Video Caso Clínico: Síndrome del muñón del cístico, resección laparoscópica del remanente

Abstract

BACKGROUND: Laparoscopic cholecystectomy is one of the most frequently performed surgical procedures, which has gradually evolved to become one of the safest surgeries. However, no procedure is without risk; in this context, biliary duct injury (BDI) is the most important intraoperative complication during cholecystectomy. Common bile duct injury reaches a variable incidence between 0.4 to 1.4%, which is associated with significant long-term morbidity, including stenosis and recurrent cholangitis, significant limitations in the life quality of the patient [1]. In order to reduce the incidence of BDI, several alternative procedures can be performed during a difficult cholecystectomy, among which we can list: cholecystostomy, subtotal cholecystectomy and/or conversion to open cholecystectomy. Subtotal cholecystectomy, according to several meta-analyses, minimizes the possibility of bile duct injury, however, it is associated with the persistence or development of symptomatic gallstones in the remnant of the gallbladder or cystic duct; when this occurs, it is necessary to reoperate on symptomatic patients [1,2]. It is estimated that between 5-40% of patients who have previously undergone cholecystectomy, may present episodes of abdominal pain like those that initially motivated the surgical indication, grouped under the term "post-cholecystectomy syndrome" (PCS) [3]. PCS is mainly caused by residual lithiasis, which represents approximately 21.3% of readmissions [4]; other causes of PCS include: stenosis or bile leak, neuroma in the scar tissue, biliary dyskinesia, Oddi sphincter dysfunction. It is also worth highlighting, within the causes, the cystic duct remnant syndrome defined as "presence of a residual cystic duct greater than 1 cm that produces symptoms as a consequence of the lithiasis inside it", with a prevalence of less than 2.5% among patients that underwent cholecystectomy; however, a high index of suspicion will allow us to recognize it in the immediate postoperative period or even several years later [3,4]. The age range of onset of cystic duct remnant syndrome is from 21 to 90 years. The female preponderance of gallstones is the probable reason for greater frequency of the syndrome in this gender. Clinically, the main reason for consultation is abdominal pain in the right hypochondrium and epigastrium, which occurs in 77% of the patients; accompanied by nausea, in 44% of patients; vomiting in 31% and fever in 19% of patients [5]. Magnetic resonance cholangiopancreatography is the non-invasive technique of choice for evaluating the biliary tree, relegating endoscopic retrograde cholangiopancreatography (ERCP) as a strictly therapeutic technique. In addition, ERCP with sphincterotomy and possible placement of a stent to aid drainage of the main bile duct can be performed, along with definitive surgical treatment, by gallbladder and/or cystic remnant resection [3]. This case report details an experience of surgical reintervention in a patient with a remnant gallbladder and cystic duct with lithiasis.