OBJECTIVE: To investigate the etiology, prevention, and management of post cholecystectomy syndrome (PCS).
METHODS: The clinical data of 25 cases with PCS after simple cholecystectomy from January 2004 to January 2008 were analyzed. RESULTS: Among the 25 patients, biliary factors accounted for 14 cases, extra-biliary factors for 7 cases, psychological factors for 1 case, and unclear etiology for 3 cases; 8 cases were reoperated and 13 cases were non-operated.
Conclusion: The etiology of PCS is complex, and preoperative emphasis on comprehensive preoperative examination and intraoperative exploration is the key to prevent PCS from occurring after surgery. Treatment should be based on different etiologies to choose a reasonable treatment plan, and most patients will gradually reduce and disappear by medical treatment or with the extension of time after surgery, only a few patients have persistent symptoms that need surgical treatment, and very few patients have psychiatric factors that require attention to psychotherapy.
I. Clinical data
Between January 2004 and January 2008, 25 patients developed similar preoperative symptoms 6 months to 2 years after simple cholecystectomy, mainly manifesting as fullness and discomfort or vague abdominal pain, including 19 cases with acid reflux, warmth, nausea and vomiting; 5 cases with dyspepsia or diarrhea; 2 cases with xanthogranuloma and fever; and 1 case with intestinal obstruction. They were hospitalized. Among them, 7 cases were male and 18 cases were female, with an average age of 46 years (32 to 72 years).
II. Methods and results
All cases in this group underwent liver function and ultrasound examination, including CT examination in 8 cases, abdominal X-ray examination in 6 cases, upper gastrointestinal barium meal examination in 8 cases, gastroscopy in 16 cases, and ERCP examination in 2 cases. It was confirmed by examination and surgery that 14 patients were related to biliary self factors, including 7 cases of residual biliary stones (6 cases of common bile duct stones and 1 case of left hepatic duct stones), 5 cases of choledochotomy for stone extraction; 1 case of endoscopic sphincterotomy for stone extraction; and 1 case of hepatic left outer lobe resection. In one case, the residual gallbladder was removed; in one case, the stump of the cystic duct was too long, and two stones were found in the stump during surgery. Five cases of biliary stricture were treated conservatively and improved. There were 7 cases of extra-biliary factors, 1 case of colon cancer, 1 case of duodenal diverticulum and 1 case of duodenal bulb ulcer, 2 cases of gastric ulcer, including 3 cases of bile reflux gastritis, which were treated and discharged by gastroenterology. 3 cases were found to have no organic lesions after various examinations, and the etiology was unknown. 1 case was related to psychological factors and improved by psychotherapy.
III. Discussion
1. Analysis of the causes of post-cholecystectomy syndrome
(1) Residual bile duct stones: The data of this group showed that the rate of residual bile duct stones in PCS patients is an important factor. Ultrasound examination was performed before the first hospitalization of 25 patients in this group, and further examination after the appearance of symptoms this time revealed the presence of biliary stones in about 28% (7/25), indicating that preoperative omission may be an important factor of residual stones after surgery. It is appropriate to retain 0.3-0.5 cm of the stump of the gallbladder duct during cholecystectomy. In this group of cases, one case of residual stone was found in the stump, which also indicates that the excessive length of the stump is closely related to the residual stone.
(2) Postoperative adhesions around the gallbladder bed: gallbladder bed can be adhesively connected to the surrounding area during cholecystectomy due to severe gallbladder inflammation or postoperative bile leakage, resulting in symptoms similar to those before surgery, and in some cases, even intestinal obstruction manifestations.
(3) Bile duct injury: According to Liu Yongxiong et al, the incidence of bile duct injury in domestic laparoscopic cholecystectomy reaches 0.32%. Bile duct injury during cholecystectomy is associated with anatomical variation, obvious edema of the gallbladder triangle, gallbladder atrophy, and repeated within the gallbladder bile duct.
(4) benign biliary stricture: it can be caused by surgical injury, but also by non-surgical injury such as gallstone disease and adjacent inflammatory lesions. When gallstones migrate through the Vater papilla or stones are embedded, papillitis and scarring can occur, and inflammatory lesions such as duodenitis, acute pancreatitis, jugular septitis, and parapapapillary diverticulitis can involve the papilla and cause chronic inflammatory changes leading to papillary stenosis. Five cases in this group were diagnosed as biliary stenosis.
(5) Preoperative or intraoperative omission of coexisting lesions: Because some lesions coexisting with gallbladder lesions and diseases with similar symptoms were missed, preoperative symptoms were not eliminated after cholecystectomy. Microscopic tumors around the bile duct and jugular abdomen may be masked by symptomatic, clearly diagnosed gallbladder lesions due to the lack of symptoms or the absence of symptoms, and are often missed preoperatively or intraoperatively, with significant symptoms after cholecystectomy. Gastroduodenal ulcer, chronic pancreatitis, and duodenal diverticulitis have clinical manifestations that resemble gallbladder lesions and are often misdiagnosed as gallbladder disorders with typical symptoms and cholecystectomy is performed. In this group, one tumor patient was missed before surgery, one case of duodenal diverticulum, two cases of gastric ulcer, and three cases of bile reflux gastritis coexisted with gallbladder stones, and the preoperative symptoms still existed after surgery.
(6) PCS, which is more difficult to diagnose at present: after cholecystectomy, symptoms similar to those before surgery appear or reappear, and after excluding organic lesions such as biliary inflammation, stones, strictures and tumors, the right upper abdominal pain caused by functional disorders of the biliary system of unknown etiology is called “post-cholecystectomy syndrome”. It is mainly caused by sphincter of Oddi dysfunction (SOD).
Some scholars have divided it into two categories: stenotic and functional. Stenotic SOD refers to the stenosis of the sphincter of Oddi caused by surgical injury, chronic inflammation and fibrosis; functional SOD, which is usually called sphincter of Oddi dyskinesia, is often not found abnormally in these patients on ancillary examinations.
(7) One patient in this group of data is related to mental factors: cholecystitis and gallbladder stones belong to the biliary distension disease in the psychosomatic diseases of Chinese medicine. It not only has gallbladder, a somatic inflammation or stone, but also has psychological problems (brain dysfunction). It is a psychosomatic disease in which psychological factors affect physical functions. Simply by removing the gallbladder, the psychological problem is not solved, so the symptoms of liver and gallbladder discomfort will still occur. Therefore, the treatment of cholecystitis and cholelithiasis should be a combination of psychological treatment and somatic treatment.
2, clinical diagnosis of PCS: the appearance or reappearance of symptoms similar to those before surgery after cholecystectomy requires careful search for the cause, and most patients are not difficult to make a diagnosis through ultrasound, gastroscopy, ERCP and CT examination. The diagnosis of PCS due to sphincter of Oddi dysfunction is relatively difficult, and the diagnostic methods of SOD include CT, MRI, hepatobiliary isotope scan and sphincter of Oddi manometry, etc.
3, treatment principles: the group data show that for different causes of PCS, different treatment methods are adopted. Hospitalization is required in the acute phase of onset, and most of them can be relieved by anti-inflammatory, antispasmodic and gastrointestinal decompression, and the indications for surgical treatment are strict. Endoscopic surgery can save about 50% of PCS patients from caesarean section, especially for elderly patients and patients with other diseases that cannot be operated. For patients with unexplained abdominal pain after cholecystectomy, first systematic examination and treatment by internal medicine for several weeks and routine psychiatric etiology examination, if the etiology is still unclear and drug treatment is ineffective, feasible dissection including examination of duodenal papilla and duodenal papilloplasty, transjugular septal resection can make most patients’ symptoms improve for a long time.
Most PCS patients are not difficult to make a diagnosis through routine ancillary examinations. It is important to focus on a thorough preoperative examination for its prevention. Treatment principles should be based on different etiologies and different treatment options. Very few patients also have a tendency to somatization disorder, which requires attention to psychotherapy.