Acquired abnormalities of the biliary tract from chronic gallstone disease

Background: Acquired abnormalities of the biliary tract from chronic gallst one disease are rare. The aim of this study was to examine the frequency wi th which these abnormalities occur and to assess the probability of encount ering such an abnormality at laparoscopic cholecystectomy. Study Design: We conducted a prospective study of all patients undergoing e lective and emergency cholecystectomy under the care of one surgeon between January 1991 and December 1997. Results: Biliary tract abnormalities from chronic gallstone disease were en countered in 10 (2%) of 486 patients undergoing cholecystectomy. Four were observed in patients undergoing elective laparoscopy cholecystectomy, and t he remainder were observed at open cholecystectomy. Five had a cholecystoch oledochal fistula (Mirizzi Syndrome Type II), and one had a stone impacted at the cystic duct-bile duct junction (Mirizzi Syndrome Type I). Two had ch olecystoduodenal fistulas and two had an absent cystic duct with a normal b ile duct. Both instances of an absent cystic duct were encountered at lapar oscopic cholecystectomy; in one the bile duct was mistaken for the cystic d uct and a 2-cm segment was excised at operation, and in the other the abnor mality was recognized and confirmed by cholangiography. Conclusions: This study demonstrates a similar incidence of acquired abnorm alities of the biliary tract from chronic gallstone disease to that already reported. But acquired absence of the cystic duct may occur more frequentl y than previously suspected. Patients with this condition are at high risk for bile duct injury during laparoscopic cholecystectomy. Clinical awarenes s of this problem with strict adherence to the principles taught at open ch olecystectomy may prevent or reduce the severity of bile duct injury in the se patients. (J Am Coll Surg 1999;189:269-273. (C) 1999 by the American Col lege of Surgeons).