Time to focus on the potential benefit of minimally invasive treatment of remnant cystic duct stump stones

Cystic duct stump stones are a well-known cause of postcholecystectomy syndrome, a term referring to the 10%–30% of patients who complain of upper abdominal pain or jaundice after a cholecystectomy [1]. Until recently, the management of stones in the cystic duct stump has been generally challenging and invasive [2] [3]. Herein, we report the minimally invasive and visually successful removal of a cystic duct stump stone using a novel peroral choledochoscope, the Eye-Max (Micro-Tech, China).

A 60-year-old woman complained of having had intermittent right upper abdominal pain for 1 year; 10 years previously she had undergone laparoscopic cholecystectomy. Physical examination was unremarkable other than upper abdominal tenderness. The results of routine laboratory testing were: total bilirubin, 31.6 µmol/L; γ-glutamyl transpeptidase, 136 U/L; alanine aminotransferase, 571 U/L; aspartate aminotransferase, 849 U/L. Magnetic resonance cholangiopancreatography and endoscopic ultrasonography both revealed a stone 6.8 mm × 5.6 mm in size impacted in the remnant cystic duct ([Fig. 1] a, b). With the patient’s consent, it was proposed to remove the stone using a peroral choledochoscope. Biliary cannulation was performed by wire-guided cannulation using a sphincterotome preloaded with a 0.025-inch guidewire (Boston Scientific, USA). The peroral choledochoscope was then advanced into the remnant cystic duct through the working channel of a duodenoscope, and a dark brown stone was seen ([Fig. 1] c). Next, a retrieval basket (Micro-Tech, China) was inserted into the remnant cystic duct through the working channel of the peroral choledochoscope. Finally, the stone was grasped under direct visualization and pulled into the duodenum ([Fig. 1] d). Repeat cholangiography screened visually for further retained stones ([Video 1]). The patient recovered uneventfully and was discharged 5 days later.

Fig. 1 a In a 60-year-old woman with a history of intermittent right upper abdominal pain after previous laparoscopic cholecystectomy, magnetic resonance cholangiopancreatography revealed a stone impacted in the remnant cystic duct. b Endoscopic ultrasonography also revealed the stone impacted in the remnant cystic duct. c A peroral choledochoscope was advanced into the remnant cystic duct and a dark brown stone was seen. d The stone was grasped under direct visualization and pulled into the duodenum by a retrieval basket.

Removal of a cystic duct stump stone using a peroral choledochoscope.Video 1

This is the second reported case in which a peroral choledochoscope was used to remove a stone from a cystic duct stump [4]. The peroral choledochoscope has several advantages: minimal invasiveness, low cost, and good visualization. It merits attention now for use in the management of cystic duct stump stones.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Kumar S, Kurian N, Singh RK. et al. Surgical management of cystic duct stump calculi causing post-cholecystectomy syndrome: a prospective study. J Minim Access Surg 2023; 19: 257-262
• 2 Popescu RC, Leopa N, Dumitru A. et al. Residual gallbladder and cystic duct stump stone after cholecystectomy: laparoscopic management. Chirurgia (Bucur) 2021; 116: 484-491
• 3 Kar A, Gulati S, Mohammed S. et al. Surgical management of cystic duct stump stone or gall bladder remnant stone. Indian J Surg 2018; 80: 284-287
• 4 Zhang WL, Ji R. Cystic duct stump stone removal by retrieval basket under direct visualization using a novel peroral choledochoscope. Endoscopy 2023; 55: E100-E101

Publication History

Article published online:
06 February 2025