Case Report

A 57 years old male, presented with history of pain in the right upper quadrant of the abdomen with nausea and occasional vomiting. There was no history of fever or obstructive jaundice. Past history revealed that he had undergone a laparoscopic cholecystectomy ten  years  earlier.  Surgery and immediate postoperative period were uneventful. He developed recurrent abdominal pain and jaundice a year after surgery. Endoscopic retrograde cholangiopancreatography (ERCP) showed a residual Common Bile Duct (CBD) stone which was extracted after sphincterotomy. A temporary stent was inserted for two months with complete relief.

 In the current presentation there were no abdominal findings. Routine hematological   and   urinary   examinations were normal. Ultrasound showed absent gall bladder  with  no  other  positive  findings. Since  symptoms  were  suggestive  of recurrent biliary disease, a Magnetic Resonance    Cholangiopancreatography  (MRCP) was advised. This showed a long cystic duct remnant, low insertion of the cystic duct and dilatation of the residual cystic duct mimicking a ‘neo-gall bladder’ (Cystic duct remnant syndrome). He was put on cholagogues and advised regular follow up.

 Fig. 1 MRCP showing dilatation of stump of cystic duct into a fusiform dilatation –‘neo gall bladder’

Discussion

 The cystic duct is subject to several anatomical developmental/congenital variations such as i) the cystic duct and common hepatic duct running parallel with a low confluence of cystic duct (Lamah et al.,2001) ii) insertion of the cystic duct in  the right or  left hepatic duct  and bifurcation of left and right hepatic ducts (Lamah et al.,2001) iii) anterior, posterior or spiral types of insertion of the cystic duct iv) absence or short cystic duct (less than 5mm)  v) double cystic duct (Fujikawa et al., 1998; Bernard et al., 2001)   vi) the right hepatic duct emptying into the cystic duct (Hashimoto et al., 2002) vii) hepatico-cystic duct (Loasnoff et al., 2002).

 Developmentally, it is from the pars cystica of hepatic bud arises both gall bladder and cystic duct. The bile duct arises also from hepatic bud proximal part to  pars cystica. During development bile duct opens first on ventral aspect of duodenum, when rotation of duodenal loop occurs, bile duct opens on the dorsomedial aspect of duodenum (Singh and Pal, 2007). Developmental anomalies such   as   Sessile   Gall   Bladder   –   direct opening of gall bladder into bile duct, agenesis – absence of gall bladder and diverticulum  from  any  part  of  the  gall bladder  has  been  documented  (Singh  and Pal, 2007).

Anatomical variations regarding the duct system have also been documented previously (Singh and Pal, 2007). This includes termination cystic duct on the left side of common hepatic duct, termination of cystic duct into right hepatic duct, opening into common hepatic duct after passing anterior to the duodenum,  opening of bile duct into either pyloric part or cardiac part or at end of stomach, partial or complete atresia of duct system, duplication of parts of duct system etc. Knowledge about the possible anatomical variations is of importance for successful treatment.

 Various authors have studied and reported on complications due to cystic duct variations.  The  left  out  cystic  duct  stump have frequently caused complications of cholecystectomy. Rogy et al., (1991) has reported post operative complication following  cholecystectomy  in  10%  which was due to remnant of cystic duct. Walsh et al.,  (2002)  has  reported  that  remnant  of cystic was the cause of relapse or recurrence of symptoms after cholecystectomy. It is preventable by identifying junction of cystic duct with CBD per operatively (Walsh et al.,2002). Tantia et al., (2008) also has reported left out cystic duct causes problems. Wani et al., (2010) has labeled this condition as post cholecystectomy Mirrizzi Syndrome.

Observations  of  the  present  study also support those previous reports. Low insertion of cystic duct in the present case might   have   evaded   surgeon’s   attention during surgery which had resulted in the remnant duct. With dilation of the remnant duct a “neo-gall bladder” was formed which had resulted in the relapse of symptoms. As concluded  by  Shaw  et  al.,  (2004)  MRCP was most useful and helped to diagnose the left out remnant duct after cholecytectomy in the present case. By presenting this interesting  case  about  left  out  cystic  duct after cholecytectomy and its involvement in post-operative complications, importance of knowledge about anatomy of extra-hepatic biliary apparatus is emphasized.

 Acknowlegements: Sincere thanks to

i. Dean,   Mahatma   Gandhi   Medical   College   & Research Institute

ii. Dr.  Ananth Krishnan, Prof  &  HOD  of  Surgery, Mahatma Gandhi Medical College & Research Institute for guidance.with the formation of common bile duct stones?

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