Answer to the question 2 from page 362

Prawidłowa odpowiedź: B.

Correct answer: B.

The patient had the residual gallbladder, remaining after the primary cholecystectomy, finally removed together with the stones. The patient has not reported similar complaint for 6 months.

Apart from surgeons, many doctors think that cholecystectomy is a surgical procedure consisting in a total gallbladder removal. Nevertheless, after such surgery almost always remains a fragment of a cystic duct and sometimes also the proximal part of a gallbladder- the greater the more difficult the surgery conditions were. Keiler at al.(1), using a traditional intravenous cholangiography in 113 patients, established that after laparoscopic cholecystectomy the cystic duct stump shorter than 1 cm was visible in 34.5%, 1–2 cm – in 36.3%, 2–3 cm – in 24.8%, and over 3 cm – in 4.4%. This situation is presented in fig. 2 (other patient) – one can notice the common hepatic duct (CHD) to which disembogues the cystic duct (which remained after cholecystectomy) which has the length of 23 mm and the diameter of 7 mm (arrow). The stone was not found in this case. The reasons of the residual gallbladder presence are various – it may be primarily left by a surgeon as a result of not recognizing it during surgical procedure or it may appear secondarily, some time after surgical procedure. In such situation one should expect the recurrence of clinical symptoms from before the surgical procedure – just like in the patient presented. Some think that gallbladder stump syndrome may occur also in the situation in which there is no concrement but there is an inflammatory process in the residual gallbladder. In the presented patient the ERCP, being a golden standard in pancreatic and bile duct diagnostics, came unstuck. This should not be surprising because there can be an inflammatory process in the remaining part of the gallbladder which can lead to cystic duct occlusion. This reason probably made the residual gallbladder fragment impossible to be contrasted in the ERCP in the patient presented and as a result no pathology was diagnosed. Apparently, one should realize the diagnostic inefficiency of this method in cystic duct stump syndrome or in gallbladder stump syndrome. The US examination in turn, in its transabdominal version is probably not able to determine the stone location. Is it then located in the residual gallbladder or in the site after its removal? Greater possibilities in this matter have endoscopic ultrasonography, cholangiography CT and cholangiography MRI in particular.

Fig. 2.

The case described is an example of the difficulties which might be encountered by the ultrasound examination performers in the assessment of porta hepatis area after cholecystectomy.