Resection of gallbladder remnants after subtotal cholecystectomy: presentation and management.

BACKGROUND: Subtotal cholecystectomy (SC) involves removal of a portion of the gallbladder typically due to hazardous inflammation. While this technique reliably prevents common bile duct (CBD) injury, future procedures can be required if the gallbladder remnant becomes symptomatic. The morbidity associated with resection of gallbladder remnants in patients that previously underwent SC is reviewed. METHODS: Records for patients having undergone redo cholecystectomy for symptomatic gallbladder remnants in a tertiary care system from 2013 to 2017 were retrospectively reviewed. RESULTS: Fourteen patients underwent repeat cholecystectomy. Five surgeons dictated the initial procedure as a subtotal cholecystectomy. All patients returned with symptomatic cholelithiasis between zero months and seven years after the index cholecystectomy. Redo cholecystectomy was attempted laparoscopically in two patients but ultimately required an open approach in all. One patient had a recognized CBD injury requiring a hepaticojejunostomy, and a second patient had a minor wound infection. Symptoms resolved in 13/14 patients. CONCLUSIONS: Redocholecystectomy (RC) for gallbladder remnants has been detailed in case reports, but no sizable North American series have been presented. These results illustrate a drawback to the reconstituting technique of SC. RC effectively resolves symptoms but requires adherence to safe principles of cholecystectomy and is one indication for an open approach.

Portal vein thrombosis after splenectomy.

BACKGROUND: Portal vein thrombosis (PVT) has been described after splenectomy, but the factors associated with its development and the clinical outcomes are poorly characterized. METHODS: Case logs of four surgeons from 1996 to 2001 were retrospectively reviewed to identify cases of postsplenectomy PVT. RESULTS: Eight cases of PVT (8%) among 101 splenectomies were identified. Indications for splenectomy in patients with PVT were myeloproliferative disease (n = 4), hemolytic anemia (n = 3), and myelodysplastic disorder (n = 1). All patients had splenomegaly (mean 1698 g, range 360 to 3150 g). Among 10 patients with myeloproliferative disease (MP), 4 patients (40%) developed PVT, compared with 4 of 12 patients (25%) with hemolytic anemia. Three of 4 patients (75%) with MP disease and spleen weight greater than 3,000 g developed PVT. Five patients developed PVT despite receiving prophylactic subcutaneous heparin postoperatively. Presenting symptoms included anorexia in 7 (88%), abdominal pain in 6 (75%), and both elevated leukocyte and platelet counts in 8 patients (100%). All diagnoses were made by contrast-enhanced computed tomography scan, and anticoagulation was initiated immediately. One patient died of intraabdominal sepsis; the others are alive with no clinical sequelae at 38 months of follow-up. CONCLUSIONS: PVT is a relatively common complication of splenectomy in patients with splenomegaly. A high index of suspicion, early diagnosis by contrast-enhanced computed tomography, and prompt anticoagulation are key to a successful outcome.