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
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
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
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
Outline
Sphincter of Oddi dysfunction
Retained Stone Bile Duct Injury
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
Lap chole greater risk than open chole for bile duct injury 1 in 120 lap chole, major BDI 0.55%, minor 0.3%
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
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
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.
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