Choledocholithiasis may still occur after cholecystectomy, whereas laparoscopic transcystic common bile duct exploration (LTCBDE) has rarely been reported in postcholecystectomy patients. A 58-year-old woman presented with a 1-day history of right upper quadrant pain 10 years after laparoscopic cholecystectomy. Magnetic resonance imaging and magnetic resonance cholangiopancreatography revealed a distal common bile duct stone of ~4 mm and common bile duct dilation to 12 mm. Intraoperatively, a cystic duct remnant measuring 0.8 cm in length and 4 mm in diameter was identified. A choledochoscope was inserted through the remnant into the common bile duct, and the stone was successfully removed. The patient recovered uneventfully and was discharged on postoperative Day 5. During 6 months of follow-up, no stone recurrence or biliary complications were observed. This case suggests that LTCBDE may be technically feasible in selected postcholecystectomy patients with a suitable cystic duct remnant and favorable biliary anatomy.

Choledocholithiasis after cholecystectomy is a clinically significant cause of recurrent biliary symptoms and may result from retained stones, recurrent stone formation, or calculi within the cystic duct remnant. Although uncommon, cystic duct stump calculi can present several years after surgery and may be associated with chronic inflammation, adhesions, and, rarely, biliary fistula formation. We report the case of a 48-year-old female with a history of open cholecystectomy who presented with recurrent right upper abdominal pain, intermittent jaundice, clay-colored stools, and high-colored urine. Magnetic resonance cholangiopancreatography (MRCP) revealed choledocholithiasis with proximal biliary dilatation, along with a cystic duct stump calculus. The patient was planned for choledochoduodenostomy; however, intraoperative findings included dense adhesions, a cystic duct remnant-common bile duct (CBD) fistula, and an impacted stump stone, making the planned procedure unsafe. The surgical approach was modified, and CBD exploration with stone extraction and T-tube drainage was performed. The postoperative course was uneventful, and a T-tube cholangiogram confirmed satisfactory ductal clearance. The patient remained asymptomatic on follow-up, with normalization of liver function tests. This case highlights the importance of considering cystic duct stump pathology in post-cholecystectomy patients with recurrent biliary symptoms and underscores the need for individualized surgical decision-making in complex reoperative biliary surgery.

There are few reliable predictors for reduced pain after biliary sphincterotomy or medical therapy in patients with sphincter of Oddi dysfunction (SOD). We explored whether prolonged intestinal bile excretion time, dilated common bile duct (CBD) diameter, or elevated alanine aminotransferase (ALT) were associated with reduced pain after treatment for SOD. This is a retrospective, single-centre study. Consecutive patients suspected of SOD were identified and screened. Medical treatment for SOD followed institutional standards in line with the Regional pain medication guidelines. The primary outcome was potential prognostic markers for reduced pain. In the biliary sphincterotomy group (n = 34), 85% patients experienced reduced pain when evaluated in the outpatient clinic, while 60% of patients receiving medical therapy (n = 159) experienced reduced pain (p = 0.009). No association was found between the hepatobiliary scintigraphy excretion time nor ALT and reduced pain in either treatment group. However, a dilated CBD was associated with reduced pain (odds ratio 2.89; 95% CI [1.02;8.17]). In SOD patients, amelioration of pain in both medically and surgically treated patients is primarily associated with common bile duct dilation, rather than hepatobiliary scintigraphy excretion time or ALT.

Remnant cholecystitis caused by cystic duct stones is a rare cause of post-cholecystectomy syndrome and it is often difficult to diagnose. We report the case of a man in his seventies with recurrent epigastric pain one year after laparoscopic cholecystectomy. Computed tomography revealed a 10-mm cystic duct stone. Endoscopic retrograde cholangiography (ERC) demonstrated macroscopic purulent bile from the remnant cystic duct, whereas bile from the common bile duct was grossly normal. This confirmed the diagnosis of localized remnant cholecystitis, without the need for cholangioscopy. ERC-guided drainage and subsequent stone removal resulted in a complete recovery. To the best of our knowledge, this is the first report demonstrating macroscopic bile differentiation and successful treatment with ERC-alone.

Acute cholangitis is a potentially life-threatening condition commonly caused by bacterial infections of the biliary tract. Here, we present an unusual case of acute cholangitis caused by Vibrio cholerae in a 76-year-old man with a history of hypertension, diabetes, asthma, and post-cholecystectomy who presented with upper abdominal pain, jaundice, and fatigue. Lab results showed elevated inflammatory markers and bilirubin. Imaging revealed gallstones and bile duct dilation. Blood cultures isolated non-toxigenic Vibrio cholerae, which was highly susceptible to all tested antibiotics. The patient was successfully treated with piperacillin/tazobactam and levofloxacin, along with supportive care. His symptoms resolved, and subsequent cultures were negative. This case highlights a rare instance of non-cholera Vibrio cholerae causing acute cholangitis and bacteremia in an elderly patient.

Titanium is widely regarded as a biocompatible and inert material commonly used in surgical implants. Despite this reputation, hypersensitivity reactions to titanium, though rare, can lead to persistent and unexplained postoperative symptoms. We report the case of a 76-year-old woman who developed progressive right upper quadrant abdominal pain, burning sensations, neuropathic symptoms, and fatigue three months after laparoscopic cholecystectomy in which titanium clips were used. Her history included documented systemic intolerance to a titanium dental implant 10 years earlier, which had required removal. Extensive laboratory and imaging evaluation was unremarkable. Titanium hypersensitivity was clinically suspected based on the temporal association between clip placement and symptom onset, along with systematic exclusion of alternative causes. MELISA® (memory lymphocyte immunostimulation assay) testing was discussed, but declined due to cost and extended turnaround time. Following diagnostic laparoscopy and removal of the four titanium clips approximately three months after symptom onset, the patient experienced complete symptom resolution within one week. She remains asymptomatic at six-month follow-up. This case highlights the importance of considering metal hypersensitivity in patients with unexplained postoperative symptoms and prior exposure to implants. Increased awareness and selective preoperative screening, particularly evaluation for prior metal intolerance, may help prevent unnecessary morbidity and repeated interventions.

Biliary peritonitis, also known as choleperitoneum, is a rare but severe complication of cholecystectomy. The symptoms are non-specific, which can cause a delay in the diagnosis, leading to potential sepsis and multi-organ failure. A 45-year-old female underwent robotic cholecystectomy for gallstone pancreatitis and cholecystitis. One week post-operatively, she presented again with abdominal pain and distention, rapidly progressing to septic shock with respiratory, renal, and neurological failure. Initial imaging showed only mild ascites. Imaging showed a biliary leak, and paracentesis confirmed a biliary peritonitis by revealing bilious fluid (ascitic bilirubin 25 mg/dL). The patient underwent endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent placement and was started on antibiotics, with improvement in clinical condition. The case highlights the diagnostic difficulty of choleperitoneum, where early imaging can be subtle. Timely, multidisciplinary management involving peritoneal drainage, ERCP with stent placement, and prophylactic antibiotics is necessary; otherwise, biliary peritonitis is associated with significant mortality and morbidity. This report underscores the need for vigilance even after technically uneventful surgery, particularly in high-risk patients.