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Postcholecystectomy Syndrome

Kathy Lee June 23, 2006

Introduction
First described in 1947 Presence of symptoms after cholecystectomy May be either:
Development of new Sx OR Continuation of Sx

10-15% of patients

Pain may persist / recur mos or yrs Preliminary Dx, should be renamed relevant to the disease identified by an adequate workup
Cause for PCS identified in 95% of patients

Preop Risk stratification


Higher risk patients:
Younger, female Urgent operation No stones documented Longer duration of symptoms prior to surgery Choledochotomy performed

No difference:
Typicality of preop symptoms Prior surgery, bile spill, stone spill

Symptoms
Colic 93% Pain 76% Fever 38% Jaundice 24%

Etiology
Anatomy GB remnant and cystic duct Etiology Residual GB Stump cholelithiasis Neuroma Anatomy Etiology SO dyskinesia, spasm or hypertrophy Periampullary SO stricture Papilloma Cancer Cholangitis Adhesions Strictures Trauma Cyst Malignancy/cholangioCA Obstruction Choledocholithiasis Dilation w/out obstruction Hypertension or nonspecific dilation Dyskinesia Fistula

Liver

Fatty infiltration of liver Hepatitis Hydrohepatosis Cirrhosis Gilbert disease Dubin-Johnson Sx Hepatolithiasis Sclerosing cholangitis Cyst

Biliary tract

Anatomy

Etiology Pancreatitis Stone Cancer

Anatomy

Etiology Constipation Diarrhea Incisional hernia IBS Bile gastritis PUD Gastric cancer Intestinal angina Coronary angina Adhesions Incisional hernia Irritable bowel disease Adrenal cancer Thyrotoxicosis 20% organ other than hepatobiliary or pancreatic Unknown Erroneous preop Dx

Pancreas

Colon

Diaphragmatic hernia Esophagus Hiatal hernia Achalasia Bone Arthritis

Stomach Vascular

Adhesions Duodenum Diverticula Irritable bowel disease Neuroma Intercostal neuralgia Spinal nerve lesions Sympathetic imbalance Neurosis Psychic anxiety

Small bowel

Nerve

Other

Workup
Hx / Px Labs
Incl LFT, INR/PTT, amylase, bili

Imaging
US : CBD <=12mm, increased with age CT : ? pancreatitis, pseudocyst HIDA scan : postop bile leak MRCP : to delineate biliary tree anatomy ERCP : to detect spincter of Oddi dysfunction
Therapeutic as well: stone extraction, stricture dilation, sphincterotomy

More common causes


Episodic RUQ pain + jaundice ~immediately postop associated with retained CBD stone, bile duct injury, bile leak Acute epigastric pain not associated with jaundice due to PUD,GERD, wound neroma, IBS, pancreatitis Stump neuroma ? long cystic duct stump
But cystic duct left long by design in lap to minimize BD injuries, no increased biliary symptom

Outline
Sphincter of Oddi dysfunction
Retained Stone Bile Duct Injury

Sphincter of Oddi Dysfunction


Complex muscular structure Surrounds distal CBD, pancreatic duct, ampulla of Vater Caused by structural or functional abN Fibrosis of sphincter from gallstone migration, operative or endoscopic trauma, pancreatitis or nonspecific inflammatory processes Sphincter dyskinesia or spasm ~1% of patient undergoing cholecystectomy

Labs: amylase, LFT ERCP: delayed emptying of contrast medium from CBD
basal sphincter pressure >40mmHg

US: dilated (>12mm) CBD Med: high-dose Ca channel blockers or nitrates, but evidence not convincing Tx: sphincterotomy (endoscopic or transduodenal)
Mucosa-mucosa apposition in surgical approach can minimize scarring and restenosis Results of both treatment similar, more dependent on presence of objective signs of sphincter dysfunction 60-80% successful if have documented objective evidence

Retained stones
More likely to occur with lap chole esp if no IOC done Can present late (20yrs!) Sx = intermittent pain in upper ab and back, n+v, pancreatitis? Dx = ERCP (therapeutic and diagnostic), MRCP Tx = ERCP+endoscopic US, repeat lap chole (for GB remnant), open excision of retained cystic duct impacted stone, holmium laser/ESWL+ERCP

Bile duct injury


Most feared complication Most recognized intraoperatively or during early postop period Long-term results acceptable with appropriate management
Otherwise recurrent cholangitis, secondary biliary cirrhosis, portal hypertension

Lap chole greater risk than open chole for bile duct injury 1 in 120 lap chole, major BDI 0.55%, minor 0.3%

Proportion of BDI by IOC, type of surgery and case complexity


IOC No
Total cases Injuries per 1000

IOC Yes
Total cases Injuries per 1000

Laparoscopic Open
Complex Not complex

4140 4017
295 7862

4.3 2.7
16.9 3.1

3397 7632
446 10583

2.1 1.0
2.2 1.3

Fletcher DR et al. Complications of cholecystectomy: risks of the laparoscopic approach and protective effects of operative cholangiography: a population-based study. Ann Surg. 1999 April; 229(4): 449457

Risk Factors
Surgeon factors
training and experience Beyond 20 cases, BDI rate decreases Tenting CBD

Patient factors
patient age, male gender obesity long period of prior symptom, number of attacks

Pathology factors
Acute chole, pancreatitis, cholangitis, obstructive jaundice Chronic inflammation, fat in the periportal area, poor exposure, bleeding obscuring operative field Aberrant biliary anatomy

Strasbergs view of safety


Dissection within the triangle of Calot to demonstrate the cystic duct and artery clearly entering the GB

Classic lap chole BDI

GB and CBD aligned by traction of GB

Cephalad traction on GB to tent the CBD out of normal location, leading to clip placement at the cystic duct-CBD junction

Prevention
Routine operative cholangiography reduce 50% of BDI or bile leak Define anatomy and limit the extent of biliary injury

Presentation
25% of ductal injuries recognized intraop Presentation within 1wk
bile leak from cystic duct stump, transected aberrant R hepatic duct, lateral injury to main bile duct Pain, fever, mild -bilirubinemia Biloma, bile peritonitis Persistent bloating or anorexia

Presentation later
Occlusion of CHD/CBD with no intraperitoneal bile leak Jaundice, abdo pain May present months to years with cholangitis or cirrhosis

Diagnosis
CT: identifies peritoneal fluid, abscess, biloma
perihepatic/intraabdominal fluid perc drained If cont bile leak thru perc drain, Tc-IDA scan Sinogram thru drain after fibrous tract formed to delineate biliary anatomy ERC if no external bile leak: for biliary anatomy

If jaundiced: CT or UIS can demonstrate ductal dilation


?level of injury one segment vs entire lobe vs entire liver

Management
Appropriate management depends on time of Dx, type, extent and level of injury Perc drain and biliary endoprosthesis if just cystic duct bile leak Partial transection: T-tube
At site of injury If more extensive, injury repaired primarily and stented

Complete transection
If recognized intraop, repaired tension-free, mucosa-to-mucosa duct enteric anastomosis
Only if no ductal length lost High rate of postop stricture formation Most require end-to-side Roux-en-Y choledochojejunsotomy or hepaticojejunostomy Pre-op transhepatic stents may help identify hepatic ducts

After early postop period: PTC for biliary decompression, operative exploration and repair in 6-8 wks when acute inflammation resolved

Results
Operative mort: <1% Complication incl cholangitis, subhepatic or subphrenic abscess, bile leak, hemobilia 2/3 restenosis within 2yrs 91% without jaundice and cholangitis
Less success if more proximal stricture (at or prox to hepatic duct birfurcation) Perc balloon dilation with stenting lower success rate (64%)

Lower quality of life surveys, esp in psychological domain even years after successful repair

References
http://www.emedicine.com/Med/topic2740.htm. Post Cholecystectomy Syndrome. Accessed June 15, 2006. Vetrhus M. Berhane T. Soreide O. Sondenaa K. Pain persists in many patients five years after removal of the gallbladder: observations from two randomized controlled trials of symptomatic, noncomplicated gallstone disease and acute cholecystitis. Journal of Gastrointestinal Surgery. 9(6):826-31, 2005 Jul-Aug Walsh RM. Ponsky JL. Dumot J. Retained gallbladder/cystic duct remnant calculi as a cause of postcholecystectomy pain. Surgical Endoscopy. 16(6):981-4, 2002 Jun. Toouli J.TitleBiliary scintigraphy versus sphincter of Oddi manometry in patients with post-cholecystectomy pain: is it time to disregard the scan?. Current Gastroenterology Reports. 7(2):154-9, 2005 May. Piccinni G. Angrisano A. Testini M. Bonomo GM. Diagnosing and treating Sphincter of Oddi dysfunction: a critical literature review and reevaluation. Journal of Clinical Gastroenterology. 38(4):350-9, 2004 Apr. Corazziari E.TitleSphincter of Oddi dysfunction. Digestive & Liver Disease. 35 Suppl 3:S26-9, 2003 Jul. Shamiyeh A. Wayand W. Laparosopic cholecystectomy: early and latre complciations and their treatment. Langenbecks Arch Surg. 389:164-171, 2004.

Disc

Kayvan

Kayvan checking out the view Samaad clapping

Ray praying

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