Reoperation of a patient following failed endoscopic management of cystic duct insufficiency – case report

Introduction: Acute cholecystectomy performed within 72 hrs of onset of inflammation ceases patient's symptoms with a significant reduction in morbidity and mortality. Conservative management is inefficient in 20% of cases, and in addition an operation is always required. Patients undergoing conservative treatment experience more complaints; in a delayed stage an operation is unavoidable.

Case report: A 77 y.o., obese female patient following a dietary lapse presented with typical symptoms of biliary colic. Acute cholecystitis was confirmed and conservative management was initiated. Despite antibiotic treatment she remained febrile, her abdominal complaints worsened and her laboratory values deteriorated. 14 days after the onset of her symptoms she was transferred to our hospital with signs of intraabdominal catastrophe. We performed laparoscopic staging and found a distended, gangrenous gall-bladder forming an abscess with the surrounding organs. After converting to laparotomy we performed oncotomy and anterograde cholecystectomy. Despite being difficult to identify due to the surrounding inflammation, the biliary structures were safely secured. Ather the 4th p.o. day biliary leakage without abdominal destruction was noticed. Endoscopic placement of endobiliary stents failed to stop cystic duct insufficiency. We proceeded with reoperation finding part of the neck of the gall-bladder on the open cystic duct. This could be explained by the slippage of ligature or erroneuosly ligating an abberant biliary duct or vessel. After ligating the cystic duct the biliary leakage stopped. 6 weeks later both stents could be removed. Patient remains without complaints.

Conclusion: Cholecystectomy performed within 72–96hrs of onset of acute cholecystitis is a gold-standard procedure. If conservative management fails to improve patient's symptoms, it is improtant to proceed with surgical treatment to avoid serious complications. In cases of empyema, or high grade local inflammatory process it is advised to perform intraoperative cholangiography to clarify biliary anatomy.