Cystic duct remnant fistulization to the gastrointestinal tract

Cystic duct remnant (CDR)-enteric fistulization is a rare entity, with only four recorded cases in the literature. CDRs can be found in at least 30% of patients after cholecystectomy and have been reported in as many as 83% of these patients. Calculous obstruction of the CDR or the common bile duct in a patient with a CDR must be present for fistulization to occur. Patients with a CDR-enteric fistula will have biliary tract symptoms after cholecystectomy and may have biliary sepsis. The septic episode or cholangitis may and can resolve when the CDR decompresses through the fistula. In a patient with persistent biliary tract symptoms, CDR should be considered as a possible cause, and common bile duct stones are often associated with CDRs. Signs of systemic infection in patients with biliary symptoms after cholecystectomy may indicate CDR fistulization. If a CDR is suspected, endoscopic retrograde cholangiopancreatography is the diagnostic and potentially therapeutic test of choice. If the patient cannot be successfully treated with endoscopic retrograde cholangiopancreatography or has recurrent symptoms, operative therapy is indicated, including division of the fistula, excision of the CDR, and common bile duct exploration. There may be an increase in the number of complications associated with CDRs, considering the increasing frequency of laparoscopic cholecystectomy resulting in more lengthy CDRs.