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When symptoms recur after cholecystectomy, the possibility of an inflamed remnant must be considered.
A woman aged 81 sought advice because of right upper quadrant pain and belching. She had experienced similar symptoms 24 months previously, at which time investigations at a district general hospital had revealed gallstones and she had undergone urgent subtotal cholecystectomy. The original operation note records that dissection of Calot's triangle was difficult because of inflammation, therefore a cuff of gallbladder was left in situ and a partial cholecystectomy was performed without intraoperative cholangiography. The patient recovered without incident and was well until her symptoms recurred. She was tender in the right upper quadrant but blood tests, including enzymatic liver function tests, were all normal. An endoscopic retrograde cholangiopancreaticogram (ERCP) revealed a stone in a large gallbladder remnant (Figure 1). The bile duct was normal.
She was then referred to our unit and after detailed risk assessment she was listed for completion cholecystectomy. At operation there was a sizeable gallbladder remnant. Calot's triangle was dissected and cholecystectomy was completed. An intraoperative cholangiogram was normal. The operative specimen contained a solitary large stone which appeared to be a primary gallstone, and chronic cholecystitis was confirmed histologically. At review two months after surgery she had recovered well.
Partial cholecystectomy (leaving a cuff of gallbladder in situ) can be a good option in the context of acute inflammation since a potentially hazardous dissection of Calot's triangle is avoided1. However, it is important to ensure that the remnant of gallbladder that is left is free of stones and also that this portion of gallbladder is small.
In the case described here, the differential diagnosis at the time of re-presentation included bile duct stones and the post-cholecystectomy syndrome. Studies of post-cholecystectomy patients record continued symptoms in up to 50% of patients2,3. After assay of liver function tests and transabdominal ultrasonography, ERCP is probably the definitive test.
Recurrence of symptoms similar to those of cholecystitis after cholecystectomy should not be attributed to entities such as the post-cholecystectomy syndrome until there has been thorough disease reappraisal. Unless the clinician is certain that the cholecystectomy was complete, the possibility of recurrent inflammation in a remnant gallbladder must be considered. The only certain way to prevent recurrence of gallstones in the gallbladder is total cholecystectomy. Finally, the value of a careful history is emphasized by the patient's insistence that the symptoms at the time of recurrence were identical to those at the time of her original illness.