Abdominal pain following cholecystectomy can occur in about 5-15 % of patients. Episodes of colic abdominal pain can be like the complaints that motivated the cholecystectomy. For any surgeon this can be a difficult issue to deal with because the patient was hoping to get asymptomatic after gallbladder removal. Was it a misdiagnosis? Was it a consequence of a bad surgery? Probably not. This is a post-cholecystectomy syndrome.
The etiology can in fact be due to a non-diagnosed gastroesophageal reflux disease, but many cases are due to biliary disorders, namely residual choledocholithiasis, biliary dyskinesia, bile leak, bile stenosis, or even cystic duct remnant syndrome (some call it cystic stump syndrome). This last pathology is rare, with only a few cases reported, and some authors even doubt its existence.
Cystic duct remnant syndrome is a post-cholecystectomy syndrome.
Márquez Rojas J et al from the Surgery Departments of Cáceres and Badajoz, Spain, published in 2014 a case report of a patient with a post-cholecystectomy syndrome due to cystic duct remnant syndrome. A female patient resorted to the surgery department because of abdominal pain years after an open cholecystectomy. Blood test were normal at time of surgery consultation, but in previous episodes elevated transaminases and bilirubin levels were noted. Ultrasound revealed linear hyperechoic images in the gallbladder bed, probably related to the cystic duct. Because of these findings a magnetic resonance cholangiopancreatography (MRCP) was performed. A long and dilated cystic duct remnant with a calculus inside was found, with a normal common bile duct. Surgery was proposed but patient refused. Dietary restriction was the only treatment offered.
Other pathologies should be ruled out to diagnose cystic duct remnant syndrome.
Cystic duct remnant syndrome is present when a cystic remnant greater than 1cm is found after cholecystectomy. It can cause a post-cholecystectomy syndrome when calculi are inside. It can occur immediately or years following open or laparoscopic cholecystectomy. Diagnosis is not easy, and other pathologies like irritable bowel syndrome, peptic ulcer, hepatitis, gastroesophageal reflux must be excluded. Ultrasound, MRCP, scintigraphy can be helpful for diagnosis confirmation. Some authors questioned its existence, but when a cystic remnant greater than 1cm with calculus inside is found and all other pathologies have been ruled out, diagnosis can be made. This means that cystic duct remnant syndrome is like an exclusion diagnosis. Is it? I do not believe having a big cystic remnant with calculi inside is normal. So, why should we think the complaints are not due to this syndrome if other pathology is present? Sometimes different pathologies work together for signs and symptoms.
Cystic duct remnant syndrome treatment is surgical removal of the cystic remnant. However, fibrotic changes between cystic remnant and common bile duct can be hard to solve, increasing the risk of main bile duct injury. Although the risk seems to be greater in laparoscopic approach comparing to open surgery, minimal invasive surgery is not an absolute contraindication. However, all surgeons (including those who think have great experience) must think twice when deciding how to approach this syndrome, I think. Because of the risks, other treatment options are available namely, lithotripsy and endoscopic retrograde cholangiopancreatography.
Surgery is the usal treatment to solve cystic duct remnant syndrome.
In conclusion, cystic duct remnant syndrome following cholecystectomy can cause episodic abdominal pain in a patient who was hoping to be asymptomatic. This post-cholecystectomy syndrome is rare but exists, and all surgeons who perform cholecystectomy (open or laparoscopic) must be aware of this condition. Do not forget that you can only diagnose what you know. Learn everything you can about everything you do. Every small knowledge can help you someday…
Link to article:
by Dr. Carlos Eduardo Costa Almeida
General Surgeon