431 Ghost Stones and Cystic Duct Exploration: Introducing a Novel Terminology to Address an Overlooked Cause of Post-Cholecystectomy Syndrome

Abstract Introduction Cystic duct stones (CDS) are a well-documented cause of persistent symptoms following cholecystectomy. In this oral presentation, we present multiple videos for cases where standard cholecystectomy would have left behind a proximally impacted cystic-duct-stone—leading to persistent symptoms. Method We hypothesize that such stones are essentially undetectable: there is no bile surrounding them to enable imaging visibility, and even if seen on ultrasound or CT, it is extremely difficult—if not impossible—to distinguish whether the stone lies within the cystic duct or outside the biliary system. Results Hence, we term these stones "Ghost Stones": real entities with clinical significance but invisible to current diagnostic tools. To prevent this scenario, we describe another novel term of cystic duct exploration and recommend it in all gallbladder surgeries—even when cholangiography is not planned. This involves:Making a small incision at the distal cystic duct for potential cholangiography."Milking" the duct from proximal to distal to express any hidden stones.Gently stroking the common bile duct in an antegrade manner along the CD to promote bile flow.If bile flow is not observed—or if the CD contains thick mucus or pus—further proximal dissection is warranted to rule out a ghost stone. Conclusions This abstract under stressed that even with complete cholecystectomy, Cystic duct stones could be missed—particularly if an intraoperative cholangiogram is not performed. Therefore, recognizing and addressing GHOST STONE through routine CYSIC DUCT EXPLORATION is highly recommended and might reduce cases of unexplained post-cholecystectomy syndrome.