Postcholecystectomy Syndrome
Content
Postcholecystectomy Syndrome Kathy Lee June 23, 2006
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
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
Symptoms • Colic 93% • Pain 76% • Fever 38% • Jaundice 24%
Etiology Anatomy GB remnant and cystic duct
Liver
Etiology Residual GB Stump cholelithiasis Neuroma
Fatty infiltration of liver Hepatitis Hydrohepatosis Cirrhosis Gilbert disease Dubin-Johnson Sx Hepatolithiasis Sclerosing cholangitis Cyst
Anatomy
Etiology
SO dyskinesia, spasm or hypertrophy Periampullary SO stricture Papilloma Cancer
Biliary tract
Cholangitis Adhesions Strictures Trauma Cyst Malignancy/cholangioCA Obstruction Choledocholithiasis Dilation w/out obstruction Hypertension or nonspecific dilation Dyskinesia Fistula
Anatomy
Pancreas
Etiology Pancreatitis Stone Cancer
Diaphragmatic hernia Esophagus Hiatal hernia Achalasia Bone
Arthritis
Adhesions Duodenum Diverticula Irritable bowel disease
Nerve
Neuroma Intercostal neuralgia Spinal nerve lesions Sympathetic imbalance Neurosis Psychic anxiety
Anatomy
Etiology
Colon
Constipation Diarrhea Incisional hernia IBS
Stomach
Bile gastritis PUD Gastric cancer
Vascular
Intestinal angina Coronary angina
Small bowel
Other
Adhesions Incisional hernia Irritable bowel disease Adrenal cancer Thyrotoxicosis 20% organ other than hepatobiliary or pancreatic Unknown
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
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
Outline Sphincter of Oddi dysfunction Retained Stone Bile Duct Injury
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
• 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
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%
Proportion of BDI by IOC, type of surgery and case complexity IOC No Total cases
Injuries per 1000
IOC Yes Total cases
Injuries per 1000
Laparoscopic
4140
4.3
3397
2.1
Open
4017
2.7
7632
1.0
Complex
295
16.9
446
2.2
Not complex
7862
3.1
10583
1.3
Fletcher DR et al. Complications of cholecystectomy: risks of the laparoscopic approach and protective effects of operative cholangiography: a population-based study.
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
Strasberg’s view of safety Dissection within the triangle of Calot to demonstrate the cystic duct and artery clearly entering the GB
Classic lap chole BDI
GB and CBD aligned by traction of GB
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
• If jaundiced: CT or UIS can demonstrate ductal dilation – ?level of injury – one segment vs entire lobe vs entire liver
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.
Disc
Kayvan
Kayvan checking out “the view” Samaad clapping
Ray praying
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
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
Symptoms • Colic 93% • Pain 76% • Fever 38% • Jaundice 24%
Etiology Anatomy GB remnant and cystic duct
Liver
Etiology Residual GB Stump cholelithiasis Neuroma
Fatty infiltration of liver Hepatitis Hydrohepatosis Cirrhosis Gilbert disease Dubin-Johnson Sx Hepatolithiasis Sclerosing cholangitis Cyst
Anatomy
Etiology
SO dyskinesia, spasm or hypertrophy Periampullary SO stricture Papilloma Cancer
Biliary tract
Cholangitis Adhesions Strictures Trauma Cyst Malignancy/cholangioCA Obstruction Choledocholithiasis Dilation w/out obstruction Hypertension or nonspecific dilation Dyskinesia Fistula
Anatomy
Pancreas
Etiology Pancreatitis Stone Cancer
Diaphragmatic hernia Esophagus Hiatal hernia Achalasia Bone
Arthritis
Adhesions Duodenum Diverticula Irritable bowel disease
Nerve
Neuroma Intercostal neuralgia Spinal nerve lesions Sympathetic imbalance Neurosis Psychic anxiety
Anatomy
Etiology
Colon
Constipation Diarrhea Incisional hernia IBS
Stomach
Bile gastritis PUD Gastric cancer
Vascular
Intestinal angina Coronary angina
Small bowel
Other
Adhesions Incisional hernia Irritable bowel disease Adrenal cancer Thyrotoxicosis 20% organ other than hepatobiliary or pancreatic Unknown
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
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
Outline Sphincter of Oddi dysfunction Retained Stone Bile Duct Injury
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
• 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
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%
Proportion of BDI by IOC, type of surgery and case complexity IOC No Total cases
Injuries per 1000
IOC Yes Total cases
Injuries per 1000
Laparoscopic
4140
4.3
3397
2.1
Open
4017
2.7
7632
1.0
Complex
295
16.9
446
2.2
Not complex
7862
3.1
10583
1.3
Fletcher DR et al. Complications of cholecystectomy: risks of the laparoscopic approach and protective effects of operative cholangiography: a population-based study.
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
Strasberg’s view of safety Dissection within the triangle of Calot to demonstrate the cystic duct and artery clearly entering the GB
Classic lap chole BDI
GB and CBD aligned by traction of GB
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
• If jaundiced: CT or UIS can demonstrate ductal dilation – ?level of injury – one segment vs entire lobe vs entire liver
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.
Disc
Kayvan
Kayvan checking out “the view” Samaad clapping
Ray praying
