Management of residual gall bladder: A 15-year experience from a north Indian tertiary care centre

Abstract

Backgrounds/AimsA residual gallbladder (RGB) following a partial/subtotal cholecystectomy may cause symptoms that require its removal. We present our large study regarding the problem of a RGB over a 15 year period.MethodsThis study involved a retrospective analysis of patients managed for symptomatic RGB from January 2000 to December 2015.ResultsA RGB was observed in 93 patients, who had a median age of 45 (25–70) years, and were comprised of 69 (74.2%) females. The most common presentation was recurrence pain (n=64, 68.8%). Associated choledocholithiasis was present in 23 patients (24.7%). An ultrasonography (USG) failed to diagnose RGB calculi in 10 (11%) patients; whereas, magnetic resonance cholangio-pancreatography (MRCP) accurately diagnosed RGB calculi in all the cases except for 2 (4%) and, additionally, detected common bile duct (CBD) stones in 12 patients. Completion cholecystectomy was performed in all patients (open 45 [48.4%]; laparoscopic 48 [51.6%] and 19 [20.4%] patients required a conversion to open). The RGB pathology included stones in 90 (96.8%), Mirizzi's syndrome in 10 (10.8%) and an internal fistula in 9 (9.7%) patients. Additional procedures included CBD exploration (n=6); Choledocho-duodenostomy (n=4) and Roux-en-Y hepatico-jejunostomy (n=3). The mortality and morbidity were nil and 11% (all wound infection), respectively. Two patients developed incisional hernia during follow up. The mean follow up duration was 23.1 months (3–108) in 65 patients and the outcome was excellent and good in 97% of the patients.ConclusionsPost-cholecystectomy recurrent biliary colic should raise suspicion of RGB. MRCP is a useful investigation for the diagnosis and assessment of any associated problems and provides a roadmap for surgery. Laparoscopic completion cholecystectomy is feasible, but is technically difficult and has a high conversion rate.

The incidence of symptomatic remnant gall bladder: a population study

“…11 With increasing availability and use of high resolution axial imaging modalities such as computed tomography and magnetic resonance imaging, it is increasingly recognized that these symptoms may be attributable to a remnant gallbladder. In two case series presented by Singh et al 7 and Concors et al, 8 diagnosis of the remnant gall bladder is often challenging. Furthermore, Singh et al identified that reporting and disclosure of a subtotal cholecystectomy was absent 71% of these cases.…”

“…Furthermore, Singh et al identified that reporting and disclosure of a subtotal cholecystectomy was absent 71% of these cases. 7 Both of these case series place particular weight on imaging, computed tomography and magnetic resonance imaging, to confirm the existence of the remnant and to define the anatomy prior to proceeding. In our patient cohort, the incidence of repeat cholecystectomy is 0.25%, for the period of 1998-2016.…”

“…However, published case series of repeat cholecystectomies show an average 18-24 month time interval from first and second procedure. 7,8 Third, the data collected is limited by the completeness of the state-based records, where incomplete coding and recording (i.e. ICU stay) was unable to be tracked and collected.…”

“…This may be in part be due to a failure of patient disclosure to the outcome of their procedure, and awareness that a gall bladder remnant remains. 7 The diagnosis of a symptomatic gall bladder remnant is dependent on proving that the remnant exists using axial biliary imaging. Once established, the decision to proceed to a completion cholecystectomy weighs the risk of surgery against the impact of the patient symptoms.…”

“…Redo or completion cholecystectomy is a complex procedure, requiring division of adhesions, high likelihood of conversion to an open procedure, and increased risk of common bile duct injury. 7,8 In this review of state-based operative practices for cholecystectomy, the primary aim was to establish the incidence of redocholecystectomy and secondly identify risk factors that lead to subtotal cholecystectomy and completion surgery.…”