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POST CHOLECYSTECTOMY SYNDROME: A TWO YEARS STUDY.

Byline: Ammadudin Nasir, Muhammad Imran, Saqib Zaheer, Tajammul Hussain and Usman Asghar

ABSTRACT

Objective: To assess the pattern of symptoms and underlying causes in patients presenting with post cholecystectomy syndrome.

Study Design: Retrospective cross sectional study.

Place and Duration of Study: All the patients who underwent open cholecystectomy from Jan 2014 to Dec 2015 in Military Hospital Rawalpindi under general anaesthesia were included in the study.

Material and Methods: The study was carried out on 626 patients undergoing open cholecystectomy. Data was collected on a specially designed Proforma from hospital management system record. All the patients underwent open cholecystectomy in Military Hospital Rawalpindi under general anaesthesia.

Results: A total of 626 patients were included in the study. About 101 (16.1%) patients presented with post cholecystectomy syndrome as a preliminary diagnosis. The study showed a female predisposition for PCS (18.73%) as compared to males (11.68%). Six (5.94%) patients presented with right hypochondrial pain and jaundice. Fifty nine (58.41%) patients presented with dyspepsia. Three (2.97%) patients presented with painless jaundice. Nine (8.91%) patients presented with diarrhea. Six (5.94%) patients presenting with pain right hypochondrium with no jaundice and 18 (17.82%) patients presenting with right hypochondrial pain and dyspepsia.

Conclusion: A thorough preoperative evaluation is important before offering cholecystectomy to a patient. Moreover, good operative techniques and better endoscopic evaluation will further lessen the peroperative and postoperative biliary complications. However, gastritis leading to dyspepsia and psychiatric disorders make a large percentage of the cause of post cholecystectomy syndrome.

Keywords: Cholecystectomy, Dyspepsia, Post cholecystectomy syndrome.

INTRODUCTION

Cholecystectomy is the most common major abdominal surgery performed in the world1. Although it has been largely replaced by laparoscopic surgery in western countries2, open cholecystectomy is still widely performed in our country for definitive management of gall stones. Post cholecystectomy syndrome (PCS) is the name given to a spectrum of signs and symptoms experienced after cholecystectomy3. The incidence of PCS ranges from very low to 47%3. The wide range can be attributed to the spectrum of causes which are labeled as post cholecystectomy syndrome. The causes of post cholecystectomy syndrome can be biliary, extrabiliary or intestinal in origin. They can be related to pathologies which were present preoperatively, as a consequence of peroperative complications or by the effects of cholecystectomy itself.

Post cholecystectomy syndrome is a preliminary diagnosis and all the patients presenting with PCS should be thoroughly investigated and a definitive diagnosis should be made and treated accordingly. Since laparoscopic cholecystectomy has replaced open cholecystectomy as the standard procedure, the incidence of post cholecystectomy syndrome with laparoscopic cholecystectomy has been reported to be higher than open chole-cystectomy4,5. This study can further be used as a baseline to compare open cholecystectomy with the incidence of PCS in laparoscopic cholecystectomy. We studied the different presentations of PCS with their underlying causes, thus giving us a better understanding and subsequently helping in management of post cholecystectomy syndrome.

Operational Definition

Post-cholecystectomy syndrome (PCS) is defined as a complex of heterogeneous symptoms, consisting of upper abdominal pain and dyspepsia, which recur and/or persist after cholecystectomy6.

PATIENTS AND METHODS

A retrospective cross sectional study was done at Military Hospital Rawalpindi for two years, from Jan 2014 to Dec 2015. A sample size of 626 patients was studied. All patients who underwent elective open cholecystectomy in the above mentioned period were included in the study by non-probability convenience sampling technique. The indications for open elective cholecystectomy were

* One episode of acute biliary pancreatits

* One episode of acute cholecystitis

* Multiple episodes of biliary colic

Patients having a history of acute/chronic pancreatitis, pancreatic tumor, hepatitis, acid peptc disease, oesophagitis, divertculitis, mesenteric ischemia were excluded from the study. Patients having a history of undergoing hepaticojejunostomy, choledochoduedenostomy, CBD exploration and any other extrabiliary surgical procedure along with cholecystectomy were also excluded from the study. The above mentioned conditions were excluded to prevent bias in the study results. All patients who presented with PCS were initially screened with USG Abdomen and Liver Function tests. All patients who either had CBD stones, dilated or narrowed CBD were further evaluated by ERCP, Those having suspicion of Malignancy underwent Triphasic CT and EUS.

After approval from the hospital's ethical and research committee, data was collected on a specially designed Proforma from hospital management system record. All the patients underwent open cholecystectomy in Military Hospital Rawalpindi under general anaesthesia. The surgeries were performed by three classified surgeons in the above mentioned hospital. Data for each patient was recorded on a patients proforma. Statistic analysis was performed by SPSS 19 for Windows. The quantitative data like age is expressed as mean +- standard deviation (SD). Frequencies and percentages were calculated for incidence of postcholecystectomy syndrome in male and female predisposition, pattern of symptoms and causes of post cholecystectomy syndrome. To know significant difference between incidence of post cholecystectomy syndrome in male and female gender chi-square test was used with a 0.05 level of significance.

Table-I: Pattern of symptoms.

S No.###Symptom###Total###Percentage(%)

1.###Right hypochondrial pain without jaundice###6###5.94

2.###Right hypochodrial pain with jaundice###6###5.94

3.###Dyspepsia###59###58.41

4.###Jaundice###3###2.97

5.###Diarrhea###09###8.91

6.###Right hypochondrial pain with dyspepsia###18###17.82

Table-II: Causes of PCS.

S No.###Cause###No.###Percentage(%)

1.###Retained stones in common bile duct###04###3.96

2.###Common bile duct stricture###02###1.98

3.###Carcinoma head of pancreas###02###1.98

4.###Periampullary ca###01###0.99

5.###Bile leak###03###2.97

6.###Responded to PPI (bile induced gastritis?)###51###50.49

7.###Gastritis on endoscopy without h.pylori###12###11.88

8.###h.pylori positive gastritis on endoscopy###04###3.96

9.###Bile salt induced diarrhea###09###8.91

10.###No organic cause###13###12.87

RESULTS

A total of 626 patients were included in the study. A total of 101 (16.1%) patients presented with post cholecystectomy syndrome as a preliminary diagnosis. The mean age of the sample is 45 +- 20. The study showed a female predis-position for PCS (18.73%) as compared to males (11.68%). The p-value is 0.02. The result is significant at p<0.05 (figure). All patients presenting with PCS, underwent abdominal ultrasound and liver function tests. Nine (8.9%) patients presenting with jaundice and had deranged Liver function tests. Out of these 09 patients, 06 (66.6%) patients presented with right hypochondrial pain and jaundice, 04 were diagnosed to have retained stones on usg abdomen. Three of them were treated by Endoscopic Retrograde Cholangio Pancreatography (ERCP) and stones were extracted, 01 had large stone more than 1 cm which was treated by choledochotomy. Remaining 02 patients had biliary stricture diagnosed on MRCP.

One pt was treated by repeated stenting while the other underwent hepatico-jejunostomy. Three (33.3%) of the patients presenting with painless jaundice, 01 had periampullary carcinoma and 02 had carcinoma head of pancreas diagnosed on contrast enhanced CT scan abdomen. Out of the 59 patients presenting with dyspepsia, 46 (77.96%) patients responded to Proton pump inhibitors, rest 13 (22.03%) patients underwent gastroduodenoscopy. Seven had chronic inflammation of the antrum and 02 being positive for H. pylori. Four patients with dyspepsia did not have any findings on endoscopy. Nine (8.19%) patients presented with diarrhea which responded to cholestyramine and resolved over a period of about six months. Out of 06 (5.94%) patients presenting with pain right hypochondrium and no jaundice, 03 (50%) patients had post operative bile leakage from drain which was attributed to liver bed bile leakage in 02 patients and cystic duct ligature slip in one pt.

Rest of the 03 (50%) had no bile leak or any abnormal radiological finding. Out of the 18 (17.84%) patients presenting with right hypochondrial pain and dyspepsia, 05 (27.77%) patients responded to PPI and were labeled as having acid peptic disease. The rest of the 13 (72.22%) patients underwent gastro-duodenoscopy with 05 having chronic inflammatory changes and 02 positive for H pylori. A total of 13 patients (12.87%) presenting with PCS had normal radiological, endoscopic and chemical findings.

DISCUSSION

Post cholecystectomy syndrome encompasses all complications possible after cholecys-tectomy except for surgical site infection6. The complications may be related to anatomical or functional disruption of the hepatobiliary system, or extra biliary symptoms which are aggravated after cholecystectomy. Due to the wide range of signs and symptoms, its incidence varies in different studies6. The incidence quoted in most international studies is upto 40% which is significant for the procedure7,8. Out of the 101 patients presenting with post cholecystectomy syndrome, the study showed a female predisposition. A review article by Jaunoo et al referenced a study which showed the incidence of recurrent symptoms among female patients was 43%, compared to 28% among male patients9 Fifty nine patients presented with dyspepsia only and 18 patients presented with dyspepsia and pain right hypochondrium.

Out of these 77 patients, 51 responded well to proton pump inhibitors with 42 patients becoming asymptomatic after six months. The symptoms of these patients can be attributed to gastrointestinal hormonal changes after cholecystectomy, disruption of various reflexes regulated by the gall bladder resulting of reflux of bile into the stomach causing gastritis. Considering the overwhelming number of patients diagnosed with PCS having gastritis, it is important to treat dyspepsia before elective cholecystectomy as it can be aggravated after surgery because of the above mentioned mechanisms. The same conclusion was made by Kim et al10. However, the incidence of bile acid induced gastritis cannot be predicted preoperatively and varies with every individual after cholecystectomy10. Bile induced gastritis warrants a study of its own with regular post operative gastroduodenoscopy after six month intervals to calculate bile reflux index and its subsequent clinical symptoms11.

Nine patients presented with diarrhea. All of them responded to cholestyramine. And most probably have the same pathophysiology as bile acid induced gastritis. All patients became asymptomatic after six months T this goes on to show that Gastro intestinal hormonal disturbances and disrupted refluxes take about six months to adapt to the new gall bladderless anatomy of the gastrointestinal tract. Kim et al also observed the sameduration in the setting of colonic symptoms9,10. Two patients presenting with biliary stricture might be due to ischemia of the common bile duct due to over zealous dissection. Among the 03 patients, presenting with biliary leak, two had bile leak direct from the liver bed and one pt had a post operative cystic ligature slip. All the patients were treated conservatively with out any significant long term morbidity. Three patients presented with carcinoma, which might have been missed in the initial evaluation of cholecys-tectomy.

In 13 patients, no cause of PCS was found after clinical and radiological evaluation. These patients predominantly presented with dyspepsia and pain right hypochondriium. Out of 13 patients, 08 were females. The cause of right hypochondrial pain can be attributed to cystic stump scarring, sphincter of oddi dysfunction12 and psychiatric conditions13. Sphincter of oddi dysfunction is difficult to diagnose as manometeric studies are not readily available. Nitrates and calcium channel blockers have not proven their efficacy in this regard14,15. With a large number of patients having no significant findings, this goes on to show that a psychiatric evaluation of the patient preoperatively is also necessary. Mertens et al concluded the same from his study16.

In our study we observed that due to adequate preoperative evaluation, the incidence of biliary causes of PCS was less. With the increasing radiological investigation like MRCP, ERCP and endoscopic ultrasound, it has become easier to diagnose common bile duct stones preoperatively, however stones can be spilled into the common bile duct during choleystectomy during retraction at the Hartmann,s pouch as might be the case in 04 patients in our study. On the basis of our study it is recommended that prior to performing a cholecystectomy a thorough history and physical examination of the patient should be carried out as to make certain whether gall stones is the underlying cause or not. 70% of gallstone are asymptomatic17 with 1 to 2% of those diagnosed become symptomatic each year. Dyspepsia should be thoroughly evaluated preoperatively before attributing it to gallstones.

There was a limitation to this study in terms of time period, as PCS can present from 2 days to 25 years18. Our two years study could not include patients presenting with late PCS, some of the causes of which are recurrent stones in common bile duct and rarely in cystic stump remnant19,20 and also late strictures caused by mild injury to the common bile duct during surgery leading to fibrosis overtime. Moreover with the advent of laparoscopic surgery, it is important to compare post cholecystectomy syndrome between the two procedures as the incidence of common bile duct injury and cystic duct remnant stone is more in laparoscopic cholecystectomy than in open cholecysctectomy20-22.

CONCLUSION

A thorough preoperative evaluation is important before offering cholecystectomy to a patient. Moreover, good operative techniques and better endoscopic evaluation will further lessen the peroperative and postoperative biliary complications. However, gastritis leading to dyspepsia make a large percentage of the cause of post cholecystectomy syndrome, which presently, cannot be ruled out effectively before surgery.

CONFLICT OF INTEREST

This study has no conflict of interest to declare by any author.

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Publication:Pakistan Armed Forces Medical Journal
Geographic Code:9PAKI
Date:Aug 31, 2018
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