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Cystic duct remnant calculi after cholecystectomy
Journal of Visceral Surgery (2011) 148, e287—e290
ORIGINAL ARTICLE
Cystic duct remnant calculi after cholecystectomy A. Sezeur a,∗,b, K. Akel a a
Service de chirurgie digestive, groupe hospitalier Diaconesses-Croix Saint-Simon, 125, rue d’Avron, Paris 75020, France b UPMC, université Pierre et Marie-Curie, 75005 Paris, France Available online 3 August 2011
KEYWORDS Cystic duct stones; Cholecystectomy; Post cholecystectomy syndrome
∗
Summary Unrecognized lithiasis of the cystic duct (CDL) may be responsible for post cholecystectomy. This retrospective study looked at the incidence of CDL during cholecystectomy, as well as the context of its occurrence; recommendations for a practical surgical approach are offered. Patients and methods: Over a period of 30 months, 143 consecutive cholecystectomies (103 women, 40 men; mean age: 57 years) were performed by the same surgeon: 142 by laparoscopy, and one by laparotomy due to a history of previous gastrectomy. The cystic duct was always opened and milked upward in search of CDL before immediate clip occlusion or performance of cholangiography (106 times, 74.1%). In seven cases, cholangiography was impossible because the cystic duct was too narrow. Results: There was no mortality. CDL was found in 21 cases (14.7%) and removed. This had not been identified by preoperative imaging (ultrasound or CT). Pain in the month preceding cholecystectomy occurred more frequently in cases of CDL (19/21[90.4%] vs 36/122 [29.5%]; P < 0.001). Similarly, liver function tests were more often abnormal with CDL (10/21 [47.6%] vs 30/122 [24.5%]; P < 0.05). However, neither jaundice nor gallbladder inflammation was predictive of CDL in this study. Echoendoscopy (EUS) was performed more often for suspected common duct lithiasis migration (CBDL) in patients with CDL than for those without (9/21 [42.8%] vs 26/122 [21.3%]; P < 0.05). CBDL was present in 12 of 143 patients (8.3%). This was treated by preoperative endoscopic sphincterotomy in 10 cases, and twice by trans-cystic stone extraction during the laparoscopic intervention. CBDL occurred more frequently in association with CDL (5/21 [23.8%] vs 7/122 [5.7%]; P < 0.01). In addition, CDL was still present at cholecystectomy in the four patients who underwent preoperative endoscopic sphincterotomy. Conclusion: Cystic duct lithiasis is found frequently during cholecystectomy; CDL is often associated with preoperative pain, abnormal liver function tests and choledocholithiasis. It can persist despite preoperative sphincterotomy. The search for and treatment of CDL should be routinely performed during cholecystectomy. © 2011 Elsevier Masson SAS. All rights reserved.
Corresponding author. E-mail address: [email protected] (A. Sezeur).
1878-7886/$ — see front matter © 2011 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.jviscsurg.2011.06.001
e288
Introduction During cholecystectomy, the cystic duct is usually ligated close to the gallbladder. However, in more than 50% of cases, the cystic duct has a length greater than 3 cm [1]. In such circumstances lithiasis of the cystic duct (CDL) downstream of the ligation can be missed if it is not systematically sought. This may explain some cases of post cholecystectomy pain reported in the literature [1—3]. Residual cystic duct lithiasis is difficult to diagnose and requires specific reintervention [1,2,4,5]. This retrospective study aims to analyze the incidence of CDL during cholecystectomy, the context of its occurrence, and to derive a practical approach for the surgeon.
Patients and methods Over a 30-month period, 144 consecutive patients underwent cholecystectomy for symptomatic gallstones diagnozed preoperatively by ultrasound or CT scan. One patient was excluded from this series because he had extensive choledocholithiasis extending continuously up into the cystic duct; he was treated by open cholecystectomy and choledocho-duodenal anastomosis. All cholecystectomies in this consecutive series were performed by one surgeon using the same operative technique. Whenever possible, the cystic duct was dissected initially, unless anatomic or inflammatory conditions prevented easy recognition of the anatomy. In difficult cases, the gallbladder was mobilized from front to back initially to facilitate identification of the cystic duct. This was then opened, and then milked to extract any possible CDL downstream from the choledochotomy. Whenever possible, an intraoperative cholangiogram was performed; the Chevassu probe was introduced and held in place by a clip for the injection. The cystic duct was then clipped or tied. If it was technically impossible to perform cholangiography or if the common bile duct had been previously explored satisfactorily, the cystic duct was clipped at the start but always after it had been opened and milked.
Results The mean age of the 143 patients was 57 years (20 to 85 years). There were 103 females and 40 males. During exploration of the cystic duct, CDL was found 21 times (14.7%). All stones were extracted during surgery. The presence of CDL was associated with symptoms of pain in the month prior to surgery (19 cases), and abnormal liver function tests (10 cases). The incidence of these findings differed significantly from that observed in patients without CDL (Table 1). Preoperative ultrasound and CT scans failed to identify CDL in any case. Acute cholecystitis was diagnozed preoperatively and confirmed during surgery in five of of 21 cases with CDL. One of these six patients underwent delayed cholecystectomy after a bout of acute pancreatitis. Preoperative endoscopic ultrasonography (EUS) was performed in 35 cases for suspected lithiasis of the common bile duct (CBD), or at least one episode of clinical passage of CBD stones. Of the 21 patients with CDL, nine underwent EUS (42.8%); this was significantly more frequent than for patients without CDL (Table 1). Only one of these nine EUS detected calculi within the cystic duct. This patient had a Type I Mirizzi’s syndrome.
A. Sezeur, K. Akel CBD stones were diagnozed in 10 of these studies, and all 10 underwent endoscopic sphincterotomy prior to cholecystectomy. Cholecystectomy was performed laparoscopically in 142 case. One of these cases was converted to open laparotomy because of the discovery of Mirizzi syndrome during surgery. One case was performed by laparotomy from the start because of a history of prior gastrectomy. Cholangiography was performed in 106 cases, but could not be performed in seven cases because the cystic duct was too narrow. Intraoperative cholangiography was performed in six cases where inflammation rendered identification of the anatomy difficult, even though they had already undergone a negative preoperative EUS. CBD stones were found in two cases by intraoperative cholangiography that had not been detected preoperatively; these were retrieved by trans-cystic duct extraction during laparoscopy. One of these two patients had CDL. CDL was present in five of the 12 patients with CBD stones in this series (23.8%); this incidence was significantly greater than in patients without CDL (P < 0.01) (Table 1). In four cases, persistent CDL was present at surgery despite preoperative endoscopic sphincterotomy which had failed to detect it despite retrograde opacification of the bile ducts. There was no mortality.
Discussion The anatomy of the cystic duct is highly variable from one patient to another [1]. It is sometimes very short and falls directly into the CBD; at other times, it is very long and passes behind or parallel to the CBD, entering it only a few millimeters above its termination. During cholecystectomy, our operative technique is to ligate the cystic duct just below the gallbladder neck to avoid the risk of damaging the bile duct during dissection. This technique leads to the risk of leaving CDL between the ligature and the termination of the cystic duct at the CBD, unless such stones are systematically sought and removed [2—5]. To avoid this pitfall, the surgeon must open the cystic duct and milk it backward from the lateral margin of the CBD to extract any residual stones which might subsequently migrate. The presence of a bulge of the cystic duct often corresponds to an impacted or migrating cystic duct stone. This can usually be removed easily through the cystic duct opening. It is not uncommon to find several stones migrating along the cystic duct. Subsequent operative cholangiography will then fully delineate the length of the cystic duct as well as the CBD [3,6]. Cholangiography should always be preceded by the retrograde milking maneuver of the cystic duct to avoid pushing distal cystic duct stones into the CBD. CDL occurs frequently: in 14.7% of cases in our study; this corresponds to data in the literature [2,7]. It is therefore surprising that cystic duct remnant stones are not reported more often after cholecystectomy. Several hypotheses may explain this: • only 50% of patients have a long cystic duct. For the others, it is likely that CDL is more easily recognized during surgery [1]; • it is likely that small stones are able to migrate spontaneously into and through the CBD. Indeed, 60% of common duct stones migrate spontaneously and are eliminated through the gastrointestinal tract [8,9];
Cystic duct remnant calculi after cholecystectomy Table 1
e289
Comparison between two groups, with and without cystic duct remnant calculi.
Pain in the month preceding surgery Jaundice Abnormal preoperative liver function tests Preoperative echoendoscopy Inflamed gallbladder at surgery CBDL**
Patient with CDL* n = 21 (14.7%)
Patient without CDL* n = 122 (85.3%)
p
19 5 10 9 6 5
36 13 30 26 28 7
< 0.001 ns < 0.05 < 0.05 ns < 0.01
(90.4%) (23.8%) (47.6%) (42.8%) (28.5%) (23.8%)
(29.5%) (10.6%) (24.5%) (21.3%) (22.9%) (5.7%)
CDL*: cystic duct lithiasis; CBDL**: common bile duct lithiasis; ns: non-significant.
• cystic duct lithiasis is frequently associated with CBD stones as shown in our study (41.6%). Yet, choledocholithiasis is often identified and treated prior to cholecystectomy by endoscopic sphincterotomy; this probably facilitates passage of unrecognized CDL. However, we found CDL persistent at the time of cholecystectomy in four patients who had undergone preoperative endoscopic sphinterotomy for CBD stones; • finally, many surgical services recommend routine cholangiography during cholecystectomy to detect CDL and CBD stones [3]. While the search for CDL should be systematic, this does not impose the need for dissection of the whole length of a long cystic duct, as others have recommended [3]. Indeed, such dissection may increase the risk of CBD wounds of electrocoagulation injury. Thus the search for CDL should be limited to an instrumental exploration of the visible part of the cystic duct to the right of the CBD; the remainder of an elongated cystic duct is visualized by cholangiography, an advantage that is rarely mentioned, even by proponents of routine operative cholangiography [6,10]. The systematic search for CDL during surgery is all the more justified because it is rarely detected by preoperative imaging of the bile ducts [4]. We also found that severe or recurrent pain in the month preceding cholecystectomy occurred frequently when CDl was present (90.9% of our cases, 70.3% of 60 cases of Mahmud et al. [4]). Like Mahmud et al. [4], we did not identify any specific operative difficulties related to the presence of CDL. When CDL is missed, it may manifest itself by postoperative pain which can be intermittent or constant [2,4,5]. This is sometimes associated with nausea, vomiting, and even acute pancreatitis [11]. The diagnosis of residual CDL is difficult. It must be routinely considered in cases of unexplained post cholecystectomy pain, since it can occur in 30% of all such cases [12]. MRCP may fail to detect residual CDL [2]. Endoscopic retrograde cholangiography must include a selective opacification of the cystic duct if residual calculi are not immediately apparent by simple retrograde opacification of the CBD. When CDL is missed at cholecystectomy, the treatment of residual stones becomes difficult. It may require the techniques of extracorporeal or endoscopic lithotripsy [13]. If these these techniques are impossible or unavailable, re-operation, which may be difficult, is often necessary [14]. In practice, any preoperative symptoms suggestive of gallstone migration [15] or choledocholithiasis — whether recent pain, jaundice, acute pancreatitis, abnormal liver function tests — should prompt a search for CDL [6], although in our series only a few of these factors are significantly
predictive of CDL (Table 1). In addition, preoperative EUS, which is the indirect reflection of all these findings, is more often prescribed in cases of CDL.
Conclusion Lithiasis of the cystic duct occurs commonly in calculous gallbladder disease. It should be systematically searched for during cholecystectomy by instrumental exploration of the cystic duct, and by cholangiography; this should reduce the incidence of post cholecystectomy pain syndromes. This is all the more justified since the diagnosis and treatment of residual cystic duct remnant lithiasis after cholecystectomy is difficult.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
References [1] Burhenne HJ. The technique of biliary duct stone extraction. Experience with 126 cases. Radiology 1974;113(3): 567—72. [2] Walsh RM, Ponsky JL, Dumot J. Retained gallbladder/cystic duct remnant calculi as a cause of postcholecystectomy pain. Surg Endosc 2002;16(6):981—4. [3] Palanivelu C, Rangarajan M, Jategaonkar PA, Madankumar MV, Anand NV. Laparoscopic management of remnant cystic duct calculi: a retrospective study. Ann R Coll Surg Engl 2009;91(1):25—9 [Epub 2008]. [4] Mahmud S, Hamza Y, Nassar AH. The significance of cystic duct stones encountered during laparoscopic cholecystectomy. Surg Endosc 2001;15(5):460—2 [Epub 2001]. [5] Lum YW, House MG, Hayanga AJ, Schweitzer M. Postcholecystectomy syndrome in the laparoscopic era. J Laparoendosc Adv Surg Tech A 2006;16(5):482—5. [6] Borie F, Millat B. La cholangiographie per opératoire. Pourquoi et comment la faire? J Chir (Paris) 2003;140(2):90—3. [7] Beyer KL, Marshall JB, Metzler MH, Elwing TJ. Endoscopic management of retained cystic duct stones. Am J Gastroenterol 1991;86(2):232—4. [8] Belghiti J, Kleinman P, Cherqui D, Perniceni T, Bernades P, Fékété F. Early treatment of biliary lithiasis in biliary pancreatitis. Gastroenterol Clin Biol 1987;11(11):786—9. [9] McMahon MJ, Pickford IR. Biochemical prediction of gallstones early in an attack of acute pancreatitis. Lancet 1979;2(8142):541—3. [10] Videhult P, Sandblom G, Rasmussen IC. How reliable is intraoperative cholangiography as a method for detecting
e290 common bile duct stones? A prospective population-based study on 1171 patients. Surg Endosc 2009;23(2):304—12 [Epub 2008]. [11] Chow M, von Waldenfels A, Pace R. An unusual case of a retained stone following laparoscopic cholecystectomy. J Laparoendosc Surg 1993;3(5):513—8. [12] Gui GP, Cheruvu CV, West N, Sivaniah K, Fiennes AG. Is cholecystectomy effective treatment for symptomatic gallstones? Clinical outcome after long-term follow-up. Ann R Coll Surg Eng 1998;80(1):25—32.
A. Sezeur, K. Akel [13] Shim CS, Moon JH, Cho YD, et al. The role of extracorporeal shock wave lithotripsy combined with endoscopic management of impacted cystic duct stones in patients with high surgical risk. Hepatogastroenterology 2005;52(64):1026—9. [14] Larmi TK, Mokka R, Kemppainen P, Seppälä A. A critical analysis of the cystic duct remnant. Surg Gynecol Obstet 1975;141(1):48—52. [15] Montariol T, Rey C, Charlier A, et al. Preoperative evaluation of the probability of common bile duct stones. French Association for Surgical Research. J Am Coll Surg 1995;180(3):293—6.
ORIGINAL ARTICLE
Cystic duct remnant calculi after cholecystectomy A. Sezeur a,∗,b, K. Akel a a
Service de chirurgie digestive, groupe hospitalier Diaconesses-Croix Saint-Simon, 125, rue d’Avron, Paris 75020, France b UPMC, université Pierre et Marie-Curie, 75005 Paris, France Available online 3 August 2011
KEYWORDS Cystic duct stones; Cholecystectomy; Post cholecystectomy syndrome
∗
Summary Unrecognized lithiasis of the cystic duct (CDL) may be responsible for post cholecystectomy. This retrospective study looked at the incidence of CDL during cholecystectomy, as well as the context of its occurrence; recommendations for a practical surgical approach are offered. Patients and methods: Over a period of 30 months, 143 consecutive cholecystectomies (103 women, 40 men; mean age: 57 years) were performed by the same surgeon: 142 by laparoscopy, and one by laparotomy due to a history of previous gastrectomy. The cystic duct was always opened and milked upward in search of CDL before immediate clip occlusion or performance of cholangiography (106 times, 74.1%). In seven cases, cholangiography was impossible because the cystic duct was too narrow. Results: There was no mortality. CDL was found in 21 cases (14.7%) and removed. This had not been identified by preoperative imaging (ultrasound or CT). Pain in the month preceding cholecystectomy occurred more frequently in cases of CDL (19/21[90.4%] vs 36/122 [29.5%]; P < 0.001). Similarly, liver function tests were more often abnormal with CDL (10/21 [47.6%] vs 30/122 [24.5%]; P < 0.05). However, neither jaundice nor gallbladder inflammation was predictive of CDL in this study. Echoendoscopy (EUS) was performed more often for suspected common duct lithiasis migration (CBDL) in patients with CDL than for those without (9/21 [42.8%] vs 26/122 [21.3%]; P < 0.05). CBDL was present in 12 of 143 patients (8.3%). This was treated by preoperative endoscopic sphincterotomy in 10 cases, and twice by trans-cystic stone extraction during the laparoscopic intervention. CBDL occurred more frequently in association with CDL (5/21 [23.8%] vs 7/122 [5.7%]; P < 0.01). In addition, CDL was still present at cholecystectomy in the four patients who underwent preoperative endoscopic sphincterotomy. Conclusion: Cystic duct lithiasis is found frequently during cholecystectomy; CDL is often associated with preoperative pain, abnormal liver function tests and choledocholithiasis. It can persist despite preoperative sphincterotomy. The search for and treatment of CDL should be routinely performed during cholecystectomy. © 2011 Elsevier Masson SAS. All rights reserved.
Corresponding author. E-mail address: [email protected] (A. Sezeur).
1878-7886/$ — see front matter © 2011 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.jviscsurg.2011.06.001
e288
Introduction During cholecystectomy, the cystic duct is usually ligated close to the gallbladder. However, in more than 50% of cases, the cystic duct has a length greater than 3 cm [1]. In such circumstances lithiasis of the cystic duct (CDL) downstream of the ligation can be missed if it is not systematically sought. This may explain some cases of post cholecystectomy pain reported in the literature [1—3]. Residual cystic duct lithiasis is difficult to diagnose and requires specific reintervention [1,2,4,5]. This retrospective study aims to analyze the incidence of CDL during cholecystectomy, the context of its occurrence, and to derive a practical approach for the surgeon.
Patients and methods Over a 30-month period, 144 consecutive patients underwent cholecystectomy for symptomatic gallstones diagnozed preoperatively by ultrasound or CT scan. One patient was excluded from this series because he had extensive choledocholithiasis extending continuously up into the cystic duct; he was treated by open cholecystectomy and choledocho-duodenal anastomosis. All cholecystectomies in this consecutive series were performed by one surgeon using the same operative technique. Whenever possible, the cystic duct was dissected initially, unless anatomic or inflammatory conditions prevented easy recognition of the anatomy. In difficult cases, the gallbladder was mobilized from front to back initially to facilitate identification of the cystic duct. This was then opened, and then milked to extract any possible CDL downstream from the choledochotomy. Whenever possible, an intraoperative cholangiogram was performed; the Chevassu probe was introduced and held in place by a clip for the injection. The cystic duct was then clipped or tied. If it was technically impossible to perform cholangiography or if the common bile duct had been previously explored satisfactorily, the cystic duct was clipped at the start but always after it had been opened and milked.
Results The mean age of the 143 patients was 57 years (20 to 85 years). There were 103 females and 40 males. During exploration of the cystic duct, CDL was found 21 times (14.7%). All stones were extracted during surgery. The presence of CDL was associated with symptoms of pain in the month prior to surgery (19 cases), and abnormal liver function tests (10 cases). The incidence of these findings differed significantly from that observed in patients without CDL (Table 1). Preoperative ultrasound and CT scans failed to identify CDL in any case. Acute cholecystitis was diagnozed preoperatively and confirmed during surgery in five of of 21 cases with CDL. One of these six patients underwent delayed cholecystectomy after a bout of acute pancreatitis. Preoperative endoscopic ultrasonography (EUS) was performed in 35 cases for suspected lithiasis of the common bile duct (CBD), or at least one episode of clinical passage of CBD stones. Of the 21 patients with CDL, nine underwent EUS (42.8%); this was significantly more frequent than for patients without CDL (Table 1). Only one of these nine EUS detected calculi within the cystic duct. This patient had a Type I Mirizzi’s syndrome.
A. Sezeur, K. Akel CBD stones were diagnozed in 10 of these studies, and all 10 underwent endoscopic sphincterotomy prior to cholecystectomy. Cholecystectomy was performed laparoscopically in 142 case. One of these cases was converted to open laparotomy because of the discovery of Mirizzi syndrome during surgery. One case was performed by laparotomy from the start because of a history of prior gastrectomy. Cholangiography was performed in 106 cases, but could not be performed in seven cases because the cystic duct was too narrow. Intraoperative cholangiography was performed in six cases where inflammation rendered identification of the anatomy difficult, even though they had already undergone a negative preoperative EUS. CBD stones were found in two cases by intraoperative cholangiography that had not been detected preoperatively; these were retrieved by trans-cystic duct extraction during laparoscopy. One of these two patients had CDL. CDL was present in five of the 12 patients with CBD stones in this series (23.8%); this incidence was significantly greater than in patients without CDL (P < 0.01) (Table 1). In four cases, persistent CDL was present at surgery despite preoperative endoscopic sphincterotomy which had failed to detect it despite retrograde opacification of the bile ducts. There was no mortality.
Discussion The anatomy of the cystic duct is highly variable from one patient to another [1]. It is sometimes very short and falls directly into the CBD; at other times, it is very long and passes behind or parallel to the CBD, entering it only a few millimeters above its termination. During cholecystectomy, our operative technique is to ligate the cystic duct just below the gallbladder neck to avoid the risk of damaging the bile duct during dissection. This technique leads to the risk of leaving CDL between the ligature and the termination of the cystic duct at the CBD, unless such stones are systematically sought and removed [2—5]. To avoid this pitfall, the surgeon must open the cystic duct and milk it backward from the lateral margin of the CBD to extract any residual stones which might subsequently migrate. The presence of a bulge of the cystic duct often corresponds to an impacted or migrating cystic duct stone. This can usually be removed easily through the cystic duct opening. It is not uncommon to find several stones migrating along the cystic duct. Subsequent operative cholangiography will then fully delineate the length of the cystic duct as well as the CBD [3,6]. Cholangiography should always be preceded by the retrograde milking maneuver of the cystic duct to avoid pushing distal cystic duct stones into the CBD. CDL occurs frequently: in 14.7% of cases in our study; this corresponds to data in the literature [2,7]. It is therefore surprising that cystic duct remnant stones are not reported more often after cholecystectomy. Several hypotheses may explain this: • only 50% of patients have a long cystic duct. For the others, it is likely that CDL is more easily recognized during surgery [1]; • it is likely that small stones are able to migrate spontaneously into and through the CBD. Indeed, 60% of common duct stones migrate spontaneously and are eliminated through the gastrointestinal tract [8,9];
Cystic duct remnant calculi after cholecystectomy Table 1
e289
Comparison between two groups, with and without cystic duct remnant calculi.
Pain in the month preceding surgery Jaundice Abnormal preoperative liver function tests Preoperative echoendoscopy Inflamed gallbladder at surgery CBDL**
Patient with CDL* n = 21 (14.7%)
Patient without CDL* n = 122 (85.3%)
p
19 5 10 9 6 5
36 13 30 26 28 7
< 0.001 ns < 0.05 < 0.05 ns < 0.01
(90.4%) (23.8%) (47.6%) (42.8%) (28.5%) (23.8%)
(29.5%) (10.6%) (24.5%) (21.3%) (22.9%) (5.7%)
CDL*: cystic duct lithiasis; CBDL**: common bile duct lithiasis; ns: non-significant.
• cystic duct lithiasis is frequently associated with CBD stones as shown in our study (41.6%). Yet, choledocholithiasis is often identified and treated prior to cholecystectomy by endoscopic sphincterotomy; this probably facilitates passage of unrecognized CDL. However, we found CDL persistent at the time of cholecystectomy in four patients who had undergone preoperative endoscopic sphinterotomy for CBD stones; • finally, many surgical services recommend routine cholangiography during cholecystectomy to detect CDL and CBD stones [3]. While the search for CDL should be systematic, this does not impose the need for dissection of the whole length of a long cystic duct, as others have recommended [3]. Indeed, such dissection may increase the risk of CBD wounds of electrocoagulation injury. Thus the search for CDL should be limited to an instrumental exploration of the visible part of the cystic duct to the right of the CBD; the remainder of an elongated cystic duct is visualized by cholangiography, an advantage that is rarely mentioned, even by proponents of routine operative cholangiography [6,10]. The systematic search for CDL during surgery is all the more justified because it is rarely detected by preoperative imaging of the bile ducts [4]. We also found that severe or recurrent pain in the month preceding cholecystectomy occurred frequently when CDl was present (90.9% of our cases, 70.3% of 60 cases of Mahmud et al. [4]). Like Mahmud et al. [4], we did not identify any specific operative difficulties related to the presence of CDL. When CDL is missed, it may manifest itself by postoperative pain which can be intermittent or constant [2,4,5]. This is sometimes associated with nausea, vomiting, and even acute pancreatitis [11]. The diagnosis of residual CDL is difficult. It must be routinely considered in cases of unexplained post cholecystectomy pain, since it can occur in 30% of all such cases [12]. MRCP may fail to detect residual CDL [2]. Endoscopic retrograde cholangiography must include a selective opacification of the cystic duct if residual calculi are not immediately apparent by simple retrograde opacification of the CBD. When CDL is missed at cholecystectomy, the treatment of residual stones becomes difficult. It may require the techniques of extracorporeal or endoscopic lithotripsy [13]. If these these techniques are impossible or unavailable, re-operation, which may be difficult, is often necessary [14]. In practice, any preoperative symptoms suggestive of gallstone migration [15] or choledocholithiasis — whether recent pain, jaundice, acute pancreatitis, abnormal liver function tests — should prompt a search for CDL [6], although in our series only a few of these factors are significantly
predictive of CDL (Table 1). In addition, preoperative EUS, which is the indirect reflection of all these findings, is more often prescribed in cases of CDL.
Conclusion Lithiasis of the cystic duct occurs commonly in calculous gallbladder disease. It should be systematically searched for during cholecystectomy by instrumental exploration of the cystic duct, and by cholangiography; this should reduce the incidence of post cholecystectomy pain syndromes. This is all the more justified since the diagnosis and treatment of residual cystic duct remnant lithiasis after cholecystectomy is difficult.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
References [1] Burhenne HJ. The technique of biliary duct stone extraction. Experience with 126 cases. Radiology 1974;113(3): 567—72. [2] Walsh RM, Ponsky JL, Dumot J. Retained gallbladder/cystic duct remnant calculi as a cause of postcholecystectomy pain. Surg Endosc 2002;16(6):981—4. [3] Palanivelu C, Rangarajan M, Jategaonkar PA, Madankumar MV, Anand NV. Laparoscopic management of remnant cystic duct calculi: a retrospective study. Ann R Coll Surg Engl 2009;91(1):25—9 [Epub 2008]. [4] Mahmud S, Hamza Y, Nassar AH. The significance of cystic duct stones encountered during laparoscopic cholecystectomy. Surg Endosc 2001;15(5):460—2 [Epub 2001]. [5] Lum YW, House MG, Hayanga AJ, Schweitzer M. Postcholecystectomy syndrome in the laparoscopic era. J Laparoendosc Adv Surg Tech A 2006;16(5):482—5. [6] Borie F, Millat B. La cholangiographie per opératoire. Pourquoi et comment la faire? J Chir (Paris) 2003;140(2):90—3. [7] Beyer KL, Marshall JB, Metzler MH, Elwing TJ. Endoscopic management of retained cystic duct stones. Am J Gastroenterol 1991;86(2):232—4. [8] Belghiti J, Kleinman P, Cherqui D, Perniceni T, Bernades P, Fékété F. Early treatment of biliary lithiasis in biliary pancreatitis. Gastroenterol Clin Biol 1987;11(11):786—9. [9] McMahon MJ, Pickford IR. Biochemical prediction of gallstones early in an attack of acute pancreatitis. Lancet 1979;2(8142):541—3. [10] Videhult P, Sandblom G, Rasmussen IC. How reliable is intraoperative cholangiography as a method for detecting
e290 common bile duct stones? A prospective population-based study on 1171 patients. Surg Endosc 2009;23(2):304—12 [Epub 2008]. [11] Chow M, von Waldenfels A, Pace R. An unusual case of a retained stone following laparoscopic cholecystectomy. J Laparoendosc Surg 1993;3(5):513—8. [12] Gui GP, Cheruvu CV, West N, Sivaniah K, Fiennes AG. Is cholecystectomy effective treatment for symptomatic gallstones? Clinical outcome after long-term follow-up. Ann R Coll Surg Eng 1998;80(1):25—32.
A. Sezeur, K. Akel [13] Shim CS, Moon JH, Cho YD, et al. The role of extracorporeal shock wave lithotripsy combined with endoscopic management of impacted cystic duct stones in patients with high surgical risk. Hepatogastroenterology 2005;52(64):1026—9. [14] Larmi TK, Mokka R, Kemppainen P, Seppälä A. A critical analysis of the cystic duct remnant. Surg Gynecol Obstet 1975;141(1):48—52. [15] Montariol T, Rey C, Charlier A, et al. Preoperative evaluation of the probability of common bile duct stones. French Association for Surgical Research. J Am Coll Surg 1995;180(3):293—6.