Post-Cholecystectomy Gall Bladder Remnant and Cystic Duct Stump stone: surgical pitfalls, causes of occurrence and completion cholecystectomy (open versus laparoscopic) as a safe surgical option of treatment: short and long term outcome. Randomized Controlled Clinical Trials.

Introduction : cholecystectomy is the standard surgical option of symptomatic gallbladder disease. The symptoms persist after cholecystectomy in 10 - 20% of cases. Residual gall bladder/cystic duct stump stone is one of the most important cause. Aim : to compare between open and laparoscopic completion cholecystectomy for gall bladder (GB) remnant and cystic duct stump stones as regard short and long term outcome. Methods : This study was conducted on 84 cases with residual GB/cystic duct stump stone that were divided into 2 groups, the open completion cholecystectomy group and the laparoscopic completion cholecystectomy group. The diagnosis was made by ultrasound and magnetic resonance cholangiopancreatography. Results : The mean operative time was 120±13 minutes in open group and 160±10 in laparoscopic group. Blood loss occurred in 8 cases in open group and 2 cases in laparoscopic group that necessitated blood transfusion. Biliary injuries detected intraoperative occurred in 3 cases with open approach and 2 cases with laparoscopic approach and suture immediately by vicryl 3/0. The mean hospital stay was shorter in laparoscopic group than open group. . Conclusion : laparoscopic Completion cholecystectomy is a safe surgical approach for cystic duct stump stone. Research Hypothesis: laparoscopic completion cholecystectomy is safe in managing gall bladder and cystic duct stump stones.

1. Introduction: 5 The incidence of gall bladder and cystic duct stump stones occurs in 5% of cases underwent urgent cholecystectomy but the incidence is much less after elective cholecystectomy [1]. The incidence of cystic duct stump stone after laparoscopic cholecystectomy is higher than open cholecystectomy; the former represents about 13.3% [2]. Some surgeons perform incomplete removal of gall bladder during difficult dissection of triangle of Calot for fear of injury of important structure in the vicinity [3].
The incidence of gall bladder and cystic duct stump stone can be prevented by complete skeletonization of cystic duct for a distance not exceeding 1 cm from the common bile duct and stone in cystic duct is pushed back in gall bladder if present [4] [5] [6].
The presence of stone in cystic duct can be diagnosed by intraoperative palpation of the cystic duct but intraoperative cholangiography may be used in diagnosis but not routinely used [7] [8].
The term of cystic duct stump syndrome falls under the differential diagnosis of post-cholecystectomy syndrome that may be caused by different causes like reflux esophagitis, peptic ulcer, irritable colon and colitis. This may lead to delay in diagnosis of cystic duct stump syndrome. [9] [10] To reach the diagnosis of cystic duct stump syndrome, history of post-cholecystectomy persistent symptoms that are present postoperative, in addition to different diagnostic modalities as ultrasonography, computed tomography (CT) scan, endoscopic retrograde cholangiopancreatography (ERCP), and magnetic resonance cholangiopancreatography (MRCP). [11].
The purpose of this study is to evaluate the role of laparoscopic completion cholecystectomy as the best surgical option for cystic duct stump and gall bladder remnant syndrome as regard safety to the patients.

The Aim Of The Work:
to assess the best surgical approach for treatment of gall bladder and cystic duct stump syndrome as regard safety to the patients.

Patients And Methods:
Study design: Prospective Randomized controlled clinical study.
Study place: our study was conducted in the general surgical unit of our University Hospitals. Numbers of patients excluded from the study were 10 patients: because of mild symptoms that the patients refused surgery and preferred medical treatment (8 patients) and patients unfit for surgery due to medical diseases (2 cases).
The following investigations were performed immediately on admission: percentage, quantitative continues group represent by mean ± SD, the following tests were used to test differences for significance;. difference and association of qualitative variable by Chi square test (X2). Differences between quantitative independent groups by t test or Mann Whitney,. P value was set at < 0.05 for significant results & <0.001 for high significant result.    Cystic duct stump syndrome is commonly seen in females than males. this is attributed to the fact that gall bladder disease is more common in female than male. In present study; the incidence was 70% in females (14 cases) compared to 30% in males (6 cases). This higher incidence in females was also reported by a study that stated that the male to female ratio was 1:1.45. [12] A study showed that patients with gall bladder and cystic duct stump stones may be asymptomatic and discovered accidentally on performing investigations for unrelated condition [15], while other studies stated that the patients may be presented with post-cholecystectomy symptoms that may be acute symptoms (symptoms of acute cholecystitis or biliary colic) or chronic symptoms (pain radiating to the shoulder, dyspepsia, food intolerance) [13] [14]. In the present study, most cases presented with right hypochondrial pain (77 cases) and asymptomatic cases are 7 cases and discovered accidently by ultrasonography for other unrelated symptoms.

Results:
A study stated that the length of cystic duct necessitate to cause post-cholecystectomy cystic duct stump stone should be longer than 1 cm [16]. In the present study, all cystic duct stumps were more than 1 cm in length.
Some studies claimed that the incidence of cystic duct stump syndrome increased in the last years due to popularity of laparoscopic cholecystectomy, and the cystic duct stump stone is the cause of In the immediate postoperative period, 8 patients developed fresh bleeding coming continuously from the drain that required re-exploration. 6 cases from cystic artery stump ligature slippage and managed easily by ligation of the bleeding artery and 2 cases from port site bleeding and treated by figure of 8 fixations of the port site.no major vessels injury recorded.
A study stated that the incidence of bile duct injuries of different forms (cutting, wrong site clips and thermal injuries) is more common in laparoscopic completion cholecystectomy than open approach.
The patient presents with abdominal pain and fever and the diagnosis is confirmed by ultrasonography the reveals biloma collection in gall bladder bed [24].In the present study, ten patients developed biliary leakage, six patients after open approach and 4 patients after laparoscopic approach. They presented mostly one week after the operation with abdominal pain, fever and jaundice, and a biloma was diagnosed by ultrasonography and aspiration. five cases underwent sonar guided catheter drainage and ERCP with plastic stent insertion in common bile duct, and five cases of mild symptoms underwent conservative treatment in the form of nasogastric tube, third generation cephalosporin injection, metronidazole 500 mg injection with adequate hydration and the patient improved after 10 days by absent collection radiologically and improvement of symptoms and signs.
In the postoperative follow up period, three cases developed biliary stricture that necessitated ERCP dilatation with stent insertion in two cases, and one was severely stenosed that treated successfully by hepaticojejunostomy after failure of ERCP dilatation and stenting.
Some studies stated that surgical approaches for post-cholecystectomy gall bladder remnant and cystic duct stump stone are safe with no mortality and minor morbidity [14] [21]. In the present study, intestinal injuries discovered nearly ten days after  Yes all ethical approval was given by our Faculty of Medicine medical ethical committee.

12-Authors contributions:
All authors shared in the study design, data analysis, writing and critical revision of the manuscript for important intellectual contents. they shared in the final approval of the version to be submitted.   adhesion with the colon is released with care Figure 10 adhesion with the colon is released with care Figure 11 blunt dissection of gall bladder bed Figure 12 blunt dissection of gall bladder bed Figure 13 another case with gall bladder remnant held by forceps Figure 14 another case with gall bladder remnant held by forceps