Postcholecystestomy syndrome (PCS), also known as postcholecystectomy sequelae and recurrent biliary tract syndrome, is a clinical syndrome related to biliary pathology that occurs after cholecystectomy. It is generally believed that about 25%-30% of gallbladder resection may have transient symptoms that may disappear quickly, while about 2%-8% may require active treatment due to persistent symptoms.
Diagnosis.
Based on medical history (history of gallbladder, bile duct or gastric and duodenal surgery), fever, abdominal pain and jaundice occurring after surgery should be considered as possible postoperative bile duct stones and bile duct strictures. b-mode ultrasound, CT, endoscopy, cholangiography can be helpful for diagnosis; ERCP or PTC and other examinations, if necessary with fine needle penetration (FNPTC) can lead to satisfactory diagnosis. Morphine-neostigmine provocation test can be done for suspected sphincter of Oddi stenosis or dysfunction. a few patients still have unknown causes and diagnostic difficulties after ERCP and FNPTC examinations.
Therapeutic measures.
The treatment of PCS is aimed at eliminating the cause, clearing the bile duct drainage and controlling the infection. Purely “symptomatic treatment” often does not yield good results. Therefore, before treatment, the cause of the disease must be further investigated and a clear diagnosis made. Treatment methods include non-surgical and surgical treatments.
I. Non-surgical treatment
1.Indications
(1) Bile duct stones <1cm in diameter and no stenosis at the lower end of the bile duct.
②Biliary tract infection without obvious bile duct obstruction.
③Acute or chronic cholecystitis, pancreatitis.
④Biliary ascariasis.
⑤ Biliary tract dysfunction.
(6) Extra-biliary diseases such as esophageal hiatal hernia, peptic ulcer, chronic pancreatitis, etc.
2.Treatment methods
①General therapy: including diet therapy, fluid infusion, correction of water, electrolyte and acid-base balance imbalance.
②Chinese herbal medicine: Chinese medicine and herbal dialectical treatment have good effect on gallbladder, bile duct stones, biliary tract infection, pancreatitis, biliary ascariasis and other diseases. For dysmenorrhea, pallor, stringy pulse and liver qi stagnation, Chai Hu Shu Huan San is added; for dysmenorrhea, chills and fever, bitter mouth and dry throat, jaundice, red tongue with yellow coating and slippery pulse, which is internal dampness and heat, Da Chai Hu Tang combined with Yin Chen Artemisia Tang is used; for dysmenorrhea, high fever, dry mouth, jaundice, yellow coating and stringy pulse, which is incandescent with fire and poison, Huang Lian Detoxification Tang with Yin Chen Artemisia Tang is used. In addition, if it is accompanied by pancreatitis, the main treatment is Qing Pancreas Tang (Chai Hu, Mu Xiang, Yuan Hu, Bai Shao, Scutellaria, Rhubarb, Mangosteen, etc.); if it is accompanied by roundworms, it can be treated with Wu Mei Tang.
③Direct pricking: for pain relief and regulation of biliary tract function.
④Other: antibiotics, antispasmodic and analgesic agents, antacids, H2-blockers, etc.
Second, surgical treatment
1. Indications
①Recurrent large bile duct stones, intrahepatic bile duct stones, jugular intussusception stones, bile duct stenosis combined with bile duct stones.
②Recurrent biliary tract infection with bile duct stricture, obstructive purulent cholangitis.
③Oddi sphincter stenosis, chronic pancreatitis with jugular abdomen or pancreatic duct obstruction.
(iv) Excessively long bile duct remains, forming a small gallbladder with inflammation.
⑤ Extra-biliary diseases that are difficult to be cured by drugs, such as esophageal hiatal hernia, ulcer disease, etc.
2.Surgical method The surgical method is decided according to the lesion.
①In case of long gallbladder or gallbladder duct, cholecystectomy or cholecystectomy should be performed.
②Choledochal duct stones should be explored by common bile duct incision to remove stones and various bile-intestinal anastomoses or transendoscopic sphincterotomy and lithotomy.
③Sphincter of Oddi stenosis can be performed by sphincterotomy.
(iv) For bile duct stenosis, choledochoplasty and repair or biliary digestive tract reconstruction is feasible. Such as common bile duct duodenal anastomosis, bile duct jejunostomy Roux-y anastomosis, Longmire surgery, etc.
⑤ Extra-biliary diseases with severe symptoms, such as esophageal hiatal hernia and ulcer disease, should also be treated with appropriate medication or surgery.
Etiology.
The development of the disease after cholecystectomy may be related to the following factors.
1, intraoperative damage to the bile ducts, due to large anatomical variation in the gallbladder and extrahepatic bile ducts, or inexperience of the operator, may damage the extrahepatic bile ducts intraoperatively, causing postoperative bile duct stenosis, and a few secondary to postoperative peribiliary infection causing damage to the bile ducts or occlusive cholangitis.
The causes of these postoperative pathological changes are unclear and may be related to the combination of common bile duct stones, especially mud-like bilirubin stones, or local chronic inflammatory edema.
3, postoperative abnormalities in bile salt metabolism and vegetative nerve dysfunction may affect the excretion of bile, the tension of the sphincter of Oddi and the pressure of the common bile duct, which may play a role in the occurrence of this disease.
Pathogenesis.
I. Due to biliary system diseases
Biliary diseases missed during cholecystectomy, such as extrahepatic or intrahepatic bile duct stones, sphincter of Oddi stenosis, etc. They can also be caused by cholecystectomy itself, such as long bile duct left behind and traumatic bile duct stenosis.
1. Bile duct stones are the most common cause of post-cholecystectomy syndrome. It can be divided into residual stones and recurrent stones, and the incidence is reported in the literature as 5% to 75%, and can even be as high as 87.8%.
(1) Residual stones The stones not removed intraoperatively can be divided into: (1) avoidable residual stones: mostly due to the lack of careful intraoperative exploration or unskilled technique. (2) Difficult to avoid residual stones: intrahepatic bile duct stones are found during intraoperative exploration and are difficult to be removed due to technical difficulties. Or due to critical condition, detailed exploration or stone extraction is not allowed.
(2) Recurrent stones Stones that have been removed at the time of surgery and occur again later are difficult to determine. Some people believe that those who have developed symptoms for more than two years can be designated as recurrent stones.
More than 95% occur after cholecystectomy, and the incidence is generally between 0.1% and 0.2%, i.e., 1 case of bile duct injury stenosis will occur in every 100-200 cases of cholecystectomy. Bile extravasation and cholestatic peritonitis occur after injury, and even if it heals, it will continue to be a fibrotic stricture with poor bile drainage and recurrent bile duct infections. Stenosis, infection and recurrence of stones are mutually causal, forming a vicious circle.
3, the gallbladder duct remains too long The gallbladder duct remains more than 1cm after cholecystectomy is residual too long. In the X-ray analysis of a group of 132 patients with post-biliary surgery syndrome, residual cystic duct was revealed in 20 cases accounting for 15.2%. This is due to inexperience of the operator, surgery during acute inflammation, anatomical abnormalities, or serious adhesions in the gallbladder neck that cannot be easily separated. It usually does not cause symptoms, but if there are stones in the cystic duct, or when the lower end of the cystic duct is obstructed, bile drainage is poor, the intraluminal pressure increases, and the residual cystic duct dilates and becomes secondary to infection, forming a small gallbladder with inflammation. The main symptoms are abdominal pain, fever and, in some cases, jaundice. Other symptoms include dyspepsia, anorexia, abdominal distension, nausea and vomiting. It is generally believed that if the common bile duct is not dilated, there is no stone, and the common bile duct is not cut and explored, it is more reasonable to cut and ligate the duct at 0.5 cm from the common bile duct. Then, if the common bile duct is dilated and there are stones, the common bile duct should be routinely explored for stones at the opening of the gallbladder, and the ligated cystic duct should be as close to the common bile duct as possible, and the shorter the residual cystic duct is, the better.
4, biliary duct postoperative dysfunction is common in young women, and can be induced by mental factors or endocrine dysfunction. It is manifested as paroxysmal right upper abdominal pain with abdominal distension, excessive sweating and rapid heart rate. However, there are no signs of infection and no positive findings on X-ray or ultrasound.
Sugawa had positive findings in 73% of post-cholecystectomy syndrome by ERCP, and 27% had no positive findings, mainly due to biliary tract dysfunction. bar-meirs in 29 cases of post-cholecystectomy syndrome, 15 cases were found to have papillary muscle dysfunction by ERCP manometry in 2 cases (14%), with altered bile duct pressure and dilatation of the common bile duct due to spasm of the sphincter of Oddi. Tanaka concluded that Biliary pressure loses its buffering effect after cholecystectomy and is directly influenced by the sphincter. Bardley and Collins believe that after cholecystectomy, the level of serum cholecystokinin increases, which can cause the sphincter of Oddi to contract, and the symptoms can appear when the bile duct pressure rises.
Second, due to extra-biliary system diseases
Some of the patient’s symptoms were already present before cholecystectomy, but the gallbladder lesion masked these symptoms. After cholecystectomy, the symptoms of gallbladder disease disappear and the symptoms of extra-biliary diseases are manifested.
Clinical manifestations.
After cholecystectomy, symptoms mostly appear weeks or months later, mainly manifested by pain and discomfort in the upper abdomen or right quarter rib area, often vague or pure pain and pressure, the nature of which is different from the pre-operative biliary colic, which may be accompanied by loss of appetite, nausea, abdominal distension, etc. Occasionally, there is bile duct spasm and colic attacks. The symptoms are related to eating, especially fatty foods. In severe cases, the infection may spread upward from the biliary tract, and chills and high fever and jaundice may occur.
Ancillary tests.
1.Biochemical examination White blood cell count, blood and urine amylase, liver function, glutamate transaminase, γ-glutamyl transpeptidase, etc. are helpful for the diagnosis of biliary obstruction.
2.Intrahepatic bile ducts are poorly visualized and extrahepatic bile ducts are not clear, and they are greatly affected by liver function, so the diagnostic value is not great.
3.B-type ultrasound can detect bile duct dilatation, gallstones, biliary tumors, pancreatitis and so on. It is simple, rapid and has some diagnostic value, but it has limitations and cannot show the whole picture of the biliary system and all the signs of disease.
4.Upper gastrointestinal tract imaging is useful for diagnosing esophageal hiatal hernia, ulcer disease, duodenal diverticulum, etc.
5.Hepatobiliary CT scan Diagnosis of liver tumor, dilated intra- and extra-hepatic bile ducts, gallstone disease, chronic pancreatitis, etc.
6.Isotope 99mTc-HDA hepatobiliary scan Observe dilated bile ducts inside and outside the liver, gallstone disease and liver lesions, function of gallbladder, etc. It is easy, non-damaging and suitable for patients with jaundice.
7.Endoscopy including esophagoscopy, gastroscopy, duodenoscopy, etc.
ERCP has exact diagnostic value for post-cholecystectomy syndrome. Hu Jiayou et al. reported 181 cases of ERCP, diagnosis of post-cholecystectomy syndrome findings and experience. The diseases found were as follows: 169 cases (93.4%) in which the cause could be determined, including 159 cases (87.8%) of biliary stones, 73 cases (40.3%) of biliary strictures, 106 cases (58.6%) of biliary dilatation, and 90 cases (49.7%) of chronic recurrent cholangitis. The diagnostic success rate of ERCP is 83.3%, which can directly and accurately show the biliary system and the whole picture of the lesion, the morphology, size, location and number of lesions.
8, PTC This direct biliary imaging method is suitable for the identification of more severe jaundice and the localization of bile duct lesions.
9.Morphine – neostigmine excitation test. The method is: to give the patient an intramuscular injection of morphine 10mg, neostigmine 1mg, respectively, before injection, 1 hour, 2 hours and 4 hours after injection of blood to measure serum amylase and lipoma. Epigastric pain and serum enzymes higher than 3 times the normal value after drug injection were considered positive.
Prevention.
Most post-cholecystectomy syndromes can be prevented and can be cured early.
1, actively carry out the combination of Chinese and Western treatment of biliary diseases, master the indications for surgery, reduce acute biliary surgery as much as possible, and choose a good surgical method.
2.Popularize biliary imaging diagnostic methods and fully understand the biliary pathological changes. Cholangiography, cholangioscopy and bile pressure measurement can help improve the therapeutic effect of biliary surgery.
3, intrahepatic bile duct lesions in China are rare and difficult to operate, so it is important to improve biliary surgery skills. If various biliary surgery can eliminate the cause, prevent biliary stricture and establish unobstructed drainage, the chance of post-biliary surgery syndrome will definitely be reduced.