CYSTIC DUCT STUMP SYNDROME TREATED WITH ROUX-EN-Y HEPATICOJEJUNOSTOMY

Objectives:

Introduction:
Post-Cholecystectomy Syndrome (PCS) is defined as the persistence of biliary symptoms following cholecystectomy. It can occasionally be caused by a remnant cystic duct with the subsequent formation of stones, leading to the term “Cystic Duct Stump Syndrome” (CDSS). Cystic duct remnant is commonly classified as a >1 cm remnant of the cystic duct due to a subtotal cholecystectomy, which appears to be a more common phenomenon with laparoscopic cholecystectomy due to efforts to prevent injury to the common bile duct.

Case Presentation: 31-year-old female presents to the emergency department with jaundice and severe abdominal pain. Past surgical history includes cholecystectomy and robotic sleeve gastrectomy 2 years prior for weight loss. Workup included CT abdomen, MRCP which revealed stricture of CBD distal to the cystic duct stump, ERCP with brush biopsy of stricture, balloon dilation of the CBD and pancreatic ducts, sphincterotomy and stent placement. Workup revealed a prominent large gallstone in her cystic duct remnant in addition to biliary stricture, and she was referred to general surgery clinic.

Patient consented for open biliary reconstruction with roux-en-y hepaticojejunostomy for removal of gallstone and bypass of biliary stricture. The gallstone was palpable intraop and visualized within cystic duct remnant and removed. A roux limb of jejunum was created in a standard fashion and was anastomosed in an antecolic fashion to the common hepatic duct. An internal/external biliary drain/stent was created using a 5fr pediatric feeding tube from the common hepatic duct-jejunal anastomosis and brought through the jejunal stump and abdominal wall placed to gravity. The incision was closed with staples, and she recovered appropriately. The biliary drain was studied on POD 3 and showed patent right and left hepatic ducts and no leak from the anastomosis.

Discussion/

Conclusion: One possible cause of post-cholecystectomy syndrome is the formation of a gallstone in the remnant of the cystic duct due, as seen with our patient. Traditional approaches utilized laparoscopic or open techniques to remove the gallstone and cystic duct remnant as well as laser lithotripsy or ERCP with basket however, Roux-en-Y hepaticojejunostomy was the appropriate surgical management for our patient to prevent ongoing cholelithiasis and choledocholithiasis in the setting of common bile duct stricture.

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