JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES Volume 25, Number 0, 2015 ª Mary Ann Liebert, Inc. DOI: 10.1089/lap.2014.0186

Full Report

Laparoscopic Remnant Cholecystectomy and Transcystic Common Bile Duct Exploration for Gallbladder/Cystic Duct Remnant with Stones and Choledocholithiasis After Cholecystectomy Jie-gao Zhu, MD, and Zhong-tao Zhang, MD, PhD

Abstract

Background: Postcholecystectomy syndrome has been a long-standing source of frustration for surgeons. The objective of this study was to assess the feasibility and safety of laparoscopic remnant cholecystectomy (LRC) and laparoscopic transcystic common bile duct (CBD) exploration (LTCBDE) when adopted as the management for gallbladder/cystic duct remnant with stones and choledocholithiasis (GRSC) after cholecystectomy. Patients and Methods: This is a retrospective study of 11 patients who underwent surgeries for GRSC: the first 4 patients (Group 1) underwent open remnant cholecystectomy and CBD exploration, whereas the last 7 patients (Group 2) underwent LRC with LTCBDE successfully. Demographic data and perioperative parameters were analyzed and compared between the two groups. Results: All 11 patients had undergone cholecystectomy for symptomatic gallstone diseases. These patients had a mean age of 62 years. The time interval between cholecystectomy and the diagnosis of GRSC ranged from 4 years to 23 years (mean, 13 years). There was a significant reduction in postoperative hospital stay (5.00 – 1.41 versus 2.14 – 1.77 days, P = .034) and blood loss (35.00 – 10.00 versus 14.29 – 7.87 mL, P = .011) in Group 2 compared with Group 1. The 30-day morbidity rate was 9.1%. At a mean follow-up of 24 months (range, 6–45 months), no symptoms had recurred, and no mortality was recorded in this study. Conclusions: LRC and LTCBDE for GRSC are safe and feasible and could be offered as a choice in centers performing advanced laparoscopic procedures.

occur after either the open or laparoscopic operative approach, especially for the difficult triangle of Calot, where the anatomy may be distorted by recurrent episodes of inflammation.7–9 Laparoscopic remnant cholecystectomy (LRC) is advised for any residual gallbladder/cystic duct remnant in the previous reports.7–9 When gallstones and common bile duct (CBD) stones are present concurrently, laparoscopic transcystic CBD exploration (LTCBDE) does not alter postoperative stay and morbidity compared with laparoscopic cholecystectomy alone.10 Multiple studies11–14 on LTCBDE have been published, but no experience of LRC and LTCBDE as the management for gallbladder/cystic duct remnant with stones and choledocholithiasis (GRSC) has been reported except a case report.15 The objective of this study was to assess the feasibility and safety of LRC and LTCBDE when adopted as the management for GRSC.

Introduction

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holecystectomy, either laparoscopically or by the conventional open method, is considered to be the ‘‘gold standard’’ operation for gallstones, which provides relief of symptoms in a large majority of cases. Nevertheless, after successful cholecystectomy, small numbers of patients continue to experience symptoms of serious and severe episodes of upper abdominal pain, similar to those experiences prior to surgery. This represents the so-called postcholecystectomy syndrome.1 Postcholecystectomy syndrome has been a longstanding source of frustration for surgeons and patients alike. Biliary sources of postcholecystectomy syndrome include common duct stone, traumatic stricture, sphincter of Oddi dysfunction, and retained gallbladder.2–5 Small numbers of postcholecystectomy syndromes are related to residual or relapse stones in the gallbladder/cystic duct remnant.6 Gallbladder/cystic duct remnant during cholecystectomy can

Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China.

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2 Patients and Methods Patients and data collection

This is a retrospective study of patients who underwent surgeries for GRSC from January 2010 to September 2013 by a surgery team. Patients were arranged for surgeries after they were diagnosed of GRSC preoperatively by abdominal ultrasonography (US) and/or computed tomography (CT) or magnetic resonance cholangiopancreatography (MRCP) (Fig. 1). The study collected and evaluated the age, sex, preoperative investigations, operative methods, operative time, blood loss, and intraoperative and postoperative complications. Operative techniques

All the surgeries were carried out with the patient under general anesthesia and positioned supine. For the laparoscopic procedure, pneumoperitoneum was created using a Veress needle supraumbilically. The standard four-port configuration (one at the supraumbilical area [10 mm], one at the subxiphoid [12 mm], and two over the right subcostal area [5 mm]) was used with a 10-mm 30 telescope at the umbilicus. For the open procedure, a right subcostal incision of about 15 cm was made. A wide dissection of adhesion at the right abdomen and the triangle of Calot was performed carefully, and the cystic artery was clipped and cut off. After the bile duct was clipped 1 cm away from the CBD, a transverse incision was made in the lateral wall of the cystic duct. After dilation with the tip of the forceps, one suture was made to expose the cystic duct. Then a 3-mm or 5-mm flexible choledochoscope, according to the diameter of the cystic duct, was inserted into the CBD. The stones were retrieved individually in a wire basket through the choledochoscope. Saline flushing was used to remove the multiple relatively small stones in the CBD. To confirm duct clearance, we relied on two to three consecutive, proximal and distal, negative choledochoscopies. Then remnant cholecystectomy was performed from the gallbladder bed after the cystic duct had been clipped and divided. At the end of the procedure, a drain was placed in the subhepatic space if necessary and was removed on the first or second postoperative day if there was no bile leak. When the adhesion of the triangle of Calot was not easy to dissect, remnant cholecystectomy was performed first with a

ZHU AND ZHANG

retrograde dissection. For patients with unfavorable cystic duct anatomy, transductal exploration was carried out if transcystic exploration was impossible or had failed. Primary closure or a T-tube drainage was performed according to the results of transductal surgery. Conversion to the open procedure was the last choice for patients in Group 2. Statistical analysis

The continuous variables were expressed as mean – standard deviation values. Statistical analysis was by the Mann–Whitney U test for nonparametric data and for continuous variables. A two-sided P value of p.05 was considered statistically significant. Results

From January 2010 to September 2013, 11 patients admitted for postcholecystectomy biliary pain were diagnosed with GRSC. Intermittent pain in the upper abdomen was the hallmark of all patients, but a variable amount of associated symptoms, such as nausea and vomiting, also occurred. In addition to recurrent biliary colic, 2 patients had documented jaundice. There were four men (36.4%) and seven women (63.6%), with a mean age of 62 years (range, 33–83 years) in this study. The general demographics of these 11 patients are shown in Table 1. All 11 patients had undergone cholecystectomy for symptomatic gallstones. Surgery for 1 patient had been performed elsewhere, and 10 were operated on in our hospital. The different procedures performed are noted in Table 2. None had had an intraoperative cholangiogram. The time interval between cholecystectomy and the diagnosis of GRSC ranaged from 4 years to 23 years (mean, 13 years). There was no standard paradigm for the sequence and type of diagnostic tests performed to establish a biliary versus nonbiliary cause for the recurrent symptoms. All 11 patients received some form of biliary imaging besides US. Four had CT, and 9 underwent MRCP (Table 2). All the operations were performed by the same surgery team experienced in laparoscopic and open biliary surgeries. The first 4 patients (Group 1) chose open remnant cholecystectomy and CBD exploration: 3 via a transcystic completion and 1 via transductal exploration received primary ductal closure for a large stone about 20 mm in diameter. The

FIG. 1. Magnetic resonance cholangiopancreatography images from 3 patients demonstrating both gallbladder remnant (arrows) and common bile duct stones (arrowheads).

LRC AND LTCBDE FOR GRSC

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Table 1. Demographic and Perioperative Outcomes Characteristic

Number of patients

Age (years) (mean – SD) Sex Male Female History of diseasesa Hypertension Diabetes mellitus Coronary heart disease ASA score (I:II:III) Primary procedure Laparoscopic cholecystectomy Open cholecystectomy

61.82 – 14.44 4 7 5 4 2 1 0:9:2 2 9

a History of two coexistent systemic diseases was recorded in 2 patients. ASA, American Society of Anesthesiologists; SD, standard deviation.

last 7 patients (Group 2) tried LRC with transcystic CBD exploration successfully. The standard four-port configuration was performed in 6 cases, and only in 1 patient was a fifth trocar inserted at the midclavicular line near the umbilicus on the left because it was required for a longitudinal adhesion to the abdominal wall right beneath the incision. In terms of patient demographics, no statistical difference was observed between the two groups. However, there was a significant reduction in postoperative hospital stay (5.00 – 1.41 versus 2.14 – 1.77 days, P = .034) and blood loss (35.00 – 10.00 versus 14.29 – 7.87 mL, P = .011) in Group 2 compared with Group 1. The operative time showed a clinical difference between Groups 1 and 2 (106.25 – 61.96 versus 115.71 – 30.88 minutes), but the difference did not reach statistical significance (P = .738). The perioperative results are summarized in Table 3. No intraoperative complications or deaths occurred. Only 1 patient in Group 2 experienced acute abdominal infection that was treated conservatively with success. On Day 2 after discharge from the hospital, his temperature was higher than 38.5C. Physical examination revealed guarding and rebound tenderness in the right abdomen. The blood test showed the

level white blood cells was raised. The patient received outpatient treatment, and antibiotics were used. The body temperature returned to normal 2 days later; 4 days later, the white blood cell count was normal, and the patient was cured. No other postoperative complications were observed in the two groups. The 30-day morbidity rate was 9.1%. At a mean follow-up of 24 months (range, 6–45 months), no symptoms had recurred, and no mortality was recorded in this study. Discussion

Postcholecystectomy syndrome is a well-known longterm complication of both laparotomic and laparoscopic gallbladder removal. Small numbers of postcholecystectomy syndromes are related to recurrence of stones in the gallbladder/cystic duct remnant.16 The true incidence of unintentional gallbladder/cystic duct remnant is uncertain, but it seems slightly higher in the laparoscopic era.8 The main problem of gallbladder/cystic duct remnant is not the retained gallbladder/cystic duct remnant, but the stones within the remnant. The stones cause acute or chronic inflammation of the remnant; thus the patients can develop symptoms of postcholecystectomy syndrome. Migration of the stones to the CBD may lead to acute cholangitis and jaundice. However, no retrospective study of GRSC has been reported to date except a case report.15 In difficult cases of cholecystectomy, owing to obscure anatomy, signs of severe acute inflammation, or both, the fear of CBD injuries may lead to incomplete mobilization of the cystic duct and/or inadequate identification of the infundibular portion of the gallbladder.17 The inadequate identification of the infundibular portion of the gallbladder may lead to inaccurate clip placement, which sometimes results in an inadvertent subtotal cholecystectomy.18 However, a retained gallbladder/cystic duct remnant is sometimes latent. In our study, there was no evidence that a gallbladder/cystic duct remnant might have been left. The postoperative period of primary cholecystectomy was uncomplicated, and no clue of retained gallbladder/cystic duct remnant occurred. Recurrent symptoms of cholelithiasis may appear at variable intervals after the removal of gallbladders. Walsh at al.,7 while reviewing 7 patients with retained gallbladder/cystic duct remnant calculi, described the time from cholecystectomy

Table 2. Characteristics of the Patients (n = 11)

Patient 1 2 3 4 5 6 7 8 9 10 11

Emergency (original surgery)

Original cholecystectomy surgery

Time from cholecystectomy (years)

Diagnostic test

Gallbladder remnant size

Yes No No No No Yes No No Yes No Yes

Open Open Open Open Laparoscopic Open Laparoscopic Open Open Open Open

8 17 21 18 4 10 4 10 23 5 23

MRCP CT MRCP CT MRCP/CT MRCP MRCP/CT MRCP MRCP MRCP MRCP

4 · 2 · 2.5 5 · 3.5 · 0.5 4·2·1 3.5 · 1.4 · 1.8 4 · 2 · 1.5 4 · 2.5 · 0.5 2 · 1.5 · 1 6·4·4 3·2·2 2.8 · 2.5 · 0.4 3 · 2.5 · 1.5

CT, computed tomography; MRCP, magnetic resonance cholangiopancreatography.

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Table 3. Operative Outcomes (n = 11) Method

Number of patients Age (years) Male:female History of diseases ASA score (I:II:III) Operative time (minutes) Blood loss (mL) Postoperative stay (days)

Total

ORC + OCBDE

LRC + LTCBDE

Pa

11 61.82 – 14.44 4:7 5 0:9:2 112.27 – 41.78 20.00 – 13.42 3.18 – 2.14

4 68.75 – 9.91 1:3 2 0:3:1 106.25 – 61.96 35.00 – 10.00 5.00 – 1.41

7 57.86 – 15.75 3:4 3 0:6:1 115.71 – 30.88 14.29 – 7.87 2.14 – 1.77

.186 1 1 1 .738 .011 .034

Data are mean – standard deviation values or number of patients as indicated. a P for open remnant cholecystectomy (ORC) + open common bile duct exploration (OCBDE) versus laparoscopic remnant cholecystectomy (LRC) + laparoscopic transcystic common bile duct exploration (LTCBDE). ASA, American Society of Anesthesiologists.

to the onset of symptoms as ranging from 14 months to 20 years (median, 8.5 years). The median time from cholecystectomy to reoperation was 13 years in our series. In the period, patients often undergo a number of examinations or even treatments for other causes or coexistent disorders for the previous cholecystectomy and nonspecific symptoms. This was actually the case with 3 of our patients, whose symptoms were erroneously ascribed to esophagitis and gastritis, causing a delay of more than 4 years in diagnosis. US of the gallbladder bed is both sensitive and specific in detecting gallstones and dilatation of bile ducts and should usually be the first investigation in cases of suspected recurrent biliary pathology.9 This was found to be positive in visualizing gallbladder/cystic duct remnant containing gallstones in 7 cases in our study. MRCP is required, in most cases, to confirm the diagnosis of a dilated cystic duct or gallbladder remnant, as well as to examine the CBD. MRCP was performed in 9 of 11 patients and confirmed gallbladder/cystic duct remnant stones in 6 patients and common bile duct stone in 9. CT is recommended in cases of suspected other causes or coexistent disorders, as it offers the opportunity for diagnosis of GRSC. Once the diagnosis of GRSC is established, the combination of a complete cholecystectomy and CBD exploration is the definite treatment. The treatment of patients with gallbladder/ cystic duct remnants is excision of the remnant performed either laparoscopically or by the open technique.8,19,20 LRC was not as difficult as was initially expected, on the condition that it is performed by experienced laparoscopic surgeons.7,8 In our study, difficulties in terms of recognizing and dissecting the cystic duct–gallbladder remnant junction were encountered. However, there was no evidence of severe inflammation or firm adhesions. Dilatation of the gallbladder/cystic duct remnant gave us the opportunity to clearly dissect the cystic duct and artery and recognize the CBD. All these were critical to the success of the transcystic procedure. Patients treated with LRC and LTCBDE had a significantly shorter hospital stay and less blood loss compared with the corresponding open procedure. However, there was no difference in the operative time between the two groups. In general, it should be explained to the patients that there is a possibility that the procedure may be converted to an open one. Only 1 patient in Group 2 experienced acute abdominal infection and was treated conservatively with success. A

mean follow-up of 24 months presented a good prognosis with no morbidity and mortality. The optimal management of GRSC remains unclear in present, but we encourage more surgeons to perform this technique because we are convinced that most patients with GRSC can be managed by this gentle technique with good results. Conclusions

Among the causes of postcholecystectomy syndrome after successful cholecystectomy, either laparotomic or laparoscopic, residual or recurrent stones in the gallbladder/cystic duct remnant must certainly be considered. Diagnosis of stones in the gallbladder/cystic duct remnant is difficult. US, CT, and MRCP are the best methods for the diagnosis of possible CBD stones. LRC and LTCBDE for GRSC are safe and feasible and could be offered as a choice in centers performing advanced laparoscopic procedures with a low morbidity rate. Disclosure Statement

No competing financial interests exist. References

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Address correspondence to: Zhong-tao Zhang, MD, PhD Department of General Surgery Beijing Friendship Hospital Capital Medical University No. 95 Yong’an Road Xicheng District, Beijing City 100050 People’s Republic of China E-mail: [email protected]

cystic duct remnant with stones and choledocholithiasis after cholecystectomy.

Postcholecystectomy syndrome has been a long-standing source of frustration for surgeons. The objective of this study was to assess the feasibility an...
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