepaticojejunostomy becomes the procedure of choice when the vascularity or viability of the hepatic duct or tissues available for duct repair is questionable. Review of the literature reveals the increase in complications with laparoscopic versus open technique in Mirizzi's syndrome. Although very little direct evidence exists we believe that when this syndrome is diagnosed or strongly suspected open biliary operation is the procedure of choice because the increased potential for major complications with the use of laparoscopic technique far outweighs the potential slight increase in morbidity of an open procedure.

Choledocholithiasis in patients with normal serum liver enzymes

Retrospective chart review of 330 patients undergoing ERCP over a two-year period yielded five patients with choledocholithiasis whose serum liver enzyme and total bilirubin levels were repeatedly normal. All were female, three were elderly, and the gallbladder was in situ in three of the five, one of whom had a large gallbladder remnant. In four patients, the common bile duct was dilated (> 10 mm), whereas none had intrahepatic duct dilatation. Four patients had a prominent ampulla, and stone size varied widely. Each patient was managed with endoscopic sphincterotomy and stone extraction followed by cholecystectomy for the four patients with the gallbladder or its remnant in situ. This small series proves that common duct stones may exist in patients with repeatedly normal serum liver enzyme and total bilirubin levels. We hypothesize that marked dilatation of the common bile duct or gallbladder may serve as a pressure sump and blunt liver enzyme elevation. Normal liver enzymes should not dissuade one from performing cholangiography in patients with suspected choledocholithiasis.

Gallbladder Ablation with Gallstones In Situ in an Animal Model

The authors evaluated a method of gallbladder sclerosis in the presence of cholelithiasis. The study was performed in 20 pigs. The gallbladders of 16 pigs contained surgically placed human gallstones. Control groups included animals that had their gallbladders sclerosed in the absence of stones, as well as a surgical sham control. Sclerosis followed cystic duct ligation to prevent extravasation of the sclerosing agent (95% Ethanol with 2 mole% trifluoroacetic acid) into the biliary tree. After sclerosis, a pigtail catheter was placed in the gallbladder to drain any post-procedure fluid accumulations. Catheters were removed after all drainage had ceased. Animals were killed at either 8 weeks (n = 6) or 6 months (n = 14). Stones were enveloped within the sclerosed and fibrotic gallbladder remnant in 13 of 15 test animals (87%). Sclerosis of gallbladders with stones in situ was achievable. Total mucosal obliteration did not appear to be required to produce a dysfunctional gallbladder in the time frame of this study.

Sclerotherapy for Ablation of the Gallbladder after Gallstone Lithotripsy with a Mechanical Lithotriptor

Chemical ablation of the gallbladder with absolute ethanol following mechanical lithotripsy with the RotoLith lithotriptor was attempted in 10 pigs after open cholecystostomy. Two gallbladders removed immediately after the sclerotherapy demonstrated extensive ulcerations of the mucosa with preserved glands and sinuses under the ulcerations. In 8 gallbladders removed 8 weeks after sclerotherapy a gallbladder remnant with hydrops and/or mucus and more or less intact epithelium was seen in all the pigs. In order to prevent regeneration of epithelium from gallbladder sinuses and glands, more effective sclerosing agents must be found.

Sclerotherapy for Ablation of the Gallbladder after Gallstone Lithotripsy with a Mechanical Lithotriptor

Chemical ablation of the gallbladder with absolute ethanol following mechanical lithotripsy with the RotoLith lithotriptor was attempted in 10 pigs after open cholecystostomy. Two gallbladders removed immediately after the sclerotherapy demonstrated extensive ulcerations of the mucosa with preserved glands and sinuses under the ulcerations. In 8 gallbladders removed 8 weeks after sclerotherapy a gallbladder remnant with hydrops and/or mucus and more or less intact epithelium was seen in all the pigs. In order to prevent regeneration of epithelium from gallbladder sinuses and glands, more effective sclerosing agents must be found.

On the mirizzi syndrome —Benign stenosis of the hepatic duct induced by a stone in the cystic duct or the neck of the gallbladder—

Three cases of Mirizzi Syndrome are reported. One of them was induced by the stone in gallbladder remnant. On the cholangiogram, one case showed narrowing of common hepatic duct near the porta hepatis, and one case revealed a tapered narrowing-like stenosis. Those findings resembled malignancy but closer examination could differentiate this syndrome from malignancy. Selective angiography was useful to differentiate the syndrome from malignancy. Even in the cases where stricture is severe, exstirpation of gallbladder or cystic duct, freeing the anterior wall of extrahepatic bile duct from marked hyperplasia of fibrous tissues and insertion of a T-tube as an internal splint through the stenosis were effective. It is the opinion of the authors, therefore, that the reconstruction of a strictured bile duct may not necessarily be done by resection of stricture and a hepatojejunostomy.

Secondary exploration of the biliary tract

The charts were examined of sixty-nine patients who between January 1, 1958 and July 1, 1964 underwent a secondary operation on the biliary tract. The median period of relief after cholecystectomy was two years for patients who later proved to have stones in the common duct, and five years for those found to have other disease of the biliary tract. Only twenty patients had the triad of pain, jaundice, and fever whereas twenty-three patients were never jaundiced. Although a normal intravenous cholangiogram did not always exclude disease of the bile ducts, the examination was of aid in selecting patients for reoperation. Operative findings consisted of stones in the common bile duct in twenty-nine patients, a cystic duct or gallbladder remnant in fourteen, stricture of the common duct in five, stenosis of the papilla of Vater in five, pancreatitis in eight, cancer of the biliary tract in four, and negative exploration of the duct in four patients. Various means of evaluating the condition of the biliary tract are discussed. Transduodenal exploration of the papilla of Vater and sphincterotomy may be employed to aid in and verify the removal of stones impacted in the terminal duct and to relieve stenosis of the sphincter of Oddi. Although no single method of inspecting the bile ducts is infallible, it would seem that their combined application would reduce the frequency of secondary operations on the biliary tract.

Intravenous cholecystangiography.

The recent discovery of a chemical compound, Cholografin, has made it possible to demonstrate the bile ducts roentgenographically even though the gallbladder is absent or abnormal. The greatest advantage of this new intravenous method is in studying the biliary tree of the patient who has had a cholecystectomy. It has also proved valuable in cases of gallbladder disease in which the ordinary Graham test has been unsuccessful. This paper, based upon the first 100 cases selected for examination with Cholografin in a hospital and private radiological office in one community, indicates the usefulness, advantages, and limitations of the new chemical. Selection of Patients Originally the limited supply of Cholografin2 restricted its use to cholecystectomized patients, to those in whom nausea or vomiting precluded the employment of an oral medium, and to those in whom diagnosis by the routine oral method was equivocal. Later, as the material became more available, its use was extended to certain cases at the special request of the surgeon or internist. Forty of the group examined had undergone cholecystectomy and in 60 the gallbladder was present. Technic A dose of 20 c.c. of the 20 per cent solution injected into the cubital vein was found sufficient for routine cholecystangiography. In obese patients and in cholecystectomized patients, however, twice that amount was employed. The manufacturer's instructions were followed closely in preparing the patient, testing for sensitivity, rate of injection, and timing the radiographic exposures (1, 5, 7). Special views, such as the vertical, lateral recumbent, and oblique were utilized as indicated. The most rewarding results of an examination occurred when each radiograph was viewed as soon as possible after its development, in order that the technic could be adapted to the individual case. The examination was not carried out when jaundice was present but was delayed until the icterus had nearly or completely subsided. European investigators had reported (4, 7, 8, 11) that in the presence of liver damage Cholografin was excreted mainly in the urine. Results of Examinations The findings in the 40 cholecystectomized patients were as follows: The symptoms in this group varied from mild indigestion to agonizing attacks of biliary colic. The interval between the performance of cholecystectomy and examination ranged from less than a year (in 5 patients) to twenty-five years. In 37 cases Cholografin outlined the biliary tree; in 26 of these the ducts were normal and in 11 some abnormality was found. The 4 cases of common duct stones were confirmed surgically (Fig. 6). Quite impressive were the cystic duct remnants, ranging from 3 to 5 cm. in length (Fig. 5); of even more interest was the sac formation at the end of the cystic duct (Fig. 3). A serious error of interpretation nearly occurred in one patient (Fig. 4), in whom reflux of Cholografin into the duodenal bulb simulated a gallbladder remnant.

Biliary fistulas

1. 1. A review of fifty-two biliary fistulas discovered at the Boston City Hospital over a twenty-year period is reported. 2. 2. Twenty-three external biliary fistulas were studied which represented surgical error in judgment or technic. 3. 3. All the external fistulas were associated with residual biliary disease: gallbladder remnant in eight; stricture, nine; common duct stone, three; biliary intestinal anastomosis, two; cancer of pancreas, one. 4. 4. Thirty internal biliary fistulas were studied and were found to result from long-standing biliary disease. 5. 5. Sixteen of the internal fistulas caused gallstone ileus. The preoperative diagnostic features of this ileus are discussed. 6. 6. The anatomic types of internal biliary fistula were: cholecystoduodenal, eight; cholecystocolic, three; cholecystogastric, one; choledochoduodenal, one; cholecystocholedochal, one. The correct treatment of each is reviewed.