Do not get stumped: multimodality imaging findings of early and late post-cholecystectomy complications.

Cholecystectomy is the most performed intra-abdominal surgical procedure in the US, with 1.2 million performed annually, and is predominantly performed laparoscopically. Although largely safe, laparoscopic cholecystectomy results in higher rates of abdominal symptoms consisting of abdominal pain and dyspepsia, which may persist or recur, collectively known as post-cholecystectomy syndrome. This article aims to (1) provide an overview of post-cholecystectomy syndrome with an emphasis on biliary complications and emergent imaging findings, (2) illustrate the spectrum of imaging findings of early and late post-cholecystectomy complications, (3) enumerate the role of various imaging modalities in evaluating post-cholecystectomy complications and address the role of selective trans-catheter coil embolization in managing bile leaks, and (4) discuss pearls and pitfalls in imaging following cholecystectomy. While common first-line imaging modalities for post-cholecystectomy complications include CT and sonography, ERCP and MRCP can delineate the biliary tree with greater detail. Scintigraphy has a higher sensitivity and specificity than CT or sonography for diagnosing bile leak and may preclude the need for ERCP. Post-operative complications include biliary duct injury or leak, biliary obstruction, remnant gallbladder/cystic duct stones and inflammation, biliary dyskinesia, papillary stenosis, and vascular injury. Subtle cases resulting in lethal outcomes, such as hemorrhage from the gallbladder bed without major vessel injury, have also been described. Cases presented will include biliary complications such as post-cholecystectomy stump cholecystitis, nonbiliary complications such as subcapsular hematoma, and normal post-surgical findings such as oxidized regenerated cellulose. Post-operative biliary complications can cause significant morbidity and mortality, and thus familiarity with the expected post-surgical appearance of the gallbladder fossa and biliary tract, as well as understanding the spectrum of complications and associated multimodality imaging findings, are essential for emergency radiologists and those practicing in the acute care setting to direct appropriate patient management. Furthermore, many of the postoperative complications can be managed by noninvasive percutaneous interventional procedures, from drain placement to cystic artery and cystic duct stump embolization.

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.

Proteobacteria Acts as a Pathogenic Risk-Factor for Chronic Abdominal Pain and Diarrhea in Post-Cholecystectomy Syndrome Patients: A Gut Microbiome Metabolomics Study.

BACKGROUND Laparoscopic cholecystectomy (LC) is regarded as the criterion standard for gallstone therapy, but post-cholecystectomy syndrome (PCS) is a common complication. This study aimed to analyze and identify differences in gut microbiome in PCS patients. MATERIAL AND METHODS This study involved 8 PCS patients (RS1), 8 asymptomatic PCS patients (RS2), and 8 healthy individuals (RS3). Genomic DNA of gut microbiome was extracted and amplified with CTAB method. PCR products were sequenced with Illumina High-Through Sequencing. Sequencing data were analyzed with QIIME software. Effective sequence of bacterial 16S-rRNA gene was clustered into OTUs using UPARSE software. Species annotations were evaluated using Mothur software. QIIME software was used to conduct complexity analysis and calculate UniFrac distances. R software was used to generate PCoA plots. RESULTS Bacterial 16S-rDNA gene sequences showed that the effective species annotative data were more than 97%. According to Ternary plot, Firmicutes and Bacteroidetes had similar abundance and contents among the 3 groups. Contents of Proteobacteria in RS1 were higher compared to RS2 and RS3. Bacterial genomic DNAs samples were clustered together in the same group; however, distances were relative far between different groups. RS1 illustrated significantly higher abundance of Proteobacteria colonies compared to healthy people (p<0.05), and illustrated higher abundance of Verrucomicrobia and lower abundance of Bacteroidetes and Firmicutes, but without significant differences (p>0.05). CONCLUSIONS Gut microbiome of PCS patients was dominated by Proteobacteria in feces and contained little Firmicutes and Bacteroidetes. The enhanced abundance of Proteobacteria might be the highly pathogenic risk factor for chronic abdominal pain and diarrhea in PCS patients.

Hepatolitiasis masiva secundaria a síndrome del sumidero / Massive hepatolithiasis due to sump síndrome

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[Aneurysm of the gastroduodenal artery in a female patient with the postcholecystectomy syndrome (a clinical case report)]. / Anevrizma gastroduodenal'noi arterii u patsientki s postkholetsistéktomicheskim sindromom.

Aneurysms of visceral arteries appear to belong to rare and potentially lethal vascular diseases. The most important role in the aetiology of aneurysms of the gastroduodenal artery is plaid by either acute or chronic pancreatitis. The article deals with a clinical case report concerning a saccular partially thrombosed aneurysm having developed in a 77-year-old woman presenting with the postcholecystectomic syndrome and detected on ultrasonographic examination of the abdominal-cavity vessels. Timely radiodiagnosis (SCT angiography of abdominal cavity vessels), adequate and timely performed endovascular occlusion of the cavity of the aneurysm with metal spirals performed in a timely manner made it possible to attain a favourable outcome. Little is known regarding the understanding of the aetiology and lack of full clarity in therapeutic approaches to aneurysms of visceral arteries predetermine the necessity to continue collecting clinical case reports concerning this rarely encountered vascular pathology in order to generalize and work out an appropriate therapeutic-and-diagnostic algorithm.

Post-laparoscopic cholecystectomy Mirizzi syndrome induced by polymeric surgical clips: a case report and review of the literature.

BACKGROUND: Laparoscopic cholecystectomy is the gold standard treatment of gallbladder disease. Post-cholecystectomy syndrome is a severe postoperative complication which can be caused by multiple mechanisms and can present with multiple disorders. The wide use of laparoscopy induces the need to understand more clearly the presentation and pathophysiology of this syndrome. Post-cholecystectomy Mirizzi syndrome is one form of this syndrome and, according to literature, this is the first report that clearly describes it. CASE PRESENTATION: We describe the case of a 62-year-old Greek woman who underwent laparoscopic cholecystectomy because of gallstone disease. A few days after surgery, post-cholecystectomy syndrome gradually developed with mild bilirubin increase in association with epigastric pain, nausea, and vomiting. After performing ultrasound, magnetic resonance cholangiopancreatography, and endoscopic retrograde cholangiopancreatography, we conducted a second laparoscopic surgery to manage the obstruction, which was converted to open surgery because of the remaining inflammation from the post-endoscopic retrograde cholangiopancreatography acute pancreatitis. Four polymeric laparoscopic clips were removed because they were identified as the cause of her post-cholecystectomy syndrome. She had a quick recovery without further complications. CONCLUSIONS: Postoperative Mirizzi syndrome induced by the migration of polymer laparoscopic clips is a rare (only one case referring to polymeric clips has been published in the literature) but a well-identified complication of laparoscopic cholecystectomy which can confuse the diagnostic and therapeutic field requiring simultaneous immediate management.

[Postcholecystectomy syndrome in children, fact or fiction?] / Síndrome postcolecistectomía en niños ¿realidad o mito?

INTRODUCTION: The postcholecystectomy syndrome (SPC) is broadly defined and published in adults, whereas in the pediatric population are hardly any articles about it. Up to a third of adults have dyspeptic symptoms without organic cause the first year after cholecystectomy. Our goal is to determine the incidence of SPC in our population. METHODS: An observational study was performed, collecting data from patients who had been done laparoscopic cholecystectomy in our hospital since 2005. Patients diagnosed choledochal cyst and biliary atresia were excluded. The following data were collected: type of dyspeptic symptoms, scheduled office visits and emergency units in the first postoperative year and in the following. Children who did not make any visits, a telephone survey was conducted. RESULTS: Data from 36 patients, including 3 patients who were excluded for presenting organic cause, were collected. The most frequent diagnosis was idiopathic cholelithiasis (64,7%). Sixteen children (48,5%) had postoperative symptoms in the first year, of which 14 went to scheduled office visit and 6 emergent (2 required hospitalization). The main symptoms were abdominal postoperative pain (100%), nausea (62,5%) and vomiting (50%). After the first year (6 patients were excluded for less follow-up), only 5 patients (18,5%) continued to symptoms (p= 0,015), 2 required visit to programmatically consultation and no one emergent. CONCLUSION: In our sample, SPC in children exists and improves after the first year. So postoperative follow-up is an important fact, and only further tests must be done if signs of organic cause.

INTRODUCCION: El síndrome postcolecistectomía (SPC) está ámpliamente definido y publicado en adultos, en cambio en la población pediátrica apenas hay artículos al respecto. Hasta un tercio de los adultos presentan síntomas dispépticos sin causa orgánica el primer año después de una colecistectomía. Nuestro objetivo es conocer la incidencia del SPC en nuestro medio. MATERIAL Y METODOS: Se realizó un estudio observacional, recogiendo datos de los pacientes colecistectomizados por laparoscopia en nuestro hospital desde 2005. Se excluyeron pacientes diagnosticados de quiste de colédoco y atresia de vías biliares. Se recogieron los siguientes datos: tipo de síntomas dispépticos, visitas a consulta de forma programada y urgente en el primer año postquirúrgico y en los años sucesivos. Se realizó encuesta telefónica a los pacientes que no efecturaron ninguna visita. RESULTADOS: Se recogieron datos de 36 pacientes, de los cuales se excluyeron 3 pacientes por presentar causa orgánica. El diagnóstico más frecuente fue la colelitiasis idiopática (64,7%). Dieciséis pacientes (48,5%) presentaron síntomas en el primer año postquirúrgico, de los cuales 14 acudieron a consultas de forma programada y 6 urgente (2 precisaron ingreso). Los síntomas principales postquirúrgicos fueron el dolor abdominal (100%), náuseas (62,5%) y vómitos (50%). Tras el primer año (6 pacientes excluidos por seguimiento menor), solo 5 (18,5%) continuaron con los síntomas (p= 0,015), 2 requirieron visita a consultas de forma programada y ninguna urgente. CONCLUSION: Según nuestra muestra, el SPC en niños existe y mejora tras el primer año, por lo que es importarte el seguimiento postquirúrgico de los mismos y solo realizar pruebas complementarias ante signos de causa orgánica.

Bloqueo fascial ecoguiado de las ramas cutáneas de los nervios intercostales: una buena alternativa analgésica para la cirugía abierta de vesícula biliar / Ultrasound-guided cutaneous intercostal branches nerves block: a good analgesic alternative for gallbladder open surgery

El abordaje laparoscópico es el tratamiento de elección para la cirugía de vesícula, sin embargo, algunos pacientes requieren una conversión de la técnica, lo que origina en ellos un dolor postoperatorio moderado-severo. Tradicionalmente los opioides han sido utilizados para tratar dicho dolor, pero sus efectos secundarios han llevado a la búsqueda de nuevas alternativas (administración de anestésicos locales en plexos, fascias, nervios o herida). Presentamos 4 casos clínicos a los que se realizó el bloqueo ecoguiado de las ramas cutáneas de los nervios intercostales en la línea axilar media de T6 a T12 con levobupivacaína como alternativa analgésica en cirugía abierta de vesícula, con unos buenos resultados (AU)

Laparoscopic cholecystectomy has become the standard treatment for gallbladder diseases. However, there are still some patients for whom conversion to open surgery is required. This surgery can produce significant post-operative pain. Opioids drugs have traditionally been used to treat this pain, but side effects have led to seeking alternatives (plexus, nerve or fascia blocks or wound). The cases are presented of 4 patients subjected to ultrasound-guided intercostal branches blocks in the mid-axillary line from T6 to T12 with levobupivacaine as an analgesic alternative in open surgery of gallbladder, with satisfactory results (AU)

[Cholagenic diarrhea is a type of postcholescystectomy syndrome].

AIM: To study the role of biliary acids (BAs) in the pathogenesis of chronic diarrhea (CD) in patients undergoing cholecystectomy (CE). SUBJECTS AND METHODS: Twenty-five patients with post-CE diarrhea were examined. A comparison group consisted of 11 patients with diarrhea-predominant irritable bowel syndrome (IBS). The results of an examination of 15 healthy individuals were taken as normal values. Daily fecal BAs were determined by an enzyme spectrophotometric technique. RESULTS: In the patients after CE, daily fecal BA losses were found to be thrice as large as that in the healthy individuals. In the comparison group of patients with IBS, fecal bile excretion was not greater than the normal values. Stool normalization with a simultaneous decrease in fecal BA losses was seen in 92% of the post-CE patients receiving a course of therapy with adsorbents and astringents. CONCLUSION: Post-CE CD is a type of postcholescystectomy syndrome.

[The role of bile acids in the pathogenesis of chronic diarrhea].

Chronic diarrhea syndrome results from excess colonic bile acids. Fibroblast growth factor 19 (FGF19), produced in the ileum is response to bile acid absorption, regulates hepatic bile acids synthesis. Bile acid malabsorption can be found in various gastrointestinal conditions: the greatest losses bile acids with excrements were marked at patients with surgical resection of terminal ileum. The maintenance in daily colonic excess bile at patients with postholecystectomy exceed more than in three times the indicators noted at control subjects, but at the patients with irritable bowel sindrom did not exceed the norm. Effective remedies in treatment chologenic diarrhea were bile acid sequestran.

[Forced resection of the liver right lobe in the patient with cholelithiasis].

There is a case of cholelithic illness complicated by cholangiolithiasis, the treatment of which resulted in resection of the right hepatic lobe.

[Clinico-morphological characteristics of major duodenal papilla benign neoformations of patients with postcholecystectomy syndrome].

The article is devoted to a problem of diagnosis and treatment of postcholecystectomy syndrome caused by benign neoformations of the major duodenal papilla. The material of study was formed by 76 patients; among them 53 ones had isolated benign neoformations of the major duodenal papilla. The medical-diagnostic algorithm applied by authors for the examination of patients with postcholecystectomy syndrome is presented. It's been defined, that benign neoformations of the major duodenal papilla take an essential place in the structure of postcholecystectomy syndrome and make 13.5% of the reasons of its occurrence. Thus, the most widespread morphological substratum of these benign neoformations is the hyperplastic polyp.

[Efficacy of rifaximine in small intestinal bacterial overgrowth syndrome in patients after cholecystectomy].

AIM: To define frequency of onset of small intestinal bacterial overgrowth syndrome (SIBOGS) in patients with postcholecystectomy syndrome (PCS); to substantiate necessity of microflora correction and assess efficacy of rifaximine in the doses 800 and 1200 mg/day. MATERIAL AND METHODS: A breath hydrogen test (BHT) was made in 82 PCS patients. Rifaximine was given to 40 SIBOGS patients: 20 of them received the drug in a dose 800 mg/day and 20--in a dose 1200 mg/day for 7 days. The efficacy was estimated by attenuation of the clinical symptoms and parameters of BHT. RESULTS: SIBOGS was detected in 73% of PCS patients. This was an indication for antibacterial treatment. Rifaximine in a dose 800 mg/day failed to attenuate pain and to eliminate dyspeptic syndromes in some patients, BHT in them was not normal. Administration of rifaximine in a dose 1200 mg/day normalized BHT in 90% patients and eliminated clinical symptoms in most of the patients. CONCLUSION: Rifaximine in a dose 1200 mg/day vs 800 mg/day in PCS patients with SIBOGS is more effective as it eliminates clinical symptoms and normalizes BHT.

[Disorders of bone mineral density in patients with cholelithiasis and postcholecystectomic syndrome].

AIM: to justify the role of biliary insufficiency (BI) in the development of disorders of bone mineral density (BMD) in patients with cholelithiasis and after cholecystectomy, to introduce with main methods of diagnosis, prevention and treatment of osteoporosis and osteopenia in biliary pathology. Recent literature data showed that development of BI in the CL and PS leads to malabsorption of vitamin D and thereby contribute to the development of osteoporosis and osteopenia. The main method of diagnosis of BMD is twoenergic X-ray densitometry.