J Gastrointest Surg

DOI 10.1007/s11605-014-2530-4

ORIGINAL ARTICLE

Surgical and Endoscopic Management of Remnant Cystic

Duct Lithiasis After Cholecystectomy—a Case Series
Michael R. Phillips & Mark Joseph & Evan S. Dellon &
Ian Grimm & Timothy M. Farrell & Christopher C. Rupp

Received: 18 December 2013 / Accepted: 21 April 2014

# 2014 The Society for Surgery of the Alimentary Tract

Abstract
Introduction Postcholecystectomy syndrome (PCS) as a result of remnant cystic duct lithiasis (RCDL), or gallstones within the
cystic duct after cholecystectomy, can cause persistent or recurrent symptoms after cholecystectomy.
Study Design A retrospective descriptive analysis was performed for all patients with RDCL at a single institution between 2001
and 2012. Details of presentation, diagnosis, and surgical and endoscopic treatments, and outcomes were collected and analyzed.
Results Twelve patients with RCDL were identified. The interval between cholecystectomy to RCDL discovery was 34.2 months
(range 0.5–168 months). On a standard liver enzyme panel, 75 % of patients had derangements in ≥1 indices, with the most
common single laboratory test abnormality occurring in gamma-glutamyl transferase (GGT) (80 %). Eight operative reports
noted that the cystic duct was noticeably dilated at the time of cholecystectomy. Two patients developed a cystic duct leak
(Strasberg type A bile duct injury) postoperatively, which was managed nonoperatively. Six cases of RCDL required surgery, and
six were managed endoscopically.
Conclusion RCDL is a potential cause of postcholecystectomy syndrome, but the true incidence is unknown. Laboratory
analysis and imaging are helpful in establishing the diagnosis of RCDL. Endoscopic therapy has a role in the treatment of
RCDL, but surgical excision of the remnant cystic duct lithiasis may be required.

Keywords Remnant cystic duct lithiasis (RCDL) .

Cholecystectomy . Postcholecystectomy syndrome

Abbreviations Introduction
RCDL Remnant cystic duct lithiasis
GGT Gamma-glutamyl transferase Cholecystectomy is the most common abdominal operation
PCS Postcholecystectomy syndrome performed by general surgeons, with an estimated 750,000
AST Aspartate aminotransferase cases in the USA each year.1 Most cholecystectomies
ALT Alanine aminotransferase are performed due to the sequelae of cholelithiasis, with
the vast majority of patients experiencing complete
M. R. Phillips (*) : M. Joseph : T. M. Farrell
symptom relief after cholecystectomy. However, approx-
Department of Surgery, University of North Carolina at Chapel Hill, imately 5 % of patients continue to have symptoms
101 Manning Drive, Chapel Hill, NC 27514, USA after cholecystectomy and are sometimes designated as
–
e-mail: miphilli@unch.unc.edu suffering from postcholecystectomy syndrome (PCS).2 6
E. S. Dellon : I. Grimm
It has been suggested that the majority of patients who
Division of Gastroenterology and Hepatology, Department of develop PCS actually suffer from nonbiliary disorders, such
Medicine, University of North Carolina at Chapel Hill, 101 Manning as gastroesophageal reflux disease, peptic ulcer disease,
Drive, Chapel Hill, NC 27514, USA nonulcer (functional) dyspepsia, or chronic pancreatitis.5
However, a small percentage of patients truly have symptoms
C. C. Rupp
Department of Surgery, Prevea Health, 1715 Dousman Street, Green attributable to the extrahepatic biliary tree, from etiologies
Bay, WI 54303, USA such as biliary strictures, retained choledocholithiasis,
 J Gastrointest Surg

sphincter of Oddi dysfunction, and remnant cystic duct lithi- Results

asis (RCDL).
The etiology of true RCDL is presumed to be from calculi
remaining from the initial cholecystectomy, rather than calculi
developing de novo because of a subtotal cholecystectomy.
Estimates suggest that at the time of cholecystectomy, nearly
15 % of patients have lithiasis present in the cystic duct, which
has been shown to correlate preoperatively with choledocho-
lithiasis, elevated liver enzymes, and pain in the months
preceding cholecystectomy. Some series have reported that
up to 30 % of patients suffering from PCS have RCDL as the
,
etiology of persistent symptoms.7 8
The true incidence of retained calculi in the cystic duct
stump, however, has not been described. Most published
series are small and aggregate heterogeneous disease process-
es, including patients with remnant gallbladders secondary to
intentional or unintentional subtotal cholecystectomy along
with patients truly having retained calculi in the cystic duct
,
stump.9 10 Estimating the actual incidence of remnant cystic
duct lithiasis is difficult, if not impossible, because patients
may obtain follow-up care from centers distinct from where
the original procedure was performed.
Given the difficulty in determining the burden of disease
attributable to RCDL, we designed a study to evaluate our
institutional experience with RCDL and herein describe the
largest case series to date specific for the condition. Our
primary goal was to define risk factors associated with
RCDL. Secondarily, while the historical gold standard for
the treatment of RCDL has been surgical excision of the cystic
duct remnant, we describe our experience in diagnosing and
treating these patients using a multidisciplinary approach.
A total of 12 patients (5 men, 7 women) with RCDL were
identified. The mean age at presentation for RCDL was
38.3 years (range 24–57 years), and average body mass index
was 35.2 kg/m2. The mean interval from initial cholecystec-
tomy to discovery of RCDL was 34.2 months (range 0.5–168
months). Final pathologic diagnoses at the initial cholecystec-
tomy included chronic cholecystitis (seven), acute cholecysti-
tis (four), and gangrenous cholecystitis (one). Only four of the
patients had their initial surgery at our institution, and opera-
tive procedures performed included eight laparoscopic chole-
cystectomies (one with intraoperative cholangiogram) and
two open cholecystectomies. The reasons for conversion to
an open procedure or the omission of intraoperative cholan-
giogram at the time of initial surgery were not available.
Each of the 12 patients had symptoms that persisted or
recurred after their initial cholecystectomy, similar in quality
to the pain experienced at their initial presentation. All patients
reported right upper quadrant or epigastric pain. Four patients
reported nausea/emesis. Three patients were discovered to
have varying degrees of jaundice. Of note, 75 % of patients
had derangements in ≥1 indices on a standard liver enzyme
panel (total bilirubin, aspartate aminotransferase [AST], ala-
nine aminotransferase [ALT], alkaline phosphatase, and
gamma-glutamyl transferase [GGT]). The most common lab-
oratory abnormality occurred in GGT (abnormal in 80 % of
those tested), followed by AST, ALT, and alkaline phospha-
tase (each abnormal in 58.3 %) (Table 1).
Table 1 Liver enzyme panels for each patient with remnant cystic duct
stump calculi at time of discovery

Patient TBili AST ALT AlkPhos GGT

Materials and Methods 1 0.3 25 22 10 20

2 4.1 96 316 415 527
We conducted a retrospective study of all patients un- 3 1.4 67 209 160 316
dergoing cholecystectomy or endoscopic retrograde 4 0.7 103 128 150 157
cholangiopancreatography (ERCP) from August 2001 to 5 1.3 92 370 70 N/A
May 2012 at the University of North Carolina (UNC) 6 1.5 156 269 181 311
Hospitals. Electronic medical record and endoscopy databases 7 3.0 925 819 185 889
were queried. Patients who underwent surgery for RCDL, or 8 0.1 17 23 73 N/A
patients identified at ERCP as having RCDL, were selected 9 1.3 31 49 125 190
for study inclusion in this case series. For each subject, we 10 0.7 32 44 130 159
recorded demographic information, existing comorbidities, 11 0.7 144 115 102 401
preoperative and postoperative symptoms, imaging results, 12 0.6 31 30 127 15
operative and pathologic findings, postoperative complica- Total abnormal (%) 50 58.3 58.3 58.3 80
tions, and mortality. Follow-up was conducted using postop-
erative clinic notes to monitor for recurrent symptoms. Elevated values are listed in bold
Statistical analysis was not performed given the small number TBili total bilirubin (upper limit of normal 1.2 mg/dL), AST aspartate
aminotransferase (upper limit of normal 55 U/L), ALT alanine amino-
of patients identified with the disease process. This study was transferase (upper limit of normal 72 U/L), AlkPhos alkaline phosphatase
approved by the Institutional Review Board of the UNC (upper limit of normal 126 U/L), GGT gamma-glutamyl transferase
School of Medicine. (upper limit of normal 68 U/L), N/A not available
J Gastrointest Surg
Initial operations consisted of nine laparoscopic and three
open cholecystectomies. No choledocholithiasis or cystic duct
calculi were noted in any of the 12 initial cholecystectomies.
Intraoperative cholangiography was performed in only one
cholecystectomy (laparoscopic) without discovery of cystic
duct lithiasis. While the actual diameter of the cystic duct was
available in only three operative reports (5, >10, >10 mm),
eight operative reports made specific notation that the cystic
duct was noticeably dilated at the time of cholecystectomy.
Only one operative report stated that the cystic duct was
normal in caliber.
Cystic duct ligation techniques were recorded. Five cystic
ducts were ligated in what is considered “usual” laparoscopic
means at our institution (application of standard titanium clip
or Hem-o-lok® clip [Teleflex, Research Triangle Park, NC]).
Of the remainder, four cystic ducts required a stapler transec-
tion, one required an Endoloop® (Ethicon Endo-Surgery,
Cincinnati, OH), and two required hand-sewn closure tech-
niques. Both the use of Endoloop® and suture ligation tech-
niques were noted in the operative report to be necessary due
to the enlarged diameter of the cystic duct.
Two patients developed cystic duct stump leaks, also
known as Strasberg type A bile duct injuries,11 after the initial
surgery. Both injuries were successfully treated by percutane-
ous drainage. Radiologic imaging was utilized extensively in
the evaluation of PCS in our series. Of all imaging modalities,
magnetic resonance cholangiopancreatography (MRCP) was
the most often utilized to obtain the diagnosis of RCDL (six).
The remaining calculi were discovered by computerized to-
mography (CT) scan (two), ultrasonography (two), operative
cholangiography (one), and ERCP (one) (Fig. 1). In most
patients, there were multiple radiologic imaging modalities
utilized in the evaluation process, with no discernible order
Fig. 1 Retained cystic duct
calculi identified by endoscopic
retrograde cholangiography (a)
and MRCP (b). Arrow denotes
filling defects identified in each
imaging modality
identifiable. The relative utilization of the various common
imaging modalities is presented in Table 2.
Management of RCDL included several modalities. There
was an equal distribution in the number of patients undergoing
reoperation (six) compared to endoscopic treatment alone
(six). Two of the six patients represented with the clinical
constellation of symptoms and findings consistent with acute
remnant cystic duct obstruction and inflammation that re-
quired urgent surgical intervention. These symptoms and
findings included persistent right upper quadrant pain for
>24 h, nausea and emesis, abnormal LFTs, leukocytosis, and
cystic duct cholelithiasis with inflammatory changes on radio-
graphic imaging. Due to the nature of clinical presentation, the
patients were taken directly to surgery without attempted
endoscopic intervention. Of the remaining four patients
treated surgically, three had failed attempts to remove stones
endoscopically, including one patient with Mirizzi syndrome
and one patient with extravasation of contrast at initial ERCP.
The final patient elected to proceed to surgery without
attempted endoscopic stone retrieval. Of the patients
undergoing repeat surgery, all were attempted laparoscopically
but required conversion to an open procedure due to
dense adhesions/chronic inflammation in the porta hepatis.
Intraoperative cholangiography revealed the presence of con-
comitant choledocholithiasis in both patients, and a common
bile duct exploration was employed for calculi removal at the
time of reoperation. Six patients were managed by ERCP;
three with sphincterotomy and balloon extraction; and one
with sphincterotomy, lithotripsy, and basket retrieval. One
patient required only balloon sweep of the common bile duct.
In the remaining patient, the cystic duct stone could not be
readily retrieved by ERCP and no further management was
employed due to the patient’s preference.

Table 2 Radiologic imaging modalities utilized in the evaluation of
postcholecystectomy syndrome and their accuracy in identifying remnant
cystic duct lithiasis (RCDL)
Radiologic Patients undergoing Number of Accuracy
study imaging modality RCDL identified (%)
Ultrasonography 9 5 55.6
CT scan 7 5 71.4
MRI 9 8 88.9
Of the 12 patients treated with surgical or endoscopic
intervention for RCDL at our institution, 9 were seen in
follow-up clinic visits by the attending gastroenterologist or
final operative surgeon. Two patients were lost to follow-up.
One patient did not live local to our institution and after
incomplete endoscopic treatment preferred no further endo-
scopic intervention or surgical referral. Of the nine patients
with available follow-up clinic notes, seven experienced
symptom resolution (77.8 %) with a mean follow-up of
11.8 months. Of the two patients with persistent symptoms,
notes suggested that one patient may have had pain from fatty
liver disease or a question of right upper quadrant incisional
hernia and the other patient had ongoing work-up for persis-
tent RCDL after initial endoscopic lithotripsy.
Discussion
The burden of disease attributable to RCDL as a cause of
postcholecystectomy syndrome has not been well-defined,
and estimates vary in the literature. It is difficult to quantify
the exact incidence at our institution, but RCDL is a rare cause
of postcholecystectomy syndrome in our patient population.
Rozsos et al. estimated that the cystic duct stump syndrome, or
an excessively long cystic duct stump, is the cause of persis-
tent or recurrent symptoms in 16 % of patients with PCS.12
There was no indication in this study regarding how many
patients had RCDL versus an isolated cystic duct stump
without calculi. In a recent study by Palanivelu et al., the
incidence of remnant cystic duct stump calculi causing symp-
toms in patients undergoing standard laparoscopic cholecys-
tectomy was estimated at 0.02 %.9 However, this estimation
was based on the number of patients undergoing remnant
resection at their institution and did not include patients un-
dergoing successful endoscopic retrieval. In addition, it is
unclear from this study how many patients had their initial
operation at the same institution as the cystic duct stump
excision, and thus, the denominator used may not be repre-
sentative of the true extent of the disease burden. This exact
situation is frequently encountered at our institution, and
nearly half of the patients in the present series had their initial
cholecystectomy at another facility. Thus, it is not possible for
J Gastrointest Surg
us to accurately state the incidence of symptomatic RCDL on
the basis of our single-institution study.
In this series, symptoms associated with PCS in cases of
RCDL, specifically right upper quadrant pain, appear to be
associated with dilation of a hollow viscus, as there was a high
rate of symptom resolution after both endoscopic and surgical
interventions. Surgical pathology results and dense adhesions
noted at the time of surgery suggest that the presence of RCDL
leads to associated portal inflammation. However, the resolution
of PCS in 77.8 % of patients in this series, regardless of method
of treatment, suggests that ongoing symptoms are related to the
presence of stones themselves within the hollow viscus.
Proposed risk factors for recurrent symptoms due to RCDL
include a cystic duct stump >1 cm in length, a low cystic duct
insertion into the common bile duct, and use of nonabsorbable
, ,
material for ligation of the cystic duct stump.9 13 14 The ac-
ceptable length of a cystic duct remnant in the laparoscopic era
has been an area of discussion due to the fact that one technical
aspect of a safe dissection within the hepatocystic triangle is to
delineate the cystic duct at the cystic duct/gallbladder-infun-
dibulum junction. In theory, this minimizes the chance for
injury of the common bile duct. However, if the cystic duct is
ligated in this location, there is often a long cystic duct
remnant present. Previous studies have concluded that in more
than 50 % of cholecystectomies, the length of the remnant
cystic duct is ≥3 cm.15 With our current series, endoscopic and
surgical reports did not describe the exact location of the
stones in relation to the site of surgical transection or the
origin of the cystic duct. One patient was noted to have a large
stone within the distal cystic duct remnant causing Mirizzi
syndrome at the time of representation. This makes it difficult
to describe the exact relationship between cystic duct length
and the occurrence of RCDL. In our opinion, given the po-
tentially devastating consequences of common bile duct inju-
ry, a long cystic duct remnant confers less risk than aggressive
dissection near the common bile duct. This assertion is
strengthened by the fact that several of the patients in our
study with RCDL were managed by endoscopic therapies
alone.
An interesting observation in our series was that the dictat-
ing surgeons noted a subjectively dilated cystic duct in 66.7 %
of these cases, with two estimated to be >1 cm in diameter.
This parallels the likelihood of surgeons utilizing special
techniques for ligation of the cystic duct at the time of chole-
cystectomy, with 58.3 % choosing either a stapling device,
ligation loop, or suturing method over titanium or Hem-o-lok
clips, as is common at our institution. This detail may
be an important indicator to the surgeon about the
possibility of calculi within the cystic duct itself that should
prompt further diagnostic modalities, such as use of intraop-
erative cholangiography.
Notably, only one patient undergoing cholecystectomy in
our study had a concomitant cholangiogram performed at the
J Gastrointest Surg
Fig. 2 Current institutional
algorithm used for the
management of
postcholecystectomy syndrome
and remnant cystic duct lithiasis
time of initial operation. Despite numerous well-designed studies
evaluating the value of intraoperative cholangiography, there is
still a lively discussion regarding the utility of routine versus
selective cholangiography. It seems reasonable to suggest that if a
selective approach is used for the identification of choledocholi-
thiasis, then a dilated cystic duct may be a potential indication to
proceed with cholangiography. However, the utility and predic-
tive value of this strategy would need further investigation.
Radiologic imaging guidelines for the evaluation of pa-
tients with suspected PCS do not exist. Previous studies
evaluating the diagnostic accuracy of various radiologic im-
aging modalities have found ultrasonography and MRCP to
be 60 and 92 % accurate, respectively.9 Our results are similar,
showing the accuracy of ultrasonography and MRCP at 55.6
and 88.9 %, respectively. While these findings support the use
of MRCP as the imaging modality of choice in the evaluation
of suspected PCS, however, the additional cost of MRCP as
well as the availability and local expertise regarding the inter-
pretation of MCRP images must be considered. Anecdotally,
our initial strategy for use of radiologic imaging began with
the least expensive and most readily available option, ultraso-
nography. If this was unrevealing, then computerized tomog-
raphy and magnetic resonance imaging were employed for
further investigation. Although the accuracy of ultrasonogra-
phy is lower than MRCP, it may be a more reasonable option
in the initial evaluation, when other diagnoses are being
entertained. Our current institutional algorithm omits the use
of ultrasonography in postcholecystectomy patients with ab-
normal liver function tests (Fig. 2). The delay of nearly 4 years
in our study between cholecystectomy and diagnosis of RCDL
speaks to the potential difficulty of this diagnosis and the need of
a high index of suspicion in patients with persistent symptoms.
Conclusion
,
Management of RCDL has traditionally been surgical.8 16
With the advent of advanced minimally invasive techniques,
successful laparoscopic management of this condition has
,
been reported,9 17 and our institution’s current algorithm re-
flects these changes (Fig. 2). In our experience, the six patients
who required operative intervention were ultimately treated
through an open approach after conversion from laparoscopy.
In all patients, the reason for conversion was dense chronic
inflammatory tissue in the porta hepatis and inability to safely
visualize the vasculo-biliary anatomy. Our institutional bias in
these situations is for early conversion to open techniques to
minimize the potential risk for vasculo-biliary injury, although
we acknowledge that this is institution-dependent. Of note, six
of the patients in our series were managed by endoscopic
techniques with successful calculi extraction from the cystic
duct remnant. This approach has previously been described,
but the actual utilization and availability of endoscopic tech-
niques are not clearly defined.18 To our knowledge, this high
rate of successful endoscopic management of remnant cystic
duct calculi has not been described before. In our experience,
endoscopy is a reasonable initial treatment option as it pro-
vides diagnostic and in some cases therapeutic alternatives.
The endoscopic approach would be favored as initial therapy
in patients presenting without recurrent inflammation of the

remnant cystic duct. The only contraindications to endoscopic
intervention would be those associated with the endoscopic
procedure itself (inability to cannulate the sphincter of Oddi,
coagulopathy, etc.). The early involvement of a biliary
endoscopist in the evaluation and treatment of PCS is crucial
to the successful management of RCDL and may obviate the
need for repeat surgery altogether.
In conclusion, RCDL can be a cause of postcholecystectomy
syndrome and the diagnosis should be entertained in a patient
with persistent or recurrent symptoms after cholecystectomy.
The ultimate diagnosis of RCDL is difficult and requires a
multidisciplinary approach, for successful management. In
many circumstances, surgery can be avoided by endoscopic
cystic duct stone retrieval methods.
Conflict of Interest All authors declare that they have no conflicts of
interest. This paper has not been published previously.
Funding Institutional support was provided by the Department of
Surgery at the University of North Carolina at Chapel Hill. There are no
relevant financial disclosures.
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