International Journal of Surgery 8 (2010) 1517

Contents lists available at ScienceDirect

International Journal of Surgery

journal homepage: www.theijs.com

Review

Postcholecystectomy syndrome (PCS)

S.S. Jaunoo*, S. Mohandas, L.M. Almond
Department of General Surgery, Worcestershire Royal Hospital, Worcester, UK

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 29 August 2009
Received in revised form
5 October 2009
Accepted 19 October 2009
Available online 24 October 2009

The term postcholecystectomy syndrome (PCS) comprises a heterogeneous group of symptoms and
ndings in patients who have previously undergone cholecystectomy. Although rare, these patients may
present with abdominal pain, jaundice or dyspeptic symptoms. Many of these complaints can be
attributed to complications including bile duct injury, biliary leak, biliary stula and retained bile duct
stones. Late sequelae include recurrent bile duct stones and bile duct strictures. With the number of
cholecystectomies being performed increasing in the laparoscopic era the number of patients presenting
with PCS is also likely to increase. We briey explore the syndrome and its main aetiological theories.
2009 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

Keywords:
Postcholecystectomy syndrome
Cholecystectomy
Laparoscopic cholecystectomy
Gallstones
Bile duct injury
Biliary leak
Abdominal pain
Jaundice

1. Introduction
Since its introduction by Muhe in 1986, laparoscopic cholecystectomy has rapidly gained in popularity and is now considered the
treatment of choice for symptomatic gallstones disease. The
advantages over laparotomy including reduced hospitalisation,
pain, morbidity, better cosmesis and nancial savings. There are
over 50,000 performed annually in the UK and Ireland1 and more
than half a million annually in the USA.2 Overall, cholecystectomy is
an established successful operation which provides total relief of
preoperative symptoms in more than 90% of patients.
2. Postcholecystectomy syndrome (PCS)
2.1. Denition
Post-cholecystectomy syndrome is dened as the recurrence of
symptoms similar to those experienced before the cholecystectomy. This usually takes the form of upper abdominal pain (mainly
right upper quadrant) and dyspepsia, with or without jaundice.
2.2. Incidence
The incidence of postcholecystectomy syndrome has been
reported to be as high as 40% in one study, and the onset of
* Corresponding author. Tel.: 44 07870192136.
E-mail address: ssj@doctors.org.uk (S.S. Jaunoo).

symptoms may range from 2 days to 25 years.3,4 There may also be

gender-specic risk factors for developing symptoms after cholecystectomy. In one study, the incidence of recurrent symptoms
among female patients was 43%, compared to 28% among male
patients.5
2.3. Aetiological theories
The most common cause of postcholecystectomy syndrome is
an overlooked extrabiliary disorder such as reux oesophagitis,
peptic ulceration, irritable bowel syndrome or chronic pancreatitis.6 The biliary aetiologies include:
1.
2.
3.
4.
5.
6.
7.
8.

Biliary strictures
Bile leakage
Retained calculi
Dropped calculi
Chronic biloma or abscess
Long cystic duct remnant
Stenosis or dyskinesia of the sphincter of Oddi
Bile salt-induced diarrhoea or gastritis

Bile duct injuries are the most serious complications associated

with laparoscopic cholecystectomy, with a rate of occurrence as low
as 0.2% but usually ranging from 0.4% to 4% for most surgeons.7
Many injuries may go unrecognized until the patient gets referred
with symptoms of abdominal pain, sepsis or jaundice soon after

1743-9191/$ see front matter 2009 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijsu.2009.10.008

16

S.S. Jaunoo et al. / International Journal of Surgery 8 (2010) 1517

cholecystectomy. Bile duct injuries may manifest in one of two

ways: biliary duct obstruction or bile leakage.
Acute biliary obstruction and bile duct injury is twice as
common with laparoscopic cholecystectomy as with open cholecystectomy.8 The classic injury occurs when the surgeon mistakes
the common hepatic duct for the cystic duct. In these patients,
radiological studies usually show diffuse or segmental intrahepatic
duct dilatation and surgical clips at the point of obstruction.
The incidence of late strictures of extrahepatic ducts has
substantially increased, perhaps as a result of the widespread use of
laparoscopic cholecystectomy.9 Thermal injury may result in acute
bile duct necrosis and bile leakage, but mild injury may result in
brosis. Furthermore, the clips themselves may rarely induce
brosis or inammatory changes around the extrahepatic ducts
that might cause a stricture.
There is little information on the natural history of common bile
duct stones (CBD), however, the incidence of retained/recurrent
calculi ranges from 1.2% to 14% with only approximately 0.3% ever
causing symptoms.10 Although MRCP is valuable in the preoperative evaluation of CBD stones, it is not routinely carried out because
of cost-benet concerns. CBD exploration and/or on-table cholangiography (OTC) can be performed during laparoscopic cholecystectomy but are not done so routinely unless there is a clear
indication. If an OTC demonstrates stones in the CBD then either the
surgeon can proceed to CBD exploration or post-operative ERCP.
Rarely, small calculi may migrate into the CBD in patients with
a patulous cystic duct when the gallbladder is pulled cephalad
during dissection. Endoscopic retrograde cholangiopancreatography (ERCP) is effective in diagnosing such cases and can offer
therapeutic options as well.
Spillage of gallstones may occur during laparoscopic cholecystectomy, with a reported incidence of 0.120%.11 Fortunately, most
of these stones are asymptomatic, although if spillage does occur
every effort should be made to retrieve the stones in view of the
small risk of developing signicant complications. The most
common of which is abscess formation either in the abdominal wall
or in the peritoneum. Spilled gallstones have also presented after
erosion through the skin,12 as a colovesical stula13 and as the cause
of an incarcerated hernia.14
Dropped gallstones leading to abscess formation can occur after
a period of months to years after surgery which can make the
diagnosis difcult. Spilled gallstones appear as small hyperechoic
lesions on ultrasound scanning that may be related to uid
collections and are found most often in the subdiaphragmatic or
subhepatic spaces. If they are calcied, they may also be seen on CT
as hyperdense areas or on T1-weighted MRI as a signal void.
Several reports have proposed that a cystic duct remnant >1 cm
in length after cholecystectomy may be responsible, as least in part,
for postcholecystectomy syndrome cystic duct stump
syndrome. There have been reports of a cystic duct remnant
causing symptoms even after the duct calculi had been removed.15
17
These authors also reported examples of the presence of stones
within both the cystic duct remnant and the CBD and suggested
that stones could be formed within the cystic duct remnant. Pain in
the right upper quadrant was found to be the outstanding symptom
and jaundice the commonest sign. The estimated incidence of
a retained stone within the cystic duct remnant is <2.5%.18 To date
there does not appear to be an increased risk of cystic duct remnant
calculi in patients who have undergone laparoscopic cholecystectomy compared to patients who have undergone open
cholecystectomy.
Sphincter of Oddi dysfunction has been implicated in the aetiology of PCS. Such dysfunction can result from a true stenosis or
secondary to spasm of the sphincter. In the majority of cases, the
dysfunction continues to present problems both in terms of

diagnosis as well as treatment. Although muscle spasm is thought

to play a signicant role in these cases, the response to smooth
muscle relaxants such as nitrates and calcium channel antagonists
has been disappointing.19 Sphincterotomy is considered to be the
most effective treatment. However, there are signicant risks
associated with this such as bleeding and pancreatitis. This makes it
necessary for the endoscopist to conclusively establish the diagnosis prior to sphincterotomy. Currently, the only reliable method is
by biliary manometry which unfortunately is both difcult to
perform and associated with considerable discomfort to the
patient. Furthermore, it carries its own risk of pancreatitis. In
addition to this, even if manometric evidence of sphincter of Oddi
dysfunction is obtained, it does not always prove that it is the cause
of the patients symptoms.20 This is somewhat unsurprising given
that sphincter of Oddi dysfunction may be associated with bowel
dysmotility such as gastroparesis and oesophageal motility
disorders.
It should be remembered that cholecystectomy is associated
with several physiological changes in the upper gastrointestinal
tract which may account for the persistence of symptoms or the
development of new symptoms after gallbladder removal. The
cholecystosphincter of Oddi reex,21 cholecysto-antral reex,22 and
cholecysto-oesophageal reexes23 are all disrupted and a number
of local upper gastrointestinal hormonal changes also occur after
cholecystectomy.24 Thus, there is an increased incidence of
gastritis, alkaline duodenogastric reux and gastro-oesophageal
reux after cholecystectomy, all of which may be the basis for
postcholecystectomy symptoms.
3. Conclusion
Overall, more than 90% of patients considered laparoscopic
cholecystectomy to have been a resounding success on their
preoperative symptoms. However, a signicant number continue to
experience symptoms (PCS) and thus patients should be thoroughly assessed and evaluated preoperatively. Furthermore, the
presence of dyspepsia in a patient with gallstones does not automatically imply that the gallstones are the cause. Patients should be
advised of both the risks of surgery and the risk of postoperative
persistence of symptoms.
Conict of interest statement
None to declare.
Funding
Not applicable.
Ethical approval
Not applicable.
References
1. Walsh TN, Russell RCG. Cholecystectomy and gallbladder conservation. Br J Surg
1992;79:45.
2. National Center for Health Statistics. 1987 summary: national hospital discharge
survey. Hyattsville, MD: National Center for Health Statistics; 1988.
3. Yamada T, editor. Textbook of gastroenterology. 2nd ed. Philadelphia: Lippincott;
1995 [chapter 104].
4. Zhou PH, Liu FL, Yao LQ, Qin XY. Endoscopic diagnosis and treatment of postcholecystectomy syndrome. Hepatobiliary Pancreat Dis Int 2003;2:11720.
5. Bodvall B, Overgaard B. Cystic duct remnant after cholecystectomy: incidence
studied by cholegraphy in 500 cases, and signicance in 103 reoperations. Ann
Surg 1966;163:38290.
6. Rogy MA, Fugger R, Herbst F, Schulz F. Reoperation after cholecystectomy. The
role of the cystic duct stump. HPB Surg 1991;4:12935.
7. Thurley PD, Rajpal D. Laparoscopic cholecystectomy: postoperative imaging. AJR
2008;191:794801.
8. Fathy O, Zeid MA, Abdallah T. Laparoscopic cholecystectomy: a report on 2000
cases. Hepatogastroenterology 2003;50:96771.

S.S. Jaunoo et al. / International Journal of Surgery 8 (2010) 1517

9. Sicklick JK, Camp MS, Lillemoe KD. Surgical management of bile duct injuries
sustained during laparoscopic cholecystectomy: perioperative results in 200
patients. Ann Surg 2005;241:78692.
10. Gerber A, Apt MK. The case against routine operative cholangiography. Am J
Surg 1982;143:7346.
11. Brockmann JG, Kocher T, Senninger NJ, Schurmann GM. Complications due to
gallstones lost during laparoscopic cholecystectomy. Surg Endosc 2002;16:122632.
12. Yamamuro M, Okamoto B, Owens B. Unusual presentations of spilled gallstones. Surg Endosc 2003;17:1498.
13. Daoud F, Awwad ZM, Masad J. Colovesical stula due to a lost gallstone following
laparoscopic cholecystectomy: a report of a case. Surg Today 2001;31:2557.
14. Bebawi M, Wassef S, Ramcharan A, Bapat K. Incarcerated indirect inguinal
hernia: a complication of spilled gallstones. JSLS 2000;4:2679.
15. Parmeggiani A, Alemanno R. The cystic stump syndrome clinical case histories.
Acta Chir Ital 1986;41(5):6527.
16. Berger H, Weinzierl M, Es Neville, Pratschke E. Percutaneous transcatheter
occlusion of cystic duct stump in postcholecystectomy bile leakage. Gastrointest
Radiol 1989;14:3346.

17

17. Tritapepe R, Pozzi C, Montorsi M, Doldi SB. The cystic dump stump syndrome
reality or fantasy. Ann Ital Chir 1989;60(3):1336.
18. Lum YW, House MG, Hayanga AJ, Schweitzer M. Postcholecystectomy
syndrome in the laparoscopic era. J Laparoendosc Adv Surg Tech
2006;16(5):4825.
19. Pasricha PJ, Miskovsky EP, Kalloo AN. Intrasphincteric injection of botulinum
toxin for suspected sphincter of Oddi dysfunction. Gut 1994;35:131921.
20. Steinberg WA. Sphincter of Oddi dysfunction: a clinical controversy. Gastroenterology 1988;95:140915.
21. Muller EC, Lewinski MA, Pitt HA. The cholecystosphincter of Oddi reex. J Surg
Res 1984;36:37783.
22. Webb TH, Lillemoe KD, Pitt HA. Gastrosphincter of Oddi reex. Am J Surg
1988;155:1938.
23. Stuart R, Byrne PJ, Marks P, Lawlor P, Gorey TF, Hennessey TPJ. Extrinsic
pathology alters oesophageal motility in the dog. Br J Surg 1990;77:A709.
24. Adrian TE, Savage AP, Bacarase-Hamilton AJ, Wolfe K, Besterman HS, Bloom SR.
Peptide YY abnormalities in gastrointestinal disease. Gastroenterology
1986;90:37984.