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Postcholecystectomy Syndrome Treatment & Management

  • Author: Steen W Jensen, MD; Chief Editor: John Geibel, MD, DSc, MSc, MA  more...
 
Updated: Dec 16, 2015
 

Approach Considerations

Postcholecystectomy syndrome (PCS) is usually a temporary diagnosis. An organic or functional diagnosis is established in most patients after a complete workup. Once a diagnosis has been established, treatment should proceed as indicated for that diagnosis. Treatment may be either medical or surgical.

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Pharmacologic Therapy

Patients with irritable bowel disease may benefit from the administration of bulking agents, antispasmodics, or sedatives. The irritable sphincter may respond to high-dose calcium channel blockers or nitrates, but the available evidence is not yet convincing. Cholestyramine has been helpful for patients with diarrhea alone.

Antacids, histamine 2 (H2) blockers, or proton pump inhibitors (PPIs) can occasionally provide relief for patients with gastroesophageal reflux disease (GERD) or gastritis symptoms. One study showed that lovastatin might provide at least some relief in as many as 67% of patients.

For patients with dyspeptic symptoms, Abu Farsakh et al showed that symptoms correlated with gastric bile salt concentration.[5]

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Surgical Intervention

Like medical therapy, surgical therapy should be directed at the specific diagnosis.[15, 16] Surgery is indicated when an identifiable cause of PCS that is known to respond well to operative intervention has been established. The most commonly performed procedure is endoscopic retrograde cholangiopancreatography (ERCP), which can be both diagnostic and therapeutic. Exploratory surgery is a last resort in the patient who lacks a diagnosis and whose condition proves refractory to medical therapy.

In 1947, Womack suggested resection of scar and nerve tissue around the cystic duct stump, though this method is somewhat controversial.[1] Others suggested resection of neuroma, cystic duct remnant, sphincter dilation, sphincterotomy, sphincteroplasty, biliary bypass, common bile duct (CBD) exploration, and stone removal. With ERCP, most of these diagnoses would have been ruled out or treated, and the idea of amputation of neuroma was controversial.

Patients abusing alcohol or narcotics are especially difficult to manage, and exploratory surgery should be postponed until they have stopped abusing these drugs.

In a few patients, no causes are identifiable and exploration is unrevealing, but the condition may respond to sphincteroplasty, including the bile and pancreatic ducts. This group of patients is not yet identifiable preoperatively.

If, after a complete evaluation (including ERCP with sphincterotomy), a patient continues to experience debilitating, intermittent right-upper-quadrant pain, and no diagnosis is found, the procedure of choice after a normal exploratory laparotomy is transduodenal sphincteroplasty.

When postcholecystectomy syndrome (PCS) results from remnant cystic duct lithiasis (RCDL; ie, gallstones within the cystic duct after cholecystectomy), endoscopic therapy may suffice, but surgical excision of the RCDL may be necessary in some cases.[17]

Procedure

After workup, the patient should be made safe for an operation, and the planned operation should be safe for the patient. The operation should be structured to follow a logical and systematic course with attention to detail and careful handling of tissues, especially those of the biliary tract.

The endoscopist should be experienced in evaluating this type of patient, and the surgeon should be experienced in operating on them. A skilled assistant should also be invited, and the radiologist and endoscopist involved in the case should be available for consultation. The patient should be the first and only individual undergoing surgery in the morning. A fresh team in the operating room is helpful in a potentially long and tedious case.

After exploration and lysis of adhesions, intraoperative cholangiography (IOC) should be performed. The only circumstance in which IOC may be omitted is when a nonbiliary source is identified and a high-quality preoperative cholangiogram is available (eg, from ERCP).

Most authorities agree that sphincteroplasty and septoplasty between the CBD and the pancreatic duct should be performed unless the head of the pancreas is hard, fibrotic, or indurated from chronic pancreatitis. In this situation, choledochoduodenostomy may prove more effective. Sphincteroplasty requires a generous right subcostal incision and mobilization of the hepatic flexure of the colon and the duodenum.

The portal structures are identified, along with the cystic duct stump. When possible, IOC should be performed through the stump. Choledochoscopy may also be helpful if a stone or potentially malignant stricture was identified. This can also be accomplished via the cystic duct stump. Once the stump is no longer needed, it is ligated with absorbable suture within 5 mm of the CBD junction. If the stump is not used, a T-tube should be placed through the choledochotomy when it is done.

A short duodenotomy is made, centered over the ampulla, and fine silk stay sutures are placed. A small biliary catheter should be placed in either an antegrade or a retrograde fashion.

With 12 o’clock representing cephalad and 9 o’clock posterior, a 3- to 5-mm incision is made at 11 o’clock through the ampulla over the catheter. Fine monofilament absorbable sutures are placed to approximate the duodenal and CBD mucosa. Placement should continue along the catheter for 2-3 cm, using fine Potts scissors. Lachrymal probes can be used to ensure that the pancreatic duct is not ligated.

Secretin (1-2 units intravenously) may be administered to help identify the location of the pancreatic duct. A septoplasty is then carried out in a similar fashion for approximately 1 cm. The result should be the easy passage of a 5-mm probe into the CBD and of a 2-mm probe into the pancreatic duct. Biopsy specimens may be taken as necessary.

The duodenum is closed in two layers. A T-tube is left whenever a choledochotomy is created. Postoperative care should be appropriate for the patient and the operation that was performed.

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Prevention

Many articles have stated that a complete preoperative evaluation is essential to minimizing the incidence of PCS and that patients should be warned of the possibility of symptoms after cholecystectomy, which may start at any time from the immediate postoperative period to decades later.

Many studies have also been performed in an attempt to identify those at increased risk for PCS and to develop a method of risk stratification. To a large extent, the data are inconsistent from study to study; however, it is generally considered that the more secure the preoperative diagnosis, the lower the risk of PCS. Other reports find a cause for PCS in as many as 95% of patients.

Since the development of oral cholecystography (OCG) in the 1920s as a preoperative aid in the detection of stones or nonfunctioning gallbladders, a wide variety of noninvasive imaging techniques have proven useful in preoperative gallbladder assessment. Ultrasonography is the most accessible and cost-effective approach in most institutions. Other noninvasive techniques include the following:

  • Hepatobiliary scintigraphy with technetium-99m ( 99m Tc)-labeled iminodiacetic acid (ie, hepatoiminodiacetic acid [HIDA] scanning), [18] with and without calculation of cholecystokinin (CCK)-stimulated ejection fraction (EF)
  • Computed tomography (CT), including helical or spiral CT
  • Magnetic resonance cholangiopancreatography (MRCP)

More invasive procedures that may prove valuable in defining the biliary anatomy include the following:

  • Percutaneous transhepatic cholangiography (PTC) and ERCP, with and without biliary and ampullary manometry and sphincterotomy
  • IOC

These procedures have helped reduce the incidence of PCS by facilitating better preoperative evaluation and diagnosis, especially in patients without stones.

As technology and understanding of the functional disorders of the GI and biliary tracts improve, the ability to make a diagnosis and to treat discovered illnesses will improve as well. PCS will be a less frequent diagnosis as patients are more efficiently screened and evaluated and as specific diagnoses are confirmed.

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Long-Term Monitoring

Follow-up care should be appropriate for the patient and the operation that was performed.

In a retrospective study of 105 patients, Coté et al investigated whether follow-up ERCP and bile duct balloon sweeps are necessary to find abnormalities in patients who have undergone endoscopic treatment for postcholecystectomy bile duct leakage.[19] Patients underwent initial ERCP at the time of bile leak treatment and follow-up ERCP after a mean interval of 6.9 weeks.

At follow-up, one or more abnormalities were found in 27.6% of patients, including persistent bile leak, CBD stones, and CBD sludge without stones.[19] Balloon sweeps, administered to a subgroup of patients, revealed a 17.6% prevalence of CBD stones or sludge at follow-up. In view of the prevalence of abnormalities after the endoscopic treatment of bile leaks, the authors recommended that follow-up ERCP and balloon sweeps be performed in patients at the time of stent removal.

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Contributor Information and Disclosures
Author

Steen W Jensen, MD Chief, Department of Surgery, Plumas District Hospital

Steen W Jensen, MD is a member of the following medical societies: American College of Surgeons, California Medical Association

Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MSc, MA Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow

John Geibel, MD, DSc, MSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract

Disclosure: Received royalty from AMGEN for consulting; Received ownership interest from Ardelyx for consulting.

Acknowledgements

Amy L Friedman, MD Professor of Surgery, Director of Transplantation, State University of New York Upstate Medical University College of Medicine, Syracuse

Amy L Friedman, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Medical Women's Association, American Society for Artificial Internal Organs, American Society of Transplant Surgeons, American Society of Transplantation, Association for Academic Surgery, Association of Women Surgeons, International College of Surgeons, International Liver Transplantation Society, NewYork Academy of Sciences, Pennsylvania Medical Society, Philadelphia County Medical Society, Society of Critical Care Medicine, and Transplantation Society

Disclosure: Nothing to disclose.

Oscar Joe Hines, MD Assistant Professor, Department of Surgery, University of California at Los Angeles School of Medicine

Oscar Joe Hines, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Endocrine Surgeons, American College of Surgeons, Association for Academic Surgery, Society for Surgery of the Alimentary Tract, and Society of American Gastrointestinal and Endoscopic Surgeons

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Acknowledgments

The author wishes to thank Gail Stentzel for her assistance with organization and data collection.

References
  1. Womack NA, Crider RL. The persistence of symptoms following cholecystectomy. Ann Surg. 1947 Jul. 126(1):31-55. [Medline].

  2. Walters JR, Tasleem AM, Omer OS, et al. A new mechanism for bile acid diarrhea: defective feedback inhibition of bile acid biosynthesis. Clin Gastroenterol Hepatol. 2009 May 6. [Medline].

  3. Zollinger R. Observations following distention of the gallbladder and common duct in man. Proc Soc Exper Biol & Med. 1922-23. 30:1260-1.

  4. Siddiqui AA, Kedika R, Mahgoub A, et al. A previous cholecystectomy increases the risk of developing advanced adenomas of the colon. South Med J. 2009 Nov. 102(11):1111-5. [Medline].

  5. Abu Farsakh NA, Stietieh M, Abu Farsakh FA. The postcholecystectomy syndrome. A role for duodenogastric reflux. J Clin Gastroenterol. 1996 Apr. 22(3):197-201. [Medline].

  6. McHardy C. Postcholecystectomy syndrome. Disease-A-Month. 1959. 1:1-40.

  7. Peterli R, Merki L, Schuppisser JP, Ackermann C, Herzog U, Tondelli P. [Postcholecystectomy complaints one year after laparoscopic cholecystectomy. Results of a prospective study of 253 patients]. Chirurg. 1998 Jan. 69(1):55-60. [Medline].

  8. Schoenemann J, Zeidler J. [Sequelae of cholecystectomy]. Z Gastroenterol. 1997 Feb. 35(2):139-45. [Medline].

  9. Russello D, Di Stefano A, Scala R, Favetta A, Emmi S, Guastella T, et al. Does cholecystectomy always resolve biliary disease?. Minerva Chir. 1997 Dec. 52(12):1435-9. [Medline].

  10. Anand AC, Sharma R, Kapur BM, Tandon RK. Analysis of symptomatic patients after cholecystectomy: is the term post-cholecystectomy syndrome an anachronism?. Trop Gastroenterol. 1995 Apr-Jun. 16(2):126-31. [Medline].

  11. Freud M, Djaldetti M, deVries A, Leffkowitz M. Postcholecystectomy syndrome: a survey of 114 patients after biliary tract surgery. Gastroenterologia. 1960. 93:288-93. [Medline].

  12. Moody FG, Vecchio R, Calabuig R, Runkel N. Transduodenal sphincteroplasty with transampullary septectomy for stenosing papillitis. Am J Surg. 1991 Feb. 161(2):213-8. [Medline].

  13. Filip M, Saftoiu A, Popescu C, et al. Postcholecystectomy syndrome - an algorithmic approach. J Gastrointestin Liver Dis. 2009 Mar. 18(1):67-71. [Medline]. [Full Text].

  14. Coelho-Prabhu N, Baron TH. Assessment of need for repeat ERCP during biliary stent removal after clinical resolution of postcholecystectomy bile leak. Am J Gastroenterol. 2010 Jan. 105(1):100-5. [Medline].

  15. Redwan AA. Multidisciplinary approaches for management of postcholecystectomy problems (surgery, endoscopy, and percutaneous approaches). Surg Laparosc Endosc Percutan Tech. 2009 Dec. 19(6):459-69. [Medline].

  16. Sakai Y, Tsuyuguchi T, Ishihara T, et al. The usefulness of endoscopic transpapillary procedure in post-cholecystectomy bile duct stricture and post-cholecystectomy bile leakage. Hepatogastroenterology. 2009 Jul-Aug. 56(93):978-83. [Medline].

  17. Phillips MR, Joseph M, Dellon ES, Grimm I, Farrell TM, Rupp CC. Surgical and endoscopic management of remnant cystic duct lithiasis after cholecystectomy--a case series. J Gastrointest Surg. 2014 Jul. 18(7):1278-83. [Medline].

  18. Mahid SS, Jafri NS, Brangers BC, et al. Meta-analysis of cholecystectomy in symptomatic patients with positive hepatobiliary iminodiacetic acid scan results without gallstones. Arch Surg. 2009 Feb. 144(2):180-7. [Medline].

  19. Cote GA, Ansstas M, Shah S, et al. Findings at endoscopic retrograde cholangiopancreatography after endoscopic treatment of postcholecystectomy bile leaks. Surg Endosc. 2009 Dec 30. [Medline].

 
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Table 1. Etiologies of Postcholecystectomy Syndrome by Anatomic Location
Anatomy Etiology
Gallbladder remnant and cystic duct Residual or reformed gallbladder



Stump cholelithiasis



Neuroma



Liver Fatty infiltration of liver



Hepatitis



Hydrohepatosis



Cirrhosis



Chronic idiopathic jaundice



Gilbert disease



Dubin-Johnson syndrome



Hepatolithiasis



Sclerosing cholangitis



Cyst



Biliary tract Cholangitis



Adhesions



Strictures



Trauma



Cyst



Malignancy and cholangiocarcinoma



Obstruction



Choledocholithiasis



Dilation without obstruction



Hypertension or nonspecific dilation



Dyskinesia



Fistula



Periampullary Sphincter of Oddi dyskinesia, spasm, or hypertrophy



Sphincter of Oddi stricture



Papilloma



Cancer



Pancreas Pancreatitis



Pancreatic stone



Pancreatic cancer



Pancreatic cysts



Benign tumors



Esophagus Aerophagia



Diaphragmatic hernia



Hiatal hernia



Achalasia



Stomach Bile gastritis



Peptic ulcer disease



Gastric cancer



Duodenum Adhesions



Duodenal diverticula



Irritable bowel disease



Small bowel Adhesions



Incisional hernia



Irritable bowel disease



Colon[4] Constipation



Diarrhea



Incisional hernia



Irritable bowel disease



Vascular Intestinal angina



Coronary angina



Nerve Neuroma



Intercostal neuralgia



Spinal nerve lesions



Sympathetic imbalance



Neurosis



Psychic tension or anxiety



Bone Arthritis
Other Adrenal cancer



Thyrotoxicosis



20% organ other than hepatobiliary or pancreatic



Foreign bodies, including gallstones and surgical clips



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