POST CHOLECYST ECTOMY SYNDROME

Abstract

Cholecystectomy is one of the most commonly performed surgical procedures and is the standard of care in treating symptomatic gallstones. Patients should be worked up carefully and their complaints listened to carefully before committing the patient to an operation and its consequences. Up to a third of patients undergoing cholecystectomy will develop recurrent and persistent abdominal pain weeks to years after surgery. In the majority of patients, symptoms are mild and short lived but 2-5% will continue to have frequent debilitating pain, a condition referred to as the postcholecystectomy syndrome (PCS). It encompasses a widely varying group of disorders; including extrabiliary, organic biliary and functional biliary diseases. Sphincter of Oddi dysfunction (SOD) is a disorder that should be suspected in patients with chronic biliary pain or recurrent pancreatitis when other organic causes have been ruled out. Two mechanisms have been proposed: Sphincter of Oddi stenosis; refers to a structural abnormality resulting from inflammation and scarring of the sphincter and the second is sphincter of Oddi dyskinesia; refers to a functional abnormality of the sphincter leading to intermittent obstruction. Biliary microlithiasis has also been identified in the bile of postcholecystectomy patients with recurrent abdominal pain. The presence of stones in a cystic duct or retained gallbladder remnant is a rare cause of PCS. Intraperitoneal stone spillage is a new complication with the introduction of laparoscopy. The incidence of chronic pancreatitis following cholecystectomy increases in direct proportion to the duration of stones before cholecystectomy. Most major bile duct injuries are as a result of misidentification of ductal structures. Technical complications and surgeon's inexperience, acute inflammation, excessive bleeding and aberrant anatomy are all risk factors for bile duct injuries. Laparoscopic cholecystectomy is also associated with a higher risk of vascular injury to the hepatic artery and/or portal vein which further increases the morbidity. Acute BDI and the ensuing biliary fistula may evolve into a ______________________________________________________________ 112 ______________________________________________________________ biliary stricture. If the biliary stricture is not appropriately managed the complications of intrahepatic lithiasis, secondary biliary cirrhosis, portal hypertension and end stage liver disease may follow. After all other organic causes of the PCS are ruled out; the diagnosis of psychosomatic pain must be entertained.

Since a PCS is of a diverse and complex pathogenesis; clinicians should employ a systematic approach to diagnose and treat a range of potential etiologies. The first step in the evaluation of a PCS should be a thorough history and physical examination to rule out common treatable conditions; which may have been previously overlooked. The workup should begin with differentiating functional pain from organic biliary pain; Rome III criteria may be employed in this process. A right upper quadrant abdominal ultrasound, liver transaminases, alkaline phosphatase and serum bilirubin are the tests most useful in making this distinction and determining the most appropriate treatment of the patient. Computed tomography scan may be useful in the initial post-operative period. Cholescintigraphy seems to be a reliable noninvasive method for identification of patients with SOD. The MRCP and EUS can be employed to diagnose pathology such as retained stone involving the cystic duct and common bile duct. The ERCP is essential in the diagnosis, classification and management of postcholecystectomy biliary injuries.

Treatment options for postcholecystectomy syndrome depend on the suspected etiology. In Type I SOD patients; a good response to sphincterotomy can be predicted regardless of manometric findings. Type II SOD patients can most benefit from manometry to select patients for sphincterotomy. Type III SOD patient pose a particular therapeutic challenge and is likely represent a chronic pain disorder or dysmotility syndrome. Surgery is the gold standard for the management of biliary injuries. Endoscopic intervention is a safe and effective method for treatment of postcholecystectomy biliary injuries as it can combine both the investigative and therapeutic arms in one

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______________________________________________________________ common procedure. Early recognition and appropriate treatment are most important and allow avoidance of serious complications in patients with IBDI. Sepsis, biliary leaks, and collections should be managed appropriately before the surgical repair. If the workup is negative, a multidisciplinary approach with pain management and psychiatry may be appropriate. Always, the successful key of PCS management still prevention.