Can I Get Gallstones Again After Having Gallbladder Removed?

J Minim Access Surg. 2015 October-Dec; 11(iv): 223–230.

Residual gallbladder stones subsequently cholecystectomy: A literature review

Pradeep Chowbey

Max Establish of Minimal Access, Metabolic and Bariatric Surgery, Max Superspeciality Hospital, Saket, New Delhi, India

Anil Sharma

Max Institute of Minimal Access, Metabolic and Bariatric Surgery, Max Superspeciality Hospital, Saket, New Delhi, Republic of india

Amit Goswami

Max Institute of Minimal Access, Metabolic and Bariatric Surgery, Max Superspeciality Hospital, Saket, New Delhi, India

Yusuf Afaque

Max Institute of Minimal Access, Metabolic and Bariatric Surgery, Max Superspeciality Hospital, Saket, New Delhi, India

Khoobsurat Najma

Max Institute of Minimal Access, Metabolic and Bariatric Surgery, Max Superspeciality Hospital, Saket, New Delhi, Republic of india

Manish Baijal

Max Establish of Minimal Access, Metabolic and Bariatric Surgery, Max Superspeciality Infirmary, Saket, New Delhi, India

Vandana Soni

Max Institute of Minimal Admission, Metabolic and Bariatric Surgery, Max Superspeciality Hospital, Saket, New Delhi, Bharat

Rajesh Khullar

Max Institute of Minimal Access, Metabolic and Bariatric Surgery, Max Superspeciality Hospital, Saket, New Delhi, India

Received 2014 Oct 21; Accepted 2014 October 25.

Abstract

BACKGROUND:

Incomplete gallbladder removal following open and laparoscopic techniques leads to rest gallbladder stones. The commonest presentation is abdominal pain, dyspepsia and jaundice. We reviewed the literature to written report diagnostic modalities, management options and outcomes in patients with residual gallbladder stones later cholecystectomy.

MATERIALS AND METHODS:

Medline, Google and Cochrane library betwixt 1993 and 2013 were reviewed using search terms residual gallstones, post-cholecystectomy syndrome, retained gallbladder stones, gallbladder remnant, cystic duct remnant and subtotal cholecystectomy. Bibliographical references from selected articles were also analyzed. The parameters that were assessed include demographics, fourth dimension of detection, clinical presentation, mode of diagnosis, nature of intervention, site of stone, surgical findings, procedure performed, complete stone clearance, sequelae and follow-upward.

RESULTS:

Out of 83 manufactures that were retrieved between 1993 and 2013, 22 met the inclusion criteria. In most series, chief diagnosis was established past ultrasound/computed tomography browse. Localization of calculi and delineation of biliary tract was performed using magnetic resonance imaging/magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography. In few series, diagnosis was established by endoscopic ultrasound, intraoperative cholangiogram and percutaneous transhepatic cholangiography. Laparoscopic surgery, endoscopic techniques and open surgery were the well-nigh common treatment modalities. The virtually common sites of residual gallstones were gallbladder remnant, cystic duct remnant and common bile duct.

Determination:

Residual gallbladder stones following incomplete gallbladder removal is an of import sequelae after cholecystectomy. Completion cholecystectomy (open or laparoscopic) is the almost common treatment modality reported in the literature for the management of residual gallbladder stones.

Keywords: Cystic duct remnant, gallbladder remnant, post-cholecystectomy syndrome, residual gallstones, retained gallbladder stones, subtotal cholecystectomy

INTRODUCTION

Laparoscopic cholecystectomy is now the gold standard for handling of symptomatic gallstones. In some patients all the same the symptoms may persist even after surgery. These include upper abdominal hurting, dyspepsia with or without jaundice. A small pct of patients with post-cholecystecomy syndrome are symptomatic due to a rest stone in a particularly long cystic duct or to the relapse of lithiasis in a gallbladder remnant.[1,2]

Incidence of incomplete gallbladder removal following conventional cholecystectomy appears very low.[3,4] In the laparoscopic era, incidence of unintentional incomplete gallbladder removal has non been reported clearly though it seems to be slightly more than the ones reported with open cholecystectomy.[5,six,seven,8,9,10,11,12,xiii,xiv,fifteen] Incomplete resection of gallbladder occurs in up to 13.3% of laparoscopic cholecystectomies.[16] Reasons for incomplete resection include poor visualization of gallbladder fossa during surgery, adhesions, concurrent inflammation, excessive bleeding, or confounding gallbladder morphology such as a built duplication or an hour glass configuration due to adenomyomatosis.[9,17]

Diagnosis and management of retained calculi tin be challenging. Most of the patients with retained calculi require surgical intervention. Our aim is to review the literature for residual gallbladder stones later cholecystectomy, discuss diagnosis and management strategies in these patients.

MATERIALS AND METHODS

A protocol for a review of the literature was adult including search methods, literature review and criteria to select the studies assessed. The review used the Medline, Google and Cochrane library between 1993 and 2003. The following search terms were used: Rest gallbladder stones, post-cholecystectomy syndrome, retained gallbladder stones, gallbladder remnant, cystic duct remnant, subtotal cholecystectomy. Secondary searches of selected manufactures and reviews were performed. Full-text sources were available for virtually titles; however some data was derived from abstracts alone. The bibliographical references of each of these articles considered were also analyzed to detect other manufactures that contributed to our review. The review included all the relevant publications in English language.

Two authors separately reviewed titles and abstracts obtained from search using a predefined information extraction form. Manufactures were retrieved when they seemed to potentially come across the inclusion criteria. The inclusion criteria were and so applied independently by both the authors to retrieved manufactures. Any differences were referred to a senior author for final analysis. In that location were no restrictions regarding the type of study or the characteristics of patients. The parameters that were assessed and analyzed include demographics, time of detection, clinical presentation, mode of diagnosis, nature of intervention, site of stone, surgical findings, procedure performed, consummate stone clearance, sequelae and follow-up. Articles with insufficient information (on the site of residual gallbladder stones, style of diagnosis), unclear methodology, published before 1993 and language other than English were excluded from the study.

RESULTS

A total of 83 manufactures published between 1993 and 2013 were establish in the databases that we searched. Among these, 18 were selected for the report on the footing of our inclusion and exclusion criteria. After analyzing the bibiliographical references of these articles, we found some other manufactures that had been published in the same period. Out of these, four new articles were selected and included in our study. Therefore, a total of 22 published articles were used for the present study. Among these articles, thirteen had been published every bit example reports and 9 as instance series (observational studies). There were no randomized studies available in the literature on the subject.

Patient Demographics

The patient demographics are stated in the accompanying tabular array [Table 1].

Tabular array 1

Patient demographics, clinical findings and nature of intervention

Clinical Presentation

The well-nigh mutual presentations were abdominal pain, fever and jaundice [Table one]. Some of the rarer clinical presentations included pseudocysts, vomiting, chills, liver abscess and pancreatitis.

Chowbey et al. reported a hateful time of detection of 4.1 years (range half-dozen/12-12 years). Walsh et al. reported that the mean time interval betwixt cholecystectomy and the diagnosis of retained calculi in a gallbladder/cystic duct remnant was ix.five years (range 14 months to 20 years). Palanivelu et al. reported a mean time of detection of 8.three months (range vi-x.7 months).

Walsh et al. reported that patients were referred to their institute with obscure persistent symptoms post-cholecystectomy. Tantia et al. in their serial reported that all the patients were symptomatic for more than iii months prior to revision cholecystectomy. Daly et al. in their case report mentioned recurrent biliary pain and obstructive jaundice equally presenting symptoms in a patient half-dozen months after undergoing laparoscopic cholecystectomy. Besides, 2 more patients presented with three episodes of typical biliary colic and cholangitis eight months and 9 months subsequently surgery respectively. Sepe et al. reported abdominal pain every bit a presenting symptom in all patients. In the case serial by Palanivelu et al., the presenting symptoms were jaundice in three patients, intestinal pain in 7 patients, cholangitis (with fever, jaundice and pain) in two patients, pruritis associated with jaundice in 1 patient and aymptomatic in ii patients. Chowbey et al. reported pain in the right hypochondrium (17 patients), recurrent biliary colics (nine patients) and jaundice (9 patients) as the most common presenting symptoms. Parmar et al. reported abdominal hurting in 36 patients, persistent dyspepsia as the commonest presenting symptoms.

Mode of Diagnosis

In nearly series, the principal diagnosis was established past ultrasound/computed tomography (CT) scan. Subsequent localization of the calculi and depiction of the biliary tract was performed by magnetic resonance imaging/magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP). In a few series the diagnosis was established by endoscopic ultrasound (EUS), laparoscopic ultrasound, intraoperative cholangioraphy and percutaneous transhepatic cholangiography.

Chowbey et al. in their series reported that the rest gallstones were diagnosed on intestinal ultrasound in 17 patients (includes 5 patients with primarycholecystostomy). The ultrasound reported 8 patients with a remnant gallbladder containing calculi. All other ultrasound reports mentioned an echogenic focus in the gallbladder fossa. The remaining 9 patients (7 patients mail service-LC and 2 patients postal service-open cholecystectomy) were diagnosed on EUS (2 patients), MRCP (4 patients) and ERCP (3 patients) respectively. In all 9 patients, a stone was reported in the residuum cystic duct stump. Seventeen patients (65.iii%) were subjected to a pre-operative ERCP.

Diagnosis was established past abdominal ultrasound, MRCP in the study by Parmar et al. Walsh et al. reported that all their patients received some form of biliary imaging for diagnosis: Half-dozen patients underwent ERC, ane patient underwent MRCP. ERC correctly diagnosed the presence of a retained stone in the cystic duct or retained gallbladder in 4 patients. Biliary imaging was not-diagnostic in the remaining 3 patients. Daly et al. reported ERCP as the diagnostic modality in one patient which showed a dilated cystic duct (vi mm) with a stone nowadays at the junction of the cystic duct with the mutual bile duct (CBD). In two more patients, ERCP conformed the diagnosis with a long cystic duct with a remnant of Hartmann's pouch and a filling defect inside in one patient and a rock in the CBD with 2 cm segment of residue gall float with dilated cystic duct in the other patient. Sepe et al. reported that all patients received biliary imaging in the form of MRCP, CT scan or ERCP. Palanivelu et al. reported that ultrasonography identified cystic duct remnant in 9 patients and MRCP identified calculus in all patients. Mahmud et al. reported that the ultrasound scan of the biliary tree was performed to establish the diagnosis.

Nature of Intervention

Nature of the intervention for residual gallstones that has been described in the literature includes Laparoscopic surgery, endoscopic techniques and open surgery. Laparoscopic surgery included remnant cystic duct stump excision and completion cholecystectomy along with drainage of the pseudocyst. Endoscopic management included endoscopic rock extraction, endoscopic pappilotomy, extracorporeal shock wave lithotripsy (ESWL), light amplification by stimulated emission of radiation lithotripsy and cholangioscope guided lithotripsy

Tantia et al. in their series of 7 patients reported that 2 patients had direct radiological bear witness of CBD calculi along with a big stump without any calculus. ERC and rock extraction were attempted in both these patients who failed due to big calculus in CBD in one and multiple stones in other. These two patients underwent laparoscopic completion cholecystectomy forth with laparoscopic CBD exploration. In the outset patient CBD clearance was confirmed with intraoperative choledochoscopy and principal closure of CBD was performed with antegrade stenting. In the 2d patient after immigration the CBD, laparoscopic choledochoduodenostomy was performed due to large stone load. The remaining 5 patients underwent laparoscopic completion cholecystectomy.

Chowbey et al. in their example serial on laparoscopic management of rest gallstones reported that 26 patients underwent a revision or laparoscopic completion cholecystectomy for balance gallstones disease. Out of these, laparoscopic excision of gallbladder remnant was performed in iii patients, and excision of cystic duct stump with stone was performed in xviii patients. A formal laparoscopic cholecystectomy was performed in 5 patients who had previously undergone cholecystostomy and cholecystolithotomy. Parmar et al. reported that all 40 patients were managed by laparoscopic excision of gallbladder remnant, except for two patients who required conversion to open surgery. These two patients required conversion due to severe dense adhesions.

Walsh et al. reported in their series that the management was accomplished partly on the basis of how the definitive diagnosis had been obtained. Three patients who were diagnosed only at the time of surgery underwent resection of gallbladder remnant (one patient) and excision of retained cystic duct with calculi (two patients). Four patients had an ERC that accurately diagnosed a retained remnant or calculi. Two of these patients were treated surgically, one via completion laparoscopic cholecystectomy and the other via open excision of a retained cystic duct with impacted stones. Two patients underwent definitive endoscopic therapy: Both required fragmentation of cystic duct calculi which was achieved with ESWL in one and Holmium laser application in the other. The stone fragments were then swept from the cystic and mutual ducts with a balloon catheter.

Daly et al. in their instance report of 3 patients reported that in one patient ERCP showed a dilated cystic duct (6 mm) with a rock present at the junction of the cystic duct with the CBD merely the CBD was normal. The stone was unable to be retrieved endoscopically subsequently a sphincterotomy was performed. A subsequent ERCP confirmed that the stone had passed. The second patient underwent ERCP. At ERCP, a long cystic duct was demonstrated with a remnant of Hartmann's pouch and a filling defect inside. A laparoscopic exploration was performed, and the gallbladder stump resected. The third patient underwent the sphincterotomy afterward the ERCP demonstrated a stone in CBD and 2 cm segment for residuum gallbladder with dilated cystic duct. The stone was retrieved at sphincterotomy. Completion cholangiogram revealed no other stones.

Sepe et al. in their serial on unmarried operator cholangioscopy for extraction of cystic duct stones reported that thirteen patients underwent 17 single operator cholangioscopy (Spyglass Direct visualization organization, Boston Scientific, Natick, Mass, United states of america) for extraction of cystic duct stones. A unmarried stone was present in the cystic duct in 9/13 patients, and at to the lowest degree 3 stones were present in iv/13 patients. In 7 patients, stones were noted to be in the distal cystic duct. Iii patients had multiple stones in the remnant cystic duct. In 3 patients, the exact location of the stones could not be ascertained despite the review of cholangiogram and endoscopy images. The decision was made to go directly to a spyglass procedure in 3 patients rather than attempt a traditional arroyo given the big and multiple cystic duct stones. Twelve of 17 procedures were completed with patients under monitored anesthesia care, and 5/17 were performed under general anesthesia. Complete cystic duct clearance on the commencement attempt was achieved in 7/13 patients. Ane patient had partial extraction on the starting time attempt and had a repeat cholangioscopy 6 weeks after achieving complete cystic duct clearance. One patient had successful extraction of 3 cystic duct stones, but one stone dislodged into the CBD and could not be removed. A stent was placed, and ERCP was performed 6 weeks later on with successful bile duct clearance. One patient had failed extraction and underwent a repeat spyglass procedure 3 months later in which the cystic duct was noted to exist articulate. Thus, complete clearance was achieved in 10 of xiii patients.

Palanivelu et al. reported that all 15 patients were successfully managed by laparoscopic excision of the remnant gallbladder/cystic duct. These patients had undergone laparoscopic subtotal cholecystectomy at the same centre. The remnant cystic duct could be completely excised in 11 patients and CBD closed with intracorporeal suturing using three.0 Vicryl. In the other iv patients, closure after remnant excision could not be achieved and a T tube was inserted into the CBD via the cystic duct opening.

Site of Rest Gallbladder Stone

The balance gallbladder stones were retrieved from the gallbladder remnant in 64 patients, remnant cystic duct in 46 patients and in 3 patients from the CBD.

Follow-upwardly

The hateful follow-upward from reported literature was 1.44 years (range 4 months-3.2 years). One patient developed obstructive jaundice. Two patients had pancreatitis and 2 patients reported bilious drainage in the mail-operative period. A minor CBD injury and port site infection were reported in one patient each.

Word

Persistence of symptoms after cholecystectomy may be due to retained stones or regeneration of stones in the remnant gallbladder.[eighteen,19] This unremarkably takes the course of right upper quadrant abdominal hurting and dyspepsia, with or without jaundice. The causes of postal service-cholecystectomy syndrome are often non-biliary like peptic ulcer, gastroesophageal reflux, pancreatic disorders, liver diseases, irritable bowel and coronary artery disease.[19] However, in some of these patients the cause may be biliary such equally choledocholithiasis, traumatic biliary stricture, sphincter of Oddi dysfunction or cystic duct/gallbladder remnant.[20,21] Patients with symptoms suggestive of gallstone affliction such every bit biliary colic and obstructive jaundice justify a detailed evaluation to dominion out whatever retained stone. The incidence of post-cholecystectomy syndrome has been reported to be as high every bit twoscore%, and the onset of symptoms may range from 2 days to 25 years.[18,22,23,24] There may also be gender-specific risk factors for developing symptoms after cholecystectomy. Bodvall and Overgaard institute that the incidence of recurrent symptoms amidst female patients was 43%, compared to 28% amidst male person patients.[25]

Several reports have proposed that a cystic duct remnant >1 cm in length after cholecystectomy may be responsible, at least in function, for mail-cholecystectomy syndrome,[26,27] other authors refute this.[4,25] Residual gallstones are more often reported in cystic duct remnants. The possible etiology of such an occurrence is often a failure to ascertain the cystic duct, CBD junction. This is more probable to occur in the presence of acute local inflammation or fibrosis. Information technology may be prudent to dissect the cystic duct upward to the common duct defining their junction in selected patients. Patients at increased chance of harboring stones in the cystic duct are patients with a history of biliary colics, pancreatitis, obstructive jaundice and those having undergone therapeutic ERCP prior to clipping and dividing the cystic duct. Stones in the cystic duct may be axiomatic on visualization or may too be palpated with the dissector. Adhesions around the cystic duct may be another indicator of an impacted rock inside information technology. In these circumstances, dissection should continue proximal to the stone towards junction of the cystic duct and CBD. With increasing experience, it is nearly always possible to apply clips on the cystic duct proximal to the stone. No attempt should be fabricated to 'milk' the stone distally, every bit such a maneuver may fragment the stone that may pass into the mutual duct and lead to biliary colic in the post-operative period.

Moody[19] included gallbladder remnant amidst the main causes of post-cholecystectomy syndromes; he cited Bodvall'southward previous experience concerning 26 cases of gallbladder remnant as a cause of mail-cholecystectomy syndrome observed in a total of 103 cases operated on, equal to an incidence of 25%.[25] Stone recurrence in a gallbladder remnant after cholecystectomy, either laparotomic or laparoscopic, may arise alternatively from three different conditions: Inadvertent incomplete gallbladder removal, incorrectly performed subtotal intentional cholecystectomy (fundectomy lonely), or ultimately the being of a duplicated or even triplicated gallbladder inadvertently missed at the intervention (or probably voluntarily missed because seemingly healthy). Incomplete gallbladder removal during cholecystectomy may be both voluntary and inadvertent. Kuster and Domagk recommend a temporary laparoscopic cholecystostomy followed by delayed laparoscopic cholecystectomy as an alternative to conversion to open up cholecystectomy in astute cholecystitis.[28] Like recommendations have been duplicated by other authors wherein a tube cholecystostomy has been suggested to be a good relieve procedure in select patients with acute cholecystitis or a poor general status.[29,xxx,31] Subtotal cholecystectomy has been recommended as a condom and feasible option in patients where anatomical distortion at Calot'southward triangle precludes a safe dissection.[31,32,33,34,35] Conversion charge per unit to open surgery is higher for patients with astute cholecystitis than in those without acute cholecystitis. Laparoscopic subtotal cholecystectomy has been suggested equally an alternative to decrease this conversion rate.[35]

Recent progress in radiological imaging has profoundly improved diagnostic accuracy in detecting the causes of persistence of symptoms in postal service-cholecystectomy patients.[1,36] Ultrasound, CT scan, ERCP, and MRCP are all effectively used to attain a diagnosis of gallbladder remnant with or without stones in patients lament of symptoms consistent with mail-cholecystectomy syndrome. However, diagnosis of residual gallbladder with gallstones remains difficult. An EUS is indicated in the presence of a loftier index of clinical suspicion with a negative abdominal ultrasound. EUS has proven its feasibility in diagnosing liver and biliary pathologies with a high sensitivity (96.2%) and specificity (88.9%) and has likewise been shown to be price constructive in avoiding a number of ERCPs.[37,38,39] ERCP is popular as a diagnostic and therapeutic tool in managing extrahepatic biliary pathology. However, it is an invasive investigation and associated with a specific procedure related complications.[40] The main advantage of MRCP is its not-invasiveness, absence of sedation and avoidance of radiations exposure. Its sensitivity and specificity are similar to EUS.[39]

Treatment options depend on the suspected etiology. Once the patient has been diagnosed with residual stone, surgical excision should be undertaken to avert potentially life-threatening complications, such as carcinoma, recurrent cholangitis, mucocele, recurrent cholelithiasis with gross dilatation of remnant, and Mirizzi syndrome.[23,41]

The first laparoscopic completion cholecystectomy was reported by Gurel et al. in 1995.[25] Traditionally, the open up technique was considered equally the procedure of choice for tackling these residual stones. Later on, the laparoscopic arroyo became popular, though only attempted in advanced centres. Later on incomplete cholecystectomy, the cystic duct stump and Calot's triangle is unremarkably embedded in inflamed scar tissue, so it was thought that the surgical risk was too loftier to reoperate laparoscopically in these cases. Equally in other surgical disciplines, minimally invasive surgery has revolutionised the management protocol of these patients, discipline to availability of expertise. Many experts accept successfully excised the cystic duct remnant laparoscopically, thus, leading to total recovery of the patient without meaning post-operative morbidity. Information technology has now been suggested that information technology is rubber and feasible to remove the gallbladder or gallbladder remnants in such patients laparoscopically.[42] Despite some previously reported contrary opinions, the laparoscopic approach to reoperations on the biliary tract appears to be a minimally invasive, safe, viable, and effective procedure when done past expert laparoscopic surgeons.[43]

Case reports of cystic duct calculi after cholecystectomy testify mixed results about interventions using ERCP solitary.[nine,23,44,9] During the terminal two decades, cases accept been reported in which cystic duct remnant stones were treated endoscopically, either percutaneously after surgical cholecystostomy or via a retrograde transpapillary approach.[45,46] Beyer et al. noted that it was easy to extract multiple stones from the cystic duct remnant in their patient, but Kodali and Petersen encountered marked problems in removing calculi from two patients with postal service-cholecystectomy Mirizzi syndrome. Not-surgical option like ESWL is as well reported.[47] With evolving experience and the development of ancillary methods, such as ESWL, EHL (Electrohydraulic lithotripsy), and light amplification by stimulated emission of radiation lithotripsy, it has become possible to treat patients with Mirizzi syndrome by using interventional endoscopic methods. ESWL, combined with advisable therapeutic endoscopic interventions, is condom and constructive for the treatment of cystic duct remnant stones and Mirizzi syndrome, specially when it is desirable to avoid surgical therapy

Footnotes

Source of Support: Nil

Conflict of Involvement: None declared.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4640007/

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