Postcholecystectomy Syndrome

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Postcholecystectomy Syndrome

• Kathy Lee
• June 23, 2006

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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

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• 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

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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

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Symptoms

• Colic 93
• Pain 76
• Fever 38
• Jaundice 24

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Etiology
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Workup

• Hx / Px
• Labs
• Incl LFT, INR/PTT, amylase, bili
• Imaging
• US CBD lt12mm, 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

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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

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Outline

• Sphincter of Oddi dysfunction
• Retained Stone
• Bile Duct Injury

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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

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• Labs ? amylase, LFT
• ERCP delayed emptying of contrast medium from
  CBD
• ? basal sphincter pressure gt40mmHg
• US dilated (gt12mm) 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

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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, nv,
  pancreatitis?
• Dx ERCP (therapeutic and diagnostic), MRCP
• Tx ERCPendoscopic US, repeat lap chole (for GB
  remnant), open excision of retained cystic duct
  impacted stone, holmium laser/ESWLERCP

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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

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

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Strasbergs view of safety
Dissection within the triangle of Calot to
demonstrate the cystic duct and artery clearly
entering the GB
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Classic lap chole BDI
GB and CBD aligned by traction of GB
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Cephalad traction on GB to tent the CBD out of
normal location, leading to clip placement at the
cystic duct-CBD junction
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Prevention

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

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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

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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

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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

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Results

• Operative mort lt1
• 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

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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 3S26-9, 2003
  Jul.
• Shamiyeh A. Wayand W. Laparosopic
  cholecystectomy early and latre complciations
  and their treatment. Langenbecks Arch Surg.
  389164-171, 2004.

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Kayvan checking out the view
Samaad clapping
Ray praying