Abstract
Objectives: To provide a comprehensive review of post-cholecystectomy complications, including their classification, diagnostic approaches, and clinical management, with a focus on imaging modalities and their role in improving patient outcomes.
Design: This review integrates current evidence from relevant studies and clinical guidelines to categorize and describe early and late complications after cholecystectomy. Imaging findings, management strategies, and multidisciplinary considerations are emphasized.
Setting: Data were synthesized from peer-reviewed literature and case studies involving post-cholecystectomy patients in diverse clinical settings.
Participants: Patients undergoing laparoscopic or open cholecystectomy and subsequently presenting with complications such as bile duct injuries, bile leaks, vascular injuries, or stone-related conditions.
Methods: A systematic approach was employed to identify common and rare complications. Each complication was categorized by anatomical location, timing of presentation, and severity. The diagnostic utility of imaging modalities, including ultrasound, computed tomography, magnetic resonance imaging, and endoscopic retrograde cholangiopancreatography was critically evaluated.
Results: Post-cholecystectomy complications significantly impact morbidity. Early complications include bile duct injuries, bile leaks, vascular injuries, and infectious processes. Late complications, such as bile duct strictures, retained stones, and Mirizzi syndrome are associated with higher diagnostic complexity. Imaging modalities play a crucial role in early detection and management, with magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography offering superior diagnostic and therapeutic potential.
Conclusion: Post-cholecystectomy complications require timely recognition and multidisciplinary management. Imaging studies are indispensable for accurate diagnosis and treatment planning. This review highlights key complications and their imaging characteristics, aiding clinicians in optimizing patient outcomes.
- Bile duct injury
- Bile leak
- Biliary obstruction
- Biliary strictures
- Computed tomography
- Endoscopic retrograde cholangiopancreatography
- Imaging modalities
- Laparoscopic cholecystectomy
- Magnetic resonance cholangiopancreatography
- Mirizzi syndrome
- Multidisciplinary management
- Post-cholecystectomy complications
- Retained stones
- Ultrasound
Laparoscopic cholecystectomy is one of the most common surgical procedures, performed, approximately 750,000 times per year in the United States.1,2 It has several advantages over open surgery, including shorter hospitalization, earlier return to activities, and lower overall complication rates; however, it has other increased complications, such as the frequency of harm to biliary structures.3,4
Post-cholecystectomy syndrome refers to persistent or new gastrointestinal symptoms after cholecystectomy, typically early in the postoperative period, but they can occur months or even years after surgery.4 The prevalence reported ranges from very low to 47%.5 Bile duct injuries (BDI) are the most common complication after cholecystectomy (0.5%).1,6 However, other complications may arise. These can be classified according to the time of presentation (short- or long-term) or the site of the complication (biliary, vascular, stone-related complications, etc.).7 For an accurate diagnosis, imaging studies such as computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound are essential.3 It is crucial to know the benefits and limitations of different imaging modalities to characterize the complications that may occur after cholecystectomy.6 In this review, our goal is to present a comprehensive description of post-cholecystectomy complications, focusing on the presentation of the images, with the objective of supporting the assessment of the different specialties involved in the multidisciplinary management of these patients (emergency physicians, internists, radiologists, surgeons, gastroenterologists, geriatricians).
Materials and Methods
A systematic search of the PubMed database was conducted following the standard protocol recommended by the National Library of Medicine. The search focused on identifying studies relevant to post-cholecystectomy complications. The following search terms were employed: “Post-cholecystectomy”; “Post-cholecystectomy” AND “Complications”; “Cholecystectomy” AND “Complications”; “Cholecystectomy” AND “Imaging”; “Post-cholecystectomy” AND “MRI”; “Post-cholecystectomy” AND “CT”; “Cholecystectomy” AND “Stricture”; “Bile Duct Injury”; “Mirizzi Syndrome”; “Biliary Complications”; and “Biloma.”
The search was restricted to articles published in English and those available as full-text articles. Inclusion criteria were as follows: studies investigating post-cholecystectomy complications; studies focusing on the epidemiology, physiopathology, imaging evaluation, diagnosis, and management of post-cholecystectomy complications; and studies exploring the mechanisms underlying post-cholecystectomy complications. Exclusion criteria were: studies that did not focus on complications occurring after cholecystectomy, and articles unavailable as full-text versions. The synthesized results are presented narratively, summarizing the key findings from the reviewed studies.
Results
Common Diseases Leading to Post-Cholecystectomy Complications
Cholelithiasis remains one of the most prevalent gastrointestinal disorders, affecting over 20.4 million individuals in the United States.8 While many cases are asymptomatic and do not require surgical intervention, incidental findings during imaging often lead to patient management decisions. Despite this, cholelithiasis is responsible for more than half of the cholecystectomies performed annually in the United States.
Other conditions frequently necessitating cholecystectomy include acute and chronic pancreatitis, chronic acalculous cholecystitis, gallbladder polyps, functional gallbladder disorders, and neoplastic lesions of the gallbladder.8 These underlying diseases contribute significantly to the procedural volume and underscore the importance of recognizing their potential complications.
Diagnostic Modalities for Post-Cholecystectomy Complications
Radiological evaluation plays a pivotal role in diagnosing post-cholecystectomy complications by identifying lesions, determining the extent of injury, guiding management planning, and confirming diagnoses.1,9 The diagnostic process often begins with non-invasive imaging modalities, such as transabdominal ultrasound and computed tomography (CT). These tools are effective for detecting biliary tract diseases, fluid collections, and vascular injuries. However, their utility may be limited in distinguishing fluid collections, such as seromas, hematomas, and bilomas.9
Magnetic resonance cholangiopancreatography (MRCP) is widely regarded as the non-invasive gold standard for evaluating bile duct injuries (BDIs). MRCP offers excellent sensitivity and specificity for diagnosing biliary injuries and other complications, while also guiding subsequent invasive procedures.10 Despite these advantages, CT remains a more commonly performed modality due to its broad availability and lower cost.6
Endoscopic retrograde cholangiopancreatography (ERCP) provides a more detailed anatomical evaluation of biliary injuries that extend beyond the immediate site of damage. Its primary therapeutic benefit lies in its ability to place stents and drainage catheters, making it the first-line intervention for many biliary complications.3,10 However, ERCP has limitations, including its inability to detect anomalous right hepatic bile ducts due to its retrograde approach. Other complementary imaging modalities include hepatobiliary scintigraphy, cholescintigraphy with hydroxyl iminodiacetic acid (HIDA), and single-photon emission computed tomography (SPECT/ CT), which offer additional diagnostic insights in specific clinical scenarios.1
Complications after Cholecystectomy
Post-cholecystectomy complications can be classified using various approaches, with one common method categorizing them by the anatomical site affected.11 These complications are further subdivided into early and late presentations.12 Early complications typically manifest within days to weeks postoperatively, while late complications may arise months or even years after surgery.
Table 1 provides a comprehensive overview of early and late complications grouped by anatomical location. This classification highlights complications affecting the gallbladder remnant, cystic duct, biliary tract, pancreas, vascular structures, and other regions. Figure 1 illustrates the most frequently encountered post-cholecystectomy complications, including bile duct injury, bile leaks, bilomas, retained gallstones, and bile duct strictures. By organizing complications based on their timing and anatomical site, clinicians can more effectively diagnose and manage these conditions, ensuring prompt intervention and improved patient outcomes.
Schematic representation of common post-cholecystectomy complications. This includes transected ducts, bile leaks, bilomas, retained gallstones in the common bile duct, and bile duct strictures.
Complications of the Gallbladder Remnant and Cystic Duct
Late Complications
Reformed Gallbladder. In some cases, following cholecystectomy, a subtotal gallbladder may remain, resulting in residual fluid-filled structures with omentum-like walls observed in the gallbladder fossa on imaging studies.11 To prevent this outcome, three techniques have been proposed to avoid dissection of the triangle of Calot, all of which involve extensive cauterization of residual gallbladder mucosa.13,14 Numerous articles and case reports highlight the persistence of cystic duct remnants after subtotal cholecystectomy, with some developing calculi.15 In certain patients, a reformed gallbladder-like structure may appear on interval CT scans, strongly resembling a normal gallbladder. These cases often necessitate repeat laparoscopic cholecystectomy for definitive management.16
Stump Cholelithiasis. Cystic duct remnants measuring more than 5 mm in diameter on imaging are considered irregular and dilated, often predisposing patients to the formation of stump cholelithiasis.11 These residual calculi can lead to recurrent symptoms and may require further surgical or endoscopic intervention.
Biliary Complications
Early Complications
Bile Duct Injury (BDI). BDI is among the most significant complications following cholecystectomy, with the most common manifestation being a defect in the common bile duct (CBD).12 Mechanisms of biliary duct injury include unintentional cutting of the bile ducts, dislodgement of surgical clips, and thermal damage caused by electrocautery.6,11 The progression of such injuries often leads to stricture formation within the duct and subsequent fibrosis or atrophy of the obstructed liver segment. This cascade of events can result in recurrent cholangitis, secondary biliary cirrhosis, liver failure, and, in severe cases, death.5
The widely accepted Strasberg classification, further complemented by the Bismuth classification, categorizes these injuries based on their anatomical location and proximity to the bifurcation of the bile duct.17 Strasberg’s classification ranges from Type A to Type E injuries, while Bismuth’s framework (Types 1–5) provides additional specificity regarding the extent and site of the injury. Figure 2 illustrates the full Strasberg-Bismuth classification, highlighting its utility in guiding both diagnosis and management.
Bismuth-Strasberg classification of bile duct injury. Strasberg classification ranges from Type A (injuries involving minor hepatic ducts) to Type E (main hepatic duct injuries classified further into E1–E5 based on the proximity and extent of the lesion). Bismuth classification describes injuries by the distance from the bile duct bifurcation and specific injuries to the right hepatic duct.17
Bile Leak. Bile leaks are another common postoperative issue, classified into low- or high-grade, based on when the leak is identified during imaging. Low-grade leaks become apparent only after complete opacification of the intrahepatic biliary system, whereas high-grade leaks are visible earlier.2 The most frequent site of presentation is the cystic duct stump. Initial imaging modalities like ultrasound and CT can detect fluid collections; however, they are often insufficient to distinguish bile leaks from other types of postoperative fluid collections. ERCP is considered the gold standard for identifying bile leaks, as it provides both accurate anatomical diagnosis and therapeutic options, such as stent placement. Nevertheless, ERCP is invasive and carries risks, including acute pancreatitis, bleeding, and cholangitis.1
Late Complications
Choledochoduodenal Fistula. Choledochoduodenal fistulas are a rare but significant late complication of cholecystectomy.18 This condition involves an abnormal communication between the bile duct and the duodenum, often resulting in pneumobilia observed on imaging. Without oral contrast, CT imaging may reveal air within the biliary tree, while the addition of contrast highlights the full extent of the fistula.6 ERCP remains the most reliable imaging modality for confirming the diagnosis and planning subsequent management. Figure 3 depicts a case of choledochoduodenal fistula, emphasizing its characteristic imaging features.
Imaging of choledochoduodenal fistula. (A) and (B) illustrate contrast medium leakage from the bile duct into the duodenum, confirming the diagnosis of a fistula.
Biloma. When a bile leak is encapsulated within a localized fluid collection, it forms a biloma, a condition with a high risk of infection.1 Bilomas commonly occur in the subhepatic and perihepatic spaces. Initial diagnostic evaluation typically involves CT or ultrasound, which can identify fluid collections and biliary duct dilation. However, these modalities often struggle to differentiate bilomas from other postoperative fluid accumulations, such as seromas, hematomas, or abscesses. MRI provides additional diagnostic clarity. On T1-weighted sequences, bilomas appear as hypointense fluid collections, while on T2-weighted sequences, they present as hyperintense lesions. A thickened wall or rim enhancement on imaging raises suspicion of superinfection or abscess formation.2 Figure 4 showcases a biloma case, including its imaging characteristics and subsequent treatment.
Imaging and management of a biloma. (A) and (B) demonstrate fluid collections in coronal and axial computed tomographic planes, respectively. (C) shows post-stent placement imaging. (D) and (E) display magnetic resonance imaging of bilomas in coronal and axial T2-weighted sequences, highlighting bilateral perihepatic and perisplenic subphrenic fluid collections.
Stricture Formation. Stricture formation is a significant late complication of laparoscopic cholecystectomy, with an incidence of up to 0.6%.1,6 This delayed complication can arise months or even years postoperatively. The etiology typically involves thermal injury to the bile ducts during surgery or fibrosis induced by surgical clips. Patients with biliary strictures often present with symptoms such as jaundice, cholangitis, or recurrent abdominal pain. Imaging studies play a critical role in diagnosis. MRCP offers high sensitivity and specificity for identifying strictures, providing detailed visualization of the biliary tree. In addition to its diagnostic capabilities, ERCP serves as a therapeutic option, enabling interventions such as stent placement or balloon dilatation.6 Prompt recognition and management of stricture formation are essential to prevent progression to more severe complications, including biliary cirrhosis or liver failure.
Mucocele. Mucocele formation is a rare but noteworthy late complication of cholecystectomy. It results from a cystic duct remnant with a blind end, which becomes distended with mucus and may compress the common hepatic duct, leading to biliary occlusion.6 Gallbladder mucoceles often evade detection during routine ultrasound examinations due to their subtle presentation. As a result, MRCP is the preferred imaging modality, even when prior studies are unremarkable.19,20 MRCP provides superior visualization of the biliary tree, facilitating the accurate diagnosis of mucoceles and guiding appropriate management. Timely identification and intervention are critical to preventing complications such as cholangitis or further obstruction.
Stone-Related Complications
Early Complications
Dropped Gallstones. Gallstone spillage occurs in 10%–30% of laparoscopic cholecystectomies, but most spilled gallstones remain clinically silent and are considered harmless.12 These stones typically localize to the subhepatic or subdiaphragmatic regions and, less commonly, in the pelvis.6 Diagnosis relies on the patient’s medical history combined with imaging studies. In a subset of cases, spilled gallstones lead to complications, including granuloma formation and abscess development, occurring in 20% of cases involving gallstone loss and 0.08%–2.9% of all laparoscopic cholecystectomies.21 Rarely, pleural empyema has been documented as a complication of gallstone loss.22 Ultrasound serves as the standard initial imaging modality. Stones appear as hyperechoic foci with posterior acoustic shadowing, demonstrating mobility when saline solution is injected. However, ultrasound is limited in assessing deeper abscesses due to restricted beam penetration. CT complements ultrasound by detecting small, low calcium-density gallstone fragments, and contrast-enhanced CT helps identify abscesses as complex, multiloculated fluid collections.21,23
Late Complications
Retained Stone/Mirizzi Syndrome. The incidence of retained stones following laparoscopic cholecystectomy ranges from 1.1% to 7%.24 Retained stones increase biliary pressure, which may displace cystic duct clips, causing bile leakage. Additionally, Mirizzi syndrome can develop due to gallstone impaction in the cystic duct remnant, triggering an inflammatory response that compresses the extrinsic bile duct. Diagnosis is heavily reliant on imaging findings and can be achieved using abdominal ultrasound, contrast-enhanced CT, or MRCP.6,25 Ultrasound findings for Mirizzi syndrome typically include intrahepatic biliary dilation, an impacted stone in the gallbladder neck, and an abrupt normalization of the common bile duct below the stone.25,26 While CT imaging is valuable for identifying potential underlying malignancies, it does not significantly enhance the diagnostic specificity compared to ultrasound. MRCP, on the other hand, is highly sensitive and offers superior diagnostic capability for identifying Mirizzi syndrome compared to ultrasound or CT. ERCP is frequently required to confirm the diagnosis and evaluate associated complications, such as cholecystobiliary fistulas. In cases where ERCP is unavailable or unsuccessful, percutaneous transhepatic cholangiography serves as an alternative diagnostic tool.14,27,28
Vascular Injury
Early Complications
Vascular complications following laparoscopic cholecystectomy are reported in 1.8%–4.1% of cases.12 These complications include vascular injury at the surgical site, pseudoaneurysm formation, and injuries at wound or trocar sites, particularly during dissection of the Calot triangle. The portal vein and right hepatic artery are the most frequently affected vessels during gallbladder fossa dissections. Additionally, due to its anatomical proximity, the middle hepatic vein is susceptible to bleeding caused by liver parenchymal injuries, occurring in 10%–15% of patients.12
While intraoperative bleeding may be evident in some cases, others require further evaluation to confirm the extent of vascular injury. Imaging studies such as thin-collimation CT angiography and mesenteric angiography with portal venous imaging are instrumental in detecting and characterizing these complications.29-31 Figures 5, 6, and 7 illustrate examples of vascular injuries, highlighting their radiological features and implications for clinical management.
Portal vein thrombosis. (A) Coronal computed tomography (CT) shows portal vein thrombosis with cavernous transformation and mesenteric thickening. (B) Axial CT and (C) sagittal CT reveal intestinal ischemia secondary to venous thrombosis.
Hepatic artery bleeding. (A) Coronal computed tomography (CT) in the arterial phase demonstrates active bleeding. (B) Shows a corresponding filling defect in the hepatic artery.
Gallbladder hematoma. (A) Axial computed tomography (CT) demonstrates a fluid collection with high attenuation (75 HU), consistent with blood. (B) Coronal CT provides a comprehensive view of the hematoma.
Other Complications
Early Complications
Infectious. Although rare, infectious complications such as cholangitis and liver abscesses may arise after laparoscopic cholecystectomy.6 Cholangitis typically manifests with wall enhancement of the intrahepatic biliary ducts on both CT and MR imaging, making these modalities essential for accurate diagnosis. Figure 8 illustrates a liver abscess, highlighting its characteristic imaging features. Surgical wound infections represent another potential complication of laparoscopic cholecystectomy. Despite being one of the safest surgical procedures, wound infection rates range from 0.71%-8.7% (32). Prompt recognition and treatment are critical to prevent further morbidity.
Liver abscess detected on imaging. (A) Coronal computed tomography (CT) shows multiple hypodense lesions with peripheral enhancement. (B) Axial CT highlights associated findings, including hepatomegaly and soft tissue edema.
Duodenal Injury. Duodenal or bowel injuries are exceedingly rare, with an incidence of 0.01%-4% of laparoscopic cholecystectomies. Among these, 58% involve the small intestine, 32% affect the large intestine, and 7% occur in the stomach.33 Most injuries result from trocar insertion, thermal damage, or, less commonly, dissection or adhesiolysis.12,34 These injuries present complex diagnostic and therapeutic challenges and can be life-threatening if not promptly recognized and managed.20,35 Duodenal injuries may be identified intraoperatively or during the postoperative period, typically within 3 days but up to 5 days post-surgery.33 Diagnostic approaches include liver function tests, which may be normal or show mild elevation. Contrast studies with gastrografin can confirm the presence of a duodenal leak, while CT imaging provides greater sensitivity than ultrasound, revealing large fluid collections around the duodenum or within the peritoneal cavity depending on the timing of the evaluation.36,37
Conclusions
Post-cholecystectomy complications significantly contribute to patient morbidity and impose a substantial financial burden on healthcare systems. Effective management of these complications requires a multidisciplinary approach informed by thorough clinical evaluation and detailed imaging studies. Imaging modalities such as ultrasound, CT, MRI, and endoscopic techniques play critical roles in the diagnosis and treatment of these conditions. This review has provided an overview of common post-cholecystectomy complications, supported by classifications, imaging findings, and representative examples to aid in clinical assessment. As a widely available and versatile imaging modality, CT often serves as the first-line tool, while advanced techniques like MRCP and ERCP offer higher diagnostic accuracy and therapeutic options in complex cases. By enhancing awareness and understanding of these complications, clinicians can improve patient outcomes through timely and accurate diagnosis and tailored treatment strategies. This review serves as a resource for healthcare providers across specialties, enabling effective collaboration in the management of post-cholecystectomy complications.
Acknowledgments
L.M.G.H and M.G.L. were research fellow at the directorate of research of HGMEL under the supervision of E.R.V. in 2022.
- Received November 25, 2024.
- Accepted January 7, 2025.
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