Complications Associated with the Cystic Duct Remnant

A successful cholecystectomy includes resection of the gallbladder and a portion of the cystic duct. Theoretically, the entire cystic duct should be removed. This is generally not possible, however, and often not advisable owing to anatomic and technical considerations.

Figure 4.20. Pseudocalculus sign. (A) Film from an ERCP shows a meniscus-shaped defect in the distal CBD simulating a stone. (B) Additional film from the ERCP in the same patient taken moments later shows the defect to have disappeared. The pseudo-calculus sign is due to contraction of the choledochal sphincter.

Figure 4.20. Pseudocalculus sign. (A) Film from an ERCP shows a meniscus-shaped defect in the distal CBD simulating a stone. (B) Additional film from the ERCP in the same patient taken moments later shows the defect to have disappeared. The pseudo-calculus sign is due to contraction of the choledochal sphincter.

The cystic duct's length, course, and angulation are variable and will determine the optimum site for ligation. Anatomically, the cystic duct has two portions; the convoluted juxtacholecystic segment, which contains the valves of Heister, and the smooth juxtacholedochal segment. Since particulate matter is more likely to be found in the proximal convoluted segment than in the distal smooth segment, it is desirable to remove the entire convoluted segment, but not necessarily the entire smooth segment.

The cystic duct may join the common duct at an acute angle, may course parallel to the common duct for a variable distance, or may course over or under the common duct to enter on its left-hand side (Figs. 4.21 and 4.22). In the latter circumstances, the walls of the cystic and common bile ducts are firmly bound together, and their junction lies deep within the hepatoduodenal ligament. Dissection in this region is associated with a high rate of bile duct injury. Complete excision of

Angular Short parallel Long parallel Spiral

Figure 4.21. Variations in the insertion of the cystic duct.

Angular Short parallel Long parallel Spiral

Figure 4.21. Variations in the insertion of the cystic duct.

FIGURE 4.22. Low medial insertion of the cystic duct. Film from an ERCP demonstrates the spiral or low medial insertion variant of cystic duct insertion. The walls of the cystic duct and common duct are usually firmly bound together.

the cystic duct is not advised, even when the junction is clearly seen at surgery, because the traction necessary for excision of the cystic duct may lead to common duct stricture. Optimally, the cystic duct remnant should be long enough to allow for adequate ligature without tenting the choledochus. With the angular configuration, it is generally advised to leave a cystic duct stump of 5 mm, although some surgeons feel that up to 1cm is safe [20]. With long remnants, stasis occurs and stones tend to re-form (Fig. 4.23). In patients with configurations other than the angular one, which occur in about 25% of the population, the cystic duct should be ligated at a site distal to the cholecystic ampulla (neck of the gallbladder), and the absence of stones in the stump should be verified.

Figure 4.23. Long cystic cholecystectomy reveals duct remnant. CT scan of the upper abdomen after a long dilated cystic duct remnant.

Figure 4.23. Long cystic cholecystectomy reveals duct remnant. CT scan of the upper abdomen after a long dilated cystic duct remnant.

The retention of calculi is the most common complication associated with the cystic duct remnant. Stones may be overlooked at the time of surgery or may form at a later date (Fig. 4.24). With long cystic duct remnants, stasis occurs, stones tend to re-form, and inflammatory changes may develop. Since most stumps will be located dorsal or pos-teromedial to the common duct and difficult to visualize in the antero-posterior projection, it is important to obtain films in the lateral or right posterior oblique projections during cholangiography to demonstrate stones in the cystic duct remnant [20]. Mirizzi's syndrome can occur secondary to a large stone impacted in the cystic duct, remnant causing compression and obstruction of the common duct.

FIGURE 4.24. Stone in cystic duct remnant. Film from an ERCP demonstrates a long cystic duct remnant that contains stones.

An excessively long cystic duct remnant with a bulbous dilatation of its proximal portion has been termed a "re-formed gallbladder"(Fig. 4.25). This can be a source of stone disease and subsequent choledo-cholithiasis. Retention of part of the gallbladder after cholecystectomy

Figure 4.25. "Re-formed gallbladder." (A) Plain film of the abdomen shows a stone in the right upper quadrant after cholecystectomy. (B) Film from the ERCP demonstrates a "re-formed gallbladder" containing calculi. (C) CT image in the same patient shows the dilated remnant and a calculus. (D) ERCP from another patient reveals a long cystic duct remnant with bulbous dilatation containing a stone.

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