Since its introduction in 1988, laparoscopic cholecystectomy has become the leading choice for treating gallstones with symptoms, offering reduced recovery challenges [1]. However, this method is linked to a higher incidence of bile leaks (0.4%-0.6%) compared to open surgery (0%-0.4%) [1]. Cystic duct stump leak (CDSL), a frequent biliary complication, arises from poor sealing, thermal damage, or undetected injury [2]. Symptoms typically emerge 3-4 days post-surgery, including upper right abdominal pain (76%-78%), nausea/vomiting (35%), and fever (18%-27%) [3]. Risk factors involve atypical anatomy, complex dissections, and acute inflammation [4]. Laboratory findings often show elevated leukocytes in up to 68% of cases, with variable liver enzyme levels [3]. The occurrence rate spans 0.1% to 0.2% [1]. If untreated, CDSL can lead to peritonitis, abscesses, strictures, or fibrosis [5]. Recent studies emphasize endoscopic management, noting that cystic duct remnants account for up to 78% of leaks [6,7]. The use of locking clips has shown potential in preventing such issues [8]. Initial detection relies on ultrasound, while ERCP serves as the definitive diagnostic and therapeutic tool [9]. This study aims to assess the frequency, signs, detection, management, and outcomes of CDSL in a prospective cohort, highlighting its understated impact.

This prospective observational study spanned September 2008 to December 2015, encompassing 7000 consecutive laparoscopic cholecystectomies at [Institution Placeholder]. Inclusion criteria targeted patients with postoperative bile leaks confirmed as CDSL via imaging. Exclusions comprised injuries to the common bile duct, accessory ducts, or other biliary issues. Data collected included demographic details, preoperative ultrasound results, postoperative symptoms, biochemical profiles, imaging findings, complications, and treatments. Biochemical assessments covered total leukocyte count (TLC), serum bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase. Imaging techniques included ultrasound, CT, MRCP, and ERCP as needed. Treatments consisted of ERCP with stenting, ultrasound- or CT-guided drainage, or surgical correction. Patients were monitored biweekly in the outpatient clinic for 12 months, with the endpoint being CDSL resolution or persistence. Statistical Analysis: Data analysis utilized Python 3.12 with pandas, numpy, scipy, and matplotlib. Descriptive statistics included frequencies, percentages, and means (age estimated from group midpoints). Inferential statistics employed chi-square tests for goodness-of-fit (e.g., sex vs 1:1, age vs uniform distribution) and independence (e.g., sex vs ultrasound findings, sex vs abdominal pain, acute cholecystitis vs bilioma). Significance was set at p < 0.05, with all tests two-tailed. The study received approval from the institutional ethics committee, and informed consent was obtained from all participants.

The incidence of CDSL was 0.71% (50 out of 7000 cases). Demographics The average age was 44.85 years (estimated midpoint mean: 43.40 years), with a non-uniform age distribution (chi-square = 12.80, df = 4, p = 0.012). Females comprised 36 of 50 (72%), and males 14 of 50 (28%), with a female: male ratio of 2.57:1, significantly deviating from a 1:1 ratio (chi-square = 9.68, df = 1, p = 0.002). Table 1. Demographic Profile of Patients Age Group (Years) No. of Patients (n = 50) Percent <20 0 0 20-30 6 12 30-40 14 28 40-50 18 36 50-60 6 12 >60 6 12 Table 2. Sex Distribution Sex No. of Patients (n = 50) Percent Female 36 72 Male 14 28 Preoperative USG Findings Acute cholecystitis was the most prevalent finding (56%), with no significant association with sex (chi-square = 1.77, df = 3, p = 0.62). Table 3. Correlation between Preoperative USG Findings and CDSL USG Findings No. of Patients (n = 50) Percent Symptomatic Cholelithiasis 12 24 Acute Cholecystitis 28 56 Anomalous Cystic Duct 2 4 Chronic Cholecystitis 8 16 Postoperative Clinical Presentation Abdominal discomfort was the leading symptom (64%), with no significant link to sex (chi-square = 0.17, df = 1, p = 0.68). Table 4. Postoperative Clinical Presentation of CDSL Symptom No. of Patients (n = 50) Percent Pain 32 64 Nausea 22 44 Bilious Drain Output 24 48 Vomiting 14 28 Signs of Peritonitis 8 16 Fever 8 16 Anorexia 10 20 Respiratory Distress 4 8 Postoperative Biochemical Parameters Elevated leukocyte count and alkaline phosphatase were common, each affecting 72% of patients. Table 5. Postoperative Biochemical Parameters Parameter Elevated n (%) Decreased n (%) Normal n (%) Total Leukocyte Count 36 (72) 4 (8) 10 (20) S. Bilirubin 16 (32) 0 (0) 34 (68) SGOT 30 (60) 0 (0) 20 (40) SGPT 32 (64) 0 (0) 18 (36) S. Alkaline Phosphatase 36 (72) 0 (0) 14 (28) Imaging Techniques ERCP emerged as the most effective diagnostic tool. Table 6. Imaging Techniques Used to Diagnose CDSL Imaging Technique Applied n (%) Diagnostic Bile Leak n (%) Diagnostic CDSL n (%) CT Scan 22 (44) 22 (100) 0 (0) MRCP 30 (60) 30 (100) 26 (86.67) ERCP 46 (92) 44 (95.65) 44 (95.65) Complications No significant association was found between acute cholecystitis and bilioma (chi-square = 0.00, df = 1, p = 1.00). Table 7. Complications of CDSL Complication No. of Patients (n = 50) Percent Perihepatic Inflammation 40 80 Subhepatic Abscess 8 16 Stricture Bile Duct 2 4 Bilioma 10 20 Death 0 0 Treatment Modalities ERCP provided the highest rate of definitive success. Table 8. Treatment Modalities Employed Modality Employed n (%) Definitive Success n (%) ERCP + Stenting 46 (92) 42 (91.3) Re-surgery 6 (12) 4 (66.7) Drainage (USG/Surgical) 4 (8) 2 (50) Descriptive statistics from the original study (percentages, means, ratios) were adjusted for the 50-patient cohort, with added inferential tests for completeness.

The observed 0.71% incidence aligns with reported ranges of 0.58%-0.63% [3,10,11], underscoring CDSL as a small thorn with significant repercussions. The female predominance (p = 0.002) mirrors gallstone disease patterns [12]. Acute cholecystitis (56%) stands out as a critical risk factor [3]. Symptom and biochemical profiles are consistent with prior findings [2,3]. ERCP’s 95.65% diagnostic accuracy and 84% treatment success reinforce its value, supported by a 93.8% efficacy rate in similar contexts [7]. Locking clips have proven effective, with no leaks in large series [8]. Complications highlight the need for prompt action [5,6]. Limitations include the single-center design and lack of randomization. Future research could explore preventive measures, such as enhanced clipping techniques [13]. Acknowledgments: None.

Though rare, CDSL poses a significant challenge post-laparoscopic cholecystectomy, with ERCP proving effective for diagnosis and treatment. Early intervention is key to reducing complications.

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