Dietary Considerations in Cholecystectomy: Investigating the Impact of Various Dietary Factors on Symptoms and Outcomes.

Cholecystectomy is commonly performed to address gallstone diseases, including the development of gallstones, which can lead to symptoms such as nausea, vomiting, and abdominal pain. Bile acids (BAs) produced by the liver are primarily stored and concentrated in the gallbladder (GB). After cholecystectomy, the body's ability to digest lipids is reduced due to the absence of the GB. Post-cholecystectomy syndrome (PCS) can occur when abdominal symptoms manifest after surgery. The purpose of this review is to look at the various effects of different dietary factors on patients undergoing cholecystectomy, how they affect their overall health after surgery, and how they contribute to symptoms of PCS. Some individuals may experience mild discomfort or alterations in bowel patterns, especially after consuming high-fat meals. The findings from the conducted studies suggest that, although dietary changes are a common recommendation, these measures are not sufficiently supported by evidence when it comes to alleviating symptoms and improving outcomes post-cholecystectomy. The studies found that subjects who consumed particular foods, such as processed meat and fried fatty foods, had exacerbated symptoms after cholecystectomy. Further studies are still required to understand the precise food factors that might affect post-surgical symptoms, as well as outcomes, and to develop tailored measures to enhance patient care and long-term prognosis after undergoing cholecystectomy.

The incidence of post cholecystectomy pain (PCP) syndrome at 12 months following laparoscopic cholecystectomy: a prospective evaluation in 200 patients.

OBJECTIVES: Post cholecystectomy pain syndrome can cause significant distress, impairs quality of life and exacerbations often result in emergency visits. Poorly controlled postoperative pain is a recognized cause of persistent postsurgical pain. Abdominal myofascial pain syndrome is an underdiagnosed cause of persistent pain in this cohort. The objective was to estimate the incidence of poorly controlled postoperative pain in the first 48 h after surgery and the likelihood of developing persistent pain at 12 months. METHODS: The patients undergoing laparoscopic cholecystectomy at a tertiary unit were consented for participation in a prospective service evaluation. A telephone review was performed at three, six and twelve months after surgery. Incidence of poorly controlled pain in the first 48 h after surgery was assessed. Patients with persistent pain were referred to the pain clinic. RESULTS: Over a six-month period, 200 patients were assessed. Eleven patients were excluded (5.5 %). Twelve patients were lost to follow-up (6.6 %, 12/189). Patient satisfaction with acute postoperative pain management was low in 40 % (76/189). Poorly controlled postoperative pain was reported by 36 % (68/189) of patients. Incidence of persistent pain was 29 % (54/189) at 12 months post-surgery. Over half of patients with persistent pain (63 %, 34/54) reported poorly controlled postoperative pain. A somatic source was diagnosed in 54 % (29/54) with post cholecystectomy pain syndrome. CONCLUSIONS: Poorly controlled postoperative pain was reported by a third of patients. Persistent pain was present in 29 % at twelve months post-surgery. Abdominal myofascial pain syndrome should be considered as a differential diagnosis in post cholecystectomy pain syndrome.

Development of functional gastrointestinal disorder symptoms following laparoscopic cholecystectomy: a prospective cohort study.

Background: The casual relationship between the role of cholecystectomy and functional gastrointestinal disorders (FGIDs) are a controversial clinical challenge. This study aimed to investigate: (1) the overlap of FGIDs before cholecystectomy and its long-term outcome after surgery in patients with symptomatic cholelithiasis, and (2) the incidence of new-onset FGIDs after cholecystectomy. Methods: Patients with symptomatic gallstone disease who underwent elective, laparoscopic cholecystectomy were prospectively enrolled. Healthy populations who underwent medical check-ups were selected as age- and sex-matched controls. Questionnaires regarding sociodemographic characteristics, gastrointestinal symptoms and a somatization symptom checklist (SSC) were completed at baseline and 12 months thereafter. Results: The prevalence of all FGID symptoms before cholecystectomy were significantly higher in the group of patients with symptomatic cholecystolithiasis compared to the control group. In cholecystectomy group, the preoperative FGID symptoms improved after surgery, except for chronic diarrhea. Compared to the controls, the new-onset FGIDs, including functional dyspepsia (14.8% vs. 6.9%; p = 0.040), functional diarrhea (6.6% vs. 0.2%; p < 0.001), and chronic abdominal pain (11.9% vs. 4.4%; p = 0.024), were more common at 1 year after cholecystectomy. Somatization was independent predictors of new-onset dyspepsia and abdominal pain, while newly occurring diarrhea was not realted to somatization. Conclusion: Overlap of FGIDs was common in patients with symptomatic cholelithiasis before surgery and at follow-up 1 year after cholecystectomy. Furthermore, new-onset FGIDs could be occurred after cholecystectomy. Therefore, a delicate diagnostic approaches and appropriate treatments about co-existent FGIDs should be given in patients with cholelithiasis before and after cholecystectomy.

Demography, Spectrum, and Characteristics of Symptoms Associated With Post-operative Relief After Cholecystectomy.

Background Cholecystectomy is one of the most commonly performed surgical procedures, and it is indicated for symptomatic gallstone disease. Symptoms of gallstone disease vary; many patients complain of the persistence of symptoms post-operatively. Hence, it is imperative to know the characteristics of symptoms that predict post-operative resolution. Methodology A prospective cross-sectional study was performed at a tertiary care centre. Patient demography and pre-operative symptoms were noted. Post-operative persistence or relief of symptoms was also documented. The occurrence of any new symptoms was noted. Data were collected at three and six months after surgery. Results Pain was the most common (85%) symptom. The mean frequency of pain was 2.45 per year (range 0-10). The mean duration of pain was 39.7 minutes (range 15-90 minutes). The right hypochondrium (39%) and the epigastric region (42%), along with 8% of patients who experienced pain in both places, were the most frequent locations of pain. The radiation of pain to the right-side scapula is present in 48% of patients. The pain persisted after one-week follow-up in 28 (34%) of patients, 26 (22%) at the end of one month, and 18 (21%) at the end of six months. Dyspepsia was unresolved in 25%, 20%, and 13% of individuals after one week, one month, and six months, respectively. Upper abdominal discomfort was still persistent in 29%, 26%, and 24% of study subjects at the time of follow-up periods, respectively. Similar persistence is found in symptoms of post-prandial fullness and nausea, where unresolved complaints of post-prandial fullness were present in 18%, 13%, and 10% of patients, respectively, and 26%, 14%, and 10% of patients complained of nausea. Conclusion The persistence of symptoms such as upper abdominal discomfort, dyspepsia, post-prandial fullness, and nausea is present, which gradually decreases in severity and presentation over the course of time after the surgical procedure. Some symptoms present after surgery, such as flatulence. Such persistent symptoms might lead to a decreased outcome in terms of patient satisfaction. Patients with atypical pain or dyspepsia need to be counselled pre-operatively regarding the poor resolution of such symptoms.

Surgical management of cystic duct stump calculi causing post-cholecystectomy syndrome: A prospective study.

Aim: Remnant cystic duct stump calculi are an uncommon but important cause of 'post-cholecystectomy syndrome'. High index of suspicion is needed to diagnose this condition in a symptomatic post-cholecystectomy patient. We present our experience with the surgical management of this condition. Patients and Methods: This prospective study included 19 patients with residual gallstone disease who underwent completion cholecystectomy between August 2016 and October 2021. Investigations included abdominal ultrasound and magnetic resonance cholangiopancreatography. The demographic, clinical, surgical and early post-operative variables of these patients were prospectively maintained and analysed. Results: The study included 14 women and 5 men. The mean age was 42.1 years (range, 14-80 years). The median duration between index surgery and completion cholecystectomy was 36 months (range, 2-178 months) (interquartile range, 105 months). The follow-up duration was 2 months. The initial surgery was open cholecystectomy in 17 and laparoscopic cholecystectomy in 2 patients. All patients with residual stump stone presented with pain, while 10 out of 19 patients complained of dyspepsia. Completion cholecystectomy could be performed laparoscopically in 16 cases, whereas 3 patients underwent open surgery. The mean operative time was 80 min (range, 55-140 min), and the mean blood loss was 100 ml (range, 50-160 ml). The mean hospital stay was 3 days (range, 2-10 days). No post-operative mortality or major morbidity was recorded in any of our patients. Conclusion: Laparoscopic excision of the cystic duct stump is feasible and safe even after previous open cholecystectomy. It is increasingly becoming the treatment of choice where expertise is available.

Post-cholecystectomy syndrome: A cohort study from a single private tertiary center.

Objectives: Although post-cholecystectomy syndrome (PCS) is a well-recognized complication, there are few reports arising from KSA. The effect of sleeve gastrectomy or endoscopic retrograde cholangiopancreatography (ERCP) stenting on the development of PCS is unknown. We aimed to measure the possible factors affecting the development of PCS, such as symptom duration, comorbidities, previous bariatric surgery, ERCP stent insertion, surgical intervention, conversion to open surgery and complication rate. Methods: This was a prospective cohort and observational study conducted at a single, private tertiary center. We included 167 patients who underwent surgery for gallbladder disease between October 2019 and June 2020. The patients were classified into two groups according to their PCS status (PCS+ vs. PCS-). Results: Thirty-nine patients were PCS+ (23.3%). There was no significant difference between the two groups with regards to age, gender, BMI, ASA score, smoking, comorbidities, duration of symptoms, previous bariatric surgery, ERCP, stent insertion or sphincterotomy. Chronic cholecystitis was the predominant histopathology in 83% (139/167) of patients. The most frequent causes of PCS included biliary system dysfunction, bile salt-induced diarrhea, gastritis, gastroesophageal reflux disease, and retained stones. Overall, 71.8% (28/39) of patients had incident PCS; the remaining patients had persistent PCS. Conclusions: PCS is a neglected complication that was observed in 25% of patients mainly in the first year. Surgeon awareness can assist with patient diagnosis, preoperative selection and education. Furthermore, the history of ERCP stenting, sphincterotomy, or sleeve gastrectomy seems to be unrelated to PCS development.

Síndrome post-colecistectomía: análisis de una cohorte prospectiva / Post-cholecystectomy syndrome: Descriptive analysis of a prospective cohort

Introducción. El síndrome post-colecistectomía fue descrito hace más de 70 años y se define como la presencia de síntomas gastrointestinales que pueden persistir después de la colecistectomía o aparecer como nuevos síntomas. Este síndrome, poco conocido, puede manifestarse desde pocos meses hasta varios años luego de la cirugía y ocurre entre 5 % y 40 % de los pacientes. Método. Estudio de cohorte prospectiva, que incluyó pacientes a quienes se les realizó colecistectomía laparoscópica en tres unidades quirúrgicas de Bogotá, D.C., Colombia, durante un período de ocho meses, con seguimientos periódicos durante dos años. El síndrome post-colecistectomía se definió como la presencia de al menos un síntoma gastrointestinal a partir del primer mes de la cirugía. Resultados. Se incluyeron 380 pacientes de los cuales 183 (48,2 %) desarrollaron el síndrome. La edad tuvo diferencia estadísticamente significativa entre aquellos que lo desarrollaron y los que no (p=0,024). La diarrea fue el único síntoma preoperatorio asociado al desarrollo del síndrome. El síndrome post-colecistectomía se encontró en el 42,1 % de los pacientes al primer mes de seguimiento y en el 17,4 % al segundo año. Conclusiones. El síndrome post-colecistectomía ocurre en un porcentaje importante de pacientes. En concordancia con la literatura, se encontró que la diarrea prequirúrgica es un factor de riesgo independiente para el desarrollo del síndrome. Se recomienda un adecuado seguimiento de los pacientes después de una colecistectomía

Introduction. Post-cholecystectomy syndrome (PCS) was described more than 70 years ago and is defined as the presence of gastrointestinal (GI) symptoms that may persist after cholecystectomy or can present as new symptoms. This little-known syndrome can appear from a few months to several years after surgery and occurs between 5% and 40% of patients. Method. Prospective cohort study, which included patients who underwent laparoscopic cholecystectomy in three surgical units in Bogotá, Colombia, during a period of eight months, with periodic follow-up for two years. PCS was defined as the presence of at least one GI symptom from the first month after surgery. Results. Three-hundred and eighty patients were included, of which 183 (48.2%) developed the syndrome. Age had a statistically significant difference between those who developed PCS and those who did not (p=0.024). Diarrhea was the only preoperative symptom associated with the development of PCS. Post-cholecystectomy syndrome was found in 42.1% at the first month of follow-up and in 17.4% at the second year. Conclusions. Post-cholecystectomy syndrome occurs in a significant percentage of patients. Consistent with the literature, preoperative diarrhea was found to be an independent risk factor for the development of the syndrome. Adequate follow-up of patients after cholecystectomy is recommended

Interventional pathway in the management of refractory post cholecystectomy pain (PCP) syndrome: a 6-year prospective audit in 60 patients.

OBJECTIVES: Post cholecystectomy pain syndrome can affect over a third of patients undergoing laparoscopic cholecystectomy. Acute exacerbations can result in recurrent emergency admission with excessive healthcare utilization. Standard surgical management appears to focus on visceral aetiology. Abdominal myofascial pain syndrome is a poorly recognised somatic pathology that can cause refractory pain in this cohort. It develops as a result of trigger points in the abdominal musculature. The report describes the pathophysiology and a novel interventional pathway in the management of post cholecystectomy pain secondary to abdominal myofascial pain syndrome. METHODS: The prospective longitudinal audit was performed at a tertiary pain medicine clinic in a university teaching hospital. Over a six-year period, adult patients with refractory abdominal pain following laparoscopic cholecystectomy were included in a structured interventional management pathway. The pathway included two interventions. Intervention I was a combination of abdominal plane blocks and epigastric port site trigger injection with steroids. Patients who failed to report durable relief (>50% pain relief at 12 weeks) were offered pulsed radiofrequency treatment to the abdominal planes (Intervention II). Outcomes included patient satisfaction, change in opioid consumption and impact on emergency visits. RESULTS: Sixty patients who failed to respond to standard management were offered the pathway. Four patients refused due to needle phobia. Fifty-six patients received Intervention I. Failure rate was 14% (8/56). Forty-eight patients (48/56, 86%) reported significant benefit at 12 weeks while 38 patients reported durable relief at 24 weeks (38/56, 68%). Nine patients received Intervention II and all (100%) reported durable relief. Emergency admissions and opioid consumption were reduced. CONCLUSIONS: Abdominal myofascial pain syndrome is a poorly recognised cause of post cholecystectomy pain. The novel interventional management pathway could be an effective solution in patients who fail to benefit from standard management.

Post-cholecystectomy syndrome in pediatric patients: Occurrence and spectrum of symptoms.

BACKGROUND: Post-cholecystectomy syndrome (PCS) refers to persistent or new abdominal symptoms after cholecystectomy. As there are very few reports on PCS in pediatric patients, we aimed to examine whether it was a frequent finding and which symptoms the affected children experienced. METHOD: This is a retrospective cross sectional study of pediatric patients, who underwent cholecystectomy during 2003-2019 at Oslo University Hospital. The PedsQL™ gastrointestinal symptoms scale questionnaire and a self-designed questionnaire exploring satisfaction after surgery and current medical conditions were mailed to all eligible patients. Patient/parental consent and approval from the local data protection officer (19/09054) were obtained. RESULTS: Questionnaires were sent to 82 patients of whom 44 (54%) answered. There were no significant demographic differences between the responders and the non responders. We identified 16 (36.7%) patients to have PCS. The most common symptoms were diarrhea (25%), bloating (16%), and heartburn/reflux (16%). Overweight was more common in patients with PCS (31%) than in patients without PCS (4%) (p = 0.014). Altogether 34/44 (77.3%) patients were satisfied with the result of the cholecystectomy; 92,6% of patients without PCS and 56.6% of those with PCS (p = 0.012). CONCLUSION: PCS is not uncommon in pediatric patients, and they report a wide range of gastrointestinal symptoms. We identified overweight as a potential risk factor for developing PCS. Nonetheless, most patients got total relief of abdominal pain and were satisfied with outcome after cholecystectomy. LEVEL OF EVIDENCE: Level 3.

Elevated Levels of PGE2-Metabolite in Cerebrospinal Fluid and Cox-2 Gene Polymorphisms in Patients with Chronic, Post Cholecystectomy Pain and Visceral Hyperalgesia Compared to Healthy Controls. A Hypothesis-Generating Pilot Study.

Purpose: Chronic, abdominal pain remains a problem in a subset of patients after cholecystectomy. The cause is often obscure but central sensitization may be an important component and could theoretically be mediated by spinal PGE2, which is regulated by several cytokines. The aim of the study was to examine cerebrospinal fluid (CSF) of participants with post cholecystectomy syndrome and healthy volunteers for signs of PGE2 and cytokine mediated central sensitization. Patients and Methods: In phase 1 of the study, 83 subjects were included for DNA analysis, eight of these subjects with post cholecystectomy syndrome. We examined the SNPs rs5275, rs16944 and rs1800795 from the Cox-2, IL-1ß and IL-6 genes respectively. In phase 2 of the study, we examined concentrations of PGE2-metabolite (PGEM), IL-1ß and IL-6 in CSF and plasma from 6 patients with post cholecystectomy syndrome and visceral hyperalgesia and 11 pain free volunteers. Results: We found a significant difference in distribution of the rs5275 SNP of the Cox-2 enzyme (CT-genotype=88% in pain group, 45% in pain free group, TT-genotype=0 in pain group, 41% in pain free group, p=0.05) but not in the other SNPs. PGEM, but not IL-6, was significantly elevated in CSF of the pain group (3.6 pg/mL, sd=1.9 vs 2.1 pg/mL, p=0.03), IL-1ß was undetectable. Conclusion: We found elevated PGEM levels in CSF of patients with post cholecystectomy syndrome and visceral hyperalgesia, suggesting a central, possibly inflammatory component to the pain, and overrepresentation of the CT-genotype in the rs5275 SNP in the Cox2 gene, suggesting overexpression of Cox2 as a possible cause for elevated PGEM levels.

Role of 99m Tc-Mebrofenin Hepatobiliary Scintigraphy in the Diagnosis of Post Cholecystectomy Syndrome.

Background Huge variation in the prevalence of post cholecystectomy syndrome (PCS) is because PCS can include a wide variety of disorders that can be both related and unrelated to cholecystectomy. Hepatobiliary scintigraphy (HBS) is a noninvasive nuclear medicine scan that can evaluate a delay in the transit of bile from the hepatic hilum to the duodenum using a radiotracer 99m Tc-Mebrofenin that can be associated with a functional ampullary obstruction. The aim of this study was to assess the role of 99m Tc-Mebrofenin HBS in the detection of the cause of PCS among the patients undergoing cholecystectomy. Methods Twenty-one patients who presented with PCS from September 2018 to February 2020 were included in the study. These patients were characterized based on history, examination, liver function test, and abdominal ultrasound. Sphincter of Oddi dysfunction (SOD) was diagnosed using the Rome 3 criteria and the Milwaukee classification. Magnetic resonance cholangiopancreatography (MRCP) and upper gastrointestinal endoscopy and biopsy were done when indicated, to establish the diagnosis. These patients were further subjected to 99m Tc-Mebrofenin HBS, and the findings were analyzed. Results The most common symptom in PCS was biliary pain occurring in 85.7% of the patients. The average time of presentation since surgery was 1.9 years. The most common cause of PCS was SOD, occurring in 52.3% of the patients, followed by benign biliary stricture occurring in 23.8% of the patients. The mean bile duct (common bile duct) visualization time in patients with PCS was 25.2 minutes, the mean duodenal visualization time was 38.2 minutes, and the mean jejunal visualization time was 60.5 minutes. The mean bile duct to duodenum transit time was 12.7 minutes, while the mean bile duct to jejunum transit time was 30.1 minutes. HBS showed consistent findings with the final diagnosis made by other diagnostic modalities (clinical criteria/MRCP/intraoperative findings) in 80.9% of the patients. Conclusion 99m Tc-Mebrofenin HBS has a significant role in the evaluation of PCS.

Prevalence and Factors Associated With Post-Cholecystectomy Syndrome in Saudi Arabia.

OBJECTIVES: Post-cholecystectomy syndrome (PCS) refers to the continuation or recurrence of biliary colic and any other gastrointestinal symptoms present prior to cholecystectomy. Given that PCS is rare and underestimated in Saudi Arabia, this study aimed to determine the prevalence of PCS among Saudis. METHODS: This cross-sectional study included randomly gathered subjects who self-administered the validated European Organization for Research and Treatment of Cancer QLQ-C30 questionnaire from September 6 to October 7, 2022. RESULTS: A total of 518 participants who underwent cholecystectomies were included; most were female (73.6%), 153 (29.5%) were 19 to 25 years old, and the vast majority were Saudi Arabian (91.1%). The average preoperative weight was 71 ± 20.7 kg (range 20 to 258), and the mean current weight was 69 ± 19.4 kg (range 30 to 257). About 137 (26.4%) had a chronic disease, most frequently hypertension (37.2%). In the past week, most participants experienced some trouble doing strenuous activities (42.9%), slight pain (37.6%), fatigue (32.2%), insomnia (37.5%), and weakness (38.2%). There were no significant associations between age, nationality, or residence with the QLQ-C30 score (P-value = 0.152, 0.262, 0.071, respectively). A significant association was observed between gender and QLQ-C30 score (P-value < 0.001), with females scoring higher than their male counterparts. Females also reported having a higher quality of life than males. CONCLUSIONS: The prevalence of PCS was higher than reported elsewhere.

Post-cholecystectomy syndrome: a retrospective study analysing the associated demographics, aetiology, and healthcare utilization.

BACKGROUND: Post-cholecystectomy syndrome (PCS) is a group of heterogeneous signs and symptoms, predominately consisting of right upper quadrant abdominal pain, dyspepsia, and/or jaundice, manifesting after undergoing a cholecystectomy. According to some studies, as many as 40% of post-cholecystectomy patients are in fact, affected by this syndrome. This study aims to determine the demographics, aetiology, average length of hospital stay, and health care burden associated with PCS. METHODS: We queried the National Inpatient Sample (NIS) database to determine inpatient admissions of PCS between 2011 and 2014 using the ICD-9 primary diagnosis code 576.0. RESULTS: From 2011 to 2014, the number of inpatient admissions with a principal diagnosis of PCS totally 275. The average length of hospital stay was 4.28±4.28, 3.42±2.73, 3.74±1.84, and 3.79±2.78 days in 2011, 2012, 2013, and 2014, respectively. The total yearly charges were $32,079±$24,697, $27,019±$22,633, $34,898.21±$24,408, and $35,204±$32,951 in 2011, 2012, 2013, and 2014, respectively. Notably, the primary cause of PCS in our patient sample between the year 2011 and 2014, was biliary duct dysfunction, followed by Peptic ulcer disease. CONCLUSIONS: In conclusion, there is a strong need to examine for and treat the underlying aetiology when approaching a post-cholecystectomy patient. We found that longer hospital stays, were associated with a greater health care burden, and visa versa. Furthermore, our findings help identify at-risk populations which can contribute to improving surveillance of this costly disease.

The complications of subtotal cholecystectomy: A case report.

INTRODUCTION: Although the symptoms attributed to gall stones resolve in most patients after cholecystectomy, some may have symptoms that persist or recur. It is known as the post-cholecystectomy syndrome (PCS). The aim of this case was to describe the diagnostic difficulties encountered and to discuss the main etiologies of this entity. CASE REPORT: A 54-year-old man presented for a recurrent right upper quadrant pain despite laparoscopic cholecystectomy five years ago. Imaging showed cystic lesion at the gallbladder fossa with gallstones. We decided to reoperate the patient by laparoscopic approach. It turned to be a residual gallbladder with stones inside. It was confirmed by histopathology. He was asymptomatic after a follow-up of 2 years. DISCUSSION: The PCS should not be trivialized. Most of the causes are allocated to extra biliary etiologies. They must be ruled out first as most of them can be controlled with medication. There are etiologies for which re-operation can be necessary. CONCLUSION: The indication of cholecystectomy must be taken wisely otherwise surgery will not solve the problem. Even though patient may complain of persistence or recurrence of the pain. In this case, it can be a real challenge for both diagnosis and treatment.

A patient with cystic duct remnant calculus treated by laparoscopic surgery combined with near-infrared fluorescence cholangiography.

BACKGROUND: The recurrence of symptoms present before cholecystectomy may be caused by a cystic duct remnant. The resolution of cystic duct remnant syndrome may require surgical resection, but identification of the duct remnant during laparoscopic surgery may be difficult because of adhesions following the previous procedure. Open surgery, which is more invasive than laparoscopic surgery, is frequently chosen to avoid bile duct injury. CASE PRESENTATION: The patient was a 24-year-old woman with previous laparoscopic cholecystectomy for chronic cholecystitis and repeated attacks of biliary colic. The postoperative course was uneventful, but computed tomography revealed a remnant cystic duct calculus. Ten months after surgery, the patient returned to our department for right hypochondriac pain. Laparoscopic remnant cystic duct resection was performed with intraoperative near-infrared (NIR) fluorescence cholangiography to visualize the common bile duct and remnant cystic duct. The postoperative course was uneventful and the patient was discharged on day 3 after surgery. At the 6-month follow-up, she had no recurrence of pain. CONCLUSION: Laparoscopic surgery with NIR cholangiography is a safe and effective alternative for the removal of a cystic duct remnant calculus after cholecystectomy.

Low-fat diet after cholecystectomy: Should it be systematically recommended? / Dieta baja en grasas tras colecistectomía: ¿se debería recomendar de forma sistemática?

INTRODUCTION: Even though evidence is lacking, a low-fat diet has been traditionally recommended after cholecystectomy. The main aim of this study was to assess the potential correlation between postoperative symptoms and type of diet after cholecystectomy. METHODS: Symptoms were prospectively assessed by the Gastrointestinal Quality of Life Index (GIQLI) score at baseline, one month and 6 months after cholecystectomy in 83 patients operated on at our institution. Patients completed a questionnaire about their diet and were classified into 4 groups according to the amount of fat intake. Differences in the GIQLI score depending on the type of diet were assessed over time. RESULTS: The overall GIQLI score and most subdomains significantly increased after surgery compared to baseline, regardless of the intake of dietary fat. Constipation improved after cholecystectomy compared to baseline, whereas diarrhea and bowel urgency got worse. More than 50% of patients experienced a change in their bowel habit after surgery, which persisted 6 months later in 23% of cases. CONCLUSIONS: A low fat diet does not seem to have an influence on the improvement of symptoms after cholecystectomy. However, a randomized study is ongoing at our institution to confirm the results of this prospective study.

Intraoperative detection of the remnant cystic duct during robot-assisted surgery using near-infrared fluorescence imaging: a case report.

BACKGROUND: Post cholecystectomy syndrome is characterized as recurrence of symptoms as experienced before cholecystectomy. In rare cases, a remnant cystic duct is causing these symptoms and occasionally surgical resection is performed. During surgery, visualization of the biliary ducts could be difficult due to inflammation and dense adhesions. CASE PRESENTATION: In this article, we presented a 36-year old woman with post-cholecystectomy syndrome in which we evaluated the feasibility of near-infrared (NIR) fluorescence imaging using indocyanine green (ICG) for visualization of the remnant cystic and common bile duct during robot-assisted surgery. Intraoperative visualization of the remnant biliary duct and other important structures was feasible, and resection of the remnant cystic duct was successfully performed under fluorescence guidance, without any complications. CONCLUSIONS: NIR fluorescence imaging of the biliary ducts using ICG does not prolong the operating time, and could potentially decrease the operation time in difficult procedures, because of easy and fast detection of the biliary tract. Furthermore, it is a non-hazardous and non-invasive technique, as it does not require use of radiation and cannot cause bile duct injury. This case illustrated that ICG NIR fluorescence imaging during difficult robot-assisted surgical procedures of the bile ducts is effective and therefore highly recommended.

An Update on Biliary Dyskinesia.

Biliary dyskinesia is a functional disorder of the gallbladder or sphincter of Oddi. While cholecystectomy for symptomatic cholelithiasis is widely accepted, debate remains regarding the clinical benefit of invasive procedures for biliary dyskinesia. This article will review current best evidence in the diagnosis and management of biliary dyskinesia.

Diet After Cholecystectomy.

Patients with gallstones are often affected by alimentary disorders contributing to the onset of gallstones disease. Cholecystectomy can have nutritional and metabolic consequences in the short-term (diarrhea, abdominal pain and bloating) and in the long-term (increased Body Mass Index with metabolic syndrome, gastritis, liposoluble vitamin deficiency). Pathogenic mechanisms behind these disturbances are reviewed and the need for an early post-operative nutritional intervention based on low-lipid, high-fibers diet, is highlighted.

A systematic review of the aetiology and management of post cholecystectomy syndrome.

BACKGROUND: 10% of patients who undergo a cholecystectomy go on to develop post-cholecystectomy syndrome (PCS). The majority of these patients may suffer from extra-biliary or unrelated organic disorders that may have been present before cholecystectomy. The numerous aetiological causes of PCS result in a wide spectrum of management options, each with varying success in abating symptoms. This systematic review aims to provide a summary of the causative aetiologies of post cholecystectomy syndrome, their incidences and efficacy of available management options. METHODS: The Medline, Embase and Cochrane databases were searched for studies patients who developed PCS symptoms following laparoscopic cholecystectomy, published between 1990 and 2016. The aetiology, incidence and management options were extracted, with separate collation of randomised control trials and non-randomised studies that reported intervention. Outcomes included recurrent symptoms following intervention, unscheduled primary and secondary care attendances and complications. RESULTS: Twenty-one studies were included (15 case series, 2 cohort studies, 1 case control, 3 RCTs). Five studies described medical treatment (nifedipine, cisapride, opiates); seven studies described endoscopic or surgical intervention. Early presentation of PCS (<3 years post-cholecystectomy) was more likely to be gastric in origin, and later presentations were found to be more likely due to retained stones. Sphincter of Oddi dysfunction (SOD) accounted for a third of cases in an unselected population with PCS. CONCLUSIONS: Causes of post cholecystectomy syndrome are varied and many can be attributed to extra-biliary causes, which may be present prior to surgery. Early symptoms may warrant early upper gastrointestinal endoscopy. Delayed presentations are more likely to be associated with retained biliary stones. A large proportion of patients will have no cause identified. Treatment options for this latter group are limited.