Residual gall bladder: An emerging disease after safe cholecystectomy

Abstract

Backgrounds/AimsResidual gallbladder mucosa left after subtotal/partial cholecystectomy is prone to develop recurrent lithiasis and become symptomatic, which mandates surgical removal.MethodsWe retrospectively evaluated the patients with residual gallbladder referred to us from January 2011 to December 2017. Based on MRCP we classified calot's anatomy to – type I where cystic duct was seen and type II where sessile GB stump was seen.Results21 patients with median age 38 years and M:F::1:9.5, had undergone cholecystectomy (3 months-20 years) prior, presented with recurrent biliary pain. 3 had jaundice (CBD stone, Mirizzi and biliary stricture), 1 had pancreatitis and one had malignancy of the GB. Imaging revealed type I anatomy in 14 (67%) and type II in 7 (33%). All underwent completion cholecystectomy – open in 18 and laparoscopic in 3 (one converted to open). Additional procedure was required in 5 patients – CBD exploration in 2 (10%) and one each Hepatico-jejunostomy, extended cholecystectomy and splenectomy. Median hospital stay was 1 day. There was no mortality and 10% morbidity. One patient with malignancy died at 2 years, two died of unrelated cause, one developed incisional hernia and the remaining were well at a median follow up of 29 months.ConclusionsResidual GB lithiasis should be suspected if there are recurrent symptoms after cholecystectomy. MRCP based proposed classification can guide the management strategy. Completion cholecystectomy is curative.

The second ‘gallbladder operation’

“…With residual GB, there have been isolated reports of bile duct stricture and malignancy. [ 15 ] As a result, unlike conventional GB calculi, residual GB calculi are more likely to cause complications (53.8% in our cohort). In management, they require additional evaluation like MRCP.…”

“…went on to classify the residual GB into anatomical types based on what they saw on the MRCP and developed a treatment strategy. [ 15 ] For cystic duct stump stones, they suggested an endoscopic method, and for a GB pouch or a sessile GB, a surgical approach. Endoscopic extraction of residual GB calculi and the use of extracorporeal shock wave lithotripsy to crush the calculi have also been reported.…”

“…reported that open surgery was performed on the majority of their patients (18/21). [ 15 ] However, centres with advanced laparoscopy have found that in the vast majority of cases, the surgery can be completed laparoscopically. [ 8 22 ]…”

The complications of subtotal cholecystectomy: A case report

“…For our patient it was a residual gallbladder (RGB) due to unintentional subtotal cholecystectomy which made the preoperative diagnosis difficult. The subtotal cholecystectomy can be performed by surgeons to avoid difficult calots dissection and iatrogenic complications [ 8 , 9 ]. If the incidence of a required subtotal cholecystectomy is estimated to 5%, the incidence of unintentional incomplete cholecystectomy is still unknown [ 10 ].…”

“…Many complications may occur due to the subtotal cholecystectomy such as biliary fistula. Even a case of de-novo malignancy in the residual gallbladder was reported [ 9 ].…”