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Laparoscopic Management of postcholecystectomy stump syndrome

Javid Ahmad Bhat, Mubashir Ahmad Shah, Irfan Nazir Mir, Prince Ajaz Ahmad.

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Introduction: Almost 10-40% of patients experience postcholecystectomy syndrome, with a contribution of 2.5% from stump syndrome. Their management can be challenging because of diagnostic dilemmas with consequent therapeutic delays. The diagnostic accuracy of MRCP is high as compared to other radiological tools. An open surgical approach managed earlier stump-related problems, but the trend is persistently shifting towards a laparoscopic approach.
Methods: A prospective study was conducted in our Institute on 45 diagnosed cases of stump syndrome. The Radiology, Gastroenterology and Surgical divisions adopted a multi-skilled team approach. MRCP was the main tool utilised for diagnosis and classifying surgical anatomy. In all patients, the initial surgical approach was Laparoscopy.
Results: The mean age was 44.65 ± 11.52 years. Right upper abdominal pain was present in 36 (81.2%) patients. The time gap between the index surgery and the development of symptoms ranged from 14 days to 12.5 years, with a median of 42 months. Index operation was the open approach in 21(47%). MRCP was diagnostic in all patients. Other findings on MRCP included Mirrizi syndrome in 4(8%) and Choledocholithiasis in 5 (10%). The type of surgical anatomy was easy in 14(31%), difficult in 26(58%) and complex in 5(11%). Preoperative ERCP was done in all 5 cases of choledocholithiasis before completion of cholecystectomy. The Laparoscopy approach was successful in 42(94%), with a mean operative time of 102±12.3 min in completion cholecystectomy patients. Four patients had significant postoperative bile leaks in whom ERCP was required in only 2 patients. No major bile duct injury or mortality occurred. The mean length of hospital stay was 3.8 days with a standard deviation of 2.6. In a mean follow-up of 33.8 months, only 3 patients had persistent symptoms.
Conclusion: MRCP is helpful in all stages of management. Laparoscopy has the potential to become the primary approach for managing this condition with a high success and a low morbidity rate. Successful outcomes are expected more when a multi-skilled approach is adopted.

Key words: stumplithiasis, completion cholecystectomy, subtotal cholecystectomy, MRCP, ERCP

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