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DOI: 10.1055/a-1882-5491
Endoscopic management of cystic duct stumpitis
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A 62-year-old man who underwent an uncomplicated laparoscopic cholecystectomy 1 year prior for acute gangrenous cholecystitis presented with abdominal pain. Computed tomography demonstrated a dilated cystic duct remnant with stones ([Fig. 1]), confirmed on magnetic resonance cholangiopancreatography. The patient declined surgical intervention. Given the recent evidence [1], the patient was referred for an endoscopic retrograde cholangiopancreatography (ERCP).
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Cholangioscopy (SpyGlass Direct Visualization System; Boston Scientific, Natick, Massachusetts, USA) during ERCP revealed a markedly inflamed and stenosed cystic duct insertion ([Fig. 2]), thought to be reactive from stone disease, precluding advancement of the cholangioscope into the cystic duct remnant. The remainder of the bile duct epithelium was normal. An occlusion cholangiogram demonstrated an obstructing stone within the cystic duct remnant ([Fig. 3]). Owing to the severe inflammation, attempted stone extraction was deferred. A 5Fr × 10-cm plastic pigtail stent was placed into the cystic duct remnant for transpapillary decompression to facilitate inflammation healing ([Fig. 4]). The patient was discharged home on a course of oral antibiotics.
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On repeat ERCP 3 months later, the stent was removed and cholangiogram demonstrated a persistent stone in the cystic duct remnant([Video 1]). Cholangioscopy was performed and the inflammation had resolved ([Fig. 5]). The cholangioscope was advanced into the remnant, and a small cholesterol stone was visualized. Electrohydraulic lithotripsy (EHL) was successfully employed and the stone was extracted. A final occlusion cholangiogram confirmed clearance of the cystic duct remnant. On 4-week follow-up, the patient confirmed complete resolution of symptoms.
Video 1 Follow-up endoscopic retrograde cholangiopancreatography 3 months after initial procedure.
Quality:
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Surgical resection of the cystic duct remnant has been the traditional approach for treatment of cystic duct remnant syndromes [2]. We report a case of cystic duct stump syndrome (stumpitis) managed solely with endoscopy. This case demonstrates that transpapillary stenting and calculi extraction can be effective for this syndrome, highlighting the expanding role endoscopy plays in the management of postsurgical conditions.
Endoscopy_UCTN_Code_CCL_1AZ_2AD
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Publication History
Article published online:
21 July 2022
© 2022. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)
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References
- 1 Hajifathalian K, Issa D, Carr-Locke D. et al. Cystic duct remnant syndrome: endoscopic approach to management. VideoGIE 2019; 4: 563-564
- 2 Kar A, Gulati S, Mohammed S. et al. Surgical management of cystic duct stump stone or gallbladder remnant stone. Indian J Surg 2018; 80: 284-287