Acquired abnormalities of the biliary tract from chronic gallstone disease

Acquired abnormalities of the biliary tract from chronic gallstone disease are rare. The aim of this study was to examine the frequency with which these abnormalities occur and to assess the probability of encountering such an abnormality at laparoscopic cholecystectomy.

We conducted a prospective study of all patients undergoing elective and emergency cholecystectomy under the care of one surgeon between January 1991 and December 1997.

Biliary tract abnormalities from chronic gallstone disease were encountered in 10 (2%) of 486 patients undergoing cholecystectomy. Four were observed in patients undergoing elective laparoscopy cholecystectomy, and the remainder were observed at open cholecystectomy. Five had a cholecystocholedochal fistula (Mirizzi Syndrome Type II), and one had a stone impacted at the cystic duct-bile duct junction (Mirizzi Syndrome Type I). Two had cholecystoduodenal fistulas and two had an absent cystic duct with a normal bile duct. Both instances of an absent cystic duct were encountered at laparoscopic cholecystectomy; in one the bile duct was mistaken for the cystic duct and a 2-cm segment was excised at operation, and in the other the abnormality was recognized and confirmed by cholangiography.

This study demonstrates a similar incidence of acquired abnormalities of the biliary tract from chronic gallstone disease to that already reported. But acquired absence of the cystic duct may occur more frequently than previously suspected. Patients with this condition are at high risk for bile duct injury during laparoscopic cholecystectomy. Clinical awareness of this problem with strict adherence to the principles taught at open cholecystectomy may prevent or reduce the severity of bile duct injury in these patients.