Early-stage T1b adenocarcinoma arising in the remnant cystic duct after laparoscopic cholecystectomy: a case report and literature review

Surgical management of cystic duct stump calculi causing post-cholecystectomy syndrome: A prospective study

Aim

Remnant cystic duct stump calculi are an uncommon but important cause of 'post-cholecystectomy syndrome'. High index of suspicion is needed to diagnose this condition in a symptomatic post-cholecystectomy patient. We present our experience with the surgical management of this condition.

Patients and Methods

This prospective study included 19 patients with residual gallstone disease who underwent completion cholecystectomy between August 2016 and October 2021. Investigations included abdominal ultrasound and magnetic resonance cholangiopancreatography. The demographic, clinical, surgical and early post-operative variables of these patients were prospectively maintained and analysed.

Results

The study included 14 women and 5 men. The mean age was 42.1 years (range, 14-80 years). The median duration between index surgery and completion cholecystectomy was 36 months (range, 2-178 months) (interquartile range, 105 months). The follow-up duration was 2 months. The initial surgery was open cholecystectomy in 17 and laparoscopic cholecystectomy in 2 patients. All patients with residual stump stone presented with pain, while 10 out of 19 patients complained of dyspepsia. Completion cholecystectomy could be performed laparoscopically in 16 cases, whereas 3 patients underwent open surgery. The mean operative time was 80 min (range, 55-140 min), and the mean blood loss was 100 ml (range, 50-160 ml). The mean hospital stay was 3 days (range, 2-10 days). No post-operative mortality or major morbidity was recorded in any of our patients.

Conclusion

Laparoscopic excision of the cystic duct stump is feasible and safe even after previous open cholecystectomy. It is increasingly becoming the treatment of choice where expertise is available.

A rare gastric metastasis secondary to residual cystic duct carcinoma: case report and literature review

An unusual gastric metastasis from residual cystic duct carcinoma was reported, which was easily mistaken as primary gastric carcinoma before the surgery. A 50-year-old Chinese man presented with right upper abdominal discomfort. Based on the biopsy and computed tomography results, an advanced gastric antrum adenocarcinoma was primarily diagnosed. Intraoperatively, there were other findings: residual cystic duct with chronic hyperplasia, a suspected purulent cavity filled with grayish-brown cloudy liquid at the distal end of the cystic duct and the gallbladder socket. The patient underwent radical operation. Histopathological findings finally suggested that adenocarcinoma of the residual cystic duct infiltrated into the whole layer of the gastric wall. Postoperative adjuvant chemotherapy and immunotherapy were administered. The patient has achieved 20-month recurrence-free survival. The comprehensive treatment including radical surgery, adjuvant chemotherapy and immunotherapy may improve the prognosis of such patients.

Cystic Duct Carcinoma: A New Classification System and the Clinicopathological Features of 62 Patients

Background

Cystic duct carcinoma (CDC) is a rare biliary malignancy with a low incidence and poor prognosis. However, the clinical landscape of the disease has not been clarified and no widely applicable classification system has been developed.

Methods

Sixty-two patients with CDC were included in this retrospective study, and a new classification system was established using imaging data. Blood indices, radiological characteristics, pathological features, surgical procedures, and overall survival data were collected. The efficacy of the new classification in predicting resectability was evaluated using receiver operating characteristic (ROC) curves, and K-means clustering and t-distributed stochastic neighbor embedding were applied to verify the conclusion.

Results

The pT stage of patients with type II CDC was significantly worse than that of type I. Patients with type II CDC were more likely to experience distant metastasis and invasion of the nervous system, vascular system, and liver. The resectability of patients with type II CDC was significantly worse than that of patients with type I CDC. Patients with type II CDC had worse prognoses. ROC curve analysis and K-means clustering revealed that the new classification could better categorize patients with CDC than currently available systems.

Conclusion

Patients with type II CDC have significantly worse clinicopathological outcomes. The new classification system has better accuracy in grouping patients with CDC.

T1b primary remnant cystic duct cancer following cholecystectomy: A case report

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Cystic duct cancer following cholecystectomy is a very rare entity.

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It is difficult to detect an early stage cystic duct cancer and confirm its superficial extension.

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Preoperative diagnosis is necessary to select a curative surgical procedure.

Introduction

Although primary cystic duct cancer is a rare entity, remnant cystic duct cancer is even more rare. We report a case of early cystic duct cancer following cholecystectomy.

Presentation of the case

A 81 year-old man complained temporary loss of appetite. He had underwent cholecystectomy for acute cholecystitis 5 years prior. Contrast enhanced computed tomography, magnetic resonance image and endoscopic ultrasonography showed remnant cystic duct tumor with protrusion to common bile duct. Endoscopic retrograde cholangiography revealed defect of contrast medium around confluence of the remnant cystic duct and common bile duct. We performed step biopsy by using forceps which revealed adenocarcinoma. Based on these findings, extrahepatic bile duct and remnant cystic duct resection were performed. The histopathology showed adenocarcinoma, pap > tub2, filling in remnant cystic duct, 30 mm in size but showed no lymphovascular or perineural invasion, no lymph node metastasis and negative surgical margin, and was classified as pT1bN0M0.

Conclusion

This is a rare case of primary carcinoma of remnant cystic duct cancer which is detected during computed tomography follow up for hepatic cell carcinoma recurrence. We confirmed remnant cystic duct cancer and its superficial extension to common bile duct with endoscopic ultrasonography and intraductal ultrasonography. Proper curative surgery was performed.