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.
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 post-cholecystectomy cystic duct stump syndrome in 16% of cases. [17] [18]. In the present study, opposite data were found that cystic duct stump and gall bladder remnant stones were common in previous open cholecystectomy than laparoscopic cholecystectomy and in the emergency cases than elective cases. This may be explained by the fact that during laparoscopic cholecystectomy, the cystic duct must be found and completely skeletonised to apply clips on it, while in open cholecystectomy you may divide the gall bladder just below Hartmann’s pouch especially in acute cholecystitis cases for fear of injury of biliary tract especially when Callot triangle is masked by adhesion.
Some studies stated that the time between initial cholecystectomy till diagnosis of gall bladder or cystic duct stump stone was 8.3 months [19] and 9.5 years [15]. In the present study, most cases present within one year after previous cholecystectomy (12 cases).
Some studies stated that the diagnosis of gall bladder remnant or cystic duct stump stones is established by different diagnostic modalities like ultrasound, CT scan, ERCP, and MRCP [14] [19] [20] [21].In our study, the primary diagnosis was established by expert abdominal ultrasonography and MRCP modality that were done in all cases.
Previously, open completion cholecystectomy is preferred as a safer technique as regard disturbed anatomy from previous adhesion and the possibility of stone tactile sensation identification during surgery, but nowadays laparoscopic approach is accepted as a safe approach by other studies [15][19][21][22].in our study, laparoscopic approach is safe as regard intraoperative and postoperative parameters.
Many studies had variations regarding the operative time and blood loss. A study reported a mean operative time was 62 min for open approach and the mean blood loss was 50 ml [21], other study stated that mean operative time was 102.4 min for laparoscopic approach, and the hospital stay was 2–4 days [14], other study reported mean operative time of 127 ± 31.32 min for laparoscopic approach and mean blood loss 165 ± 74.5 ml, and mean hospital stay of 3.2 ± 1.8 days[23]. In the present series, mean operative time was 120 ± 13 minutes for open approach and 160 ± 10 minutes for laparoscopic approach. ten cases received blood transfusion intraoperative, 8 cases during open approach and 2 cases during laparoscopic approach, and the length of hospital stay was 5.4 ± 3.2 days for open versus 4.3 ± 4.5 days for laparoscopic group.
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 operations occurred in 4 patients after open approach and 2 patients after laparoscopic approach. The patients diagnosed with abdominal pain and intra-abdominal collection that was diagnosed by oral contrast computerized tomography and showing the leakage that confirmed by sonar guided aspiration. all cases were open bowel with no peritonism and so conservative treatment were first option in all cases. Four patients showed complete recovery clinically, laboratory and radiologically and 2 cases required re-exploration.one case showed duodenal injury that was treated with closure the defect and gastrojejunostomy and the other was transverse colon injury that was treated by temporarily colostomy and 2 months later ,the continuity of gastrointestinal tract was restored. In present study, mortality occurred in four cases of due to postoperative pancreatitis in two cases, one cases that had duodenal injury and the last one from postoperative pulmonary atelectasis. Pancreatitis postoperatively was in patients aged 62 old male and 67 old female that diagnosed postoperatively by abdominal pain, vomiting, fever, abdominal tenderness and diagnosis confirmed by CT. patient underwent conservative treatment with nothing per mouth, fluid and antibiotic but died after 5 days and 11 days respectively from sepsis and multisystem organ failure.