Cholecystectomy in children: indications, clinical, laboratory and histopathological findings and cost analysis.

BACKGROUND: The most common indication for cholecystectomy in children is cholelithiasis, and routine histopathological examination is performed on all gallbladder specimens. Currently, selective histopathological examination is suggested instead of routine examination due to the low frequency of gallbladder cancer in adults. The purpose of this study was to evaluate the indications, clinical, laboratory and histopathological findings of the cholecystectomy in children. We also questioned the contribution and cost-effectiveness of routine histopathological evaluation in diagnosis and treatment. METHODS: A total of 114 children underwent cholecystectomy between the years 2008 and 2022. The clinical findings, laboratory, and imaging results of the patients and histopathological findings of the gallbladder specimens were evaluated retrospectively. RESULTS: Cholelithiasis were diagnosed in 71%, choledochal malformation in 15.8%, hydrops of gallbladder and/or biliary sludge in 12.3%, and hypoplasia of gallbladder in 0.9% of the patients. Histopathologically significant findings were observed in only 3 patients (2.6%); adenomyomatosis in 2 and angiodysplasia and pyloric metaplasia in 1. While the cost of a cholecystectomy and histopathologic examination combined amounted to 27.77% of the minimum wage in Türkiye in 2024, the histopathologic examination alone constitutes just 0.67% of the minimum wage and 2.4% of the operation fee. CONCLUSION: In children undergoing cholecystectomy, histopathological examination does not provide any significant contribution to the patient's diagnosis and follow-up management. In children, selective gallbladder histopathological examination might reduce health costs and save time for pathologists.

Intraoperative Bleeding Complications Leading to Blood Transfusions (BloTs) in 17,412 Cholecystectomies in Finland: A Study With Special Reference to Elderly Patients.

BACKGROUND/AIM: Cholelithiasis (Chole) is one of the most common diseases needing operative management worldwide. However, there are few studies assessing the intraoperative bleeding (IOB) complications leading to blood transfusions (BloTs) in elderly patients with cholecystectomy (Ccy). PATIENTS AND METHODS: Outcome after IOB complications and need for BloTs in a cohort of 17,412 patients with Ccys were assessed with special reference to elderly Ccy patients. RESULTS: A total of 17,412 patients underwent Ccy and 11% of Ccy patients (1,856/17,412) were aged ≥75 years. The Ccy patients ≥75 years underwent more often emergency/open Ccys. Red blood cell BloTs were administered five times more often to Ccy patients ≥75 years versus Ccy patients <75 years (13% versus 2.6%, p<0.001). In Ccys by emergency surgery indications, the need for BloTs was four times higher in Ccy patients ≥75 years versus Ccy patients <75 years (5.5% versus 1.3%, p<0.001). CONCLUSION: The elderly Chole patients have a higher risk than younger Chole patients for perioperative IOB complications and thus are more likely to need BloTs.

Gallstones in a Looking-Glass: A Case Report on the Successful Laparoscopic Management of Cholelithiasis in Situs Inversus Totalis.

Situs inversus is an uncommon congenital condition where the internal organs are arranged in a mirrored or reversed orientation within the body. In this unique anatomical variation, the placement of visceral organs is flipped, presenting a mirror-image configuration relative to their standard positions. While situs inversus itself does not predispose an individual to gallbladder disorders, the anatomical variation poses unique challenges for healthcare professionals in managing abdominal pathologies. This case report describes the successful management of a 52-year-old male patient with situs inversus totalis who presented with gallstone-induced obstructive jaundice and underwent endoscopic retrograde cholangiopancreatography (ERCP) with stenting, followed by a laparoscopic cholecystectomy. The surgical procedure required exceptional visual-motor skills and extensive reorientation to accurately identify and navigate the left upper quadrant anatomy, which is the mirror image of the typical surgical approach. The case highlights the importance of thorough preoperative planning, comprehensive anatomical knowledge, and a multidisciplinary team approach to ensure favorable outcomes for patients with this rare condition.

Adrenal Schwannoma Presenting as an Incidentaloma in a Patient with Uterine Fibroids and Cholelithiasis: a Rare Case Report.

Schwannomas, which are benign mesenchymal tumors derived from Schwann cells, are common in the central nervous system. While they are commonly seen in the extremities and head-neck area, their presence in visceral organs, particularly the adrenals, is uncommon. Adrenal schwannomas are frequently discovered incidentally, offering a diagnostic difficulty because of their uncommon presentation. A 46-year-old woman initially sought treatment for symptoms related to uterine fibroids and biliary stones. Diagnostic imaging uncovered an adrenal incidentaloma, necessitating a laparoscopic right adrenalectomy. The mass was determined to be an adrenal schwannoma based on its spindle-shaped cells and S-100 immunohistochemistry positivity. The patient's symptoms improved, and she was discharged with stable vital signs. Preoperative diagnosis of adrenal schwannomas is difficult and requires histological confirmation. When diagnosing non-secreting adrenal tumors with unusual radiology, surgeons should investigate for schwannoma. Post-resection adrenal schwannoma follow-up studies are scarce; however, they imply a low risk of recurrence or metastasis.

Caecal Volvulus in a Foramen of Winslow Hernia Masquerading as Biliary Colic.

Internal hernias account for a minority of cases of intestinal obstruction. Within this group, internal hernias through the foramen of Winslow (FW) are an even rarer subcategory with a paucity of cases reported in the literature. We present a case of a 48-year-old female presenting with right upper quadrant pain akin to biliary colic with sonographic evidence of cholelithiasis. Her symptoms swiftly worsened, and she re-presented with symptoms of bowel obstruction. She was subsequently found to have a caecal volvulus herniating through the FW on computed tomography (CT). She underwent an emergency laparotomy to reduce the hernia and prevent further recurrence, which highlighted the importance of a comprehensive history and the increasing role of cross-sectional imaging in emergency surgery.

Advancements in Cholelithiasis Diagnosis: A Systematic Review of Machine Learning Applications in Imaging Analysis.

Gallstone disease is a common condition affecting a substantial number of individuals globally. The risk factors for gallstones include obesity, rapid weight loss, diabetes, and genetic predisposition. Gallstones can lead to serious complications such as calculous cholecystitis, cholangitis, biliary pancreatitis, and an increased risk for gallbladder (GB) cancer. Abdominal ultrasound (US) is the primary diagnostic method due to its affordability and high sensitivity, while computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) offer higher sensitivity and specificity. This review assesses the diagnostic accuracy of machine learning (ML) technologies in detecting gallstones. This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for reporting systematic reviews and meta-analyses. An electronic search was conducted in PubMed, Cochrane Library, Scopus, and Embase, covering literature up to April 2024, focusing on human studies, and including all relevant keywords. Various Boolean operators and Medical Subject Heading (MeSH) terms were used. Additionally, reference lists were manually screened. The review included all study designs and performance indicators but excluded studies not involving artificial intelligence (AI)/ML algorithms, non-imaging diagnostic modalities, microscopic images, other diseases, editorials, commentaries, reviews, and studies with incomplete data. Data extraction covered study characteristics, imaging modalities, ML architectures, training/testing/validation, performance metrics, reference standards, and reported advantages and drawbacks of the diagnostic models. The electronic search yielded 1,002 records, of which 34 underwent full-text screening, resulting in the inclusion of seven studies. An additional study identified through citation searching brought the total to eight articles. Most studies employed a retrospective cross-sectional design, except for one prospective study. Imaging modalities included ultrasonography (four studies), computed tomography (three studies), and magnetic resonance cholangiopancreatography (one study). Patient numbers ranged from 60 to 2,386, and image numbers ranged from 60 to 17,560 images included in the training, validation, and testing of the diagnostic models. All studies utilized neural networks, predominantly convolutional neural networks (CNNs). Expert radiologists served as the reference standard for image labelling, and model performances were compared against human doctors or other algorithms. Performance indicators such as sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were commonly used. In conclusion, while the reviewed machine learning models show promising performance in diagnosing gallstones, significant work remains to be done to ensure their reliability and generalizability across diverse clinical settings. The potential for these models to improve diagnostic accuracy and efficiency is evident, but the careful consideration of their limitations and rigorous validation are essential steps toward their successful integration into clinical practice.

Mirizzi Syndrome and Its Surgical Interventions: A Case Report.

A rare side effect of cholelithiasis, called Mirizzi syndrome (MS), arises when gallstones that are impacted in the Hartmann's pouch or the cystic duct extrinsically compress the common bile duct. This condition is typically managed with a cholecystectomy. In this case report, different surgical approaches are described according to each type of Mirizzi. We report a 62-year-old female who presented with abdominal pain. She underwent endoscopic retrograde cholangiopancreaticography (ERCP) and was diagnosed with MS. We performed a subtotal cholecystectomy with a choledochoduodenostomy.

Controversial Surgical Approach to Recurrent Gallstone Ileus.

Gallstone ileus is a rare but potentially serious complication of gallstone disease, which presents as a mechanical intestinal obstruction due to impaction and fistulization of a gallstone, most commonly in the small intestine. Since it usually occurs in elderly patients, the symptoms can be very diverse and with a late presentation. We present the case of a 90-year-old patient with intestinal obstruction and acute abdominal pain who experienced gallstone ileus and underwent surgery, and a few days after being discharged returned with a recurrence of the symptoms, was re-operated, and a second stone was found.

Cholelithiasis, Gut Microbiota and Bile Acids after Bariatric Surgery-Can Cholelithiasis Be Prevented by Modulating the Microbiota? A Literature Review.

BACKGROUND: Cholelithiasis is one of the more common complications following bariatric surgery. This may be related to the rapid weight loss during this period, although the exact mechanism of gallstone formation after bariatric surgery has not been fully elucidated. METHODS: The present literature review focuses on risk factors, prevention options and the impact of the gut microbiota on the development of gallbladder stones after bariatric surgery. RESULTS: A potential risk factor for the development of cholelithiasis after bariatric surgery may be changes in the composition of the intestinal microbiota and bile acids. One of the bile acids-ursodeoxycholic acid-is considered to reduce the concentration of mucin proteins and thus contribute to reducing the formation of cholesterol crystals in patients with cholelithiasis. Additionally, it reduces the risk of both asymptomatic and symptomatic gallstones after bariatric surgery. Patients who developed gallstones after bariatric surgery had a higher abundance of Ruminococcus gnavus and those who did not develop cholelithiasis had a higher abundance of Lactobacillaceae and Enterobacteriaceae. CONCLUSION: The exact mechanism of gallstone formation after bariatric surgery has not yet been clarified. Research suggests that the intestinal microbiota and bile acids may have an important role in this.

Bouveret Syndrome: Etiology, Clinical Presentation, Differential Diagnosis, Complications, and Treatment Options.

Bouveret syndrome is one of the complications of gallstone disease possibly fatal, which proposes the presence of a large stone obliterating the lumen of the duodenum or stomach because of the formation of a bilioenteric fistula. This review article, therefore, plans to review the causes, patient characteristics, diagnostic workup, associated conditions, and treatment of Bouveret syndrome. A literature search was also performed through scientific databases such as Scopus, Google Scholar, and PubMed concerning articles related to Bouveret syndrome written by different authors. The terms employed for the search were bilioduodenal fistula, Bouveret syndrome, gastric outlet obstruction, and gallstone ileus. Both case reports and systematic reviews that were written in the English language and published between the years 2000 and 2024 were considered. Finally, the review establishes the relevant concerns surrounding the diagnosis of Bouveret syndrome, focusing on the diagnosing issues. It emphasises the need for some specialities' involvement and focuses on the importance of endoscopic intervention. For patients, endoscopy remains the first line of treatment, while surgery is necessary in cases where conservative methods cannot be used. The article also focuses on new approaches to treating the conditions, such as percutaneous gallbladder stone dissolution. Latterly, further developments in minimally invasive surgery pertain to refining methods, including endoscopic removal and lithotripsy, to improve the survival rate of patients. Further investigation is required, especially regarding the administration schedule in relation to this disorder and goals that can reduce mortality and morbidity, especially in elderly patients with comorbid diseases.

Unaccounted Gallbladder.

Gallbladder agenesis is a rare anatomical variant, and most cases are asymptomatic and diagnosed on autopsy. Few of them may present with features suggestive of biliary tract pathology. A 32-year-old male presented with complaints of intermittent epigastric pain for three months. Abdominal ultrasonography was suggestive of chronic calculous cholecystitis, and he was planned for laparoscopic cholecystectomy. However, no gallbladder was found during the surgery. Postoperative evaluation was suggestive of an absent gallbladder with a normal ductal system. A provisional diagnosis of sphincter of Oddi dysfunction was made based on his symptoms. Congenital absence of gallbladder is a rare anomaly and only a few of the affected individuals are symptomatic. Lack of specific features, coupled with the inability of standard abdominal ultrasonography to detect the absence of gallbladder, can put the treating surgeon in a dilemma intraoperatively. Agenesis of the gallbladder is often missed and this entity should be kept in mind while having difficulty in visualizing the gallbladder. An astute surgeon should be wary of this diagnosis during difficult dissection to avoid bile duct injuries.

Intestinal obstruction induced by gallstone migration through unusual location of a cholecystogastric fistula: A rare case report.

INTRODUCTION: Gallstone ileus is a rare condition resulting from cholelithiasis, associated with the formation of a fistula between the gallbladder and the intestinal tract. It is responsible for less than 0.1 % of cases of mechanical bowel obstruction. PRESENTATION OF CASE: A 54-year-old male with hypertension presented with symptoms of intestinal obstruction, including inability to pass stool, anorexia, abdominal pain, vomiting, and oliguria. Physical examination revealed epigastric tenderness and a distended abdomen without jaundice. Laboratory tests indicated mild anemia. The patient initially refused any surgical interventions, so he was placed on conservative treatment for 24 h. Subsequently, an emergency exploratory open laparotomy was performed, revealing a gallstone causing small bowel obstruction. A constricted ileal loop, 15 cm in length, with stone impaction was resected, and an end-to-end anastomosis was performed. A cholecystogastric fistula was identified and repaired, and a retrograde cholecystectomy was performed. The patient recovered without complications. DISCUSSION: Gallstone ileus occurs when a fistula develops between the gallbladder and the intestinal tract. Notably, the presence of a fistula connecting the gallbladder and stomach ranges from 0 % to 13.3 %. Cholecystoenteric fistulas (CEFs) typically occur in elderly women in their seventh or eighth decade of life. Diagnosis often relies on CT scanning, and surgical intervention remains the primary treatment. Interestingly, despite improved awareness and imaging techniques, some cases are still discovered incidentally during surgery. CONCLUSION: This case highlights the diagnostic and therapeutic challenges posed by gallstone ileus, and emphasizes the importance of considering gallstone-related disorders in differential diagnoses for acute abdominal obstruction.

Intrahepatic Duct Incision and Closure for the Treatment of Multiple Cholelithiasis in a Dog.

This report describes the successful intrahepatic duct incision and closure for the treatment of multiple cholelithiasis in a dog with untreated hypothyroidism. A 12-year-old spayed female Spitz dog weighing 11.3 kg was diagnosed with multiple cholelithiasis, and a quadrate liver lobectomy and cholecystectomy were performed. Large gallstones were located in the left liver lobe's intrahepatic duct distal to the anastomosis of the intrahepatic ducts of the left medial and lateral lobes. The dilated intrahepatic duct was packed off with wet gauze, and incision and closure were performed on the most dilated section, which was proximal to the largest gallstone. After surgery, the patient showed normal liver function and was discharged with normal total bilirubin and C-reactive protein levels. On postoperative day 83, no stones were observed in the dilated common bile duct (CBD), and the degree of dilatation of the CBD had decreased from 9 mm to 4 mm, with no obstructions. Right intrahepatic gallstones were confirmed without dilatation. Hypothyroidism was managed medically. Hepatic duct incision and closure can be performed in dogs with multiple cholelithiasis. Although not the first option, intrahepatic bile duct incision proves to be a new alternative for the successful treatment of cholelithiasis in dogs.

Cholelithiasis and cholecystectomy increase the risk of gastroesophageal reflux disease and Barrett's esophagus.

Background: Cholelithiasis or cholecystectomy may contribute to the development of gastroesophageal reflux disease (GERD), Barrett's esophagus (BE), and esophageal adenocarcinoma (EAC) through bile reflux; however, current observational studies yield inconsistent findings. We utilized a novel approach combining meta-analysis and Mendelian randomization (MR) analysis, to assess the association between them. Methods: The literature search was done using PubMed, Web of Science, and Embase databases, up to 3 November 2023. A meta-analysis of observational studies assessing the correlations between cholelithiasis or cholecystectomy, and the risk factors for GERD, BE, and EACwas conducted. In addition, the MR analysis was employed to assess the causative impact of genetic pre-disposition for cholelithiasis or cholecystectomy on these esophageal diseases. Results: The results of the meta-analysis indicated that cholelithiasis was significantly linked to an elevated risk in the incidence of BE (RR, 1.77; 95% CI, 1.37-2.29; p < 0.001) and cholecystectomy was a risk factor for GERD (RR, 1.37; 95%CI, 1.09-1.72; p = 0.008). We observed significant genetic associations between cholelithiasis and both GERD (OR, 1.06; 95% CI, 1.02-1.10; p < 0.001) and BE (OR, 1.21; 95% CI, 1.11-1.32; p < 0.001), and a correlation between cholecystectomy and both GERD (OR, 1.04; 95% CI, 1.02-1.06; p < 0.001) and BE (OR, 1.13; 95% CI, 1.06-1.19; p < 0.001). After adjusting for common risk factors, such as smoking, alcohol consumption, and BMI in multivariate analysis, the risk of GERD and BE still persisted. Conclusion: Our study revealed that both cholelithiasis and cholecystectomy elevate the risk of GERD and BE. However, there is no observed increase in the risk of EAC, despite GERD and BE being the primary pathophysiological pathways leading to EAC. Therefore, patients with cholelithiasis and cholecystectomy should be vigilant regarding esophageal symptoms; however, invasive EAC cytology may not be necessary.

Cholecystogastric fistula: A case report and review of the literature.

INTRODUCTION: Cholecystogastric fistula is an abnormal communication between the gallbladder and the stomach, it is a rare complication of chronic cholethiasis. Preoperative diagnosis is difficult as patients often present with non-specific symptoms. CASE PRESENTATION: A 63-year-old female presented to the outpatient clinic with symptomatic cholelithiasis. Physical examination was unremarkable. Laboratory investigations, including complete blood count (CBC) and liver function test (LFT), were within normal limits. Upper abdominal ultrasound revealed hepatomegaly and gallbladder contraction with multiple gallstones. Intraoperative exploration during laparoscopic cholecystectomy revealed adhesions with cholecystogastric fistula, necessitating meticulous dissection, fistula excision, and primary closure. Postoperatively, the patient recovered uneventfully, with a negative methylene blue leak test allowing early oral intake. Discharged home in stable condition, subsequent follow-up showed resolution of symptoms, and histopathological examination confirmed absence of neoplastic changes. DISCUSSION: Optimal surgical management of cholecystogastric fistula is debatable, laparoscopic surgery have led to improved outcomes in the management of these cases. Utilizing which approach should be determined based on the clinical scenario for each patient and the surgeon experience. CONCLUSION: Cholecystogastric fistula is a rare complication of chronic cholethiasis. Preoperative diagnosis requires high index of suspicion. Complete laparoscopic management is safe.

Biliary complications associated with weight loss, cholelithiasis and choledocholithiasis.

Biliary complications like cholelithiasis and choledocholithiasis are more common in bariatric surgery patients due to obesity and rapid weight loss. Patients with a body mass index > 40 face an eightfold risk of developing cholelithiasis. Post-bariatric surgery, especially after laparoscopic Roux-en-Y gastric bypass (LRYGB), 30% of patients develop biliary disease due to rapid weight loss. The aim of this review is to analyze the main biliary complications that occur after bariatric surgery and its management. A review of the literature was conducted mainly from 2010 up to 2023 with regard to biliary complications associated with bariatric patients in SciELO, PubMed, and MEDLINE. Patients undergoing LRYGB have a higher incidence (14.5%) of symptomatic calculi post-surgery compared to those undergoing laparoscopic sleeve gastrectomy at 4.1%. Key biliary complications within 6 to 12 months post-surgery include: Cholelithiasis: 36%; Biliary colic/dyskinesia: 3.86%; Acute cholecystitis: 0.98%-18.1%; Chronic cholecystitis: 70.2%; Choledocholithiasis: 0.2%-5.7% and Pancreatitis: 0.46%-9.4%. Surgeons need to be aware of these complications and consider surgical treatments based on patient symptoms to enhance their quality of life.

Percutaneous transhepatic choledochoscopy in the management of hepatolithiasis: a narrative review.

Background and Objective: From the 1980s and continuing into the 21st century, percutaneous transhepatic choledoscopy (PTCS) has been increasingly used in the clinical management of cholelithiasis. However, when compared to conventional minimally invasive techniques such as endoscopic retrograde cholangiopancreatography (ERCP), PTCS is characterized by greater invasiveness and a higher rate of complications. As a result, PTCS is frequently used as a supplementary treatment option. Nevertheless, it plays a unique and indispensable role in addressing hepatolithiasis. In this study, to facilitate safer clinical applications and gain a deeper understanding of PTCS-related complications, we conducted a comprehensive examination of these complications. Methods: Research studies related to PTCS were reviewed in PubMed, Web of Science, and China National Knowledge Infrastructure (CNKI) (year range, 1952-2024). There was no restriction on language. The occurrence and management of complications at various steps of PTCS were examined and compared with those of first-line minimally invasive treatments via a tabular method. Additionally, we evaluated the feasibility of using PTCS in the context of intrahepatic bile duct stones. Key Content and Findings: Information on the types, incidence, and treatment of complications of PTCS was extracted in this review. A total of 5,923 results were retrieved, of which 41 were excluded. The reason for exclusion was that the article was a meeting comment. The findings indicate that PTCS plays an important role in the treatment of biliary tract diseases. Conclusions: Although PTCS is frequently used as an adjunctive therapeutic approach, its distinct utility in treating intrahepatic bile duct stones remains difficult to replace. Thus, a deeper understanding of PTCS-related complications, coupled with ongoing advancements in instrumentation, could significantly enhance the efficiency of minimally invasive gallstone management.

Hepatic artery pseudoaneurysm: three case reports and literature review.

Laparoscopic surgery is extensively applied in the treatment of hepatobiliary diseases. Hepatic artery pseudoaneurysm (HAP) is a rare complication following hepatic biliary surgery through laparoscopy. The clinical manifestations of HAP are diverse and can be fatal. Given its severity, rapid assessment and management are crucial to ensuring a good prognosis. Here, we report three cases of HAP; two underwent laparoscopic surgery due to cholelithiasis, and another caused by trauma. The first case exhibited a pseudoaneurysm involving the distal portion of the right hepatic artery main trunk. The second patient had a pseudoaneurysm at the bifurcation of the left and right hepatic arteries. The third case involved a patient with a pseudoaneurysm involving a branch of the right hepatic artery. The main clinical manifestations of all three cases were bleeding from the biliary tract (the first two cases showed postoperative bleeding in the T-tube, while the third case exhibited gastrointestinal bleeding). The final diagnosis was obtained through digital subtraction angiography. The three patients underwent successful transcatheter arterial embolization operation and a follow-up revealed they were disease-free and alive. This article aims to highlight a rare complication of laparoscopic hepatobiliary surgery and share our experience in early diagnosis and treatment of HAP.

Pediatric gallstone disease-Management difficulties in clinical practice.

BACKGROUND: Gallstone disease (GD) is no longer an exclusive condition of adulthood, and its prevalence is increasing in pediatric age. The management and the extent of the etiological investigation of GD in children and adolescents remains controversial. This study aimed to analyze the difficulties in the work-up and management of pediatric GD patients. METHODS: A retrospective study performed in a single tertiary center enrolled sixty-five patients with GD followed from January 2014 to June 2021. Patients were categorized conveniently according to their age at diagnosis: Group A (<10years, n=35) and Group B (≥10years, n=30). We analyzed demographic, clinical and laboratory data, ultrasonographic findings at presentation, therapeutics and complications. RESULTS: Symptoms were more frequent in patients >10years old (p=0.001). Cholecystectomy was performed in 31 patients (47.7%). A multivariate regression logistic model identified the age >10years (OR=6.440, p=0.005) and underlying entities (OR=6.823, p=0.017) as independent variables to perform surgery. Spontaneous resolution of GD was more common in children <2years old. A multivariate regression logistic model showed a trend for those >10years old to develop more complications. Two out of 18 patients were diagnosed with ABCB4 gene mutations in heterozygosity. CONCLUSIONS: Decision-making on cholecystectomy remains challenging in asymptomatic patients. Identifying predictive factors for the development of complications has proven difficult. However, we found a trend toward the development of complications in individuals older than 10years.

Biliary anatomic variant and recurrent acute cholecystitis, cholelithiasis in gallbladder remnant in patient with autosomal dominant polycystic kidney disease.

Autosomal dominant polycystic kidney disease (ADPKD) is the most common inherited renal disorder. ADPKD is not only associated with progression of renal disease, but also several hepatobiliary manifestations. This report is of a 49-year-old female with recurrent cholelithiasis and cholecystitis following subtotal cholecystectomy in the context of aberrant biliary anatomy and ADPKD. There were significant adhesions obscuring the cystic duct, necessitating the second cholecystectomy be performed open. The right posterior hepatic duct was adhered to the gallbladder wall and was perforated while attempting to remove the gallbladder remnant. The duct was repaired over a T-tube, without any subsequent biliary leak. The cystic duct was hugely dilated and impacted with stones down to the junction with the common bile duct, which were evacuated, and the cystic duct was oversewn along with the remnant of the gallbladder wall. The recovery course was unremarkable.