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MULTIDISCIPLINARY APPROACH TO MANAGEMENT OF SUBTOTAL CHOLECYSTECTOMY COMPLICATIONS WITH URSODIOL: A CASE REPORT AND REVIEW OF THE LITERATURE
Rachel McNulty
*, Kathryn A. Stackhouse, Faris El-Khider
Cleveland Clinic Akron General, Akron, OH
Cases of acute cholecystitis with severe gallbladder (GB) inflammation may result in subtotal cholecystectomy (STC) to mitigate perioperative complications. Patients remain vulnerable to subsequent GB disease and morbidity; postoperative bile leak, endoscopic retrograde cholangiopancreatography (ERCP), percutaneous drainage. Guidance for management of these cases has yet to be established in the literature. Remnant cholecystectomy may be definitive but is not always feasible. We present a case of remnant cholecystitis in a patient with prior STC temporized with ursodiol.
A 74-year-old man with a history of STC 3.5 years prior presented to the emergency room with two days of epigastric pain, nausea and chills. Laboratory testing revealed leukocytosis, total bilirubin 1.4 mg/dL, normal alkaline phosphatase (ALP) and transaminases. Abdominal CT showed a dilated and inflamed cystic duct remnant with a possible stone in an uncertain anatomic space (Fig. 1). MRCP showed thick-walled remnant GB with layering sludge, exophytic cystic foci (Fig. 2), and cholelithiasis in what was determined to be either the remnant GB or cystic duct. His transaminases increased; ERCP was performed with sweeping of the biliary tree revealing only purulent sludge, without choledocholithiasis. Patient’s symptoms, leukocytosis, transaminases and bilirubin normalized post-ERCP. This patient recently underwent cervical laminectomy, preventing surgical clearance, so he was started on ursodiol to prevent further symptoms until his remnant cholecystectomy, planned in the near future.
During the emergent fenestrating STC performed for acute cholecystitis years prior, the GB was dissected to the infundibulum and left open to a JP drain; closure of the cystic duct was not noted. An ERCP for bile leak on postoperative day (POD) 2 failed due to difficult biliary duct cannulation. ERCP on POD 3 was performed with placement of a CBD stent. Days after JP drain removal, the patient returned with abdominal pain and fever. Abdominal CT showed biloma, requiring JP drain replacement. A third ERCP at that time was notable for choledocholithiasis with successful stone removal. He was treated with ursodiol for the next year for persistent pain, bloating and elevated ALP. He then remained asymptomatic without treatment for a year prior to his presentation above. In total, he required 2 JP drains, a CBD stent and 4 ERCPs with multiple courses of ursodiol and antibiotics since his STC.
Morbidity following STC, especially without control of the cystic duct, is known. Reported rates of remnant cholecystectomy –a high-risk operation- vary. Ursodiol may prevent symptoms and recurrent cholecystitis when surgery is not an option. More research is needed to know its post-STC efficacy in reducing morbidity and need for remnant cholecystectomy to guide hepatopancreaticobiliary surgeons and gastroenterologists.
Figure 1. Abdominal CT. Arrow points to hyperdense material representing possible cholelithiasis versus biliary sludge.
Figure 2. MRCP demonstrating layering sludge. Arrow points to exophytic lesions of remnant gallbladder.
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