Abstract
Background
Since the introduction of the Critical View of Safety approach in laparoscopic cholecystectomy, exposure of the common bile duct, and common hepatic duct is not recommended, therefore, the length of the cystic duct remnant is no longer controlled. The aim of this case‒control study is to evaluate the relationship between the length of the cystic duct remnant and the risk for bile duct stone recurrence after cholecystectomy.
Methods
All MRIs with dedicated sequences of the biliary tract taken between 2010 and 2020 from patients who underwent prior cholecystectomy were reviewed. The length of the cystic duct remnant was measured and compared between the patients with and without bile duct stones using multivariate logistic regression analysis.
Results
A total of 362 patients were included in this study, 23.5% of whom had bile duct stones on MRI. The cystic duct remnant was significantly longer in the patients with stones than in the control group (median 31 mm versus 18 mm, P < 0.001). In the MRIs performed > 2 years after cholecystectomy, the cystic duct remnant was also significantly longer in the patients with bile duct stones (median 32 mm versus 21 mm, P < 0.001). A cystic duct remnant ≥ 15 mm in length increased the odds of stones (OR = 2.3, P = 0.001). Overall, the odds of bile duct stones increased with an increasing cystic duct remnant length (≥ 45 mm, OR = 5.0, P < 0.001).
Conclusions
An excessive cystic duct remnant length increases the odds of recurrent bile duct stones after cholecystectomy.
Similar content being viewed by others
Avoid common mistakes on your manuscript.
Introduction
Cholecystectomy is one of the most commonly performed abdominal surgeries worldwide, and the laparoscopic approach is currently considered the gold standard for the treatment of gallstone disease.1 As the rate of bile duct injury in the first years after the first laparoscopic cholecystectomy is increased compared to open cholecystectomy, the focus has shifted to preventing those injuries, leading to the adoption of the Critical View of Safety (CVS) routine.2 The aim of safe cholecystectomy principles is to promote the recognition of gallbladder elements before resection to reduce the risk of the common bile duct and vascular injuries and avoid mistakes due to anatomical alterations and altered visual perception.3,4 CVS is achieved by dissecting the entire infundibulum off the liver bed and exposing the elements of the Calot triangle before resection.1,5,6 This routine is currently widely used and recommended by a multisociety consensus conference on the prevention of bile duct injuries during cholecystectomy, which included the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), the American Hepato-Pancreato-Biliary Association, the International Hepato-Pancreato-Biliary Association, the Society for Surgery of the Alimentary Tract, and the European Association for Endoscopic Surgery.5,7 CVS is also the method recommended by the SAGES Safe Cholecystectomy program.1 This approach led to a significant reduction in the major bile duct injury rate after laparoscopic cholecystectomy to 0.15–0.36%.7
Even though the overall morbidity and mortality rates associated with this surgical procedure were reduced. 6 the issue of recurrent bile duct stones (BDSs) after cholecystectomy remained. The rate is estimated to be 1–3%8 and has been reported to be higher in patients undergoing laparoscopic cholecystectomy than in those undergoing open cholecystectomy.9–11 Recurrent BDS is associated with complications, such as pancreatitis and cholangitis, increasing long-term morbidity and mortality.10
The etiology of recurrent BDS has not yet been fully elucidated, but a possible association with the remnant cystic duct stump has been suggested.9,11 The first observation of a cystic duct remnant (CDR) with a so-called reformed gallbladder containing stones was published in 1912 by Flörcken,12 and in 1966, Bodvall et al. correlated the severity of postoperative biliary distress with the presence of a CDR measuring ≥ 10 mm in length.13 Subsequently, other authors have also reported this correlation, and they have reported significant CDR lengths of 0.5, 1, and 1.5 cm.11,14,15,16 However, very little is known about the CDR length after cholecystectomy, with one study from 1992 reporting a length < 1 cm in 34.5%, 1–2 cm in 36.3%, 2–3 cm in 24.8%, and > 3 cm in 4.4% of patients after laparoscopic cholecystectomy.17 Moreover, CVS does not take into account the CDR length because the focus on safe cholecystectomy principles lies in the prevention of bile duct injuries. Applying the CVS principles does not require exposure to the common bile duct and common hepatic duct.18
Considering the hypothesis that a longer cystic duct remnant increases the risk of bile duct stones and, thus, the risk of long-term postoperative complications, the aim of this study was to determine the relationship between cystic duct remnant length and the reappearance of bile duct stones after cholecystectomy.
Materials and Methods
Data Collection
This case‒control study was conducted in accordance with the STROBE criteria (http://strobe-statement.org). First, all abdominal MRIs (magnetic resonance imaging) performed between January 1, 2010, and December 31, 2020, on adult patients (> 18 years old) at our institution were screened, and patients with remaining gallbladder were excluded. After this initial screening, the MRIs were re-evaluated by a board-certified radiologist and excluded if there were no dedicated MRI sequences of the biliary tract; if a biliodigestive anastomosis was present; or bilio-pancreatic anatomical variations were present, such as periampullar diverticulum or a modified hilar anatomy. Patients presenting with periampullary diverticula were excluded due to the higher risk of recurrent BDS, especially after cholecystectomy,19,20 and patients with modified hilar anatomy, e.g., due to tumor infiltration, were excluded because of the potentially altered radiological interpretation.
For all included patients, the age at the time of MRI, sex, indication for MRI, and date of cholecystectomy were extracted from written radiological reports if available. The presence of gallstones in the biliary tract was evaluated, and the length of the CDR was measured by a board-certified radiologist on the cholangio-MRI 3D magnetic resonance cholangiopancreatography (MRCP) sequence (IRM 3 T GE) in the axial, coronal, or sagittal plane depending on the best visualization of the CDR. The maximal length measured for each patient was then extracted. The patients without stones were defined as the control group.
According to the literature, remnant BDS was defined as stones present on MRCP in the first 2 years after cholecystectomy, and recurrent BDS was defined as stones present on MRCP at least 2 years after cholecystectomy.10,21,22,23 Therefore, to evaluate the CDR length in BDS recurrence, a subgroup analysis with MRCP performed within and at least 2 years after cholecystectomy was performed.
Statistical Analysis
Descriptive statistics were determined for the demographic data. Dichotomous data were reported as numbers and proportions, and continuous data were reported as the medians and interquartile ranges (IQRs). Demographic data of both groups were compared using logistic regression. Normal distribution was assessed with Shapiro‒Wilk’s method. The effect of CDR length on the presence of gallstones was analyzed using a multivariate logistic regression model adjusted for age, sex, and indication for MRI. The odds ratios (ORs) and 95% confidence intervals (CIs) were estimated. All statistical analyses were performed using R. A two-sided level of significance of 0.05 was utilized for all analyses.
Results
Patient Selection
All radiological reports of the patients who underwent abdominal MRI at our institution from 2010 to 2020 (N = 4 461) were screened for a remaining gallbladder (Fig. 1). After screening, 540 MRI scans of the patients with a history of cholecystectomy were analyzed by a radiologist; 145 patients were excluded due to the absence of dedicated MRI sequences of the biliary tract or radiological artifacts. Three patients presented with a remaining gallbladder on radiological re-evaluation and were excluded. Among the remaining patients, 30 were excluded due to anatomical variations according to our exclusion criteria. Finally, 362 patients were included in the analysis.
Baseline Characteristics
The baseline characteristics of the study population are provided in Table 1. In 256 patients (70.7%), MRCP was performed due to symptoms compatible with biliary stones, such as abdominal pain, cholestasis, dilatation of the biliary tract on other imaging, or pancreatitis and cholangitis. In 102 patients (28.2%), an abdominal MRI was performed for follow-up of a pathology that was not related to biliary stones, such as liver cirrhosis, cystic lesions of the pancreas, or inflammatory bowel disease. Overall, 85 patients (23.5%) presented with stones in the biliary tract on MRCP and were compared to the control group without stones (277 patients). Symptoms compatible with biliary stones were significantly more frequent in the patients with BDS on MRCP than in controls (N = 76, 89.4% vs. N = 180, 65.0%, P < 0.001). The patients presenting with stones were significantly older, with a median age of 69 compared to a median age of 63 years in the control group. No significant difference was found related to sex.
MRCP was performed within 2 years after cholecystectomy in 27.1% of the patients (N = 99) and in 56.4% of the patients after more than 2 years (N = 204). No significant difference in the occurrence of stones based on the timing of cholecystectomy prior to MRCP was shown.
Length of the Cystic Duct Remnant
The cystic duct stump was significantly longer in the patients with stones in the biliary tract than in the control group (median 31 mm vs. 19 mm, P < 0.001; Table 2). A subgroup analysis of the patients who underwent MRCP more than 2 years after cholecystectomy revealed a significant difference in the median CDR length between the patients with and without BDS (32 mm vs. 21 mm, P < 0.001).
Figure 2 shows the cumulative curve of the patients presenting with and without BDS related to the CDR length. In a multivariate logistic regression model adjusted for age, sex, and indication for MRI (Fig. 3), a CDR ≥ 15 mm or ≥ 20 mm in length increased the odds of stones more than twofold (OR = 2.3, 95% CI 1.22;4.58, P = 0.001 and OR = 2.6, 95% CI 0.29;3.26, P = 0.001, respectively). Overall, the odds of BDS increased with increasing cystic duct stump length (CDR ≥ 45 mm, OR = 5.0, 95% CI 2.34;11.07, P < 0.001; Fig. 2).
Discussion
Stones in the biliary tree are present in up to 1–3% of patients after cholecystectomy,8,9 and may lead to significant morbidity. Thus, our study aimed to evaluate whether the length of the cystic duct stump correlates with the occurrence of stones after cholecystectomy. Indeed, our data suggest that a long CDR is associated with a significant increase in BDS after cholecystectomy. In particular, the CDR was significantly longer in patients presenting with stone recurrence, i.e., at least 2 years after cholecystectomy.
Although a higher OR was calculated for a CDR > 10 mm in length, the large CI due to the small number of patients limits the statistical interpretation. Beyond 15 mm, however, every millimeter of remnant cystic duct increased the odds of gallstones. Few authors have previously described a possible correlation between symptoms following cholecystectomy and a CDR exceeding 10 mm in length.13,14,24 However, all studies were performed between 1966 and 1991 and included patients who underwent cholecystectomy before the laparoscopic era and the routine use of CVS.
To the best of our knowledge, this study is the first to describe the length of the CDR in the modern laparoscopic era. As described above, in the technique of laparoscopic cholecystectomy applying CVS, it is not recommended to obtain exposure of the entire cystic duct from the neck of the gallbladder to its union with the common bile duct; therefore, the length of the CDR remains unknown.
In our study, retrospectively measured cystic duct stumps showed that an increasing length was associated with higher rates of recurrent stones, suggesting that a shorter CDR might decrease BDS recurrence after cholecystectomy.
Our data do not question the validity of CVS. Considering the low risk of BDS recurrence and the high morbidity and mortality of bile duct injuries, aiming for a shorter cystic duct stump should not jeopardize safety. Thus, validated techniques to visualize the cystic duct and at the same time avoid bile duct injuries, such as transcystic intraoperative cholangiography25,26,27 or biliary tract visualization with near-infrared imaging with indocyanine green28,29 during cholecystectomy, might be employed to avoid exceedingly long CDR while maintaining the established safety principles.
The present retrospective, radiological study has several limitations. First, clinical data, especially regarding indication for surgery, open or laparoscopic approach, and other risk factors except for age and sex, were not available due to the study design. On the other hand, little is known about other factors associated with a higher risk of recurrent BDS after cholecystectomy, with most studies focusing on patients who have undergone endoscopic stone extraction with a preserved gallbladder. The known risk factors for gallstones include the composition and properties of the stones, female sex, age, and biological and lifestyle factors.30,31 Anatomical factors such as common bile duct angulation and initial common bile duct diameter have been described as potentially influencing the recurrence of stones after ERCP but have not been studied after cholecystectomy.32,33 More knowledge about the impact of these factors on recurrence rates after cholecystectomy is needed.
Furthermore, information about the preoperative presence of BDS was not available, raising the question of remnant BDS. To minimize this bias, a subgroup analysis of patients who underwent MRCP more than 2 years after cholecystectomy was performed. Whether patients underwent ERCP or spontaneous stone migration before MRCP was also rarely available. In addition, patients who underwent ERCP postoperatively without prior MRCP were not included. This probably led to an underestimation of the rate of symptomatic stones after cholecystectomy. However, our study showed a BDS frequency of 23.5% in patients for which an MRI had been prescribed, which is comparable with the study by Shiraz et al., who found that 17.6% of BDS in patients suffered from postcholecystectomy syndrome.10
Finally, only patients who had an MRCP after a cholecystectomy were included, leading to a selection bias with an overinclusion of patients with BDS (23.5%), although this complication is described in up to 1–3% of patients after cholecystectomy.8,9 However, adjusting the statistical model for the indication of the MRI did not show any difference.
The results of the present study are preliminary and warrant confirmation in a prospective study including further clinical data, broader risk stratification, and the use of systematic intraoperative cholangiography with measurements of the cystic duct.
Conclusion
In conclusion, our results show a clear trend of longer cystic duct stump in patients presenting BDS and that every excess millimeter of CDR increases the odds of biliary stones after cholecystectomy. This suggests that a longer cystic duct stump may lead to increased morbidity and complications related to stones, such as cholangitis and pancreatitis. If technically feasible and under favorable anatomical conditions, aiming for a short CDR might be beneficial; however, the safety principles should by no means be neglected.
Abbreviations
- CVS :
-
Critical View of Safety
- SAGES :
-
Society of American Gastrointestinal and Endoscopic Surgeons
- BDS :
-
Bile duct stone
- CDR :
-
Cystic duct remnant
- MRI :
-
Magnetic resonance imaging
- MRCP :
-
Magnetic resonance cholangiopancreatography
- IQR :
-
Interquartile range OR: odds ratio
- OR:
-
Odds ratio
- CI :
-
Confidence interval
References
The SAGES Safe Cholecystectomy Program- Strategies for Minimizing Bile Duct Injuries: Adopting a Universal Culture of Safety in Cholecystectomy. Available from: https://www.sages.org/safe-cholecystectomy-program. Accessed 3 Feb 2023
de’Angelis N, Catena F, Memeo R, Coccolini F, Martínez-Pérez A, Romeo OM, De Simone B, Di Saverio S, Brustia R, Rhaiem R, Piardi T, Conticchio M, Marchegiani F, Beghdadi N, Abu-Zidan FM, Alikhanov R, Allard M-A, Allievi N, Amaddeo G, Ansaloni L, Andersson R, Andolfi E, Azfar M, Bala M, Benkabbou A, Ben-Ishay O, Bianchi G, Biffl WL, Brunetti F, Carra MC, Casanova D, Celentano V, Ceresoli M, Chiara O, Cimbanassi S, Bini R, Coimbra R, Luigi de’Angelis G, Decembrino F, De Palma A, de Reuver PR, Domingo C, Cotsoglou C, Ferrero A, Fraga GP, Gaiani F, Gheza F, Gurrado A, Harrison E, Henriquez A, Hofmeyr S, Iadarola R, Kashuk JL, Kianmanesh R, Kirkpatrick AW, Kluger Y, Landi F, Langella S, Lapointe R, Le Roy B, Luciani A, Machado F, Maggi U, Maier RV, Mefire AC, Hiramatsu K, Ordoñez C, Patrizi F, Planells M, Peitzman AB, Pekolj J, Perdigao F, Pereira BM, Pessaux P, Pisano M, Puyana JC, Rizoli S, Portigliotti L, Romito R, Sakakushev B, Sanei B, Scatton O, Serradilla-Martin M, Schneck A-S, Sissoko ML, Sobhani I, ten Broek RP, Testini M, Valinas R, Veloudis G, Vitali GC, Weber D, Zorcolo L, Giuliante F, Gavriilidis P, Fuks D, Sommacale D. 2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy. World J Emerg Surg 2021; 16: 30.
Strasberg SM, Sanabria JR, Clavien PA. Complications of laparoscopic cholecystectomy. Can J Surg J Can Chir 1992; 35: 275–280.
Berci G, Morgenstern L. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995; 180: 638–639.
Conrad C, Wakabayashi G, Asbun HJ, Dallemagne B, Demartines N, Diana M, Fuks D, Giménez ME, Goumard C, Kaneko H, Memeo R, Resende A, Scatton O, Schneck A-S, Soubrane O, Tanabe M, van den Bos J, Weiss H, Yamamoto M, Marescaux J, Pessaux P. IRCAD recommendation on safe laparoscopic cholecystectomy. J Hepato-Biliary-Pancreat Sci 2017; 24: 603–615.
Gupta V, Jain G. Safe laparoscopic cholecystectomy: Adoption of universal culture of safety in cholecystectomy. World J Gastrointest Surg 2019; 11: 62–84.
Brunt LM, Deziel DJ, Telem DA, Strasberg SM, Aggarwal R, Asbun H, Bonjer J, McDonald M, Alseidi A, Ujiki M, Riall TS, Hammill C, Moulton C-A, Pucher PH, Parks RW, Ansari MT, Connor S, Dirks RC, Anderson B, Altieri MS, Tsamalaidze L, Stefanidis D. Safe Cholecystectomy Multi-society Practice Guideline and State of the Art Consensus Conference on Prevention of Bile Duct Injury During Cholecystectomy. Ann Surg 2020; 272: 3–23.
von Schönfels W, Buch S, Wölk M, Aselmann H, Egberts JH, Schreiber S, Krawczak M, Becker T, Hampe J, Schafmayer C. Recurrence of gallstones after cholecystectomy is associated with ABCG5/8 genotype. J Gastroenterol 2013; 48: 391–396.
Palanivelu C, Rangarajan M, Jategaonkar PA, Madankumar MV, Anand NV. Laparoscopic Management of Remnant Cystic Duct Calculi: A Retrospective Study. Ann R Coll Surg Engl 2009; 91: 25–29.
Shirah BH, Shirah HA, Zafar SH, Albeladi KB. Clinical patterns of postcholecystectomy syndrome. Ann Hepato-Biliary-Pancreat Surg 2018; 22: 52.
Phillips MR, Joseph M, Dellon ES, Grimm I, Farrell TM, Rupp CC. Surgical and endoscopic management of remnant cystic duct lithiasis after cholecystectomy--a case series. J Gastrointest Surg Off J Soc Surg Aliment Tract 2014; 18: 1278–1283.
Flörcken H. Gallenblasenregeneration mit Steinrezidiv nach Cholecystektomie. Deutsch Z Chir 1912; 113: 604–605.
Bodvall B, Overgaard B. Cystic Duct Remnant After Cholecystectomy: Incidence Studied by Cholegraphy in 500 Cases, and Significance in 103 Reoperations. Ann Surg 1966; 163: 382–390.
Hopkins SF, Bivins BA, Griffen WO. The problem of the cystic duct remnant. Surg Gynecol Obstet 1979; 148: 531–533.
Jonson G, Nilsson DM, Nilsson T. Cystic duct remnants and biliary symptoms after cholecystectomy. A randomised comparison of two operative techniques. Eur J Surg Acta Chir 1991; 157: 583–586.
Sitenko VM, Nechaĭ AI, Stukalov VV, Kalashnikov SA. Large stump of the cystic duct. Vestn Khir Im I I Grek 1976; 116: 56–59.
Keiler A, Pernegger C, Hornof R. Laparoscopic cholecystectomy - current status. Wien Klin Wochenschr 1992; 104: 29–38.
Strasberg SM, Brunt LM. Rationale and Use of the Critical View of Safety in Laparoscopic Cholecystectomy. J Am Coll Surg 2010; 211: 132–138.
Li X, Zhu K, Zhang L, Meng W, Zhou W, Zhu X, Li B. Periampullary Diverticulum May Be an Important Factor for the Occurrence and Recurrence of Bile Duct Stones. World J Surg 2012; 36: 2666–2669.
Oak JH, Paik CN, Chung WC, Lee K-M, Yang JM. Risk Factors for Recurrence of Symptomatic Common Bile Duct Stones after Cholecystectomy. Gastroenterol Res Pract 2012; 2012: 1–6.
Costamagna G, Tringali A, Shah SK, Mutignani M, Zuccalà G, Perri V. Long-term follow-up of patients after endoscopic sphincterotomy for choledocholithiasis, and risk factors for recurrence. Endoscopy 2002; 34: 273–279.
Wu S-D, Tian Y, Kong J, Ding R-Y, Jin J-Z, Guo R-X. Possible relationship between cholecystectomy and subsequent occurrence of primary common bile duct stones: a retrospective review of data. Hepatobiliary Pancreat Dis Int HBPD INT 2007; 6: 627–630.
Schofer JM. Biliary Causes of Postcholecystectomy Syndrome. J Emerg Med 2010; 39: 406–410.
Rogy MA, Függer R, Herbst F, Schulz F. Reoperation After Cholecystectomy. The Role of the Cystic Duct Stump. HPB Surg 1991; 4: 129–135.
Altieri MS, Yang J, Obeid N, Zhu C, Talamini M, Pryor A. Increasing bile duct injury and decreasing utilization of intraoperative cholangiogram and common bile duct exploration over 14 years: an analysis of outcomes in New York State. Surg Endosc 2018; 32: 667–674.
Marks B, Al Samaraee A. Laparoscopic Exploration of the Common Bile Duct: A Systematic Review of the Published Evidence Over the Last 10 Years. Am Surg 2021; 87: 404–418.
Rystedt JML, Wiss J, Adolfsson J, Enochsson L, Hallerbäck B, Johansson P, Jönsson C, Leander P, Österberg J, Montgomery A. Routine versus selective intraoperative cholangiography during cholecystectomy: systematic review, meta-analysis and health economic model analysis of iatrogenic bile duct injury. BJS Open 2021; 5: zraa032.
Tebala GD, Bond-Smith G. Indocyanine Green Fluorescence in Elective and Emergency Laparoscopic Cholecystectomy. A Visual Snapshot. Surg Technol Int 2020; 37: 69–71.
Liu Y, Peng Y, Su S, Fang C, Qin S, Wang X, Xia X, Li B, He P. A meta-analysis of indocyanine green fluorescence image-guided laparoscopic cholecystectomy for benign gallbladder disease. Photodiagnosis Photodyn Ther 2020; 32: 101948.
Yoo ES, Yoo BM, Kim JH, Hwang JC, Yang MJ, Lee KM, Kim SS, Noh CK. Evaluation of risk factors for recurrent primary common bile duct stone in patients with cholecystectomy. Scand J Gastroenterol 2018; 53: 466–470.
Wu Y, Xu CJ, Xu SF. Advances in Risk Factors for Recurrence of Common Bile Duct Stones. Int J Med Sci 2021; 18: 1067–1074.
Ryu S, Jo IH, Kim S, Kim Y-J, Chung WC. Clinical Impact of Common Bile Duct Angulation on the Recurrence of Common Bile Duct Stone: A Meta-analysis and Review. Korean J Gastroenterol Taehan Sohwagi Hakhoe Chi 2020; 76: 199–205.
Baek YH, Kim HJ, Park JH, Park DI, Cho YK, Sohn CI, Jeon WK, Kim BI. Risk Factors for Recurrent Bile Duct Stones after Endoscopic Clearance of Common Bile Duct Stones. Korean J Gastroenterol 2009; 54: 36.
Funding
The study was supported and open access provided by an HFR Research Grant, an intern institutional research fund of the HFR Fribourg – Cantonal Hospital.
Author information
Authors and Affiliations
Contributions
• Burckhardt O.: study design, data acquisition, analysis and interpretation, and writing of the manuscript
• Peisl S.: study design, data acquisition, analysis and interpretation, and writing of the manuscript
• Rouiller B.: study design, data acquisition and analysis, and critical review of the manuscript
• Colinet E.: study design, data acquisition and analysis, and critical review of the manuscript.
• Egger B.: study idea and design, critical data analysis and interpretation, critical review of the manuscript, and senior and corresponding author
• All authors approved the final version of the manuscript and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Corresponding author
Ethics declarations
Conflict of Interest
The authors declare no competing interests.
Previous Communication
None.
Ethical Approval
This study was approved by the local Research Ethics Board (project ID 2021–00441, Commission cantonale VD d’éthique de la recherche sur l’être humain, CER-VD).
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
About this article
Cite this article
Burckhardt, O., Peisl, S., Rouiller, B. et al. Length of the Remnant Cystic Duct and Bile Duct Stone Recurrence: a Case‒Control Study. J Gastrointest Surg 27, 1122–1129 (2023). https://doi.org/10.1007/s11605-023-05607-x
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11605-023-05607-x